Development of a Novel Risk Stratification Score to Predict 30-Day Mortality in Cervical Trauma Patients: CLAAD Score.

STUDY DESIGN: Case control. OBJECTIVE: Traumatic cervical spine injuries are associated with a substantial risk of mortality. The aim of this study is to develop a novel mortality prediction model for patients with cervical trauma who require operative treatment. SUMMARY OF BACKGROUND DATA: Patients with cervical spine trauma have a high risk of postoperative complications and mortality. There are few reliable systems that can accurately predict mortality after surgery for cervical spine trauma, and those that do exist are typically not specific to cervical trauma. MATERIALS AND METHODS: The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients undergoing surgery for cervical spine trauma. Univariate analyses were performed to identify variables associated with mortality. Variables that were found to be significant in the univariate models were compiled into a multivariable model. The final model was compared with the American Society of Anesthesiologists (ASA), a modified Charlson comorbidity index (mCCI), and the 5-factor modified frailty index (mFI-5) in respect to predicting 30-day mortality after cervical trauma. The score was then externally validated using the Nationwide Inpatient Sample (NIS) database. RESULTS: Fifty-five (6.7%) of 822 patients did not survive 30 days after surgery. The final multivariable logistic regression model consisted of the following variables: circumferential fusion "C." long "L" fusion (more than 4 levels), anemia "A," age over 60 "A," and dialysis "D." The risk of mortality increased with increasing CLAAD score, with mortality rates of 0.9%, 3.1%, 7.4%, 22.7%, and 14.3% for scores of 0, 1, 2, 3, and 4, respectively. The CLAAD model had an AUC of 0.73 for predicting mortality after cervical trauma. CONCLUSIONS: The CLAAD score is a simple and effective system that can help identify patients at risk of increased mortality within 30 days of cervical trauma. LEVEL OF EVIDENCE: Level III.

Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries.

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries. METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding. RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score. CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

Cervical Spine Injury is Rare in Self-Inflicted Craniofacial Gunshot Wounds: An Institutional Review and Comparison to the US National Trauma Data Bank (NTDB).

BACKGROUND: Cadaveric and older radiographic studies suggest that concurrent cervical spine fractures are rare in gunshot wounds (GSWs) to the head. Despite this knowledge, patients with craniofacial GSWs often arrive with spinal motion restriction (SMR) in place. This study quantifies the incidence of cervical spine injuries in GSWs to the head, identified using computerized tomography (CT). Fracture frequency is hypothesized to be lower in self-inflicted (SI) injuries. METHODS: Isolated craniofacial GSWs were queried from this Level I trauma center registry from 2013-2017 and the US National Trauma Data Bank (NTDB) from 2012-2016 (head or face abbreviated injury scale [AIS] >2). Datasets included age, gender, SI versus not, cervical spine injury, spinal surgery, and mortality. For this hospital's data, prehospital factors, SMR, and CTs performed were assessed. Statistical evaluation was done with Stata software, with P <.05 significant. RESULTS: Two-hundred forty-one patients from this hospital (mean age 39; 85% male; 66% SI) and 5,849 from the NTDB (mean age 38; 84% male; 53% SI) were included. For both cohorts, SI patients were older (P < .01) and had increased mortality (P < .01). Overall, cervical spine fractures occurred in 3.7%, with 5.4% requiring spinal surgery (0.2% of all patients). The frequency of fracture was five-fold greater in non-SI (P < .05). Locally, SMR was present in 121 (50.2%) prior to arrival with six collars (2.5%) placed in the trauma bay. Frequency of SMR was similar regardless of SI status (49.0% versus 51.0%; P = not significant) but less frequent in hypotensive patients and those receiving cardiopulmonary resuscitation (CPR). The presence of SMR was associated with an increased use of CT of the cervical spine (80.0% versus 33.0%; P < .01). CONCLUSION: Cervical spine fractures were identified in less than four percent of isolated GSWs to the head and face, more frequently in non-SI cases. Prehospital SMR should be avoided in cases consistent with SI injury, and for all others, SMR should be discontinued once CT imaging is completed with negative results.

Morbidity and mortality in cervical spine injuries in the elderly.

