Diagnostic accuracy of an artificial intelligence algorithm versus radiologists for fracture detection on cervical spine CT.

OBJECTIVES: To compare diagnostic accuracy of a deep learning artificial intelligence (AI) for cervical spine (C-spine) fracture detection on CT to attending radiologists and assess which undetected fractures were injuries in need of stabilising therapy (IST). METHODS: This single-centre, retrospective diagnostic accuracy study included consecutive patients (age ≥18 years; 2007-2014) screened for C-spine fractures with CT. To validate ground truth, one radiologist and three neurosurgeons independently examined scans positive for fracture. Negative scans were followed up until 2022 through patient files and two radiologists reviewed negative scans that were flagged positive by AI. The neurosurgeons determined which fractures were ISTs. Diagnostic accuracy of AI and attending radiologists (index tests) were compared using McNemar. RESULTS: Of the 2368 scans (median age, 48, interquartile range 30-65; 1441 men) analysed, 221 (9.3%) scans contained C-spine fractures with 133 IST. AI detected 158/221 scans with fractures (sensitivity 71.5%, 95% CI 65.5-77.4%) and 2118/2147 scans without fractures (specificity 98.6%, 95% CI 98.2-99.1). In comparison, attending radiologists detected 195/221 scans with fractures (sensitivity 88.2%, 95% CI 84.0-92.5%, p < 0.001) and 2130/2147 scans without fracture (specificity 99.2%, 95% CI 98.8-99.6, p = 0.07). Of the fractures undetected by AI 30/63 were ISTs versus 4/26 for radiologists. AI detected 22/26 fractures undetected by the radiologists, including 3/4 undetected ISTs. CONCLUSION: Compared to attending radiologists, the artificial intelligence has a lower sensitivity and a higher miss rate of fractures in need of stabilising therapy; however, it detected most fractures undetected by the radiologists, including fractures in need of stabilising therapy. Clinical relevance statement The artificial intelligence algorithm missed more cervical spine fractures on CT than attending radiologists, but detected 84.6% of fractures undetected by radiologists, including fractures in need of stabilising therapy. KEY POINTS: The impact of artificial intelligence for cervical spine fracture detection on CT on fracture management is unknown. The algorithm detected less fractures than attending radiologists, but detected most fractures undetected by the radiologists including almost all in need of stabilising therapy. The artificial intelligence algorithm shows potential as a concurrent reader.

Shifting Perspectives: Equal Blunt Cerebrovascular Risk in Low-Versus High-Energy Cervical Fracture.

INTRODUCTION: Clinical implications of screening for blunt cerebrovascular injury (BCVI) after low-energy mechanisms of injury (LEMI) remain unclear. We assessed BCVI incidence and outcomes in LEMI versus high-energy mechanisms of injury (HEMI) patients. METHODS: In this retrospective cohort study, blunt trauma adults admitted between July 2015 and June 2021 with cervical spine fractures, excluding single spinous process, osteophyte, and chronic fractures were included. Demographics, comorbidities, injuries, screening and treatment data, iatrogenic complications, and mortality were collected. Our primary end point was to compare BCVI rates between LEMI and HEMI patients. RESULTS: Eight hundred sixty patients (78%) were screened for BCVI; 120 were positive for BCVI. LEMI and HEMI groups presented similar BCVI rates (12.6% versus 14.4%; P = 0.640). Compared to HEMI patients (n = 95), LEMI patients (n = 25) were significantly older (79 ± 14.9 versus 54.3 ± 17.4, P < 0.001), more likely to be on anticoagulants before admission (64% versus 23.2%, P < 0.001), and less severely injured (LEMI injury severity score 10.9 ± 6.6 versus HEMI injury severity score 18.7 ± 11.4, P = 0.001). All but one LEMI and 90.5% of the HEMI patients had vertebral artery injuries with no significant difference in BCVI grades. One HEMI patient developed acute kidney injury because of BCVI screening. Eleven HEMI patients developed BCVI-related stroke with two related mortalities. One LEMI patient died of a BCVI-related stroke. CONCLUSIONS: BCVI rates were similar between HEMI and LEMI groups when screening based on cervical spine fractures. The LEMI group exhibited no screening or treatment complications, suggesting that benefits may outweigh the risks of screening and potential bleeding complications from treatment.

