Improving the staging of neck injuries using a new index, the Neck Functional Holistic Analysis Score: Clustering approach to determine degrees of impairment.

BACKGROUND: Traumatic cervical spine injuries are amongst the traffic injuries that can cause most harm to a person. Classifying subtypes of clinical presentations has been a method used in other pathologies to diagnose more efficiently and to address the appropriate treatment and the prognosis. The management of patients suffering from cervical injuries could be improved by classifying the severity of the impairment. This will allow clinicians to propose better treatment modalities according to the severity of the injury. MATERIALS AND METHODS: The present study is a retrospective cohort study performed with the clinical data from 772 patients stored at Fisi-(ON) Health Group. All the patients treated for cervical spine injuries are evaluated using the EBI-5® system, which is based on inertial measurement unit (IMU) technology. The normalized range of motion of each patient was incorporated into a single index, the Neck Functional Holistic Analysis Score (NFHAS). RESULTS: Clustering analysis of the patients according to their NFHAS resulted in five groups. The Kruskal-Wallis H test showed that there were statistically relevant differences in the ROM values and NFHAS of the patients depending on the cluster they were assigned to: FE X2(4) = 551.59, p = 0.0005; LB ROM X2(4) = 484.58, p = 0.0005; RT ROM X2(4) = 557.14, p = 0.0005; NFHAS X2(4) = 737.41, p = 0.0005. Effect size with ηp2 for the comparison of groups were: FE = 0.76, LB = 0.68, RT = 0.76 and NFHAS = 0.96. CONCLUSION: The NFHAS is directly correlated to the available ROM of the patient. The NFHAS serves as a good tool for the classification of cervical injury patients. The degree of impairment shown by the cervical injury can now be staged correctly using this new classification.

Traumatic Neck and Skull Base Injuries.

Patients with blunt and penetrating traumatic injuries to the skull base and soft tissues of the neck present to the emergency department every day. Fortunately, truly life-threatening injuries to these regions are relatively uncommon. However, when encountered and not correctly diagnosed, these entities may result in severe morbidity or mortality. The radiologist plays a critical role recognizing these injuries, in which findings may often be subtle and the anatomy potentially challenging to identify. Multisection CT and CT angiography are commonly performed to assess these injuries in the emergency department. Vascular injury to the neck may result in dissection, occlusion, pseudoaneurysm formation, or frank extravasation resulting in stroke or death. Airway compromise may result from laryngotracheal injury. Injuries to the pharynx and esophagus may result in perforation. Injuries to the temporal bone may result in vascular injury to the internal carotid artery or facial nerve injury, which would require immediate surgery or intervention to prevent paralysis.©RSNA, 2019.

Surgical Practice in Traumatic Spinal Fracture Treatment with Regard to the Subaxial Cervical Injury Classification and Severity and the Thoracolumbar Injury Classification and Severity Systems: A Review of 58 Patients at the University of Wisconsin.

OBJECTIVES: Spine surgeons at a Level 1 Trauma Center have observed a high incidence of spine and spinal cord injuries owing to falls from tree stands. These injuries have been retrospectively reviewed in the context of the Thoracolumbar Injury Classification and Severity (TLICS) and the Subaxial Cervical Injury Classification and Severity (SLICS) classification systems to assess inter-user reliability and validity. We hypothesize that the inter-rater reliability will be similar between neuroradiology and neurosurgery raters and validity of the scoring system will be maintained at our institution. METHODS: The University of Wisconsin Hospital and Clinics' trauma database was reviewed for tree stand-related injuries from 1999 to 2013, with a focus on patients suffering from spine and spinal cord injuries. The TLICS and SLICS scores were then independently determined for these injuries by a neurosurgeon and a neuroradiologist. RESULTS: When cases were grouped by management recommendation (operative, equivocal, and nonoperative) reviewer agreement was 12/15 (80%) of SLICS and 38/52 (73%) of TLICS scores. Operative SLICS positive predictive value reached 100%, however, with a wide confidence interval. Conversely, the SLICS negative predictive value was poor at 54%-60%, with frequent operative treatment for patients assigned nonoperative scores. TLICS scores reached 77.8% and 93.3% positive predictive value per reviewer, whereas negative predictive values reached 93.9% and 89.2%, respectively. CONCLUSIONS: The TLICS and SLICS systems provide good-to-excellent inter-rater reliability. SLICS validity was poor, whereas TLICS was reasonable for nonoperative cases and moderate for operative cases. Systems such as the TLICS and the SLICS may be best applied in the educational setting to confirm the fracture morphology and presence or absence of ligamentous injury between surgeons and radiologists.

