Independent predictors of survival after traumatic atlanto-occipital dissociation.

BACKGROUND: Atlanto-occipital dissociation (AOD) occurs when the skull base is forcibly separated from the vertebral column. Existing literature on AOD is sparse and risk factors for mortality are unknown. This study determined independent predictors of survival after AOD. METHODS: Patients who sustained AOD were identified from the National Trauma Data Bank (2007-2014). Those arriving without signs of life or with missing mortality data were excluded. Study groups were defined as patients who survived to hospital discharge versus patients who died in hospital. Demographics, injury data, interventions, and outcomes were compared between groups using univariate analysis. Multivariate logistic regression was used to determine independent predictors of survival. RESULTS: After applying exclusion criteria, 1,489 patients (<1% of National Trauma Data Bank) were identified. Median age was 37 years (interquartile range [IQR), 20-59 years], and 59% of patients were male. Atlanto-occipital dissociation occurred almost exclusively after blunt mechanisms (97%), most commonly motor vehicle collisions (66%). Median injury severity score (ISS) was 25 (IQR, 10-36), with 22% mortality. Median time to death was 1,358 minutes (IQR, 281-4,451 minutes), approximately 23 hours. Independent predictors of survival were higher Glasgow Coma Scale score on admission (p < 0.001), lower ISS (p = 0.011), lower Abbreviated Injury Scale score for the head (p = 0.001), and the lack of need for exploratory laparotomy (p < 0.001). Time to neurosurgical intervention of the spine was not predictive of survival (p > 0.05). Patients who survived had a median hospital length of stay of 5 days (IQR, 1-14 days) and intensive care unit length of stay of 1 day (IQR, 0-7 days). The most common discharge destination was home (n = 393 [34%]). CONCLUSIONS: Traumatic AOD is not uniformly fatal, with 78% of patients who arrive alive to hospital surviving to discharge. When death occurs, it is typically within the first 23 hours. Lower ISS and higher Glasgow Coma Scale score on admission independently predict survival, while time to neurosurgical intervention does not. Survivors have a short hospital stay and are commonly discharged home. This study suggests that AOD among patients who arrive alive to hospital may not be as devastating as previously considered. LEVEL OF EVIDENCE: Progonostic/Epidemiological, level III; Therapeutic, level IV.

Traumatic atlanto-occipital dissociation: No longer a death sentence.

BACKGROUND: Traumatic atlanto-occipital dissociation is considered highly unstable and was once believed to be uniformly fatal. With recent advances in prehospital care, coupled with early diagnosis and stabilization, these injuries are potentially survivable. The aim of this study was to identify potentially modifiable risk factors associated with improved outcomes after a traumatic atlanto-occipital dissociation. METHODS: Patients with traumatic atlanto-occipital dissociation over a 17-year period were identified and stratified by age, sex, injury severity, and severity of shock. Time to diagnosis, time to and method of stabilization, and mortality were compared. Multivariable logistic regression was performed to determine which factors were independent predictors of mortality. RESULTS: Fifty-two patients were identified with a mean age of 44, an admission Glasgow Coma Score of 8, and an Injury Severity Score of 34; of these 52 patients, 38 (73%) underwent stabilization. Overall mortality was 33%. Of the survivors, 34 patients (97%) were discharged neurologically intact. One patient was discharged with neurologic deficits. Multivariable logistic regression identified admission Glasgow Coma Score (odds ratio 0.7; 95% confidence interval 0.552-0.877) as the only independent predictor of death after traumatic atlanto-occipital dissociation. CONCLUSION: Traumatic atlanto-occipital dissociation remains a rare injury following blunt trauma. Clinical presentation is a predictor of mortality. Prompt diagnosis is crucial in promoting rapid stabilization and improving survivability. Survival to hospital discharge portends improved functional outcome.

Prognostic factors in traumatic atlanto-occipital dislocation.