Triage tools for detecting cervical spine injury in paediatric trauma patients.

BACKGROUND: Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES: To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS: For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA: We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

The Effect of Concomitant Spinal Cord Injury on Postoperative Health-related Quality of Life After Traumatic Subaxial Cervical Spine Injuries: A Nationwide Registry Study.

OBJECTIVE: To evaluate the effect of spinal cord injury (SCI) on the health-related quality of life (HRQoL) in patients surgically treated for traumatic subaxial cervical spine injuries and investigate the agreement between objective neurologic outcomes and patient reported outcome measures (PROMs) in that context. STUDY DESIGN: Observational study on prospectively collected multi-institutional registry data. SETTING: Sweden. PARTICIPANTS: Patients with traumatic subaxial spine injuries identified in the Swedish Spine Registry (Swespine) between 2006 and 2016. INTERVENTIONS: Anterior, posterior, or anteroposterior cervical fixation surgery. MAIN OUTCOMES: Patient-reported outcome measures (PROMs) consisting of EQ-5D-3Lindex and Neck Disability Index (NDI). RESULTS: Among the 418 identified patients, 93 (22%) had a concomitant SCI. In this group, 30 (32%) had a complete SCI (Frankel A), and the remainder had incomplete SCIs (17%) Frankel B; 25 (27%) Frankel C; 22 (24%) Frankel D. PROMs significantly correlated with the Frankel grade (P<.001). However, post hoc analysis revealed that the differences between adjacent Frankel grades failed to reach both statistical and clinical significance. On univariable linear regression, the Frankel grade was a significant predictor of a specific index derived from the EQ-5D-3L questionnaire (EQ-5D-3Lindex) at 1, 2, and 5 years postoperatively as well as the NDI at 1 and 2 years postoperatively (P<.001). Changes of PROMs over time from 1, to 2, and 5 years postoperatively did not reach statistical significance, regardless of the presence and degree of SCI (P>.05). CONCLUSION: Overall, the Frankel grade significantly correlated with the EQ-5D-3Lindex and NDI and was a significant predictor of PROMs at 1, 2, and 5 years. PROMs were stable beyond 1 year postoperatively regardless of the severity of the SCI.

Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM).

BACKGROUND: There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence-based guidelines for practicing clinicians to support safe and effective airway management in this setting. METHODS: An expert multidisciplinary, multi-society working party conducted a systematic review of contemporary literature (January 2012-June 2022), followed by a three-round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury. RESULTS: We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre-oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front-of-neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre-hospital care, military settings and principles in human factors. CONCLUSIONS: It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.

Pediatric trauma population spine immobilization during resuscitation: A call for improved guidelines.

INTRODUCTION: This review aims to evaluate current practices regarding spine immobilization in pediatric trauma patients to evaluate their efficacy, reliability, and impact on clinical outcomes to guide future research and improved evidence-based practice guidelines. METHODS: PubMed, ProQuest, Embase, Google Scholar, and Cochrane were queried for studies pertaining to spinal immobilization practices in pediatric trauma patients. Articles were separated into studies that explored both the efficacy and clinical outcomes of spine immobilization. Outcomes evaluated included frequency of spinal imaging, self-reported pain level, emergency department length of stay (ED-LOS), and ED disposition. RESULTS: Six articles were included, with two studies examining clinical outcomes and 4 studies evaluating the efficacy and reliability of immobilization techniques. Immobilized children were significantly more likely to undergo cervical spine imaging (OR 8.2, p < 0.001), be admitted to the floor (OR 4.0, p < 0.001), be taken to the ICU or OR (OR 5.3, p < 0.05) and reported a higher median pain score. Older children were significantly more likely to be immobilized. No immobilization techniques consistently achieved neutral positioning, and patients most often presented in a flexed position. Lapses in immobilization occurred in 71.4% of patients. CONCLUSION: Immobilized pediatric patients underwent more cervical radiographs, and had higher hospital and ICU admission rates, and higher mean pain scores than those without immobilization. Immobilization was inconsistent across age groups and often resulted in lapses and improper alignment. Further research is needed to identify the most appropriate immobilization techniques for pediatric patients and when to use them.

The prevalence of complicated cervical injuries in near-hanging patients without abnormal levels of consciousness or neck signs.

