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Global Spine Journal May 2024Systematic Review and Meta-Analysis. (Review)
Review
STUDY DESIGN
Systematic Review and Meta-Analysis.
OBJECTIVE
Identify the incidence, mechanism of injury, investigations, management, and outcomes of Vertebral Artery Injury (VAI) after cervical spine trauma.
METHODS
A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines (PROSPERO-ID CRD42021295265). Three databases were searched (PubMed, SCOPUS, Google Scholar, CINAHL PLUS). Incidence of VAI, investigations to diagnose (Computed Tomography Angiography, Digital Subtraction Angiography, Magnetic Resonance Angiography), stroke incidence, and management paradigms (conservative, antiplatelets, anticoagulants, surgical, endovascular treatment) were delineated. Incidence was calculated using pooled proportions random effects meta-analysis.
RESULTS
A total of 44 studies were included (1777 patients). 20-studies (n = 503) included data on trauma type; 75.5% (n = 380) suffered blunt trauma and 24.5% (n = 123) penetrating. The overall incidence of VAI was .95% (95% CI 0.65-1.29). From the 16 studies which reported data on outcomes, 8.87% (95% CI 5.34- 12.99) of patients with VAI had a posterior stroke. Of the 33 studies with investigation data, 91.7% (2929/3629) underwent diagnostic CTA; 7.5% (242/3629) underwent MRA and 3.0% (98/3629) underwent DSA. Management data from 20 papers (n = 475) showed 17.9% (n = 85) undergoing conservative therapy, anticoagulation in 14.1% (n = 67), antiplatelets in 16.4% (n = 78), combined therapy in 25.5% (n = 121) and the rest (n = 124) managed using surgical and endovascular treatments.
CONCLUSION
VAI in cervical spine trauma has an approximate posterior circulation stroke risk of 9%. Optimal management paradigms for the prevention and management of VAI are yet to be standardized and require further research.
PubMed: 37924280
DOI: 10.1177/21925682231209631 -
Global Spine Journal Nov 2023Retrospective database analysis.
STUDY DESIGN
Retrospective database analysis.
OBJECTIVE
Polytraumatized patients with spinal injuries require tailor-made treatment plans. Severity of both spinal and concomitant injuries determine timing of spinal surgery. Aim of this study was to evaluate the role of spinal injury localization, severity and concurrent injury patterns on timing of surgery and subsequent outcome.
METHODS
The TraumaRegister DGU was utilized and patients, aged ≥16 years, with an Injury Severity Score (ISS) ≥16 and diagnosed with relevant spinal injuries (abbreviated injury scale, AIS ≥ 3) were selected. Concurrent spinal and non-spinal injuries were analysed and the relation between injury severity, concurrent injury patterns and timing of spinal surgery was determined.
RESULTS
12.596 patients with a mean age of 50.8 years were included. 7.2% of patients had relevant multisegmental spinal injuries. Furthermore, 50% of patients with spine injuries AIS ≥3 had a more severe non-spinal injury to another body part. ICU and hospital stay were superior in patients treated within 48 hrs for lumbar and thoracic spinal injuries. In cervical injuries early intervention (<48 hrs) was associated with increased mortality rates (9.7 vs 6.3%).
CONCLUSIONS
The current multicentre study demonstrates that polytrauma patients frequently sustain multiple spinal injuries, and those with an index spine injury may therefore benefit from standardized whole-spine imaging. Moreover, timing of surgical spinal surgery and outcome appear to depend on the severity of concomitant injuries and spinal injury localization. Future prospective studies are needed to identify trauma characteristics that are associated with improved outcome upon early or late spinal surgery.
PubMed: 37963389
DOI: 10.1177/21925682231216082 -
The Spine Journal : Official Journal of... Dec 2023Spinal cord injury (SCI) is a global health problem with a heavy economic burden. Surgery is considered as the cornerstone of SCI treatment. Although various... (Review)
Review
BACKGROUND CONTEXT
Spinal cord injury (SCI) is a global health problem with a heavy economic burden. Surgery is considered as the cornerstone of SCI treatment. Although various organizations have formulated different guidelines on surgical treatment for SCI, the methodological quality of these guidelines has still not been critically appraised.
PURPOSE
We aim to systematically review and appraise the current guidelines on surgical treatments of SCI and summarize the related recommendations with the quality evaluation of supporting evidence.
STUDY DESIGN
Systematic review.