Traumatic atlanto-occipital dislocation (AOD) is an ominous injury with high mortality and morbidity in trauma patients. Improved survival has been observed with advancements in pre-hospital and hospital care. Furthermore, high quality imaging studies are accessible at most trauma centers; these are crucial for prompt diagnosis of AOD. The objective of this study is to perform a comprehensive literature review of traumatic AOD, with specific emphasis on identifying prognostic factors for survival. A review of the literature was performed using the Medline database for all traumatic atlanto-occipital articles published between March 1959 and June 2015; 141 patients from 60 total studies met eligibility criteria for study inclusion. A binary logistic regression model was utilized to identify prognostic factors. The analysis assessed age, sex, spinal cord injury (SCI), traumatic brain injury (TBI), polytrauma injury (PI), and Traynelis AOD Classification. Only TBI was statistically significantly associated with death (OR 8.05 p<0.05); SCI did not reach statistical significance for predicting mortality in AOD patients (OR 1.25 p>0.05). Age, sex, PI, and Traynelis AOD Classification did not meet significance to predict mortality in AOD patients. We found that patients with TBI are eight times more likely to die than patients without TBI. A high degree of suspicion for AOD during pre-hospital care, as well as, prompt diagnosis and management in the trauma center play a key role in the treatment of this devastating injury. The relationship between survival and factors such as TBI and SCI should be further explored.

The Relationship of Obesity to Increasing Health-Care Burden in the Setting of Orthopaedic Polytrauma.

BACKGROUND: With the rise of obesity in the American population, there has been a proportionate increase of obesity in the trauma population. The purpose of this study was to use a computed tomography-based measurement of adiposity to determine if obesity is associated with an increased burden to the health-care system in patients with orthopaedic polytrauma. METHODS: A prospective comprehensive trauma database at a level-I trauma center was utilized to identify 301 patients with polytrauma who had orthopaedic injuries and intensive care unit admission from 2006 to 2011. Routine thoracoabdominal computed tomographic scans allowed for measurement of the truncal adiposity volume. The truncal three-dimensional reconstruction body mass index was calculated from the computed tomography-based volumes based on a previously validated algorithm. A truncal three-dimensional reconstruction body mass index of <30 kg/m(2) denoted non-obese patients and ≥ 30 kg/m(2) denoted obese patients. The need for orthopaedic surgical procedure, in-hospital mortality, length of stay, hospital charges, and discharge disposition were compared between the two groups. RESULTS: Of the 301 patients, 21.6% were classified as obese (truncal three-dimensional reconstruction body mass index of ≥ 30 kg/m(2)). Higher truncal three-dimensional reconstruction body mass index was associated with longer hospital length of stay (p = 0.02), more days spent in the intensive care unit (p = 0.03), more frequent discharge to a long-term care facility (p < 0.0002), higher rate of orthopaedic surgical intervention (p < 0.01), and increased total hospital charges (p < 0.001). CONCLUSIONS: Computed tomographic scans, routinely obtained at the time of admission, can be utilized to calculate truncal adiposity and to investigate the impact of obesity on patients with polytrauma. Obese patients were found to have higher total hospital charges, longer hospital stays, discharge to a continuing-care facility, and a higher rate of orthopaedic surgical intervention.

Historical implant or current best standard? Minimum five year follow-up outcomes of cemented Thompson hemiarthroplasties.

UK NICE guidelines recommend abandoning the Thompson hemiarthroplasty (TH) in favour of a 'proven prosthesis' such as the Exeter Trauma Stem. The aim of this study was to assess the hip fracture treatment with the TH. Between 2002 and 2006, 430 cemented THs were performed (minimum 5 year follow-up). Death rates at 1 year and 5 years were 26.6% and 67.4% with low complication (Dislocation 1.4%) and revision rate (1.2%). The TH remains a reliable and proven implant in appropriate patients (over the age of 80, with low activity levels, low ambulatory status and who maybe cognitively impaired), due to low complication and revision rates. Modern implants may provide better function or longevity, but there is little evidence to support abandoning the TH.