BACKGROUND: Cervical injuries are important complications of near-hanging, which is defined as self-injury by hanging if the patient survives at admission. Previous studies have reported that complicated cervical injuries due to near-hanging are uncommon. The primary aim of this study was to evaluate whether cervical imaging can be safely omitted for near-hanging patients who are alert and have no abnormal neck symptoms or signs. METHODS: This was a retrospective observational study to investigate the prevalence of cervical injuries among hospitalized near-hanging patients between April 2014 and June 2023. The primary outcome was the prevalence of any complicated cervical injuries, which included laryngeal fractures, laryngeal deviations, spinal cord injuries, cervical spine fractures, and blunt cerebrovascular injuries. The primary aim of this study was to determine the primary outcome among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. RESULTS: During the study period, a total of 63 near-hanging patients were hospitalized. Of these, 11 patients (18%) with normal levels of consciousness and no neck symptoms or signs at admission were included. The median age of the patients was 37 years (IQR 27 to 53); 5 (45%) were women, and none had cardiac arrest at the scene. For the primary outcome, no complicated cervical injuries (0%; 95% CI, 0% to 27%) occurred among the small number of near-hanging patients who had normal levels of consciousness and no abnormal neck symptoms or signs at admission. CONCLUSIONS: There were no cases of complicated cervical injuries among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. Further prospective multicenter studies are warranted to investigate whether cervical imaging can be safely omitted in assessments of these patients.

Channelled versus nonchannelled Macintosh videolaryngoscope blades in patients with a cervical collar: a randomized controlled noninferiority trial.

PURPOSE: Channelled blades have the advantage of avoiding stylet use and potential airway injury during videolaryngoscopic intubation. Nevertheless, the effectiveness of channelled Macintosh-type blades has not yet been fully established. We sought to assess the utility of channelled Macintosh-type blades for videolaryngoscopic intubation under cervical spine immobilization. METHODS: We conducted a randomized controlled noninferiority trial in neurosurgical patients with a difficult airway simulated by a cervical collar. Videolaryngoscopic intubation with a reinforced tracheal tube was performed using a channelled Macintosh-type blade without a stylet (channelled group, n = 130) or a nonchannelled Macintosh-type blade with a stylet (nonchannelled group, n = 131). The primary outcome was intubation success rate. Secondary outcomes included time to intubation and incidence or severity of intubation-related complications (subglottic, lingual, and dental injuries; bleeding; sore throat; and hoarseness). RESULTS: The initial intubation success rate was 98% and 99% in the channelled and nonchannelled groups, respectively, showing the noninferiority of the channelled group (difference in proportions -0.8%; 95% confidence interval [CI], -4.8% to 2.9%; predefined noninferiority margin, -5%; P = 0.62). Fewer participants in the channelled group had subglottic injuries than in the nonchannelled group (32% [32/100] vs 57% [54/95]; difference in proportions, -25%; 95% CI, -39% to -11%; P < 0.001). There were no significant differences between the two groups in the overall intubation success rate, time to intubation, and incidence or severity of other intubation-related complications. CONCLUSIONS: For videolaryngoscopic intubation in patients with a cervical collar, channelled Macintosh-type blades are an alternative to nonchannelled Macintosh-type blades, with a noninferior initial intubation success rate and a lower incidence of subglottic injury. STUDY REGISTRATION: CRIS.nih.go.kr ( KCT0005186 ); first submitted 29 June 2020.