METHODS
Medline, Cochrane library, Web of Science, Embase, Google Scholar, and online guideline databases were searched from January 2000 to January 2022. The most updated and recent guidelines containing evidence-based or consensus-based recommendations and established by authoritative associations were included. The Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument containing 6 domains (eg, applicability) was used to appraise the included guidelines. An evidence-grading scale (ie, level of evidence, LOE) was utilized to evaluate the quality of supporting evidence. The supporting evidence was categorized as A (the best quality), B, C, and D (the worst quality).
RESULTS
Ten guidelines from 2008 to 2020 were included, however, all of them acquired the lowest scores in the domain of applicability among all the six domains. Fourteen recommendations (eight evidence-based recommendations and six consensus-based recommendations) were totally involved. The SCI types of the population and timing of surgery were studied. Regarding the SCI types of the population, eight guidelines (8/10, 80%), two guidelines (2/10, 20%), and three guidelines (3/10, 30%) recommended surgical treatment for patients with SCI without further clarification of characteristics, incomplete SCI, and traumatic central cord syndrome (TCCS), respectively. Besides, one guideline (1/10, 10%) recommended against surgery for patients with SCI without radiographic abnormality. Regarding the timing of surgery, there were eight guidelines (8/10, 80%), two guidelines (2/10, 20%), and two guidelines (2/10, 20%) with recommendations for patients with SCI without further clarification of characteristics, incomplete SCI, and TCCS, respectively. For patients with SCI without further clarification of characteristics, all eight guidelines (8/8, 100%) recommended for early surgery and five guidelines (5/8, 62.5%) recommended for the specific timing, which ranged from within 8 hours to within 48 hours. For patients with incomplete SCI, two guidelines (2/2, 100%) recommended for early surgery, without specific time thresholds. For patients with TCCS, one guideline (1/2, 50%) recommended for surgery within 24 hours, and another guideline (1/2, 50%) simply recommended for early surgery. The LOE was B in eight recommendations, C in three recommendations, and D in three recommendations.
CONCLUSIONS
We remind the reader that even the highest quality guidelines often have significant flaws (eg, poor applicability), and some of the conclusions are based on consensus recommendations which is certainly less than ideal. With these caveats, we found most included guidelines (8/10, 80%) recommended early surgical treatment for patients after SCI, which was consistent between evidence-based recommendations and consensus-based recommendations. Regarding the specific timing of surgery, the recommended time threshold did vary, but it was usually within 8 to 48 hours, where the LOE was B to D.
Topics: Humans; Spinal Cord Injuries; Evidence-Based Medicine; Consensus
PubMed: 37339698
DOI: 10.1016/j.spinee.2023.06.385 -
Injury Jul 2023Recently, quadrilateral plate (QLP) fractures of acetabulum have attracted increasing attention. However, evidence for the appropriate classification of QLP fractures is...
BACKGROUND
Recently, quadrilateral plate (QLP) fractures of acetabulum have attracted increasing attention. However, evidence for the appropriate classification of QLP fractures is still lacking, making it difficult to understand and manage these fractures. This study aimed to introduce a new classification for QLP fractures and evaluate its reproducibility.
METHODS
A series of 1101 consecutive patients with acetabular fractures from 8 level-I trauma centers were enrolled in this study. All patients underwent preoperative radiograph and computed tomography imaging. QLP fractures were identified and classified using the new and Judet-Letournel classification system. The inter- and intra-observer reliabilities (kappa coefficients, κ) of these two systems were investigated by 4 observers. Furthermore, surgical approaches and fixation methods for each fracture type are described.
RESULTS
In total, 243 (243/1101, 22%) patients with QLP fractures were identified and included in this analysis. The mean κ value of the intra-observer reliability was 0.84 (range, 0.763-0.919) for the new classification, indicating excellent agreement, and the inter-observer reliability was 0.762 (range, 0.625-0.876), indicating substantial agreement. The values were 0.649 (range, 0.523-0.708) and 0.584 (0.497-0.646), respectively, according to the Judet-Letournel classification. Six cases (6/243, 2.5%) could not be classified using the Judet-Letournel classification. The selection of surgical approaches and fixation methods depends on the fracture type; however, an anterior intra-pelvic approach and buttressing fixation using the plate or screw are preferred for QLP fractures.