Head and neck injury patterns in fatal falls: epidemiologic and biomechanical considerations.

Fatal falls often involve a head impact, which are in turn associated with a fracture of the skull or cervical spine. Prior authors have noted that the degree of inversion of the victim at the time of impact is an important predictor of the distribution of skull fractures, with skull base fractures more common than skull vault fractures in falls with a high degree of inversion. The majority of fatal fall publications have focused on skull fractures, and no research has described the association between fall circumstances and the distribution of fractures in the skull and neck. In the present study, we accessed data regarding head and neck fractures resulting from fatal falls from a Swedish autopsy database for the years 1992-2010, for the purposes of examining the relationships between skull and cervical spine fracture distribution and the circumstances of the fatal fall. Out of 102,310 medico-legal autopsies performed there were 1008 cases of falls associated with skull or cervical spine fractures. The circumstances of the falls were grouped in 3 statistically homogenous categories; falls occurring at ground level, falls from a height of <3 m or down stairs, and falls from ≥3 m. Only head and neck injuries and fractures that were associated with the fatal CNS injuries were included for study, and categorized as skull vault and skull base fractures, upper cervical injuries (C0-C1 dislocation, C1 and C2 fractures), and lower cervical fractures. Logistic regression modeling revealed increased odds of skull base and lower cervical fracture in the middle and upper fall severity groups, relative to ground level falls (lower cervical <3 m falls, OR = 2.55 [1.32, 4.92]; lower cervical ≥3 m falls, OR = 2.23 [0.98, 5.08]; skull base <3 m falls, OR = 1.82 [1.32, 2.50]; skull base ≥3 m falls, OR = 2.30 [1.55, 3.40]). C0-C1 dislocations were strongly related to fall height, with an OR of 8.3 for ≥3 m falls versus ground level. The findings of increased odds of skull base and lower cervical spine fracture in falls from a height are consistent with prior observations that the risk of such injuries is related to the degree of victim inversion at impact. The finding that C0-C1 dislocations are most common in falls from more than 3 m is unique, an indication that the injuries likely result from high energy shear forces rather than pure tension, as previously thought.

Can CT angiography replace conventional bi-planar angiography in the management of severe scapulothoracic dissociation injuries?

Severe scapulothoracic dissociation (SSTD) (Type III or IV; Zelle classification) is often life-threatening and is commonly associated with other devastating injuries. Rapid evaluation, including of the vascular system, is critical to limit the time to definitive therapy. CT angiography (CTA) has evolved as a diagnostic tool, replacing angiography (angio) as it can simultaneously evaluate bony, soft tissue, and vascular injuries. We hypothesized that CTA would be useful in evaluating patients with SSTD. We retrospectively reviewed the trauma registry between June 2002 and June 2010 to identify patients over 18 years of age who sustained SSTD. Patients that were transferred or died before diagnostic imaging were excluded. Comparisons were made between the group that underwent angio before surgery compared with CTA with regards to outcome and length of hospital and intensive care unit stay. Fourteen patients were identified with Type III or IV SSTD over the study period. In the CTA group, mean Injury Severity Score was higher, but time to definitive operative intervention was significantly shorter. There was no difference in amputation rates or mortality. Replacing arteriography with CTA in the preoperative workup of patients with SSTD reduces time to surgery. Despite a greater injury severity in the group in which CTA was used as the primary imaging modality, length of stay, amputation rates, and mortality were no different. CTA can be safely used to evaluate patients with suspected SSTD.

Hemiarthroplasty of the hip with and without cement: a randomized clinical trial.