RéSUMé: OBJECTIF: Les lames avec canal ont l'avantage de ne pas nécessiter l'utilisation d'un stylet et d'ainsi éviter les lésions potentielles des voies aériennes lors de l'intubation vidéolaryngoscopique. Néanmoins, l'efficacité des lames avec canal de type Macintosh n'a pas encore été pleinement établie. Nous avons cherché à évaluer l'utilité des lames avec canal de type Macintosh pour l'intubation vidéolaryngoscopique lorsque le rachis cervical était immobilisé. MéTHODE: Nous avons mené une étude randomisée contrôlée de non-infériorité chez des patient·es de neurochirurgie présentant des voies aériennes difficiles simulées par le port d'un collier cervical. L'intubation vidéolaryngoscopique avec une sonde trachéale renforcée a été réalisée à l'aide d'une lame Macintosh avec canal sans stylet (groupe avec canal, n = 130) ou d'une lame Macintosh sans canal avec stylet (groupe sans canal, n = 131). Le critère d'évaluation principal était le taux de réussite de l'intubation. Les critères d'évaluation secondaires comprenaient le temps d'intubation et l'incidence ou la gravité des complications liées à l'intubation (lésions sous-glottiques, linguales et dentaires, saignements, maux de gorge et enrouement). RéSULTATS: Le taux de réussite initial de l'intubation était de 98 % et 99 % dans les groupes avec et sans canal, respectivement, montrant la non-infériorité du groupe lame avec canal (différence de proportions −0,8 %; intervalle de confiance [IC] à 95 %, −4,8 % à 2,9 %; marge de non-infériorité prédéfinie, −5 %; P = 0,62). Les lésions sous-glottiques ont été moins nombreuses dans le groupe avec canal que dans le groupe sans canal (32 % [32/100] vs 57 % [54/95]; différence de proportions, −25 %; IC 95 %, −39 % à −11 %; P < 0,001). Il n'y avait pas de différences significatives entre les deux groupes en matière de taux global de réussite de l'intubation, de temps d'intubation et d'incidence ou de gravité des autres complications liées à l'intubation. CONCLUSION: Pour l'intubation vidéolaryngoscopique des patient·es portant un collier cervical, les lames avec canal de type Macintosh constituent une alternative aux lames sans canal de type Macintosh, avec un taux de réussite d'intubation initial non inférieur et une incidence plus faible de lésions sous-glottiques. ENREGISTREMENT DE L'éTUDE: CRIS.nih.go.kr ( KCT0005186 ); première soumission le 29 juin 2020.

Utility of brain imaging in pediatric patients with a suspected accidental spinal injury but no brain injury-related symptoms.

PURPOSE: Imaging is the gold standard in diagnosing traumatic brain injury, but unnecessary scans should be avoided, especially in children and adolescents. Clinical decision-making rules often help to distinguish the patients who need imaging, but if spinal trauma is suspected, concomitant brain imaging is often conducted. Whether the co-occurrence of brain and spine injuries is high enough to justify head imaging in patients without symptoms suggesting brain injury is unknown. OBJECTIVE: This study aims to assess the diagnostic yield of brain MRI in pediatric patients with suspected or confirmed accidental spinal trauma but no potential brain injury symptoms. METHODS: We retrospectively reviewed the medical and imaging data of pediatric patients (under 18 years old) who have undergone concomitant MRI of the brain and spine because of acute spinal trauma in our emergency radiology department over a period of 8 years. We compared the brain MRI findings in patients with and without symptoms suggesting brain injury and contrasted spine and brain MRI findings. RESULTS: Of 179 patients (mean age 11.7 years, range 0-17), 137 had symptoms or clinical findings suggesting brain injury, and 42 did not. None of the patients without potential brain injury symptoms had traumatic findings in brain MRI. This finding also applied to patients with high-energy trauma (n = 47) and was unrelated to spinal MRI findings. CONCLUSION: Pediatric accidental trauma patients with suspected or confirmed spine trauma but no symptoms or clinical findings suggesting brain injury seem not to benefit from brain imaging.

Open reduction and C1C3 posterior Harms-Goel fixation for unstable Hangman's fracture: technical note.

Hangman's fracture occurs in the elderly following low kinetic energy fall from their height, or in the young during traffic accident. Classically described as bipedicular C2 fracture, Hangman's fracture results from oblique hyperextension-flexion vector forces which can lead to anterior dislocation of C1C2 complex over C3 vertebral body in case of associated damage to C2C3 disc and ligaments. Even though most cases of Hangman's fracture are not displaced (grade 1) and can be managed with orthopaedic treatment using cervical brace, highly displaced cases of Hangman's fractures (some grade 2, all grade 3) require surgical stabilization. Given the limited capabilities of reduction and the odds for mechanical failure of anterior C2C3 discectomy and fusion, we provide a reproducible method using a specific rod persuader on C1 screws aiming to realign and stabilize displaced cases of Hangman fracture using the C1C3 "Harms-Goel" procedure.

Long-term outcomes after surgery for subaxial cervical spine injuries in octogenarians, a matched population-based cohort study.