Post-intubation acute laryngeal injuries in infants and children: A new classification system.

OBJECTIVE: To compare the Classification of Acute Laryngeal Injuries (CALI) with other classifications to determine which of these offers the greatest sensitivity and specificity in predicting the development of subglottic stenosis. METHODS: All children intubated for the first time in the pediatric intensive care unit were included and subjected to flexible fiber-optic laryngoscopy (FFL) within 8 h of extubation. Their injuries were categorized using the CALI, as well as adapted classifications from Lindholm, Colice and Benjamin. The children were followed up to determine who developed subglottic stenosis. RESULTS: This study included 194 children, with a median age of 2.67 months. The sensitivity and specificity of the CALI were 90% and 73%, respectively. The CALI showed greater specificity than the adapted classifications from Colice and Benjamin (p < 0.001 for both), and greater sensitivity than the adapted classification from Lindholm (p < 0.001). CONCLUSIONS: Based on the CALI, 90% of children who developed subglottic stenosis had moderate to severe injuries on the initial FFL. The CALI includes all injury types described by Benjamin, as well as a proposed severity scale for these lesions, and was predictive of the development of chronic laryngeal injury.

A comparative agreement evaluation of two subaxial cervical spine injury classification systems: the AOSpine and the Allen and Ferguson schemes.

PURPOSE: We performed an agreement study using two subaxial cervical spine classification systems: the AOSpine and the Allen and Ferguson (A&F) classifications. We sought to determine which scheme allows better agreement by different evaluators and by the same evaluator on different occasions. METHODS: Complete imaging studies of 65 patients with subaxial cervical spine injuries were classified by six evaluators (three spine sub-specialists and three senior orthopaedic surgery residents) using the AOSpine subaxial cervical spine classification system and the A&F scheme. The cases were displayed in a random sequence after a 6-week interval for repeat evaluation. The Kappa coefficient (κ) was used to determine inter- and intra-observer agreement. RESULTS: Inter-observer: considering the main AO injury types, the agreement was substantial for the AOSpine classification [κ = 0.61 (0.57-0.64)]; using AO sub-types, the agreement was moderate [κ = 0.57 (0.54-0.60)]. For the A&F classification, the agreement [κ = 0.46 (0.42-0.49)] was significantly lower than using the AOSpine scheme. Intra-observer: the agreement was substantial considering injury types [κ = 0.68 (0.62-0.74)] and considering sub-types [κ = 0.62 (0.57-0.66)]. Using the A&F classification, the agreement was also substantial [κ = 0.66 (0.61-0.71)]. No significant differences were observed between spine surgeons and orthopaedic residents in the overall inter- and intra-observer agreement, or in the inter- and intra-observer agreement of specific type of injuries. CONCLUSION: The AOSpine classification (using the four main injury types or at the sub-types level) allows a significantly better agreement than the A&F classification. The A&F scheme does not allow reliable communication between medical professionals.

AOSpine subaxial cervical spine injury classification system.

PURPOSE: This project describes a morphology-based subaxial cervical spine traumatic injury classification system. Using the same approach as the thoracolumbar system, the goal was to develop a comprehensive yet simple classification system with high intra- and interobserver reliability to be used for clinical and research purposes. METHODS: A subaxial cervical spine injury classification system was developed using a consensus process among clinical experts. All investigators were required to successfully grade 10 cases to demonstrate comprehension of the system before grading 30 additional cases on two occasions, 1 month apart. Kappa coefficients (κ) were calculated for intraobserver and interobserver reliability. RESULTS: The classification system is based on three injury morphology types similar to the TL system: compression injuries (A), tension band injuries (B), and translational injuries (C), with additional descriptions for facet injuries, as well as patient-specific modifiers and neurologic status. Intraobserver and interobserver reliability was substantial for all injury subtypes (κ = 0.75 and 0.64, respectively). CONCLUSIONS: The AOSpine subaxial cervical spine injury classification system demonstrated substantial reliability in this initial assessment, and could be a valuable tool for communication, patient care and for research purposes.

Multidetector CT of blunt cervical spine trauma in adults.