CONCLUSION
This study presents a new classification for QLP fractures, showing higher intra- and inter-observer reliabilities than those obtained using the Judet-Letournel classification. This allowed us to obtain an in-depth and comprehensive understanding of QLP fractures. Additionally, the new classification might guide further studies on surgical strategies for QLP fractures.
LEVEL OF EVIDENCE
Level II.
Topics: Humans; Acetabulum; Reproducibility of Results; Fractures, Bone; Fracture Fixation, Internal; Hip Fractures; Spinal Fractures
PubMed: 37164901
DOI: 10.1016/j.injury.2023.04.049 -
Acta Orthopaedica Et Traumatologica... Jul 2023This study aimed to determine whether isotretinoin and acitretin have beneficial effects on neural tissue damage following acute spinal cord injury.
OBJECTIVE
This study aimed to determine whether isotretinoin and acitretin have beneficial effects on neural tissue damage following acute spinal cord injury.
METHODS
Thirty-six rats were randomly divided into 6 groups: control, sham spinal cord injury, spinal cord injury with isotretinoin 15 mg/kg for 14 days, spinal cord injury with isotretinoin 15 mg/kg for 28 days, spinal cord injury with acitretin 10 mg/kg for 14 days, and spinal cord injury with acitretin 10 mg/kg for 28 days. The damage to the spinal cord was formed by the clip compression technique. A neurological evaluation was conducted on days 1, 14, and 28. All rats were sacrificed following the treatment period, and samples of their spinal cords were collected for histopathological analysis.
RESULTS
The inclined plane angle was significantly increased on the 14th and 28th days in the isotretinoin 15 mg and acitretin 10 mg groups, compared to the spinal injury group (P=.049 and P=.009, respectively). The Drummond-Moore criterion was significantly higher in the acitretin 10 mg group than in the injury group (P=.026). Cleaved Caspase-3 expression was similar in the isotretinoin 15 mg day 28 group and the control group (P > .05), but significantly decreased in the acitretin 10 mg 14th-day and acitretin 10 mg 28th-day groups compared to spinal injury isotretinoin 15 mg 14th-day and isotretinoin 15 mg 28th-day groups (P < .05).
CONCLUSION
This was the first study elaborating that isotretinoin and acitretin reduced neuronal apoptosis and improved functional recovery after spinal cord injury. These neuroprotective effects might open a window of opportunity for patients.
Topics: Animals; Rats; Acitretin; Isotretinoin; Spinal Cord Injuries; Spinal Injuries; Nerve Regeneration
PubMed: 37670445
DOI: 10.5152/j.aott.2023.22128 -
Medicine Sep 2023The Injury Severity Score (ISS) is widely used to evaluate patients with multiple injuries. This study investigated the association between ISS and clinical outcomes of...
The Injury Severity Score (ISS) is widely used to evaluate patients with multiple injuries. This study investigated the association between ISS and clinical outcomes of patients with spinal cord injury (SCI) in an aging Japanese population. This retrospective cohort study investigated patients admitted to a Japanese university hospital. In the study, 89 patients with traumatic SCI were included. Traumatic SCI was categorized as monotrauma or polytrauma, and the ISS was used to evaluate trauma severity. Spearman's correlation coefficient was used to estimate the correlation between ISS and the American Spinal Injury Association (ASIA) motor score, Barthel Index (activities of daily living assessment), and the European Quality of Life (QOL) scale (EQ5d) as an assessment of QOL at admission or the last follow-up with the adjustment for age, sex, and body mass index. Return to home and work were analyzed using the chi-squared test after the ISS was divided into three groups (<14, 14-19, and 20). The mean ISS was significantly higher for polytrauma than monotrauma. Significant negative correlations between the ISS and ASIA motor scores at the first visit (P < .001, r = -0.37) and the last follow-up (adjusted, P = .007, r = -0.30) were observed. The Barthel Index was also negatively correlated with ISS at the first visit (P = .04, r = -0.21) and at the last follow-up period (P < .001, r = -0.35). Moreover, ISS was significantly negatively correlated with EQ5d score at the last follow-up (P = .01, r = -0.28). The chi-squared test demonstrated that patients with an ISS of < 14 returned home (P = .03), while those with an ISS of < 19 returned to work (P = .02). ISS is associated with paralysis, activities of daily living, QOL, and lifestyle in patients with SCI and is an important initial injury assessment method.