PURPOSE: We aimed to investigate surgical outcomes in octogenarians with subaxial cervical spine injuries and determine the predictors of complications and mortality. METHODS: Eligible for inclusion were all patients surgically treated between 2006 and 2018, with either anterior or posterior fixation for subaxial spine injuries. A cohort of octogenarians was identified and matched 1:1 to a corresponding cohort of younger adults. Primary outcomes were perioperative complications and mortality. RESULTS: Fifty-four patients were included in each of the octogenarian and younger groups (median age: 84.0 vs. 38.5). While the risks for surgical complications, including dural tears and wound infections, were similar between groups, the risks of postoperative medical complications, including respiratory or urinary tract infections, were significantly higher among the elderly (p < 0.05). Additionally, there were no differences in operative time (p = 0.625) or estimated blood loss (p = 0.403) between groups. The 30 and 90-day mortality rates were significantly higher among the elderly (p = 0.004 and p < 0.001). These differences were due to comorbidities in the octogenarian cohort as they were revoked when propensity score matching was performed to account for the differences in American Society of Anesthesiology (ASA) grade. Multivariable logistic regression revealed age and ASA score to be independent predictors of complications and the 90-day mortality, respectively. CONCLUSIONS: Octogenarians with comorbidities were more susceptible to postoperative complications, explaining the increased short-term mortality in this group. However, octogenarians without comorbidities had similar outcomes compared to the younger patients, indicating that overall health, including comorbidities, rather than chronological age should be considered in surgical decision-making.

Predictors of failure after primary anterior cervical discectomy and fusion for subaxial traumatic spine injuries.

INTRODUCTION: Traumatic subaxial fractures account for more than half of all cervical spine injuries. The optimal surgical approach is a matter of debate and may include anterior, posterior or a combined anteroposterior (360º) approach. Analyzing a cohort of patients initially treated with anterior cervical discectomy and fusion (ACDF) for traumatic subaxial injuries, the study aimed to identify predictors for treatment failure and the subsequent need for supplementary posterior fusion (PF). METHODS: A retrospective, single center, consecutive cohort study of all adult patients undergoing primary ACDF for traumatic subaxial cervical spine fractures between 2006 and 2018 was undertaken and 341 patients were included. Baseline clinical and radiological data for all included patients were analyzed and 11 cases of supplementary posterior fixation were identified. RESULTS: Patients were operated at a median of 2.0 days from the trauma, undergoing 1-level (78%), 2-levels (16%) and ≥ 3-levels (6.2%) ACDF. A delayed supplementary PF was performed in 11 cases, due to ACDF failure. On univariable regression analysis, older age (p = 0.017), shorter stature (p = 0.031), posterior longitudinal ligament (PLL) injury (p = 0.004), injury to ligamentum flavum (p = 0.005), bilateral facet joint dislocation (p < 0.001) and traumatic cervical spondylolisthesis (p = 0.003) predicted ACDF failure. On the multivariable regression model, older age (p = 0.015), PLL injury (p = 0.048), and bilateral facet joint dislocation (p = 0.010) remained as independent predictors of ACDF failure. CONCLUSIONS: ACDF is safe and effective for the treatment of subaxial cervical spine fractures. High age, bilateral facet joint dislocation and traumatic PLL disruption are independent predictors of failure. We suggest increased vigilance regarding these cases.

A system of predictive scores to evaluate the risk of multilevel noncontiguous spinal fractures in patients with traumatic cervical spine injury.

PURPOSE: To develop a predictive scoring system to identify traumatic cervical spine injury patients at a high risk of having multilevel noncontiguous spinal fractures. METHODS: This 12-year retrospective observational cohort study included 588 traumatic cervical spine-injured patients. Patients were categorized into two groups: patients with multilevel noncontiguous spinal fractures and patients without this remote injury. Potential risk factors were examined using multivariable analysis to derive a predictive risk score from independent predictors. Results are presented as odds ratio with a 95% confidence interval (95% CI). The accuracy of the calculated predicted score was demonstrated by the area under the receiver operating characteristic curve (AuROC). RESULTS: The incidence of noncontiguous fracture among the patients was 17% (100 of 588). The independent risk factors associated with multilevel noncontiguous spinal fractures were motor weakness, intracranial injury, intrathoracic injury, and intraabdominal injury. The AuROC of the prediction score was 0.74 (95% CI 0.69, 0.80). The patients were classified into three groups, low-risk group (score< 1), moderate-risk group (score 1-2.5), and high-risk group (score≥ 3), based on the predicted risk of multilevel noncontiguous spinal fractures. CONCLUSIONS: This tool can potentially help preventing the missed diagnosis of cervical spine injuries with multilevel noncontiguous spinal fractures. CT scans or MRI of the entire spine to investigate remote multilevel noncontiguous spinal fractures may have a role in cervical spine-injured patients who have at least one of the independent risk factors and are strongly suggested for patients with scores in the high-risk group.