BACKGROUND: Controversy exists regarding the use of cement for hemiarthroplasty to treat a displaced subcapital femoral neck fracture in elderly patients. The primary hypothesis of this study was that use of cement would provide better visual analog pain scores following this procedure in an elderly patient population. METHODS: Elderly patients (at least seventy years of age) without severe cardiopulmonary compromise who presented to one institution with a displaced subcapital femoral neck fracture were offered inclusion in the study. One hundred and sixty patients (mean age, eighty-five years) with an acute displaced femoral neck fracture were randomly allocated to hemiarthroplasty with either a cemented Exeter or an uncemented Zweymüller Alloclassic component. Clinical and radiographic follow-up was performed for two years and the outcomes were recorded by a blinded assessor. The main clinical outcome measures were pain, mortality, mobility, complications, reoperations, and quality of life measured with use of validated instruments. RESULTS: The mean visual analog pain score at rest did not differ significantly between the groups. The total number of complications was greater in the uncemented group (sixty-three compared with twenty-eight in the cemented group). Subsidence was significantly more common in the uncemented group (eighteen compared with one in the cemented group). Intraoperative or postoperative fracture was also significantly more common in the uncemented group (eighteen compared with one in the cemented group). The mortality rate did not differ significantly between the groups at any time point (thirty-five deaths in the uncemented group compared with thirty-two in the cemented group at two years). The Oxford hip score was significantly poorer in the uncemented group at six weeks (38.8 compared with 35.7 in the cemented group), and it was also poorer or similar at later follow-up time points although the differences were not significant. There was also a trend toward poorer mobility and greater dependence on walking aids in the cemented group. The postoperative Short Musculoskeletal Function Assessment and Mini-Mental State Examination scores did not differ significantly between the groups. CONCLUSIONS: In elderly patients (seventy years or older) without severe cardiopulmonary compromise who were treated with hemiarthroplasty for a displaced femoral neck fracture, use of a cemented Exeter implant and use of an uncemented Alloclassic implant provided a comparable outcome with regard to pain. However, implant-related complication rates were significantly lower in the group treated with a cemented implant. Trends toward better function and better mobility in the cemented group were observed. These trends reached significance in particular functional scores at some postoperative time points. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic injuries associated with hip fractures in those aged over 60 years: a study of patterns of injury and outcomes for 1971 patients.

INTRODUCTION: There has been little research into the consequence of suffering a hip fracture and associated orthopaedic injures. The aim of this research paper is to describe the patient characteristics, patterns of injury and to define the effect on outcomes of orthopaedic injuries occurring simultaneously with hip fractures. PATIENTS AND METHODS: Hip fracture data was collected prospectively. Patients under 60 years of age were excluded from the study. Between 2004 and 2010 we treated 1971 consecutive patients aged 60 years or older with a hip fracture. RESULTS: 81 (4.1%) patients sustained a simultaneous fracture or dislocation. 90% (73/81) of these injuries were in the upper limb and 88% (71/81) were ipsilateral, with the wrist (34 cases) and the proximal humerus (21 cases) being the commonest site of injury. Median hospital stay was significantly longer for those with additional injures. Pubic rami fractures were not seen in association with a hip fracture. Those patients who sustained a concomitant wrist fracture tended to be slightly fitter than those without associated injuries whist those with an associated humeral fracture were slightly frailer. Mortality was increased for those with an associated proximal humeral fracture but was lower with an associated wrist fracture. DISCUSSION AND CONCLUSION: Simultaneous injuries occurring with hip fractures are mainly seen in the ipsilateral upper limb. They present a greater challenge to the multidisciplinary team than a solitary hip fracture, experiencing a longer hospital stay and inevitably a higher financial cost. Those patients with wrist fractures have the best prognosis in terms of mortality, whereas a proximal humerus fracture may indicate a higher risk of mortality.

Neurologic outcome of surgical and conservative treatment of rheumatoid cervical spine subluxation: a systematic review.

