Incidence of Traumatic Spinal Fractures in the Netherlands: Analysis of a Nationwide Database.

STUDY DESIGN: Retrospective database study based on prospectively collected data. OBJECTIVE: The aim of this study was to describe the current incidence and epidemiology of traumatic spinal fractures in the Netherlands SUMMARY OF BACKGROUND DATA.: Traumatic spinal fractures may lead to severe disability and have considerable consequences on healthcare capacity and costs. Several studies have reported a large and increasing share of fractures in elderly. Currently, a reliable, detailed, and up to date incidence of these injuries in the Netherlands is lacking. These numbers could aid in the composition of preventative measures. METHODS: All patients from 2010 to 2017 that were admitted with a spinal fracture were included. Patients were selected based on Abbreviated Injury Scores (AIS) codes. Collected data consisted of patient- and injury characteristics, afflicted spine-region, associated injury, referral- and discharge location, and geographic region of admittance. RESULTS: Overall, 29,637 patients were included in this study. The incidence of spinal fractures increased from 2010 to 2017 (from 21.5 to 24.0 per 100,000 inhabitants). Most patients were injured by a (low-energy) fall from the same level followed by (high-energy) traffic accidents. Elderly patients (≥65 years of age) made up 42% of all patients. The proportion of elderly increased significantly faster over the years compared to younger patients. More than half of polytrauma (injury severity score ≥16) patients had fractures in multiple spine regions. 5,5% of all patients suffered spinal cord injury (SCI), most often associated with cervical fractures in polytrauma patients. Regional differences were found mainly in presentation through referral and low- and high-energy falls. CONCLUSION: The incidence of patients with spinal fractures increased and elderly made up a large part. Preventative measures could be regional dependent and should focus on low-energy falls, traffic accidents, and bicycle accidents in specific. In polytraumatized patients there should be special attention for any additional spine fractures and SCI. LEVEL OF EVIDENCE: 3.

Pedicle screw fixation of thoracolumbar fractures: conventional short segment versus short segment with intermediate screws at the fracture level-a systematic review and meta-analysis.

OBJECTIVE: Posterior short-segment fixation (4-screw construct = 4S) is the conventional surgical technique for thoracolumbar fractures. The effect of adding two intermediate pedicle screws at the fractured level (6-screw construct = 6S) is still a matter of debate. This review aims to compare the results between 4 and 6S pedicle screw fixation for thoracolumbar fractures. METHODS: A systematic review and meta-analysis were performed. The databases PubMed, Embase and Google Scholar were searched until January 2020. Inclusion criteria were studies comparing 4S and 6S techniques in patients with thoracolumbar fractures. Non-comparative studies and studies without full text were excluded. Cochrane risk of bias was assessed, and the GRADE approach was used to present the quality of evidence. RESULTS: Twenty-seven studies, of which 21 randomized controlled trials, with a total of 1890 patients (940 with 4S and 950 with 6S) were included. Meta-analysis showed that the 6S technique resulted in significantly lower pain scores, better short-term and long-term Cobb angles, less loss of correction and less implant failures. However, longer operation time and more blood loss were seen with the 6S technique. Length of hospital stay, Oswestry Disability Index scores and infections did not differ significantly between the 6S and 4S techniques. Quality of the evidence according to GRADE was moderate to low. CONCLUSION: In the treatment of thoracolumbar fractures, adding intermediate screws at the fracture level (6S) results in less post-operative pain, better radiological outcomes and less implant failure at the cost of a longer operation time and higher blood loss.

The Predictive Value of the Load Sharing Classification Concerning Sagittal Collapse and Posterior Instrumentation Failure: A Systematic Literature Review.

