Antibiotic Prophylaxis and Spinal Infection After Gunshot Wounds to the Spine: A Retrospective Study.

INTRODUCTION: Spinal and paraspinal infections (SPIs) are a potential complication following traumatic spinal column injury, and we sought to determine the association of antibiotic prophylaxis on SPI development following a spinal gunshot wound (GSW). METHODS: A single-center retrospective cohort study was performed on adults who sustained a GSW to the spinal column over 11 y. Patients were excluded if they died within 24 h or had a mechanism other than GSW. Antibiotic use and injury patterns were analyzed. RESULTS: A total of 330 patients were included in analysis. Most were male (88%), Black (79%), and averaged 27 y old. Mortality was 4%. Prophylactic antibiotics were administered in 65%; and median duration was 5 d. Nine patients (2.7%) developed SPI. Hollow viscus injury (HVIs) (66.7% versus 23.1%, P < 0.001), primarily colon injuries (55.6% versus 12.5%, P < 0.001), were independently associated with SPI. Antibiotic use was not associated with a decrease in SPI (3% versus 2%; P = 0.41). Of the patients who developed SPI, seven received 3 d of antibiotics or less, and this was not statistically significant (P = 0.49). CONCLUSIONS: Patients with HVIs have a higher incidence of SPI, following spinal GSW. Although antibiotic use and duration did not have a statistically significant association with SPI, no patient, even with HVIs, who received 4 or more days of antibiotics developed an infection. Due to the low incidence of SPI, a multicenter trial may help determine the optimal duration of prophylactic antibiotics. However, we recommend a maximum of 4 d of antibiotics for SPI prophylaxis following GSW.

The evidence against somatotopic organization of function in the primate corticospinal tract.

We review the spatial organization of corticospinal outputs from different cortical areas and how this reflects the varied functions mediated by the corticospinal tract. A long-standing question is whether the primate corticospinal tract shows somatotopical organization. Although this has been clearly demonstrated for corticofugal outputs passing through the internal capsule and cerebral peduncle, there is accumulating evidence against somatotopy in the pyramidal tract in the lower brainstem and in the spinal course of the corticospinal tract. Answering the question on somatotopy has important consequences for understanding the effects of incomplete spinal cord injury. Our recent study in the macaque monkey, using high-resolution dextran tracers, demonstrated a great deal of intermingling of fibres originating from primary motor cortex arm/hand, shoulder and leg areas. We quantified the distribution of fibres belonging to these different projections and found no significant difference in their distribution across different subsectors of the pyramidal tract or lateral corticospinal tract, arguing against somatotopy. We further demonstrated intermingling with corticospinal outputs derived from premotor and supplementary motor arm areas. We present new evidence against somatotopy for corticospinal projections from rostral and caudal cingulate motor areas and from somatosensory areas of the parietal cortex. In the pyramidal tract and lateral corticospinal tract, fibres from the cingulate motor areas overlap with each other. Fibres from the primary somatosensory cortex arm area completely overlap those from the leg area. There is also substantial overlap of both these outputs with those from posterior parietal sensorimotor areas. We argue that the extensive intermingling of corticospinal outputs from so many different cortical regions must represent an organizational principle, closely related to its mediation of many different functions and its large range of fibre diameters. The motor sequelae of incomplete spinal injury, such as central cord syndrome and 'cruciate paralysis', include much greater deficits in upper than in lower limb movement. Current teaching and text book explanations of these symptoms are still based on a supposed corticospinal somatotopy or 'lamination', with greater vulnerability of arm and hand versus leg fibres. We suggest that such explanations should now be finally abandoned. Instead, the clinical and neurobiological implications of the complex organization of the corticospinal tract need now to be taken into consideration. This leads us to consider the evidence for a greater relative influence of the corticospinal tract on upper versus lower limb movements, the former best characterized by skilled hand and digit movements.

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.

Unusual spinal injury in a child caused by a wooden foreign body.

Traumatic penetrating spinal injuries with wooden objects are rare. A 6-year-old boy presented with history of fall from tree 1 month back. It resulted in a penetrating injury at the lumbosacral area, followed by a discharging sinus without any neurological deficit. Radiological imaging showed a foreign body at the spinous process level traversing L4-5 and is lodged in L3-4 intervertebral body causing listhesis of L3 over L4. The wooden stick was retrieved with a meticulous surgical procedure. Proper imaging and early surgery are necessary to prevent any complications and early recovery.