OBJECTIVE: Rheumatoid arthritis commonly involves the upper cervical spine and can cause significant neurologic morbidity and mortality. However, there is no consensus on the optimal timing for surgical intervention: whether surgery should be performed prophylactically or once neurologic deficits have become apparent. METHODS: A systematic review of the literature was performed to analyze neurologic outcome (Ranawat) and survival time (Kaplan-Meier) after surgical or conservative treatment using the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation system) criteria. RESULTS: Twenty-five observational studies were selected. No randomized controlled trials (RCTs) could be found. All of the studies had a high risk of bias. Twenty-three studies reported the neurologic outcome after surgery for 752 patients. Neurologic deterioration rarely occurred in Ranawat I and II patients. Ranawat III patients did not fully recover. The 10-year survival rates were 77%, 63%, 47%, and 30% for Ranawat I, II, IIIA, and IIIB, respectively. The Ranawat IIIB patients had a significantly worse outcome. Another 185 patients treated conservatively were described in 7 studies. Neurologic deterioration rarely occurred in Ranawat I patients, but was almost inevitable in Ranawat II, IIIA, and IIIB patients. The Kaplan-Meier analysis showed a 10-year overall survival rate of 40%. CONCLUSION: There are no RCTs that compared surgery with conservative treatment. In observational studies, surgical neurologic outcomes were better than conservative treatment in all patients with cervical spine involvement, and in asymptomatic patients with no neurologic impairment (Ranawat I) the outcomes were similar; however, the evidence is weak. Survival time of surgical and conservative treatment could not be compared.

[Vertebral fractures in patients with ankylosing spondylitis: a retrospective analysis of 66 patients]. / Wirbelfrakturen bei patienten mit spondylitis ankylosans: eine retrospektive analyse von 66 patienten.

PURPOSE: Retrospective analysis of vertebral fractures in patients with ankylosing spondylitis (AS) for the evaluation of associations with mortality, concurrent neurological deficits, and other complications. MATERIALS AND METHODS: Image analysis (conventional radiographs, CT, MRI) was applied to all patients with AS admitted between 1997 and 2007 due to vertebral fractures to determine fracture location and classification. Patient characteristics, trauma mechanism, neurological symptoms, and other complications were documented. RESULTS: 66 patients (54 male, age 64 +/- 11 years) were enrolled in the study. 74 % of patients suffered from minor trauma. 51 % and 56 % had cervicothoracic and thoracolumbar fractures, respectively, while 8 % had multi-level fractures. 63 % of patients suffered combined vertebrodiscal fractures. 70 % revealed neurological symptoms, significantly correlating with spinal stenosis (p = 0.024; Odds ratio 4.265) and hyperlordosis (p = 0.014; OR 4.806). 68 % developed complications with non-combined fractures (p = .042; OR 4.954) and paravertebral hematomas (p = .009; OR 16.969) representing independent risk factors. The female gender (p = 0.005; OR 15.617) and conservative therapy (p = 0.040; OR.094) exerted significant influence on the mortality rate. CONCLUSION: Vertebral fractures frequently occur in patients with AS after minor trauma and often lead to neurological symptoms, which in turn are associated with spinal stenosis and hyperlordosis. Paravertebral hematomas and non-combined fractures are accompanied by higher incidences of other complications. The female gender entails a higher mortality rate.

High mortality rate in rheumatoid arthritis with subluxation of the cervical spine: a cohort study of operated and nonoperated patients.