BACKGROUND: The aim of our study was to identify the demographics and complications in elderly cervical spine injuries and predictive factors for surgery, complications and mortality. We hypothesized younger healthier patients were more likely to undergo surgical intervention. METHODS: A retrospective review of 225 consecutive patients aged 65 years and over with cervical spine injuries was carried out over a 3-year period. RESULTS: There were 113 males and 112 females with an average of 79.7 years (range 65-98). The most common fracture was C2 peg type (21.8%). Five patients had complete spinal cord injury (2.2%), 25 had incomplete spinal cord injury (11.1%) and 84% were neurologically intact. Fifty-four patients were managed operatively (24%), while 171 patients were managed non-operatively (76%). The operative group had higher rates of pneumonia (odds ratio (OR) 5.3, 95% confidence interval (CI) 2.6-10.7, P < 0.01), cardiac arrhythmia (OR 4.1, 95% CI 1.5-11.2, P < 0.01) and respiratory failure (OR 2.6, 95% CI 1.2-5.5, P < 0.05). There was no difference in mortality between the operative and non-operative group (18.5% and 12.9%, P = 0.3). Patients with complete spinal cord injury had 100% mortality. Significant predictive factors for complications and death were neurological deficits, comorbidities and the presence of other injuries (P < 0.05). Surgery was not predictive for death and the operative group was younger than the non-operative group (P < 0.05). CONCLUSIONS: In the setting of a high complication rate, consideration should be given to palliation in elderly patients with complete spinal cord injury and there must be good rational for surgery.

Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study.

BACKGROUND: High rates of pneumonia and death have been reported among elderly patients with rib fractures. This study aims to identify patterns of injury and risk factors for pneumonia and death in elderly patients with rib fractures. METHODS: A retrospective multicenter observational study was performed using data registered in the national trauma registry between 2008 and 2015 in the South West Netherlands Trauma region. Data regarding demographics, mechanism of injury, pulmonary and cardiovascular history, pattern of extra-thoracic and intrathoracic injuries, ICU admission, length of stay, and morbidity and mortality following admission were collected. RESULTS: Eight hundred eighty-four patients were included. Median age was 76 years (P25-P75 70-83). 235 patients (26.6%) were 81 years or older. Moderate or worse extra-thoracic injuries were present in 456 patients (51.6%), of whom 146 (16.6%) had severe head injuries and 45 (5.1%) severe spinal injuries. Median ISS was 9 (P25-P75 5-18). The rate of pneumonia was 10% (n = 84). Ten percent of patients (n = 88) died. Risk factors for in-hospital mortality included age (OR 3.4; p = 0.003), presence of COPD (OR 1.3; p = 0.01), presence of cardiac disease (OR 2.6; p = 0.003), severe or worse head (OR 3.5; p < 0.001), abdominal (OR 6.8; p = 0.004) and spinal injury (OR 4.6; p = 0.011) by AIS, number of rib fractures (OR 2.6; p = 0.03), and need for chest tube drainage (OR 2.1; p = 0.021). CONCLUSIONS: Pneumonia and death occur in about 10% of elderly patients with rib fractures. Apart from the severity of thoracic injuries, the presence and severity of extra-thoracic injuries and cardiopulmonary comorbidities are associated with poor outcome.

Optimal timing of initiation of thromboprophylaxis in spine trauma managed operatively: A nationwide propensity-matched analysis of trauma quality improvement program.

BACKGROUND: Patients with spinal trauma are at high risk for venous thromboembolic events (VTE). Guidelines recommend prophylactic anticoagulation but they are unclear on timing of initiation of thromboprophylaxis. The aim of our study was to assess the impact of early versus late initiation of venous thromboprophylaxis in patients with spinal trauma who underwent operative intervention. METHODS: We performed a 2-year (2013-2014) review of patients with isolated spine trauma (spine-Abbreviated Injury Scale score, ≥ 3 and no other injury in another body region with Abbreviated Injury Scale score, > 2) who underwent operative intervention and received thromboprophylaxis postoperatively. Patients were divided into two groups based on the timing of initiation of thromboprophylaxis: early(<48 hours) and late(≥48 hours), and were matched in a 1:1 ratio using propensity score matching for demographics, admission vitals, injury parameters, type of operative intervention, hospital course, and type of prophylaxis(low molecular weight heparin vs. unfractionated heparin). Outcomes were rates of deep vein thrombosis (DVT) and/or pulmonary embolism, red-cell transfusions, the rate of operative interventions for spinal cord decompression and mortality after initiation of thromboprophylaxis. RESULTS: Nine thousand five hundred eighty-five patients underwent operative intervention and received anticoagulants, of which 3554 patients (early, 1,772; late, 1,772) were matched. Matched groups were similar in demographics, injury parameters, emergency department vitals, hospital length of stay, rates of inferior vena cava (IVC) filter placement and time to operative procedure. Patients who received thromboprophylaxis within 48 hours of operative intervention, unlike those who did not, were less likely to develop DVT (2.1% vs. 10.8%, p < 0. 01). However, the rate of pulmonary embolism was similar in both groups (p = 0.75). Additionally, there was no difference in postprophylaxis red cell transfusion requirements (p = 0.61), rate of postprophylaxis decompressive procedure on the spinal cord (p = 0.27), and mortality (p = 0.53). CONCLUSION: Early VTE prophylaxis is associated with decreased rates of DVT in patients with operative spinal trauma without increasing the risk of bleeding and mortality. The VTE prophylaxis should be initiated within 48 hours of surgery to reduce the risk of DVT in this high-risk patient population. LEVEL OF EVIDENCE: Therapeutic studies, level IV.