Pediatric case of a penetrating lumbar spinal injury.

PURPOSE: Penetrating spinal injuries are generally extremely rare and are seldom encountered in pediatric patients. The non-compliance of pediatric patients with physical examination can sometimes delay diagnosis and treatment. Here, we present a case of a child who had a fall and suffered penetrating spinal trauma due to a small glass fragment. CASE REPORT: A penetrating foreign body was detected in the lumbar spinal region of a 2-year-old patient with complaints of increased restlessness on physical activity followed by difficulty in walking. The patient was operated on and followed up without any complications in the perioperative and late postoperative periods. CONCLUSION: A detailed physical examination is necessitated in the pediatric age group because of insufficient anamnesis. The high number of patients per physician, especially in societies having a low socioeconomic standard, prevents detailed examinations, and unnecessary examinations may cause delays in diagnosis. However, one must note that the skin findings of pediatric patients can be very helpful, especially in pediatric neurosurgery, and examination should not be neglected.

Abusive spinal injury: imaging and updates.

Child physical abuse has significant morbidity and mortality in the pediatric population. There is growing evidence that abusive spinal injury has been under-recognized, changing historical perceptions that these injuries are relatively uncommon. Increased utilization of MRI has been pivotal in recognizing that most abusive spinal injuries involve the soft tissues and ligaments or manifest as intrathecal blood products, which are often undetectable by radiography or CT. Detecting spinal injury in the work-up of non-accidental trauma improves management for abused children and their siblings (defined as siblings or other household members). This review highlights key points in the imaging literature of abusive spinal injury, describes typical patterns of injury, and addresses appropriate imaging practice for work-up.

Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update.

The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.

Effects of minimally invasive surgery combined with specialized pain management nursing care on postoperativepain improvement and life quality after spinal injury.

Objective: To determine the impacts to research the impacts of pain's Specialized Pain Management Nursing Care in the perioperative period on pain symptoms and life quality of patients experiencing minimally invasive surgery for spinal injury. Method: Eighty patients with a spinal injury who underwent minimally invasive surgery in the Department of Orthopedics of Baoding No.1 Hospital from January 2018 to December 2021 were retrospectively analyzed. They were split into two groups following different nursing methods (n=40 each group). Specialized Pain Management Nursing Care were given to patients in the observation group. Those in the control group were given treated with routine care. Their pain score and nursing effect were compared, after which their quality of life, daily living ability and complication rate compared and analyzed. Results: The pain degree in the control group was considerably more than that in the observation group in the 1st postoperative period. The pain degree, which decreased in both groups, slumped more significantly in the observation group on the 2nd and 3rd postoperative days. The postoperative hospital stays and pain duration in the observation group were shorter than those in the control group (P<0.05), and the nursing effect was significantly better than that in the control group (P<0.05). After postoperative nursing intervention. Conclusion: Minimally invasive surgery integrated with the Specialized Pain Management Nursing Care can remarkably ameliorate pain after spinal injury surgery, reducing complications' incidence, and improving the life quality for patients.

[Scoring system for unstable spinal gunshot wounds: the study protocol]. / Ball'naya takticheskaya klassifikatsiya nestabil'nykh ognestrel'nykh ranenii pozvonochnika: protokol issledovaniya.

Morphology of injuries following gunshot wounds requires specific treatment approaches. Currently, there are no similar classifications for assessing fracture stability with subsequent tactical recommendations. Taking into account diagnostic limitations (contraindications for MRI due to implantable metal fragments, limitations of functional radiography of the spine in seriously injured patients), we make decisions considering CT data. In this study, we will determine severity of vertebral damage and effect of these damages on mechanical stability of spinal motion segments. In the future, CT-based assessment of inter-expert agreement will be performed. Finally, we will propose the scoring system for classification of spinal gunshot wounds. OBJECTIVE: To present a research protocol for development of new scoring system for unstable spinal gunshot wounds based on inter-expert agreement assessment. MATERIAL AND METHODS: To create a new tactical classification, we will distinguish and analyze clinical and CT data of patients with thoracolumbar spinal gunshot wounds. The Delphi method will be used to collaborate between several surgeons. A three-stage study will result a questionnaire (for 30 clinical cases). We will develop tactical scoring system and analyze statistical data (kappa). DISCUSSION: Various classifications have been developed for closed spinal injuries. These systems describe the nature of injury and allow one to develop tactical decisions for further actions. Another mechanism of injuries following gunshot wounds does not allow the classification of closed injuries to be adequately applied in some cases. Indeed, spinal structures follow either direct passage of a wounding projectile through the spine or transferring the energy of this projectile in contrast to classical compression, distraction and rotational-translation mechanisms typical for closed trauma.