STUDY DESIGN: In a prospective cohort study 532 patients with rheumatoid arthritis (RA) and subluxations of the cervical spine were consecutively collected during 1974-1999. OBJECTIVE: The aims of the study were to assess important factors affecting the mortality rate and the timing of surgical intervention. SUMMARY OF BACKGROUND DATA: The average follow-up time from the first visit to death or to the end of the study was 8.5 (SD, 5.7) years. Of the 217 operated patients 144 (66%) died, and of the 315 nonoperated patients 137 (43%) died. METHODS: Patients were selected for operative intervention based on anterior, vertical and subaxial subluxations, pain, and/or cervical neurology. Survival analyses were used for comparisons between patients with RA and the normal population, and between the operated and those treated conservatively. RESULTS: The survival rate for all RA patients was significantly reduced when compared with average survival in Norway (P < 0.001). The operated group had a significantly lower survival rate than the nonoperated group. In patients with severe instability of the cervical spine, the defined selection criteria for surgical intervention were specific. By comparison of calculated propensity scores, the operated and nonoperated groups were too different to be directly comparable. After surgery only 11 patients (5%) experienced residual pain in the neck or neurologic symptoms. None of these patients were alive at the end of the study, signifying that residual pain or neurologic symptoms are poor prognostic signs (P = 0.015). In the operated group, anterior subluxation and vertical settling greater than the lower indication limits did not have a significant influence on the survival rate, but there was a reduced survival for patients with subaxial subluxations. A clear association was found between increased vertical settling and sudden death. CONCLUSION: RA with neck involvement is a progressive and serious condition with reduced lifetime expectancy. Hence, our interpretation is that operative intervention improves local symptoms and most likely changes the condition from worse to better by increasing lifetime expectancy in high risk patients. Since the per- and postoperative complications are few, a changed attitude toward more liberal indications for earlier surgery may reduce the symptoms and the mortality rate even more.

Acute outcomes of cervical spine injuries in the elderly: atlantaxial vs subaxial injuries.

BACKGROUND/OBJECTIVE: Recent studies have reported on the outcomes of spinal cord injuries in the elderly. Our aim was to identify acute survival differences between elderly patients with atlantoaxial injuries relative to subaxial injuries at our institution and to determine whether operative treatment is associated with improved survival rates in either population. STUDY DESIGN: Retrospective database review of all traumatic cervical spine injuries in patients at least 65 years of age at a single tertiary care center. METHODS: A total of 193 consecutive patients at least 65 years of age treated at a single tertiary care center over a 12-year period were identified. Initial hospitalization records were reviewed. Patients were divided by anatomic level of injury: atlantoaxial (C1 or C2) and subaxial (C3 or below). Demographics, mechanism, and mortality rates were compared. Each group was further divided by treatment (operative or nonoperative), and inpatient survival rates were compared. RESULTS: Statistically similar survival rates were observed among patients with atlantoaxial and subaxial injuries (P = 0.10). Patients with nonoperatively treated subaxial injuries died at significantly higher rates than did their operatively treated peers (P < 0.05). CONCLUSIONS: In this large comprehensive series of elderly patients with cervical spine injuries, survival rates were comparable regardless of anatomic level of injury. The operative treatment of subaxial injuries was associated with an improved acute survival rate vs nonoperative management. Further prospective study is needed to better assess this relationship.

Survivors of occipitoatlantal dislocation injuries: imaging and clinical correlates.

OBJECT: Although rare, traumatic occipitoatlantal dislocation (OAD) injuries are associated with a high mortality rate. The authors evaluated the imaging and clinical factors that determined treatment and were predictive of outcomes, respectively, in survivors of this injury. METHODS: The medical records and imaging studies obtained in 33 patients with OAD were reviewed retrospectively. Clinical factors that predicted outcomes, especially neurological injury at presentation and imaging findings, were evaluated. The most sensitive method for the diagnosis of OAD was the measurement of basion axial-basion dens interval on computed tomography (CT) scanning. Five patients with severe traumatic brain injuries (TBIs) were not treated and subsequently died. Of the 28 patients in whom treatment was performed, 23 underwent fusion and five were fitted with an external orthosis. Abnormal findings of the occipitoatlantal ligaments on magnetic resonance (MR) imaging, associated with no or questionable abnormalities on CT scanning, provided the rationale for nonoperative treatment. Of the 28 patients treated for their injuries, perioperative death occurred in five, three of whom had presented with severe neurological injuries. The mortality rate was highest in patients with a TBI at presentation. The mortality rate was lower in patients presenting with a spinal cord injury, but in this group there was a higher rate of persistent neurological deficits. CONCLUSIONS: The spines in patients with CT-documented OAD are most likely unstable and need surgical fixation. In patients for whom CT findings are normal and MR imaging findings suggest marginal abnormalities, nonoperative treatment should be considered. The best predictors of outcome were severe brain or upper cervical injuries at initial presentation.