STUDY DESIGN: Systematic review. OBJECTIVE: In 1994, the Load Sharing Classification (LSC) was introduced to aid the choice of surgical treatment of thoracolumbar spine fractures. Since that time this classification system has been commonly used in the field of spine surgery. However, current literature varies regarding its use and predictive value in relation to implant failure and sagittal collapse. The objective of this study is to assess the predictive value of the LSC concerning the need for anterior stabilization to prevent sagittal collapse and posterior instrumentation failure. METHODS: An electronic search of PubMed, Medline, Embase, and the Cochrane Library was performed. Inclusion criteria were (1) cohort or clinical trial (2) including patients with thoracolumbar burst fractures (3) whose severity of the fractured vertebrae was assessed by the LSC. RESULTS: Five thousand eighty-two articles have been identified, of which 21 articles were included for this review. Twelve studies reported no correlation between the LSC and sagittal collapse or instrumentation failure in patients treated with short-segment posterior instrumentation (SSPI). Seven articles found no significant relation; 5 articles found no instrumentation failure at all. The remaining 9 articles experienced failure in patients with a high LSC or recommended a different surgical technique. CONCLUSIONS: Although the LSC was originally developed to predict the need for anterior stabilization in addition to SSPI, many studies show that SSPI only can be sufficient in treating thoracolumbar fractures regardless of the LSC. The LSC might have lost its value in predicting sagittal collapse and posterior instrumentation failure.

The addition of an anti-rotation screw to the dynamic hip screw.

The aim of this study is to assess if there is a difference in outcomes between a dynamic hip screw with or without an anti-rotation screw in the treatment of hip fractures. All patients with an intracapsular hip fracture who underwent dynamic hip screw osteosynthesis between January 2010 and December 2013 in three Dutch hospitals were reviewed. Minimal follow-up was one year. The study included a total of 364 patients. 24 patients were lost to follow-up and excluded. 297 (87.4%) were in the dynamic hip screw group and 43 (12.6%) in the dynamic hip with anti-rotation screw group. Direct comparison of patient characteristics of the two groups showed significant differences in age, sex, Garden classification and Pauwels classification. Patients operated with a dynamic hip screw and anti-rotation screw are significantly younger and their fractures are significantly more dislocated and steeper. To draw conclusions about differences in outcome, a randomised clinical trial should be performed.

Thoracoscopic Correction of Post-traumatic Kyphosis with an Expandable Cage: Radiologic and Patient-Reported Outcomes.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To determine the long-term functional and radiological outcomes after thoracoscopic post-traumatic kyphosis (PTK) correction (PTKC). OVERVIEW OF LITERATURE: PTK after insufficient treatment of unstable fractures usually presents with pain and decreased back function. The results of PTKC using a minimally invasive thoracoscopic approach with an anterior titanium cage have not previously been reported. METHODS: Data in this study were collected from all patients who underwent thoracoscopic PTKC with an expandable cage between 2007 and 2017. Kyphosis and intervertebral body height were assessed on radiographic material. Quality of life (QOL) and functional outcome scores were determined by the Euroquol 5 dimensions (EQ5D) and the Oswestry Disability Index (ODI). Additionally, satisfaction and subjective symptom improvement were determined. RESULTS: Fourteen patients were treated for symptomatic PTK using a combined thoracoscopic anterior and posterior approach. Nine patients received initial conservative fracture treatment and five patients underwent initial posterior fracture fixation. All patients presented with pain and without neurologic injury. The mean time between injury and PTKC was 15.4 months. Cobb angle (CA) improved with 10.6° immediately after PTKC. During the first follow-up, 4.8° kyphosis correction was lost, but CAs remained stable at longer follow-up. Bony fusion was achieved in 92% of the patients after 16 months. The majority of patients reported an improvement of symptoms 85 months after surgery, satisfaction with and willingness to undergo the procedure again. The mean EQ5D index score was 0.71 and the mean ODI score was 22.3. CONCLUSIONS: The results of minimally invasive thoracoscopic PTKC using an expandable cage were satisfactory. The majority of the patients were satisfied after treatment and no neurological complications occurred. Functional and QOL scores were fairly good. Whereas some postoperative kyphosis correction was lost over time, bony fusion was achieved in the majority of the patients. The thoracoscopic approach minimizes surgical morbidity, does not lead to serious complications, and provides a good option for PTKC.

Epidemiology of Spinal Fractures in a Level One Trauma Center in the Netherlands: A 10 Years Review.