Brown Sequard syndrome in a patient with Klippel-Feil syndrome following minor trauma: a case report and literature review.

BACKGROUND: There are some cases of Klippel-Feil syndrome with spinal cord injury in clinical work. However, there is no literature report on Brown-Sequard syndrome after trauma. We report a case of Brown-Sequard syndrome following minor trauma in a patient with KFS type III. Her Brown-Sequard syndrome is caused by Klippel-Feil syndrome. CASE PRESENTATION: We found a 38-year-old female patient with KFS in our clinical work. She was unconscious on the spot following a minor traumatic episode. After treatment, her whole body was numb and limb activity was limited. Half an hour later, she felt numb and weak in the right limb and weak in the left limb. She had no previous hypertension, diabetes, or coronary heart disease. After one-month treatment of medication, hyperbaric oxygen, rehabilitation, and acupuncture in our hospital, her muscle strength partially recovered, but the treatment effect was still not satisfactory. Then, she underwent surgical treatment and postoperative comprehensive treatment, and rehabilitation training. She was able to take care of herself with assistance, and her condition improved from grade B to grade D according to the ASIA (ASIA Impairment Scale) classification. CONCLUSION: KFS, also known as short neck deformity, is a kind of congenital deformity characterized by impaired formation and faulty segmentation of the cervical spine, often associated with abnormalities of other organs. The cervical deformity in patients with KFS can alter the overall mechanical activity of the spine, as well as the compensatory properties of the spine for decelerating and rotatory forces, thus increasing the chance of spinal cord injury (SCI) following trauma. Many mechanisms can make patients more susceptible to injury. Increased range of motion of the segment adjacent to the fused vertebral body may lead to slippage of the adjacent vertebral body and altered disc stress, as well as cervical instability. SCI can result in complete or incomplete impairment of motor, sensory and autonomic nervous functions below the level of lesion. This woman presented with symptoms of BSS, a rare neurological disorder with incomplete SCI. Judging from the woman's symptoms, we concluded that previously she had KFS, which resulted in SCI without fracture and dislocation following minor trauma, with partial BSS. After the comprehensive treatment of surgery, hyperbaric oxygen, rehabilitation therapy, and neurotrophic drugs, two years later, we found her symptoms significantly improved, with ASIA Impairment Scale from grade B to grade D, and her ability to perform activities of daily living with aids.

Neurological Analysis Based on the Terminal End of the Spinal Cord and the Narrowest Level of Injured Spine in Thoracolumbar Spinal Injuries.

This study aimed to clarify neurological differences among the epiconus, conus medullaris, and cauda equina syndromes. Eighty-seven patients who underwent surgery for acute thoracolumbar spinal injuries were assessed. We defined the epiconus as the region from the terminal end of the spinal cord to the proximal 1.0 to 2.25 vertebral bodies, the conus medullaris as the region proximal to < 1.0 vertebral bodies, and the cauda equina as the distal part of the nerve roots originating from the spinal cord. On the basis of the distance from the terminal end of the spinal cord to the narrowest level of the spinal canal, the narrowest levels were ordered as follows: the epiconus followed by the conus medullaris and cauda equina. The narrowest levels were the epiconus in 22 patients, conus medullaris in 37 patients, and cauda equina in 25 patients. On admission, significantly more patients had a narrowed epiconus of Frankel grades A-C than a narrowed cauda equina. At the final follow-up, there were no significant differences in neurological recovery among those with epiconus, conus medullaris, or cauda equina syndrome. Anatomically classifying the narrowest lesion is useful for clarifying the differences and similarities among these three syndromes.

Treatment strategy on traumatic mid-lumbar spondyloptosis with concomitant multiple injuries: A case report and literature review.