Results after 24 years of prophylactic surgery for rheumatoid atlantoaxial subluxation.

We evaluated the use of surgical stabilisation for atlantoaxial subluxation after a follow-up of 24 years in 50 rheumatoid patients who had some degree of pain but no major neurological deficit. The mortality of patients treated by atlantoaxial fusion was significantly lower than for those who received conservative treatment. The deaths resulted from infection or comorbid conditions. The significantly high relative risks of mortality from conservative treatment compared with surgical treatment were mutilating disease and susceptible factors on both of the HLA-DRB1 alleles. Relief from pain and neurological and functional recovery were better, and the radiological degree of atlantoaxial translocation was less in those who were surgically treated compared with those who were not. Two patients had superficial local infections after surgery. We conclude that prophylactic atlantoaxial fusion is better than conservative treatment in these patients.

Venous thromboembolism prophylaxis after head and spinal trauma: intermittent pneumatic compression devices versus low molecular weight heparin.

Although there are alternative methods and drugs for preventing venous thromboembolism (VTE), it is not clear which modality is most suitable and efficacious for patients with severe (stable or unstable) head/spinal injures. The aim of this study was to compare intermittent pneumatic compression devices (IPC) with low-molecular-weight heparin (LMWH) for preventing VTE. We prospectively randomized 120 head/spinal traumatized patients for comparison of IPC with LMWH as a prophylaxis modality against VTE. Venous duplex color-flow Doppler sonography of the lower extremities was performed each week of hospitalization and 1 week after discharge. When there was a suspicion of pulmonary embolism (PE), patients were evaluated with spiral computed tomography. Patients were analyzed for demographic features, injury severity scores, associated injuries, type of head/spinal trauma, complications, transfusion, and incidence of deep venous thrombosis (DVT) and PE. Two patients (3.33%) from the IPC group and 4 patients (6.66%) from the LMWH group died, with their deaths due to PE. Nine other patients also succumbed, unrelated to PE. DVT developed in 4 patients (6.66%) in the IPC group and in 3 patients (5%) in the LMWH group. There was no statistically significant difference regarding a reduction in DVT, PE, or mortality between groups ( p = 0.04, p > 0.05, p > 0.05, respectively). IPC can be used safely for prophylaxis of VTE in head/spinal trauma patients.

High rates of neurological improvement following severe traumatic pediatric spinal cord injury.

STUDY DESIGN: Retrospective single-center study OBJECTIVES: To determine the long-term outcome of pediatric spinal cord injuries SUMMARY OF BACKGROUND DATA: Spinal cord injuries are uncommon events in the pediatric population. In the few large series reported in the literature, recovery of neurologic function was demonstrated after mild injuries but was rare after severe injuries. METHODS: A total of 4,876 cases of pediatric trauma treated at the Children's Hospital of Los Angeles over a 9-year period (1993-2001) were reviewed. During the study period, 91 cases of spinal cord or spinal column injury were identified, and 30 cases involving a spinal cord injury were identified. Cauda equina injuries were excluded. Seven craniocervical, 12 cervical, 5 thoracic, and 6 thoracolumbar cases were identified. There were 6 cases of spinal cord injury without radiographic abnormality. Eight of the 30 patients received methylprednisolone at the time of admission. Follow-up ranged from 2 to 54 (mean = 19) months. RESULTS: Twenty patients presented with complete injuries (ASIA grade A). Of these, 7 died, 7 had no neurologic recovery, and 6 experienced neurologic improvement. Five of these six eventually became ambulatory with functional gains occurring over a 4- to 50-week period. None of these 5 patients was found to have spinal cord injury without radiographic abnormality. Of the remaining 10 patients (grades B-D), 8 experienced improvements in neurologic function. Cervical dislocation injuries were associated with a low likelihood of neurologic improvement and atlanto-occipital injuries were associated with early death. CONCLUSIONS: Recovery of neurologic function following severe traumatic spinal cord injury occurs with a significantly greater incidence in children than adults, and these improvements can occur over a prolonged postinjury period.