STUDY DESIGN: Retrospective epidemiological study. OBJECTIVE: To describe the epidemiology of spinal fractures over a 10 years period in a level one trauma center in the Netherlands. SUMMARY OF BACKGROUND DATA: Spinal fractures may have large socioeconomic consequences. The prevalence and outcomes likely change over the years owing to improved traffic safety, increasing population age and improved medical treatment. This is the first study to address the epidemiology of spinal fractures over a large period in the Netherlands. METHODS: All patients with a cervical, thoracic, or lumbar spine fracture admitted to a level one trauma center from 2007 to 2016 were prospective registered and retrospectively analyzed. In addition to patient, accident, and associated injury characteristics, radiological and surgery data were obtained from the hospital's Electronic Patient File system. RESULTS: Between 2007 and 2016, 1479 patients with a total of 3029 spinal fractures were admitted. Approximately 40.8% were female and 59.2% were male, with a mean age of 52.0 years; 4.9% of fractures occurred at a juvenile age (0-18 years) and 63.6% at the age of 19 to 64 years. Most fractures occurred in the thoracic spine, followed by the lumbar and cervical spine. The most common cause of injury was a fall from height, followed by traffic accidents. Spinal cord injury occurred in 8.5% and associated injuries were reported in 73% of the patients. Sixteen percent of the admitted patients were treated operatively. Over time, there was a larger increase in amount of spine fractures in elderly (≥ 65 years) compared with younger people. CONCLUSION: The total amount of spine fractures per year increased over time. In addition, there was a larger increase in amount of spine fractures in patients over 65 years of age compared with younger patients. Despite this increase, a considerable amount of spine fractures still occur in the age-group of 19 to 64 years. Most fractures were located in the thoracic spine. This study might stimulate development of policy on precautionary actions to prevent spine fractures. LEVEL OF EVIDENCE: 4.

Three-Dimensional Thoracoscopic Surgery for Spine Fractures: A Technical Report With First Results and Experiences.

STUDY DESIGN: Technical report. OBJECTIVES: Conventional 2-dimensional (2D) video-assisted thoracoscopy (VATS) is a technical procedure mainly performed by experienced surgeons. The technique may, however, come with difficulties in hand-eye coordination and estimation of depth. Three-dimensional thoracoscopy can help overcome these difficulties by providing a stereoscopic 3D view. The objective of this study is to report the first experience and results with 3D thoracoscopy for spine surgery in trauma patients. METHODS: The first 4 patients treated with anterior stabilization for traumatic spine fractures using 3D thoracoscopy in an academic hospital are described. Baseline characteristics, operative time, and blood loss were retrospectively collected. This data is compared with a cohort of patients treated in the same center with the conventional 2D technique. Additionally, the treating surgeons' and residents' experience with the technique is described. Surgical equipment consists of 3D compatible video monitors, a videoscope with 2 cameras, and special glasses to be worn by the personnel. RESULTS: Four patients were successfully treated using 3D thoracoscopy. Operative time was comparable to that of the conventional 2D technique and less blood loss occurred. No per- or postoperative complications or problems occurred. Per-operative views were of very high quality and provided improved depth perception. Surgeons and residents deemed the technique helpful, especially during technically demanding aspects of the procedure. CONCLUSIONS: While a shorter learning curve, decreased surgery time, and blood loss have to be proven in future prospective studies, the first experience with 3D-VATS for spine surgery is positive, and future use in minimally invasive spine surgery seems feasible.

Thoracoscopic anterior stabilization for thoracolumbar fractures in patients without spinal cord injury: quality of life and long-term results.