Spondyloptosis in the clinic is rarely reported. We herein present a 47-year-old female, who suffered from a crush injury directly by a heavy cylindrical object from the lateral side. She was diagnosed to have traumatic L3 spondyloptosis with multiple traumas. Staged surgical procedures were conducted and a three-year follow-up was obtained. Eventually, normal spinal alignment was restored, and neurological deficits were gradually improved. At three years follow-up, the motor strength scores and function of the sphincters were incompletely improved. Previously published reports on traumatic lumbar spondyloptosis were reviewed and several critical points for management of this severe type of spinal injury were proposed. First, thoracolumbar and lumbosacral junction were mostly predilection sites. Second, numerous patients involving traumatic lumbar spondyloptosis were achieved to American Spinal Injury Association grade A. Third, lumbar spondyloptosis was commonly coupling with cauda equina injury. Finally, the outcomes were still with poorly prognosis and recovery of patients was correlation to spondyloptosis severity. Based on this case report and literatures review, we highlighted that the spinal alignment restoration relying on staged operations and following rehabilitation hereof are both important once facing with multiple traumas. Furthermore, we suggested to perform routine CT angiography during lumbar spondyloptosis to justify whether there are large vessel compression or injury.

[Treatment of tracheoesophageal fistula and consequences of severe spinal injury]. / Lechenie trakheopishchevodnogo svishcha i posledstvii tyazheloi travmy pozvonochnika.

Modern approaches to intensive care and anesthesiology make it possible to save patients with various severe traumas. Prolonged mechanical ventilation allows stabilizing the patient's status, but can result severe complications including tracheoesophageal fistula. Our patient received severe combined injury after road accident, i.e. compression-comminuted fractures of DIV, DV, DVI vertebrae with spinal cord compression, ThIII compression fracture, compression-comminuted fracture of bodies and arches ThIV, V, VI with ThVI dislocation, lower paraplegia and pelvic organ dysfunction, left-sided laryngeal paresis, brain concussion and contusion of both lungs. Mechanical ventilation has been performed for 1.5 months. The patient suffered inflammatory complications: bilateral pneumonia complicated by right-sided pleural empyema, sepsis, tracheostomy suppuration followed by cervical soft tissue abscess. Pleural drainage and debridement, as well as drainage of abscess were performed. At the same time, we diagnosed external esophageal fistula at the CVII level. Tracheoesophageal fistula closure via cervical access was carried out at the first stage. Postoperative period was uneventful. After 20 days, we performed spondylosynthesis ThI-ThVII, and decompression laminectomy ThIV-ThVI. Spine stabilization by metal elements has a beneficial effect even without spinal cord recovery regarding better conditions for neurological and social rehabilitation. Thus, treatment was performed in a highly specialized multi-field hospital by thoracic surgeons and vertebrologists. We realized the treatment plan and obtained favorable results with minimal risk of postoperative complications.

Upper Extremity Functional Status in Patients with Chronic Tetraplegia in Universiti Malaya Medical Centre.

Background: Persons with tetraplegia rank improved upper extremity (UE) function as the most important rehabilitation outcome because it allows them greater independence in activities of daily living (ADL). The aim of this study was to describe UE status in patients with tetraplegia using the International Spinal Cord Injury Upper Extremity Basic Data Set version 1.1 (ISCI-UE 1.1) and to determine differences in UE status between tetraplegic individuals with traumatic and non-traumatic SCIs. Methods: This cross-sectional study was conducted among patients with tetraplegia who attended the SCI rehabilitation clinic of a tertiary hospital from September 2021 to August 2022. Both upper limbs were assessed using ISCI-UE 1.1. Results: One hundred patients were included in this study, of whom 80 were men. The mean (SD) age of the patients was 54.30 (16.95) years old. In these patients, most SCIs (62%) were of traumatic origin. Two hundred UEs were evaluated, of which 109 showed good hand function (level 5) and 10 had the poorest hand function (level 1). Meanwhile, 130 UEs showed good shoulder function (level D) and 10 had the poorest shoulder function (level A). A statistically significant association with UE status (reach-and-grasp ability and shoulder function) was found in both the non-traumatic and traumatic SCI groups, with better hand and shoulder functions in the non-traumatic SCI group (right-hand, P = 0.004 and left hand, P = 0.001; right shoulder, P < 0.001 and left shoulder, P = 0.002). Conclusion: ISCI-UE 1.1 is a feasible tool for documenting UE function in patients with tetraplegia. Compared with the individuals with traumatic SCI in this study, those with non-traumatic SCI demonstrated better upper extremity functionality.

[Endoscopic treatment of mine-explosive spine injuries: 3 clinical cases and literature review]. / Endoskopicheskoe lechenie minno-vzryvnykh ranenii pozvonochnika: 3 klinicheskikh nablyudeniya i obzor literatury.