Are severity and location of facial trauma risk factors for cervical spine injuries? 10-year analysis based on the use of the AO spine injury classification and the comprehensive facial injury (CFI) score.

PURPOSE: This study aims to demonstrate a correlation between cervical spine injury and location and severity of facial trauma. METHODS: We did a 10-year retrospective analysis of prospectively collected patients with at least one facial and/or cervical spine injury. We classified facial injuries using the Comprehensive Facial Injury (CFI) score, and stratified patients into mild (CFI < 4), moderate (4 ≤ CFI < 10) and severe facial trauma (CFI ≥ 10). The primary outcome was to recognize the severity and topography of the facial trauma which predict the probability of associated cervical spine injuries. RESULTS: We included 1197 patients: 78% with facial injuries, 16% with spine injuries and 6% with both. According to the CFI score, 48% of patients sustained a mild facial trauma, 35% a moderate one and 17% a severe one. The midface was involved in 45% of cases, then the upper facial third (13%) and the lower one (10%). The multivariate analysis showed multiple independent risk factors for associated facial and cervical spine injuries, among them an injury of the middle facial third (OR 1.11 p 0.004) and the facial trauma severity, having every increasing point of CFI score a 6% increasing risk (OR 1.06 p 0.004). CONCLUSIONS: Facial trauma is a risk factor for a concomitant cervical spine injury. Among multiple risk factors, severe midfacial trauma is an important red flag. The stratification of facial injuries based on the CFI score through CT-scan images could be a turning point in the management of patients at risk for cervical spine injuries before imaging is available.

Comparison of iCT-based navigation and fluoroscopic-guidance for atlantoaxial screw placement in 78 patients with traumatic cervical spine injuries.

BACKGROUND CONTEXT: Studies have shown biomechanical superiority of cervical pedicle screw placement over other techniques. However, accurate placement is challenging due to the inherent risk of neurovascular complications. Navigation technology based on intraoperative 3D imaging allows highly accurate screw placement, yet studies specifically investigating screw placement in patients with traumatic atlantoaxial injuries are scarce. The aim of this study was to compare atlantoaxial screw placement as treatment of traumatic instabilities using iCT-based navigation or fluoroscopic-guidance with intraoperative 3D control scans. METHODS: This was a retrospective review of patients with traumatic atlantoaxial injuries treated operatively with dorsal stabilization of C1 and C2. Patients were either assigned to the intraoperative navigation or fluoroscopic-guidance group. Screw accuracy, procedure time, and revisions were compared. RESULTS: Seventy-eight patients were included in this study with 51 patients in the navigation group and 27 patients in the fluoroscopic-guidance group. In total, 312 screws were placed in C1 and C2. Screw accuracy was high in both groups; however, pedicle perforations > 1 mm occurred significantly more often in the fluoroscopic-guidance group (P = 0.02). Procedure time was on average 23 min shorter in the navigation group (P = 0.02). CONCLUSIONS: This study contributes to the available data showing that navigated atlantoaxial screw placement proves to be feasible as well as highly accurate compared to the fluoroscopic-guidance technique without prolonging the time needed for surgery. When comparing these data with other studies, the application of different classification systems for assessment of screw accuracy should be considered.

Long-term trends and risk factors of tracheostomy and decannulation in patients with cervical spinal cord Injury.

