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The Surgeon : Journal of the Royal... Dec 2022Major trauma has seen a demographic shift in recent years and it is expected that the elderly population will comprise a greater burden on the major trauma service in...
INTRODUCTION
Major trauma has seen a demographic shift in recent years and it is expected that the elderly population will comprise a greater burden on the major trauma service in the near future. However, whether a similar trend exists in those undergoing operative intervention for spinal trauma remains to be elucidated.
AIMS
To compare the presentation and outcomes of patients ≥65 years of age sustaining spine trauma to those <65 years at a national tertiary referral spine centre.
METHODS
The local Trauma Audit Research Network (TARN) database was analysed to identify spinal patients referred to our institution, a national tertiary referral centre, between 01/2016 and 05/2019. Patients were divided into a young cohort (16-64 years old) and an elderly cohort (> 64 years old). No explicit distinction was made between major and minor spine trauma cases. Variables analysed included patient demographics, injury severity, mortality, interventions, mechanism of injury and length of hospital stay.
RESULTS
A total of 669 patients were admitted of which 480 patients underwent operative intervention for spinal trauma. Within the elderly cohort, this represented 75.3% of cases. Among the younger population, road traffic collisions were the most common mechanism of injury (37.1%), while low falls (<2 m) (57.4%) were the most common mechanism among the older population. Patients ≥65 years old had significantly longer length of stay (21 days [1-194] v 14 days [1-183]) and suffered higher 30-day mortality rates (4.6% [0-12] v 0.97% [0-4]).
CONCLUSION
Orthopaedic spinal trauma in older people is associated with a significantly higher mortality rate as well as a longer duration of hospitalization. Even though severity of injury is similar for both young and old patients, the mechanism of injury for the older population is of typically much lower energy compared to the high energy trauma affecting younger patients.
Topics: Humans; Aged; Adolescent; Young Adult; Adult; Middle Aged; Spinal Injuries; Accidents, Traffic; Length of Stay; Databases, Factual; Demography; Injury Severity Score; Retrospective Studies
PubMed: 34600828
DOI: 10.1016/j.surge.2021.08.010 -
CMAJ : Canadian Medical Association... Nov 2012There is uncertainty about the optimal approach to screen for clinically important cervical spine (C-spine) injury following blunt trauma. We conducted a systematic... (Comparative Study)
Comparative Study Review
BACKGROUND
There is uncertainty about the optimal approach to screen for clinically important cervical spine (C-spine) injury following blunt trauma. We conducted a systematic review to investigate the diagnostic accuracy of the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) criteria, 2 rules that are available to assist emergency physicians to assess the need for cervical spine imaging.
METHODS
We identified studies by an electronic search of CINAHL, Embase and MEDLINE. We included articles that reported on a cohort of patients who experienced blunt trauma and for whom clinically important cervical spine injury detectable by diagnostic imaging was the differential diagnosis; evaluated the diagnostic accuracy of the Canadian C-spine rule or NEXUS or both; and used an adequate reference standard. We assessed the methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies criteria. We used the extracted data to calculate sensitivity, specificity, likelihood ratios and post-test probabilities.
RESULTS
We included 15 studies of modest methodologic quality. For the Canadian C-spine rule, sensitivity ranged from 0.90 to 1.00 and specificity ranged from 0.01 to 0.77. For NEXUS, sensitivity ranged from 0.83 to 1.00 and specificity ranged from 0.02 to 0.46. One study directly compared the accuracy of these 2 rules using the same cohort and found that the Canadian C-spine rule had better accuracy. For both rules, a negative test was more informative for reducing the probability of a clinically important cervical spine injury.
INTERPRETATION
Based on studies with modest methodologic quality and only one direct comparison, we found that the Canadian C-spine rule appears to have better diagnostic accuracy than the NEXUS criteria. Future studies need to follow rigorous methodologic procedures to ensure that the findings are as free of bias as possible.