PURPOSE: To determine the health-related quality of life (QOL), safety and radiologic parameters after thoracoscopic treatment of traumatic thoracolumbar fractures using a distractible cage in patients without spinal cord injury (SCI). METHODS: Retrospective cohort study of patients treated between 2004 and 2012 in a university level-one trauma center. Patient and treatment characteristics were collected from the hospital information system. All available radiographic material was assessed for fracture characteristics and Cobb angle at consecutive times. Patients completed the SF-36 and EQ-5D QOL questionnaires at follow-up. RESULTS: 105 patients were treated with a distractible cage, which was performed thoracoscopically in 86 cases, including 16 patients with SCI. Of 70 eligible patients, 46 were available for follow-up and completed the questionnaires at median 49 months after surgery. QOL was lower on most domains compared to the general population. Compared to patients who underwent solely posterior fixation for less severe fractures, QOL did not differ significantly. The complication rate was low (10%) with one re-operation. Mean loss of correction was 6.8° and bony fusion on CT scan was present in 98% of patients. Maintenance of kyphosis correction was significantly better for two segments anterior fixation compared to one segment. CONCLUSIONS: Thoracoscopic anterior stabilization leads to a high percentage of bony fusion in highly unstable thoracic and thoracolumbar fractures with limited post-operative loss of correction and no hardware failure. QOL of these patients does not return to normal population values but is comparable to that of patients with less severe fractures treated with solely posterior instrumentation. These slides can be retrieved under Electronic Supplementary Material.

Systematic review and meta-analysis of tube thoracostomy following traumatic chest injury; suction versus water seal.

PURPOSE: Tube thoracostomy is frequently used in thoracic trauma patients. However, there is no consensus on whether low pressure suction or water seal is the optimal method of tube management. Against this background, we performed a systematic review of studies comparing suction and water seal management of chest tubes placed for traumatic chest injuries in adults. Evaluated outcomes are duration of chest tube treatment, length of stay in hospital, incidence of persistent air leak, clotted hemothorax, and the need for (re-)interventions. METHODS: A systematic literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was performed. Included studies were evaluated according to the Cochrane Collaboration's tool for assessing the risk of bias, and according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for assessing the quality of evidence. RESULTS: After assessment of 120 identified studies, three RCT's (randomized controlled trials) were included in this review and meta-analysis. A favorable effect of suction was found for duration of chest tube treatment [MD (mean difference) - 3.38 days, P = 0.005], length of stay in hospital (MD -3.90 days, P = 0.0003), and the incidence of persistent air leak [OR (odds ratio) 0.27, P = 0.001]. No significant difference was found for the incidence of clotted hemothorax and (re-)interventions. The quality of evidence according to GRADE was low, except for persistent air leak (moderate). CONCLUSIONS: Suction seems to have a positive effect on duration of chest tube treatment, length of stay in hospital and persistent air leakage in chest trauma. However, available data was limited and the quality of evidence was (very) low to moderate according to GRADE.

Is postoperative bracing after pedicle screw fixation of spine fractures necessary? Study protocol of the ORNOT study: a randomised controlled multicentre trial.

INTRODUCTION: The most common surgical treatment of traumatic spine fractures is through a posterior approach using pedicle screws and rods. Postoperative treatment protocols including the use of postoperative orthoses however differ between hospitals and surgeons. A three-point hyperextension orthosis is designed to support proper posture and unload the anterior column. Some motion remains when wearing an orthosis, and its main value in postoperative treatment is therefore believed to be pain relief and patient confidence. This could consequently shorten recovery time. On the other hand, an orthosis could also lead to muscle weakness and slow down recovery. Any orthosis-related complications might also be avoided. Additionally, recent studies on conservative fracture treatment show no difference in radiological outcomes with or without an orthosis. To date, no randomised studies have been performed on the use of postoperative orthoses. METHODS AND ANALYSIS: Patients undergoing posterior fixation with pedicle screws for a traumatic thoracolumbar fracture (T7-L4) will be included in this randomised controlled multicentre non-inferiority trial. Forty-six patients will be randomised 1:1 to one of the two parallel groups; one group will wear a postoperative orthosis for 6 weeks followed by 6 weeks of weaning and one group will not wear an orthosis. The primary outcome is pain at 6 weeks reported on the Numerical Rating Scale. Secondary outcomes consist of pain on other moments, analgesic use, complications and length of hospital stay, quality of life (EuroQuol 5 Dimensions), back pain-related function (Oswestry Disability Index) and radiological outcomes with a follow-up of 1 year. Orthosis compliance is monitored weekly in the orthosis group. ETHICS AND DISSEMINATION: The institutional review board (METc VUmc) approved this study on 11 October 2016 under case number 2016.389. After completion of the trial, the results will be offered to an international scientific journal for peer-reviewed publication. TRIAL REGISTRATION NUMBER: NCT03097081 and NTR6285; Pre-results.