Topics: Humans; Injury Severity Score; Quality of Life; Retrospective Studies; Activities of Daily Living; East Asian People; Spinal Cord Injuries; Multiple Trauma; Aging; Spinal Injuries
PubMed: 37773811
DOI: 10.1097/MD.0000000000035369 -
European Journal of Orthopaedic Surgery... Oct 2023Post-traumatic osteoarthritis (PTOA) is a disabling complication of open reduction and internal fixation (ORIF) for acetabular fractures. There is a trend towards acute... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Post-traumatic osteoarthritis (PTOA) is a disabling complication of open reduction and internal fixation (ORIF) for acetabular fractures. There is a trend towards acute total hip arthroplasty (THA), 'fix-and-replace', in patients considered to have a poor prognosis and likelihood of PTOA. Controversy remains between early fix-and-replace, versus delayed THA as required after initial ORIF. This systematic review included studies comparing functional and clinical outcomes between acute versus delayed THA after displaced acetabular fractures.
METHODS
Comprehensive searches following the PRISMA guideline were performed on six databases for articles in English published anytime up to 29 March 2021. Two authors screened articles and discrepancies were resolved by consensus. Patient demographics, fracture classification, functional and clinical outcomes were compiled and analysed.
RESULTS
The search yielded 2770 unique studies, of which five retrospective studies were identified with a total of 255 patients. Of them, 138 (54.1%) were treated with acute and 117 (45.9%) treated with delayed THA. Delayed THA group represented a younger cohort compared to the acute group (mean age, 64.3 vs 73.3). The mean follow-up time for the acute and delayed group was 23 and 50 months, respectively. There was no difference in functional outcomes between the two study groups. Complication and mortality rates were comparable. Delayed THA had a higher revision rate compared to the acute group (17.1 vs 4.3%; p = 0.002).
CONCLUSION
Fix-and-replace had functional outcomes and complication rates similar to ORIF and delayed THA, but lower revision rates. Although the quality of studies was mixed, sufficient equipoise now exists to justify randomised studies in this area. PROSPERO registration: CRD42021235730.
Topics: Humans; Middle Aged; Arthroplasty, Replacement, Hip; Retrospective Studies; Acetabulum; Fractures, Bone; Hip Fractures; Open Fracture Reduction; Fracture Fixation, Internal; Spinal Fractures; Osteoarthritis; Treatment Outcome
PubMed: 36810707
DOI: 10.1007/s00590-023-03489-y -
Clinics in Orthopedic Surgery Dec 2023Traumatic spinal injuries in children are uncommon and result in different patterns of injuries due to the anatomical characteristics of children's spines. However,...
BACKGROUND
Traumatic spinal injuries in children are uncommon and result in different patterns of injuries due to the anatomical characteristics of children's spines. However, there are only a few epidemiological studies of traumatic spinal injury in children. The purpose of this study was to investigate the characteristics of traumatic spinal injury in children.
METHODS
We retrospectively reviewed the cases of pediatric patients (age < 18 years) with traumatic spinal injury who were treated at a level 1 trauma center between January 2017 and December 2021. We divided them into three groups according to age and analyzed demographics, injury mechanism, level of injury, and injury pattern.
RESULTS
A total of 62 patients (255 fractures) were included, and the mean age was 13.8 ± 3.2 years. There were 5 patients (22 fractures) in group I (0-9 years), 24 patients (82 fractures) in group II (10-14 years), and 33 patients (151 fractures) in group III (15-17 years). Both the Injury Severity Score and the Revised Trauma Score were highest in group I, but there was no statistical difference between the age groups. Fall from height was the most common injury mechanism, of which 63% were suicide attempts. The level of spinal injury was different in each age group, T10-L2 injury being the most common. In all age groups, the number of multilevel continuous injury was larger than that of single-level injury or multilevel noncontinuous injury. Surgical intervention was required in 33.9%, and mortality was 3.2%.
CONCLUSIONS
In our study, fall from height was the most common mechanism of injury, and there were many suicide attempts associated with mental health issues. Thoracolumbar junction injuries were predominant, and the rate of multilevel contiguous injuries was high. The support and interest of the society and families for adolescent children seem crucial in preventing spinal trauma, and image testing of the entire spine is essential when evaluating pediatric spinal injuries.