Topics: Algorithms; Australia; Canada; Cervical Vertebrae; Emergency Medicine; Emergency Service, Hospital; Female; Humans; Injury Severity Score; Male; Neck Injuries; Needs Assessment; Sensitivity and Specificity; Spinal Injuries; Tomography, X-Ray Computed; Wounds, Nonpenetrating
PubMed: 23048086
DOI: 10.1503/cmaj.120675 -
Academic Emergency Medicine : Official... Dec 2017Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency... (Observational Study)
Observational Study
BACKGROUND
Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions.
OBJECTIVES
The objective was to determine the interobserver agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma.
METHODS
This was a planned, substudy of a four-site, prospective cohort of children < 18 years transported by EMS to pediatric EDs for evaluation of CSI after blunt trauma. Inclusion criteria were trauma team activation and/or EMS-initiated spinal motion restriction. Exclusion criteria were penetrating trauma, transfer to another facility for definitive care, state custody, or substantial language barrier. For each eligible child, the transporting EMS provider and treating ED provider independently recorded their clinical assessment for CSI. This included mechanism of injury and patient history and physical examination findings. We assessed each paired variable for interobserver agreement between EMS and ED provider using kappa (κ) analysis. We considered variables with κ lower confidence interval values ≥0.4 to have moderate or better agreement.
RESULTS
We obtained 1,372 paired observations for 29 variables. After finding prevalence and observer bias were adjusted for, all variables achieved moderate to better agreement including eight variables previously shown to be independently associated with CSI in children: diving mechanism, high-risk motor vehicle collision, altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, and predisposing medical condition. EMS and ED providers, however, showed less than moderate agreement for their overall gestalt for CSI in children. Of note, both EMS and ED providers did not assess for neck pain, inability to move the neck, and/or cervical spine tenderness in more than 10% of study patients.
CONCLUSIONS
Emergency medical services and ED providers achieved at least moderate agreement in the assessment of CSI risk factors in children after blunt trauma. However, EMS and ED providers did not achieve moderate agreement on gestalt for CSI and some risk factors went unassessed by providers. These findings support the development of a pediatric CSI risk assessment tool for EMS and ED providers to reduce interventions for those children at very low risk for CSIs while still identifying all children with injury.
Topics: Adolescent; Child; Child, Preschool; Emergency Medical Services; Emergency Service, Hospital; Female; Humans; Male; Neck Injuries; Observer Variation; Prospective Studies; Risk Assessment; Risk Factors; Spinal Injuries; Wounds, Nonpenetrating
PubMed: 28921731
DOI: 10.1111/acem.13312 -
Journal of Neurosurgery. Spine Jan 2023The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System...
OBJECTIVE
The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5-10 years, 10-20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery).
METHODS
A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson's chi-square or Fisher's exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility.
RESULTS
The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5-10 years: 0.69 vs 10-20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5-10 years: 0.62 vs 10-20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5-10 years: 0.61 vs 10-20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36).
CONCLUSIONS
The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system.
Topics: Humans; Reproducibility of Results; Observer Variation; Spinal Injuries; Cervical Vertebrae; Surgeons
PubMed: 35986731
DOI: 10.3171/2022.6.SPINE22454 -
International Journal of Clinical... 2022Facial fractures can be accompanied by serious and life-threatening injuries such as cervical spine injury (CSI), which can lead to serious consequences if misdiagnosed.
BACKGROUND
Facial fractures can be accompanied by serious and life-threatening injuries such as cervical spine injury (CSI), which can lead to serious consequences if misdiagnosed.
OBJECTIVE
To assess the patterns of maxillofacial fractures and to explore the association between these fractures and cervical spine injuries (CSIs) in patients with a traumatic facial injury.
METHODS
A retrospective analysis was conducted on the data of the subjects who were admitted to the King Abdullah University Hospital (KAUH) and had a maxillofacial fracture in the period from January 2017 through December 2020. Stepwise binary logistic regression analysis was conducted to find the variables which are significantly and independently associated with CSIs.