Combined anteroposterior fixation using a titanium cage versus solely posterior fixation for traumatic thoracolumbar fractures: A systematic review and meta-analysis.

STUDY DESIGN: Systematic review with meta-analysis. OBJECTIVE: Additional anterior stabilization might prevent posterior implant failure, but over time, the disadvantageous of bone grafts have become evident. The objective of this systematic review was to compare risks and advantages of additional anterior stabilization with a titanium cage to solely posterior fixation for traumatic thoracolumbar fractures. METHODS: An electronic search was performed in the literature from 1980 to March 2016. Studies comparing only posterior with anteroposterior fixation by means of a titanium cage were included in this study. Data extraction and Cochrane risk of bias assessment were done by two independent authors. In addition, the PRISMA statement was followed, and the GRADE approach was used to present results. RESULTS: Of the 1584 studies, two randomized controlled trials (RCTs) and one retrospective cohort study were included in the meta-analysis. The RCTs reported evidence of high quality that anteroposterior stabilization maintained better kyphosis correction than posterior stabilization alone. However, these results were neutralized in the meta-analysis by the cohort study. Implant failure was reported by one study, in the posterior group. No differences in follow-up visual analog scale scores, neurologic improvement, and complications were found. Operation time, blood loss, and hospital stay all increased in the anteroposterior group. CONCLUSIONS: Patients with a highly comminuted or unstable fracture could benefit from combined anteroposterior stabilization with a titanium cage, for some evidence suggests this prevents loss of correction. However, large randomized studies still lack. There is a risk of cage subsidence, and increased perioperative risks have to be considered when choosing the optimal treatment.

[A homeless, uninsured illegal alien suffering from psychosis and multiple fractures: providing efficient care to such patients]. / Een dakloze, onverzekerde illegaal met multipele fracturen en een psychose: Hoe kun je zo'n patiënt doelmatige zorg verlenen?

We present the case of a 37-year-old psychotic, homeless man from Albania, who sustained multiple fractures after jumping from a third-floor window. The patient was uninsured and did not consent to transfer to a hospital in Albania because of paranoid delusions. Eventually he was hospitalised for nearly 30 weeks in hospital and a nursing home. Various factors of this complex case are considered, such as the co-morbidity of somatic and psychiatric symptoms, the absence of family support and the financial regulations that apply to uninsured patients. Doctors who are presented with similar complex cases are advised to organise frequent multidisciplinary evaluations with all health care workers involved. We encourage searching for creative interventions which serve both the best interests of the individual patient, and - where possible - also minimize the total cost of health care to society.

Thoracoabdominal computed tomography in trauma patients: a cost-consequences analysis.

BACKGROUND: CT is increasingly used during the initial evaluation of blunt trauma patients. In this era of increasing cost-awareness, the pros and cons of CT have to be assessed. OBJECTIVES: This study was performed to evaluate cost-consequences of different diagnostic algorithms that use thoracoabdominal CT in primary evaluation of adult patients with high-energy blunt trauma. MATERIALS AND METHODS: We compared three different algorithms in which CT was applied as an immediate diagnostic tool (rush CT), a diagnostic tool after limited conventional work-up (routine CT), and a selective tool (selective CT). Probabilities of detecting and missing clinically relevant injuries were retrospectively derived. We collected data on radiation exposure and performed a micro-cost analysis on a reference case-based approach. RESULTS: Both rush and routine CT detected all thoracoabdominal injuries in 99.1% of the patients during primary evaluation (n = 1040). Selective CT missed one or more diagnoses in 11% of the patients in which a change of treatment was necessary in 4.8%. Rush CT algorithm costed € 2676 (US$ 3660) per patient with a mean radiation dose of 26.40 mSv per patient. Routine CT costed € 2815 (US$ 3850) and resulted in the same radiation exposure. Selective CT resulted in less radiation dose (23.23 mSv) and costed € 2771 (US$ 3790). CONCLUSIONS: Rush CT seems to result in the least costs and is comparable in terms of radiation dose exposure and diagnostic certainty with routine CT after a limited conventional work-up. However, selective CT results in less radiation dose exposure but a slightly higher cost and less certainty.