Modern warfare is characterized by common mine-explosive injuries. The last ones are accompanied by multiple injuries, large area of damage and severe clinical status of victims. OBJECTIVE: To demonstrate treatment of mine-explosive spinal injuries using modern minimally invasive endoscopic techniques. MATERIAL AND METHODS: The authors present 3 victims with various mine-explosive injuries. Endoscopic removal of fragments from the lumbar and cervical spine was successful in all cases. DISCUSSION: Most of victims with injuries of the spine and spinal cord do not require urgent surgery and can underwent surgical treatment after clinical stabilization. At the same time, minimally invasive techniques provide surgical treatment with minimal risk and earlier rehabilitation, as well as reduce the risk of infectious complications associated with foreign bodies. CONCLUSION: Careful selection of patients for spinal video endoscopy will ensure positive outcomes. Minimization of iatrogenic postoperative injuries is especially important in patients with combined trauma. However, well-experienced surgeons should perform these procedures at the stage of specialized medical care.

[Recovery of spinal cord functions after experimental complete crossection under the effect of chitosan polymeric compounds]. / Vozmozhnosti klinicheskogo vosstanovleniya funktsii spinnogo mozga pri ego polnom peresechenii v eksperimente pod vozdeistviem polimernykh soedinenii khitozana.

Currently, there is no effective method of treating complete spinal cord intersection. One of the promising experimental approaches is substances promoting repair and fusion of axonal membranes. OBJECTIVE: To study clinical and functional recovery in experimental animals with transected spinal cord after management with photo-cross-linked chitosan in a homogeneous mixture with polyethylene glycol. MATERIAL AND METHODS: We studied 20 rabbits with a model of complete spinal cord transection at the level of Th9. There were control and experimental groups (n=10; n=10). In the experimental group, we intraoperatively injected photo-cross-linked chitosan in a homogeneous mixture with polyethylene glycol. Neurological status was assessed using the modified Basso Beattie Bresnahan scale. Histological examination was performed after removing the animals from the experiment. RESULTS: In the experimental group, significant regression of neurological disorders was accompanied by partial recovery of movements, sensitivity and control of pelvic functions by the 30th day of the experiment. There was no mortality in the experimental group. Paraplegia and anesthesia persisted in the control group while mortality was 40% (n=4). Histological analysis in the main group revealed axonal «bridges¼ in the area of injury and spread of DiI dye through this area. CONCLUSION: These phenomena confirm the positive effect of chitosan and polyethylene glycol on functional recovery after experimental spinal cord injury. These data are consistent with histological findings.

The Effect of the Eastern Association for the Surgery of Trauma Guideline on Spinal Magnetic Resonance Imaging Use in Obtunded Adult Blunt Trauma Patients Over Time.

BACKGROUND: Evidence-based guidelines suggest computed tomography without magnetic resonance imaging (MRI) is sufficient to rule out clinically significant cervical spine injury in obtunded adult blunt trauma patients. This study evaluated MRI utilization over time to investigate the impact of the 2015 Eastern Association for the Surgery of Trauma guidelines suggesting cervical collar clearance with computed tomography alone in this population. We hypothesized that MRI utilization would decrease following the guidelines. MATERIALS AND METHODS: We performed a retrospective cross-sectional study of the National Trauma Data Bank from 2007 to 2018 using multivariable logistic regression of the likelihood of spinal MRI utilization. Blunt trauma patients 18 y and older with a Glasgow Coma Scale (GCS) of 8 or less, Abbreviated Injury Score head of 4 or greater, intubated for at least 72 h were included. RESULTS: The sample consisted of 76,450 patients from 567 trauma centers. Controlling for age, gender, race/ethnicity, insurance status, injury mechanism, Injury Severity Score, GCS, GCS motor, hospital teaching status and trauma center level, patients seen after 2015 had a higher odds ratio (OR) of undergoing spinal MRI relative to those seen before 2015 (OR 1.77, 95% CI 1.49-2.09; P < 0.001). Each year was associated with a significantly increased OR of undergoing spinal MRI compared to the year prior (OR 1.10, 95% CI 1.05-1.15; P < 0.001). CONCLUSIONS: Spinal MRI use has been increasing in obtunded adult blunt trauma patients including after the release of the Eastern Association for the Surgery of Trauma guidelines in 2015. Future work should identify whether this is driven by improper MRI utilization and, if so, strategies to promote guideline adherence.

Neurotrauma in the Syrian War: analysis of 41,143 cases from July 2013-July 2015.