RESULTS
A total of 394 maxillofacial fractures were reported for a total of 221 subjects. The mandible was the most common site of the reported fractures (41.88%). The majority of the subjects had associated injuries (70.6%), of which 82.7% were CSIs. The most common type of the CSIs was the vertebral fracture (52%). Increased age (OR = 1.543, < 0.05), having a mandibular fracture (OR = 4.382, < 0.01), and having a maxillary fracture (OR = 3.269, < 0.05) were significantly associated with the presence of CSI.
CONCLUSION
The current study revealed that the most common type of facial fracture occurred in the mandible area, and CSI was the most common fracture-associated injury (82.7%). Increased age and having mandibular or maxillary fracture were associated with an increased risk of developing CSI. Therefore, it is necessary to rule out the presence of concomitant CSI during the emergency management of maxillofacial fractures, particularly for elderly patients and those with mandibular or maxillary fractures.
Topics: Aged; Cervical Vertebrae; Humans; Jordan; Maxillary Fractures; Retrospective Studies; Skull Fractures; Spinal Injuries; Tertiary Care Centers
PubMed: 35989870
DOI: 10.1155/2022/4107382 -
Scientific Reports Nov 2020In order to enhance the reliability of the application to clinical practice of the TLICS classification, we retrospectively reviewed the patients with thoracolumbar...
In order to enhance the reliability of the application to clinical practice of the TLICS classification, we retrospectively reviewed the patients with thoracolumbar spine injuries who underwent magnetic resonance imaging (MRI) and analyzed the validity of the TLICS classification and the necessity of MRI. We enrolled 328 patients with thoracolumbar spine injury who underwent MRI. All patients were classified into conservative and operative treatment groups. The TLICS score of each group was analyzed and the degree of consistent with the recommended treatment through the TLICS classification was examined. Of the total 328 patients, 138 patients were treated conservatively and 190 patients were treated by surgery. Of the 138 patients who underwent conservative treatment, 131 patients (94.9%) had a TLICS score of 4 points or less, and matched with the recommendation score for conservative treatment according to the TLICS classification (match rate 94.9%, 131/138). Of the 190 patients who underwent operative treatment, 160 patients (84.2%) had a TLICS score of 4 points or more (match rate 84.2%, 160/190). All of 30 mismatched patients with a TLICS score of 3 points or less (15.8%) had stable burst fracture without neurological deficit. We retrospectively reviewed the validity of the TLICS classification for the injuries of the thoracolumbar spine, based on MRI in a large group of patients. Treatment with TLICS classification showed high validity, especially in conservative group, and MRI should be an essential diagnostic tool for accurate evaluation of posterior ligamentous complex injury.
Topics: Adult; Aged; Aged, 80 and over; Conservative Treatment; Female; Fractures, Bone; Humans; Injury Severity Score; Ligaments; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Middle Aged; Retrospective Studies; Spinal Injuries; Thoracic Vertebrae; Trauma Severity Indices; Young Adult
PubMed: 33177557
DOI: 10.1038/s41598-020-76473-9 -
The Cochrane Database of Systematic... Dec 2017Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population.
OBJECTIVES
To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma.
SEARCH METHODS
We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility.
SELECTION CRITERIA
We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy.
MAIN RESULTS
Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity.
AUTHORS' CONCLUSIONS
There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.
Topics: Cervical Vertebrae; Checklist; Child; Cohort Studies; Decision Support Techniques; Humans; Magnetic Resonance Imaging; Radiography; Reference Standards; Spinal Injuries; Tomography, X-Ray Computed; Triage; Wounds, Nonpenetrating
PubMed: 29215711
DOI: 10.1002/14651858.CD011686.pub2 -
Korean Journal of Radiology Jun 2019The Korean Society of Radiology and the National Evidence-based Healthcare Collaborating Agency developed a primary imaging test for suspected traumatic thoracolumbar... (Review)
Review
Primary Imaging Test for Suspected Traumatic Thoracolumbar Spine Injury: 2017 Guidelines by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency.