Injuries Due to Wedging of Bicycle Wheels in On-road Tram Tracks.

BACKGROUND: In cities with trams as public transportation, tram tracks are often on public roads, creating a shared road situation with other road participants like cyclists. Beside the risk of direct collisions, this situation can also lead to bicycle wheels getting wedged in tram tracks, causing cyclists to fall. OBJECTIVES: The aim of this study was to gain more insight in the injury pattern of this trauma mechanism and to draw attention to the risks of the infrastructural situation with on-road tram tracks. PATIENTS AND METHODS: A one-year, prospective, observational cohort study was conducted. All patients admitted after presentation to the emergency department of a level 1 trauma center, who got injured because their bicycle wheels got wedged in tram tracks, were included. Data were collected on patient demographics, type of injury and treatment. RESULTS: Ten patients were included. Six were male. The mean age was 38 years. Six patients required surgery, mostly because of extremity injuries. Mean duration of admission was 4 days. Mean injury severity score was 13. One patient died as a result of the injuries sustained in the accident. CONCLUSIONS: Tram tracks on public roads are potentially dangerous and can lead to serious injuries and even mortality amongst cyclist. Operative intervention is frequently needed.

Case Report: Bilateral reexpansion pulmonary edema following treatment of a unilateral hemothorax.

Bilateral re-expansion pulmonary edema (RPE) is an extremely rare entity. We report the unique case of bilateral RPE following a traumatic, unilateral hemopneumothorax in a young healthy male. Bilateral RPE occurred only one hour after drainage of a unilateral hemopneumothorax. The patient was treated with diuretics and supplemental oxygen. Diagnosis was confirmed by excluding other causes, using laboratory findings, chest radiography, pulmonary and cardiac ultrasound and high resolution computed tomography. His recovery was uneventful. The pathophysiology of bilateral RPE is not well known. Treatment is mainly supportive and consists of diuretics, mechanical ventilation, inotropes and steroids. In case of a pulmonary deterioration after the drainage of a traumatic pneumothorax, bilateral RPE should be considered after exclusion of more common causes of dyspnea.

Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients.

BACKGROUND: Trauma is the fifth leading cause of death worldwide, and in people younger than 40 years of age, it is the leading cause of death. During the resuscitation of trauma patients at the emergency department, there are two different commonly used diagnostic strategies. Conventionally, there is the use of physical examination and conventional diagnostic imaging, potentially followed by selective use of computed tomography (CT). Alternatively, there is the use of physical examination and conventional diagnostics, followed by a routine (instead of selective) use of thoracoabdominal CT. It is currently unknown which of the two strategies is the better diagnostic strategy for patients with blunt high-energy trauma. OBJECTIVES: To assess the effects of routine thoracoabdominal CT compared with selective thoracoabdominal CT on mortality in blunt high-energy trauma patients. SEARCH METHODS: We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (Issue 4, 2013); MEDLINE (OvidSP), EMBASE (OvidSP) and CINAHL for all published randomised controlled trials (RCTs). We did not restrict the searches by language, date or publication status. We conducted the search on the 9 May 2013. SELECTION CRITERIA: We included RCTs of trauma resuscitation algorithms using routine thoracoabdominal CT versus algorithms using selective CT in this review. We included all blunt high-energy trauma patients (including blast or barotrauma). DATA COLLECTION AND ANALYSIS: Two authors independently evaluated the search results. MAIN RESULTS: The systematic search identified 481 references; after removal of duplicates, 396 remained. We found no RCTs comparing routine versus selective thoracoabdominal CT in blunt high-energy trauma patients. We excluded 381 studies based on the abstracts of the publications because of irrelevance to the review topic, and a further 15 studies after full-text evaluation. AUTHORS' CONCLUSIONS: We found no RCTs of routine versus selective thoracoabdominal CT in patients with blunt high-energy trauma. Based on the lack of evidence from RCTs, it is not possible to say which approach is better in reducing deaths.

An evidence based blunt trauma protocol.