STUDY DESIGN: Retrospective study. OBJECTIVES: To investigate the risk factors of tracheostomy and decannulation after cervical spinal cord injury (CSCI) and their epidemiological changes over the past 8 years in Beijing Bo'ai Hospital, China Rehabilitation Research Center (CRRC), China. SETTING: Beijing Bo'ai Hospital, CRRC. METHODS: We reviewed 8 years of patient data (2013.1.1 to 2020.12.31) at CRRC, focusing on those hospitalized and diagnosed with CSCI. We analyzed changes in demographic and clinical data's trends. Logistic regression analysis was used to determine factors impacting tracheostomy and decannulation. RESULTS: Finally, 1641 CSCI patients met the inclusion criteria. Over the past 8 years, the proportion of tracheostomized patients with CSCI was 16.3%, and the proportion of successfully decannulated of tracheostomized patients with TCSCI was 77.9%. We found that Traumatic (OR = 1.8, 95% CI = 1.06, 3.22; p = 0.046), Motor level of injury (C5-C8) (OR = 0.32, 95% CI = -1.91,-0.34; p = 0.005), AIS = A/B/C (OR = 22.7/11.1/4.2, 95% CI = 12.16,42.26/5.74,21.56/2.23,7.89; p < 0.001/p < 0.001/p < 0.001), age > 56 (OR = 1.6, 95% CI = 1.04, 2.32; p = 0.031) were the risk factors for tracheostomy. By analyzing the risk factors of decannulation failure in tracheostomized patients with TCSCI through multivariable logistic regression, statistically significant differences were found in age > 45 (OR = 4.1, 95% CI = 1.44, 11.81; p = 0.008), complete injury (OR = 2.7, 95% CI = 1.26, 5.95; p = 0.011), facet dislocation (OR = 2.8, 95% CI = 1.13,7.07; p = 0.027). CONCLUSIONS: Recent years have witnessed shifts in the epidemiological characteristics of CSCI. Identifying the factors influencing tracheostomy and decannulation in CSCI can aid in improving patient prognosis.

Temporal dynamics of gait function in acute cervical spinal cord injury.

BACKGROUND: Following spinal cord injury (SCI), gait function reaches a post-recovery plateau that depends on the paralysis severity. However, the plateau dynamics during the recovery period are not known. This study aimed to examine the gait function temporal dynamics after traumatic cervical SCI (CSCI) based on paralysis severity. METHODS: This retrospective cohort study included 122 patients with traumatic CSCI admitted to a single specialized facility within 2 weeks after injury. The Walking Index for Spinal Cord Injury II (WISCI II) was estimated at 2 weeks and 2, 4, 6, and 8 months postinjury for each American Spinal Injury Association Impairment Scale (AIS) grade, as determined 2 weeks postinjury. Statistical analysis was performed at 2 weeks to 2 months, 2-4 months, 4-6 months, and 6-8 months, and the time at which no significant difference was observed was considered the time at which the gait function reached a plateau. RESULTS: In the AIS grade A and B groups, no significant differences were observed at any time point, while in the AIS grade C group, the mean WISCI II values continued to significantly increase up to 6 months. In the AIS grade D group, the improvement in gait function was significant during the entire observation period. CONCLUSIONS: The plateau in gait function recovery was reached at 2 weeks postinjury in the AIS grade A and B groups and at 6 months in the AIS grade C group.

Risk factors affecting cervical spondylotic myelopathy complicated with traumatic central cord syndrome and the efficacy of different treatment options.

OBJECTIVE: To analyze the influencing factors and treatment options of cervical spondylotic myelopathy (CSM) complicated with traumatic central cord syndrome (TCCS). METHODS: A total of 243 patients with CSM admitted to our hospital from January 2021 to September 2022 were retrospectively analyzed, and then divided into the control group (n = 152) and the observation group (n = 91) according to the presence or absence of concurrent TCCS. The clinical data and imaging data of the two groups were compared, and multivariate logistic regression was used to analyze the influencing factors of CSM complicated with TCCS. Patients in the observation group were further divided into the zero notch anterior cervical interbody fusion device (Zero-P) group (n = 45) and the cervical spine locking plate (CSLP) group (n = 46) according to the treatment mode, and the perioperative indexes of the two groups were compared. The treatment effects were evaluated by the American Spinal Injury Association (ASIA) and the Japanese Orthopedic Association (JOA) before surgery, 1 week after surgery and 6 months after surgery. The height of intervertebral space and the cervical lordosis angle were measured. RESULTS: Multivariate logistic regression analysis showed that the injury mechanism (hyperextension injury), hand muscle weakness, cervical instability, age, degree of cervical spinal stenosis, degree of cervical spinal cord compression, and changes in intramedullary high signal were the risk factors, while the type of compression (soft), ASIA score and JOA score were the protective factor for CSM complicated with TCCS (P < 0.05). Patients in Zero-P group had much shorter operation time and hospitalization time than these in CSLP group (P < 0.05). The cervical lordosis angle and intervertebral space height at 1 week and 6 months after operation in the two groups were both largely higher than these before operation, and the cervical lordosis angle and intervertebral space height in the Zero-P group were significantly higher than these in the CSLP group one week after surgery (P < 0.05). The ASIA score and JOA score were obviously increased in the two groups 1 week and 6 months after surgery, and the ASIA score and JOA score in the Zero-P group were significantly higher than these in the CSLP group at 1 week after surgery (P < 0.05). CONCLUSION: The mechanism of TCCS in CSM is still controversial, which it is generally believed to be caused by cervical hyperextension injury. The clinical symptoms are diverse, and the treatment methods are also different. This study shows that the mechanism of injury, type of compression, hand muscle weakness, cervical instability, age, cervical stenosis compression, and intramedullary high signal changes are all risk factors for CSM complicated with TCCS. Early identification of risk factors and targeted interventions can effectively reduce the complicated rate of TCCS. Zero-P and CSLP surgical fixation have good efficacy in the treatment of TCCS, and there is little difference in efficacy between the two. However, Zero-P fixation surgery has the advantages of short operation time and fast postoperative recovery.