The Korean Society of Radiology and the National Evidence-based Healthcare Collaborating Agency developed a primary imaging test for suspected traumatic thoracolumbar spine injury. This guideline was developed using an adaptation process involving collaboration between the development committee and the working group. The development committee, consisting of research methodology experts, established the overall plan and provided support on research methodology. The working group, composed of radiologists with expertise in musculoskeletal imaging, wrote the recommendation. The guidelines recommend that thoracolumbar spine computed tomography without intravenous contrast enhancement be the first-line imaging modality for diagnosing traumatic thoracolumbar spine injury in adults.
Topics: Adult; Contrast Media; Evidence-Based Practice; Guidelines as Topic; Humans; Lumbar Vertebrae; Radiography; Republic of Korea; Spinal Injuries; Thoracic Vertebrae; Tomography, X-Ray Computed
PubMed: 31132816
DOI: 10.3348/kjr.2018.0792 -
Pediatrics May 2014Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children.
BACKGROUND AND OBJECTIVE
Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children.
METHODS
We conducted a 5-year retrospective review of children <16 years old with CSIs at 17 Pediatric Emergency Care Applied Research Network hospitals. Investigators reviewed imaging reports and consultations to assign CSI type. We described cohort characteristics using means and frequencies and used Fisher's exact test to compare differences between 3 age groups: <2 years, 2 to 7 years, and 8 to 15 years. We used logistic regression to explore the relationship between injury level and age and mechanism of injury and between neurologic outcome and cord involvement, injury level, age, and comorbid injuries.
RESULTS
A total of 540 children with CSIs were included in the study. CSI level was associated with both age and mechanism of injury. For children <2 and 2 to 7 years old, motor vehicle crash (MVC) was the most common injury mechanism (56%, 37%). Children in these age groups more commonly injured the axial (occiput-C2) region (74%, 78%). In children 8 to 15 years old, sports accounted for as many injuries as MVCs (23%, 23%), and 53% of injuries were subaxial (C3-7). CSIs often necessitated surgical intervention (axial, 39%; subaxial, 30%) and often resulted in neurologic deficits (21%) and death (7%). Neurologic outcome was associated with cord involvement, injury level, age, and comorbid injuries.
CONCLUSIONS
We demonstrated a high degree of variability of CSI patterns, treatments and outcomes in children. The rarity, variation, and morbidity of pediatric CSIs make prompt recognition and treatment critical.
Topics: Accidents, Traffic; Adolescent; Age Factors; Athletic Injuries; Causality; Cervical Vertebrae; Child; Child, Preschool; Cohort Studies; Female; Humans; Male; Neurologic Examination; Retrospective Studies; Spinal Cord Injuries; Spinal Injuries
PubMed: 24777222
DOI: 10.1542/peds.2013-3505 -
American Family Physician Jan 1999Significant cervical spine injury is very unlikely in a case of trauma if the patient has normal mental status (including no drug or alcohol use) and no neck pain, no... (Review)
Review
Significant cervical spine injury is very unlikely in a case of trauma if the patient has normal mental status (including no drug or alcohol use) and no neck pain, no tenderness on neck palpation, no neurologic signs or symptoms referable to the neck (such as numbness or weakness in the extremities), no other distracting injury and no history of loss of consciousness. Views required to radiographically exclude a cervical spine fracture include a posteroanterior view, a lateral view and an odontoid view. The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7 and T1. The most common reason for a missed cervical spine injury is a cervical spine radiographic series that is technically inadequate. The "SCIWORA" syndrome (spinal cord injury without radiographic abnormality) is common in children. Once an injury to the spinal cord is diagnosed, methylprednisolone should be administered as soon as possible in an attempt to limit neurologic injury.
Topics: Algorithms; Cervical Vertebrae; Diagnosis, Differential; Humans; Radiography; Spinal Injuries
PubMed: 9930127
DOI: No ID Found