A number of new developments in cervical spine imaging have transpired since the introduction of 64-section computed tomographic (CT) scanners in 2004. An increasing body of evidence favors the use of multidetector CT as a stand-alone screening test for excluding cervical injuries in polytrauma patients with obtundation. A new grading scale that is based on CT and magnetic resonance (MR) imaging findings, the cervical spine Subaxial Injury Classification and Scoring (SLIC) system, is gaining acceptance among spine surgeons. Radiographic measurements described for the evaluation of craniocervical distraction injuries are now being reevaluated with the use of multidetector CT. Although most patients with blunt trauma are now treated nonsurgically, evolution in the understanding of spinal stability, as well as the development of new surgical techniques and hardware, has driven management strategies that are increasingly favorable toward surgical intervention. It is therefore essential that radiologists recognize findings that distinguish injuries with ligamentous instability or a high likelihood of nonfusion that require surgical stabilization from those that are classically stable and can be treated with a collar or halo vest alone. The purpose of this article is to review the spectrum of cervical spine injuries, from the craniocervical junction through the subaxial spine, and present the most widely used grading systems for each injury type.

[Diagnosis and treatment of cervicothoracic injuries].

It analyzed the diagnosis and treatment results of 123 patients with cervicothoracic injuries for 21 years. The frequency of cervicothoracic injuries among all patients with cervical injuries was 5.7%. Preoperative and postoperative diagnosis included radial and endoscopic methods. The complications rate was 43.6%. The most severe complications were observed in patients with delayed diagnosis of trachea and esophagus injuries.

Developmental framework to validate future designs of ballistic neck protection.

The number of neck injuries has increased during the war in Afghanistan, and they have become an appreciable source of mortality and long-term morbidity for UK servicemen. A three-dimensional numerical model of the neck is necessary to allow simulation of penetrating injury from explosive fragments so that the design of body armour can be optimal, and a framework is required to validate and describe the individual components of this program. An interdisciplinary consensus group consisting of military maxillofacial surgeons, and biomedical, physical, and material scientists was convened to generate the components of the framework, and as a result it incorporates the following components: analysis of deaths and long-term morbidity, assessment of critical cervical structures for incorporation into the model, characterisation of explosive fragments, evaluation of the material of which the body armour is made, and mapping of the entry sites of fragments. The resulting numerical model will simulate the wound tract produced by fragments of differing masses and velocities, and illustrate the effects of temporary cavities on cervical neurovascular structures. Using this framework, a new shirt to be worn under body armour that incorporates ballistic cervical protection has been developed for use in Afghanistan. New designs of the collar validated by human factors and assessment of coverage are currently being incorporated into early versions of the numerical model. The aim of this paper is to describe this developmental framework and provide an update on the current progress of its individual components.

[The magnitude and the structure of ENT sanitary losses in modern local armed conflicts].

The objective of the present study was to estimate the magnitude and the structure of ENT losses in modern local armed conflicts. We have considered characteristics of battle injuries inflicted in modern wars based on the materials collected during the armed conflicts in the Caucasus during 1999-2002 and stored in the Military Medical Museum (MMM) of the Russian Defense Ministry. A total of 5608 case records of the surgical treatment of mechanical injuries were analysed including 4002 gunshot wounds and 1606 closed injuries (contusions). ENT and neck wounds were the main and concomitant injuries in 102 and 107 subjects respectively who accounted for 2.5% and 2.7% of all the wounded servicemen. Fifty five (3.93%) and 21 (1.3%) of the 1606 subjects had a closed ENT and neck wound as the leading and concomitant injury, respectively. According to the materials collected in MMM, ENT contusion was the main injury in 111 (25%) of the 410 servicemen who had received contused wounds in the armed conflict of 1999-2002.

Conservative management of laryngeal perforation in a rural setting: case report and review of the literature on penetrating neck injuries.

Penetrating neck injuries (PNIs) are infrequent but can result in significant morbidity and mortality. Although surgical management of unstable patients with penetrating neck trauma is the standard of care, management of stable patients remains controversial owing to the possibility of occult injuries. Recent studies suggest that physical examination and ancillary imaging may be sufficiently accurate to diagnose or rule out surgically significant injuries in PNI. We report a patient with a laryngeal perforation who was managed conservatively in a rural hospital without complications and review the literature pertinent to cases of this nature.

Thoracic and neck trauma. Part three.

Previous parts to this series on thoracic and neck trauma discussed the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 describes specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. This section, part 3 of 4, discusses other types of thoracic injuries and their management, such as trauma to the diaphragm and heart.

Life-threatening versus non-life-threatening manual strangulation: are there appropriate criteria for MR imaging of the neck?