Topics: Adolescent; Child; Humans; Fractures, Bone; Retrospective Studies; Spinal Fractures; Spinal Injuries; Spine; Trauma Centers; Infant, Newborn; Infant; Child, Preschool
PubMed: 38045581
DOI: 10.4055/cios23118 -
Brain & Spine 2024Injuries to the rigid spine have a distinguished position in the broad spectrum of spinal injuries due to altered biomechanical properties. The rigid spine is more prone... (Review)
Review
Injuries to the rigid spine have a distinguished position in the broad spectrum of spinal injuries due to altered biomechanical properties. The rigid spine is more prone to fractures. Two ossification bone disorders that are of particular interest are Ankylosing Spondylitis (AS) and Diffuse Idiopathic Skeletal Hyperostosis (DISH). DISH is a non-inflammatory condition that leads to an anterolateral ossification of the spine. AS on the other hand is a chronic inflammatory disease that leads to cortical bone erosions and spinal ossifications. Both diseases gradually induce stiffening of the spine. The prevalence of DISH is age-related and is therefore higher in the older population. Although the prevalence of AS is not age-related the occurrence of spinal ossification is higher with increasing age. This association with age and the aging demographics in industrialized nations illustrate the need for medical professionals to be adequately informed and prepared. The aim of this narrating review is to give an overview on the diagnostic and therapeutic measures of the ankylosed spine. Because of highly unstable fracture configurations, injuries to the rigid spine are highly susceptible to neurological deficits. Diagnosing a fracture of the ankylosed spine on plain radiographs can be challenging. Moreover, since 8% of patients with ankylosing spine disorders (ASD) have multiple non-contagious fractures, a CT scan of the entire spine is highly recommended as the primary diagnostic tool. There are no consensus-based guidelines for the treatment of spinal fractures in ASD. The presence of neurological deficit or unstable fractures are absolute indications for surgical intervention. If conservative therapy is chosen, patients should be monitored closely to ensure that secondary neurologic deterioration does not occur. For the fractures that have to be treated surgically, stabilization of at least three segments above and below the fracture zone is recommended. These fractures mostly are treated via the posterior approach. Patients with AS or DISH share a significant risk for complications after a traumatic spine injury. The most frequent complications for patients with thoracolumbar burst fractures are respiratory failure, pseudoarthrosis, pneumonia, and implant failure.
PubMed: 38681176
DOI: 10.1016/j.bas.2024.102811 -
International Journal of Surgery... Feb 2024Population data that examines recent national trends in the prevalence of fractures are lacking in the United States (US).
BACKGROUND
Population data that examines recent national trends in the prevalence of fractures are lacking in the United States (US).
MATERIALS AND METHODS
Analyses were based on 1999-2020 data from the National Health and Nutrition Examination Survey (NHANES). Primary outcomes included the prevalence of hip, wrist, and vertebral fractures among adults aged greater than or equal to 50 years. Changes in the prevalence over time were determined by joinpoint regression analysis. The authors also described the variation by fracture subtypes, sociodemographic characteristics, and their combination.
RESULTS
For adults aged greater than or equal to 50 years in NHANES 2017-March 2020, the authors estimated that there was 2.6 million Americans with hip fractures, 14.6 million Americans with wrist fractures, and 5.2 million Americans with vertebral fractures. The prevalence of wrist fractures significantly increased from 8.7% (7.4-9.9%) in 1999-2000 to 12.8% (11.6-14.1%) in 2017-March 2020 among adults aged greater than or equal to 50 years ( P for trend=0.04); significant increases were also observed in fractures that occurred at age less than 50 years, non-Hispanic White, high family income groups, and several combination subgroups (e.g. fractures occurred at age <50 years among women). The prevalence of vertebral fractures increased from 2.2% (1.7-2.8%) in 1999-2000 to 4.6% (3.7-5.5%) in 2017-March 2020 among adults aged greater than or equal to 50 years ( P for trend=0.02); significant increases were also observed in 50-64 years, women, non-Hispanic White, high family income groups and several combination subgroups (e.g. fractures that occurred at age <50 years among women). The authors did not observe significant trend changes in the prevalence of hip fractures among adults aged greater than or equal to 50 years between 1999 and 2020.
CONCLUSION
The estimated prevalence of wrist and vertebral fractures significantly increased among US adults aged greater than or equal to 50 years from 1999 to 2020, although hip fractures did not significantly change.
Topics: Adult; United States; Humans; Female; Middle Aged; Nutrition Surveys; Prevalence; Wrist Fractures; Hip Fractures; Spinal Fractures
PubMed: 37921645
DOI: 10.1097/JS9.0000000000000883