Case report: A complete lower cervical fracture dislocation without permanent neurological impairment.

BACKGROUND: Complete fractures and dislocations of the lower cervical spine are usually associated with severe spinal cord injury. However, a very small number of patients do not have severe spinal cord injury symptoms, patients with normal muscle strength or only partial nerve root symptoms, known as "lucky fracture dislocation". The diagnosis and treatment of such patients is very difficult. Recently, we successfully treated one such patient. CASE PRESENTATION: A 73-year-old male patient had multiple neck and body aches after trauma, but there was sensory movement in his limbs. However, preoperative cervical radiographs showed no significant abnormalities, and computed tomography (CT) and magnetic resonance imaging (MRI) confirmed complete fracture and dislocation of C7. Before operation, the halo frame was fixed traction, but the reduction was not successful. Finally, the fracture reduction and internal fixation were successfully performed by surgery. The postoperative pain of the patient was significantly relieved, and the sensory movement of the limbs was the same as before. Two years after surgery, the patient's left little finger and ulnar forearm shallow sensation recovered, and the right flexion muscle strength basically returned to normal. CONCLUSION: This case suggests that when patients with trauma are encountered in the clinic, they should be carefully examined, and the presence of cervical fracture and dislocation should not be ignored because of the absence of neurological symptoms or mild symptoms. In addition, positioning during handling and surgery should be particularly avoided to increase the risk of paralysis.

Safety of anterior cervical corpectomy and fusion (ACCF) for the treatment of subaxial cervical spine injuries, a single center comparative matched analysis.

INTRODUCTION: Anterior Cervical Discectomy and Fusion (ACDF) and Anterior Cervical Corpectomy and Fusion (ACCF) are both common surgical procedures in the management of pathologies of the subaxial cervical spine. While recent reviews have demonstrated ACCF to provide better decompression results compared to ACDF, the procedure has been associated with increased surgical risks. Nonetheless, the use of ACCF in a traumatic context has been poorly described. The aim of this study was to assess the safety of ACCF as compared to the more commonly performed ACDF. METHODS: All patients undergoing ACCF or ACDF for subaxial cervical spine injuries spanning over 2 disc-spaces and 3 vertebral-levels, between 2006 and 2018, at the study center, were eligible for inclusion. Patients were matched based on age and preoperative ASIA score. RESULTS: After matching, 60 patients were included in the matched analysis, where 30 underwent ACDF and ACCF, respectively. Vertebral body injury was significantly more common in the ACCF group (p = 0.002), while traumatic disc rupture was more frequent in the ACDF group (p = 0.032). There were no statistically significant differences in the rates of surgical complications, including implant failure, wound infection, dysphagia, CSF leakage between the groups (p ≥ 0.05). The rates of revision surgeries (p > 0.999), mortality (p = 0.222), and long-term ASIA scores (p = 0.081) were also similar. CONCLUSION: Results of both unmatched and matched analyses indicate that ACCF has comparable outcomes and no additional risks compared to ACDF. It is thus a safe approach and should be considered for patients with extensive anterior column injury.