INTRODUCTION: Despite nearly a decade of conflict, little is known about trauma and injuries resulting from the Syrian war. METHODS: Secondary analysis was conducted of an administrative dataset of patient presentations to a network of 95 war-affected hospitals in Syria from July 2013-July 2015. Logistic regression was performed to identify factors associated with mortality of neurotrauma patients. RESULTS: Of 193,618 overall trauma presentations, 41,143 were for neurotrauma (37,410 head trauma, 1407 spinal trauma, and 3133 peripheral nervous system). There were 31,359 males (76.2%) and 9784 females (23.8%). Males aged 19-30 years (10,113; 24.6%) were the largest single demographic group. Presumed non-combatants including females, elders, and children under 13 years (16,214; 39.4%) were the largest group of patients overall. There were 16,881 (41.0%) presentations with blunt injuries (blunt/crush injuries) and 21,307 (51.8%) patients with penetrating injuries (shrapnel, cut, gunshot). A total of 36,589 patients (89.6%) were treated and discharged from the hospital, 2100 (5.1%) were transferred to another facility, 2050 patients (5.0%) died in-hospital, 26 remained in the hospital (0.1%), and 108 (0.3%) had unknown disposition. The median length of hospital stay was 1 day. There were 4034 (9.7%) neurosurgical procedures documented. Patients with combined neurotrauma and general trauma suffered 30 times higher mortality than neurotrauma alone (aOR: 30.4; 95% CI: 20.8-44.2, p < 0.0001). CONCLUSION: The Syrian War resulted in large volumes of neurotrauma patients. Presumed non-combatants comprised 39.4% of patients who survived to treatment at a facility. Further study is needed on long-term needs of neurotrauma victims of the Syrian war.

The birth of modern military neurosurgery through the eyes of Harvey Cushing's war memoir From a Surgeon's Journal, 1915-1918.

Dr. Harvey Cushing is considered the father of modern neurological surgery, and his role and efforts in World War I continue to have a lasting effect on today's practice of neurosurgery. During World War I, he embodied the tenets of a neurosurgeon-scientist: he created and implemented novel antiseptic techniques to decrease infection rates after craniotomies, leading him often to be referred to as "originator of brain wound care." His contributions did not come without struggles, however. He faced criticism for numerous military censorship violations, and he developed a severe peripheral neuropathy during the war. However, he continued to stress the importance of patient care and his surgical prowess was evident. In this paper, the authors summarize Cushing's notes published in From a Surgeon's Journal, 1915-1918 and discuss the impact of his experiences on his own practice and the field of neurosurgery.

Telemedicine for Preventing and Treating Pressure Injury After Spinal Cord Injury: Systematic Review and Meta-analysis.

BACKGROUND: Pressure injury is a common complication after a spinal cord injury. Long-term multidisciplinary follow-up is difficult after such patients have been discharged. Telemedicine promises to provide convenient and effective support for the prevention and treatment of pressure injury, but previous attempts to demonstrate that have produced inconsistent results. OBJECTIVE: The aim of this study is to evaluate the effectiveness of telemedicine in preventing and treating pressure injury among community-dwelling patients with spinal cord injury, and determine which telemedicine form is more effective. METHODS: This systematic review was performed according to the PRISMA-NMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Network Meta-Analysis) standards. Ten databases were searched to identify randomized controlled trials and quasi-experimental studies related to the effectiveness of telemedicine intervention in patients with spinal cord injury. Two researchers worked independently and blindly selected studies, extracted data, and assessed the risk of bias. The results were described as relative risk (RR) and weighted mean difference and 95% CI. RESULTS: The 35 studies comprised 25 randomized controlled trials and 10 quasi-experimental studies involving 3131 patients. The results showed that telemedicine can significantly (P<.05) reduce the incidence of pressure injury (RR 0.24, 95% CI 0.14-0.41; P<.05; I2=0%), promote faster healing (RR 0.73, 95% CI 0.62-0.85; P<.05; I2=0%), and yield lower scores on the pressure ulcer scale of healing (weighted mean difference=-1.98, 95% CI -3.51 to -0.46; P<.05; I2=0%). Cumulative ranking estimates showed that combining telemedicine with conventional intervention (93.5%) was the most effective approach. CONCLUSIONS: Telemedicine is a feasible way to prevent pressure injury among patients with spinal cord injuries. It can decrease the incidence and severity of pressure injury and accelerate patients' healing without imposing economic burden. It is best used in tandem with other, more conventional interventions. Due to the limited quality and quantity of included studies, large-scale and well-designed randomized controlled trials are warranted.