The aim of the study was to determine objective radiological signs of danger to life in survivors of manual strangulation and to establish a radiological scoring system for the differentiation between life-threatening and non-life-threatening strangulation by dividing the cross section of the neck into three zones (superficial, middle and deep zone). Forensic pathologists classified 56 survivors of strangulation into life-threatening and non-life-threatening cases by history and clinical examination alone, and two blinded radiologists evaluated the MRIs of the neck. In 15 cases, strangulation was life-threatening (27%), compared with 41 cases in which strangulation was non-life-threatening (73%). The best radiological signs on MRI to differentiate between the two groups were intramuscular haemorrhage/oedema, swelling of platysma and intracutaneous bleeding (all p = 0.02) followed by subcutaneous bleeding (p = 0.034) and haemorrhagic lymph nodes (p = 0.04), all indicating life-threatening strangulation. The radiological scoring system showed a sensitivity and specificity of approximately 70% for life-threatening strangulation, when at least two neck zones were affected. MRI is not only helpful in assessing the severity of strangulation, but is also an excellent documentation tool that is even admissible in court.

Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control--Part 2: case studies.

Recent research highlights sensorimotor control disturbances in those with neck disorders. Assessment and management of the symptoms of dizziness, altered cervical proprioception, eye and head co-ordination and disturbances to postural stability in those with neck disorders are important and are presented in a companion article. In this paper, four case studies are presented to illustrate the formulation and use of a tailored program designed to retrain balance, cervical proprioception and eye and head movement control in those with neck disorders. This program should be used in conjunction with a multi-modal approach to the management of neck disorders. Such a combined approach should address causes of abnormal cervical afferent input as well as the important links between the cervical, vestibular and ocular systems and adaptive changes in the sensorimotor control system.

Emergency parotidectomy for penetrating zone III neck trauma.

Penetrating trauma to the face and upper zone III of the neck may present unique challenges when the parotid gland and associated neurovascular structures are involved. We report a case of massive hemorrhage from penetrating neck trauma that necessitated emergency parotidectomy for vascular exposure. Facial nerve repair was also necessary, underscoring the importance of this approach not only for successful vascular control but also for preservation of nearby vital structures. The management of penetrating trauma to the parotid region,and relevant anatomy, are discussed.

The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system.

STUDY DESIGN: Systematic review of literature and expert clinical opinions of the members of the Spine Trauma Study Group were combined to develop and refine this algorithm. OBJECTIVE: To develop an evidence-based algorithm for surgical approaches to manage subaxial cervical injuries using a systematic review of the literature, expert opinion, and anticipated patient preferences. SUMMARY OF BACKGROUND DATA: There is lack of consensus in the management of subaxial cervical spine trauma, in part, because of the lack of a clinically relevant system for classifying these injuries. The newly developed Subaxial Injury Classification scoring system categorizes injury morphology into 3 broad groups, includes an assessment of the integrity of the discoligamentous soft tissue structures and the patient's neurologic status, and thus guides surgical or nonsurgical treatment. The choice of a specific surgical technique and approach is currently not evidence based, and this gap in knowledge is one which the current article seeks to address. METHODS: A literature review followed by a consensus of experts approach was used to develop the algorithm and to ensure face and content validity. RESULTS: An algorithm is presented to guide the choice of surgical approach in cervical subaxial burst fractures, distraction injuries, and translation or rotation injuries. The burst or compression injuries and distraction injuries are more likely to be treated with a single anterior approach, whereas the more severe translation or rotation injuries may more commonly be approached posteriorly or with combined anterior and posterior surgery. CONCLUSION: This algorithm; derived from the Subaxial Injury Classification scoring system, will assist surgeons in answering the 2 most common questions they face when managing subaxial cervical spine trauma: "Should I operate?" and "Which surgical approach should I select?"

Acute injury patterns of intimate partner violence victims.

Although millions of women receive injuries from intimate partner violence (IPV) each year in the United States alone, there has been only limited research of acute injury patterns and the types, locations, and mechanisms of IPV injuries. The mechanism of being punched to the face with a fist resulting in blunt trauma-related injuries is most commonly reported. Strangulation, especially manual strangulation, is a frequently cited mechanism of injury; however, less is known about the types of injuries that result from strangulation. In general, clinicians should assess all patients who present for treatment of head, neck, and face injuries for IPV. There is little consistency between and much inaccuracy with medical terms used to describe types of injuries. To increase the accuracy and generalizability of findings from studies of acute IPV injuries, researchers need to use more standardized medical forensic terminology.