OBJECTIVE: Currently CT is rapidly implemented in the evaluation of trauma patients. In anticipation of a large international multicentre trial, this study's aim was to evaluate the clinical feasibility of a new diagnostic protocol, used for the primary radiological evaluation in adult blunt high-energy trauma patients, especially for the use of CT. METHODS: An evidence-based flow chart was created with criteria based on trauma mechanism, physical examination and laboratory analyses to indicate appropriateness of conventional radiography (CR), sonography and CT of head, cervical spine and trunk. To evaluate this protocol, the authors prospectively included 81 consecutive patients. Collected data included protocol adherence and number and type of performed CR and CT scans. The authors also determined the time needed to perform radiological investigations, adverse events in the CT room and clinically relevant missed injuries after 1-month clinical follow-up. RESULTS: There was 99% adherence to the protocol concerning CT. Seventy-nine patients (98%) received one or more CT scans: 72 (89%) had thoracoabdominal, 78 (96%) cervical spine and 54 (67%) had cranial CT. In 30 patients, one or more CT scans of body regions could be omitted. In 38%, CR was wrongly omitted or performed incorrectly at a variance with the protocol. No major adverse events occurred in the CT room and no clinically relevant injuries were missed. CONCLUSIONS: The authors introduced a diagnostic protocol that seems feasible and safe for the evaluation of adult blunt high-energy trauma patients. Implementation of this protocol has the potential to reduce unnecessary radiological investigations, especially CT scans.

Effects on mortality, treatment, and time management as a result of routine use of total body computed tomography in blunt high-energy trauma patients.

BACKGROUND: Currently, total body computed tomography (TBCT) is rapidly implemented in the evaluation of trauma patients. With this review, we aim to evaluate the clinical implications-mortality, change in treatment, and time management-of the routine use of TBCT in adult blunt high-energy trauma patients compared with a conservative approach with the use of conventional radiography, ultrasound, and selective computed tomography. METHODS: A literature search for original studies on TBCT in blunt high-energy trauma patients was performed. Two independent observers included studies concerning mortality, change of treatment, and/or time management as outcome measures. For each article, relevant data were extracted and analyzed. In addition, the quality according to the Oxford levels of evidence was assessed. RESULTS: From 183 articles initially identified, the observers included nine original studies in consensus. One of three studies described a significant difference in mortality; four described a change of treatment in 2% to 27% of patients because of the use of TBCT. Five studies found a gain in time with the use of immediate routine TBCT. Eight studies scored a level of evidence of 2b and one of 3b. CONCLUSION: Current literature has predominantly suboptimal design to prove terminally that the routine use of TBCT results in improved survival of blunt high-energy trauma patients. TBCT can give a change of treatment and improves time intervals in the emergency department as compared with its selective use.

Incidental Findings on Routine Thoracoabdominal Computed Tomography in Blunt Trauma Patients.

BACKGROUND:: Thoracoabdominal MultiDetector-row Computed Tomography (MDCT) is frequently used as a diagnostic tool in trauma patients. One potential side-effect of performing MDCT is the detection of incidental findings and their subsequent consequences on medical treatment. The objective was to evaluate frequency and effects of incidental findings in trauma patients. METHODS:: The reports of 1,047 consecutive blunt trauma patients (mean age, 40 years) who underwent routine contrast-enhanced thoracoabdominal MDCT were evaluated. Incidental findings were categorized by a trauma radiologist into four hierarchic categories based on their clinical consequences. We recorded additional diagnostic workup and treatment performed in conjunction with these incidental findings. RESULTS:: Of the 1,047 patients, 372 (mean age, 56 years; 61% male) had one or more incidental findings on thoracoabdominal MDCT. Complementary investigation or therapy was performed in 72 of these 372 patients; 29 of these patients required additional invasive evaluation or treatment. Nineteen patients underwent surgery due to an incidental finding. Nine patients were diagnosed with a not previously identified malignancy. CONCLUSIONS:: Routine thoracoabdominal MDCT in the evaluation of trauma patients revealed a significant number of incidental findings. Based on radiologic findings it is possible to decide whether additional follow-up or treatment is necessary.