Atlantooccipital dislocation in children: presentation, diagnosis, and management.

Atlantooccipital dislocation (AOD) injuries are highly unstable, and usually result in significant neurological injury and death. Recently the postinjury survival period has increased. In a review of the literature the authors found 41 cases in which survival was greater than 48 hours. This is likely due to improved on-scene resuscitation, spinal immobilization, transportation, new diagnostic techniques, and a higher index of suspicion. Diagnosis is usually made with plain cervical radiographs, but there are shortcomings associated with this modality in the pediatric population. Diagnosis is aided by high-resolution computerized tomography and magnetic resonance imaging. Infants and toddlers may undergo orthotic immobilization alone, whereas older children usually undergo early occipital cervical fusion. Those with incomplete AOD may be managed successfully with orthotic immobilization.

High mortality in patients with rheumatoid arthritis and atlantoaxial subluxation.

OBJECTIVE: To study relationships between atlantoaxial subluxation (AAS) and total mortality in patients with rheumatoid arthritis (RA). METHODS: Radiological reports and clinical files of patients with RA were reviewed for the presence of cervical spine involvement verified by cervical radiographs. RESULTS: Among 241 patients with cervical radiographs, anterior AAS > or = 4 mm was found in 5% [95% confidence interval (CI) 2-8] of patients. Vertical and posterior subluxations were found in 1.4 and 0.5%, respectively. The mean observation time from RA diagnosis to AAS was 3.9 years. Patients with AAS had 8 times higher mortality than patients without AAS (95% CI 3-25). According to the death certificate, the patients died from cancer, stroke, and myocardial infarction. Cervical spine disorder was not mentioned on the death certificate. However, an autopsy was not performed. CONCLUSION: We found high mortality in RA patients with AAS. AAS in the cervical spine developed relatively early in the course of the disease. Analyses adjusted for seropositivity, erosiveness, and glucocorticosteroids did not reduce the mortality rate ratio. Our results underline the need for careful evaluation of patients with RA with respect to development of AAS.

Traumatic occipitoatlantal dislocation.

BACKGROUND: Traumatic occipitoatlantal dislocation (OAD) is a severe ligamentous injury resulting in instantaneous death or severe neurological deficit. However, survivors of OAD, both short and long term, have been increasingly reported; this may be because of improved prehospital care, more rapid transportation, a high index of suspicion, and new radiological techniques. METHODS: The medical records and film of three patients who had traumatic OAD were retrospectively reviewed. Diagnosis was made by lateral cervical spine radiography, computed tomography (CT), or magnetic resonance imaging (MRI). Treatment consisted of early respiratory support and subsequent posterior surgical fusion. RESULTS: The three survivors of traumatic OAD represent 3.1% of all cervical spine injuries in our service. Two were children and the other was a 64-year-old man, all of whom suffered from severe neurological deficits. Lateral cervical spine radiographs led to the diagnosis of OAD. Two were longitudinal, and one was anterior. Two patients died within 2 weeks after injury. The remaining patient, who had anterior OAD, survived longer, which allowed posterior fusion with a U-shape Steinman pin and wiring to be performed. However, she died 5 months after injury because of septicemia. CONCLUSION: Early recognition and treatment may improve the outcome of this injury. Treatment consists of early respiratory support and subsequent surgical fusion.