Evaluation of severe and fatal injuries in extreme and contact sports: an international multicenter analysis.

PURPOSE: The participation in extreme and contact sports has grown internationally, despite the significant risk for major and multiple injuries. We conducted this multicenter study to evaluate sport-specific injury patterns and mechanisms, to characterize individuals at risk and to identify possible approaches for prevention. METHODS: We compared demographic data, severity and patterns of injuries; and the pre- and in-hospital management from an international population-based prospective trauma database (TraumaRegister DGU®). The registry was screened for sport-related injuries, and only patients with major injuries [Injury Severity Score (ISS) ≥ 9 points] related to extreme or contact sports activities were included (January 1, 2002, to December 31, 2012). Parameters were compared for different types of sports activities: (1) Airborne sports, (2) Climbing, (3) Skateboarding/Skating, (4) Contact sports. The following countries participated: Germany, Austria, Switzerland, Finland, Slovenia, Belgium, Luxembourg, and The Netherlands. Statistical analyses were performed with SPSS (Version 22, IBM Inc., Armonk, New York). RESULTS: A total of 278 athletes were identified within the study period and classified into four groups: Airborne sports (n = 105) were associated with the highest injury severity (ISS 22.4 ± 14.6), followed by climbing (n = 35, ISS 16.5 ± 12), skating (n = 67, ISS 15.2 ± 10.3) and contact sports (n = 71, ISS 10.4 ± 9.2). Especially high falls resulted in a significant rate of spinal injuries in airborne activities (68.6%, p < 0.001) and in climbing accidents (45.7%). Skating was associated with the highest rate of loss of consciousness (LOC) at scene (27.1%), the highest pre-hospital intubation rate (33.3%), and also the highest in-hospital mortality (15.2%, p < 0.001), related to major head injuries. CONCLUSIONS: Extreme and contact sports related major injuries predominantly affect young male athletes. Especially skaters are at risk for debilitating and lethal head injuries. Individuals recognizing sport-specific hazards might modify their risk behavior. LEVEL OF EVIDENCE: Descriptive Epidemiologic Study, Level II.

AIS scores in spine and spinal cord trauma: Epidemiological considerations.

BACKGROUND: The Abbreviated Injury Scale (AIS) is an internationally accepted coding system created by the Association for the Advancement of Automotive Medicine, utilized to code traumatic injuries as a function of severity, the latter often defined as mortality risk. Periodic reassessment of that risk is prudent, in light of advances in health care and relationship of nonanatomic factors to death. OBJECTIVE: The objective of this study was to reevaluate the risk of death associated with spine fractures with and without neurologic deficit, age factors associated with it, and the impact of hospital coding on the accuracy of these efforts. METHODS: Medical records and imaging of patients treated at a level 1 trauma center from 2014 through 2016 with discharge International Classification of Diseases, 10th revision (ICD-10) diagnoses of spinal trauma and spinal cord injury (SCI) were reviewed. Data were collected on demographics, complications, neurologic status, and outcomes. RESULTS: Three hundred seventy patients met the criteria for inclusion in this effort. Errors in ICD-10 discharge codes were seen in 45% of the cases, both false positive and negative. One hundred thirty-four patients, with a mean age of 45, were admitted with neurologic deficit. There were 8 SCI-related deaths; 2 were postoperative out of 110 undergoing surgical treatment. All deaths in this group were in patients with upper level SCI, with a mean age of 68. Ten patients had spontaneous neurologic improvement within 24 h. One hundred nineteen patients without deficit had AIS 2 scored fractures; there was one postoperative death out of 47 patients undergoing surgical treatment. One hundred seventeen patients without deficit suffered AIS 3 fractures; 66 underwent surgery without any deaths. There was one nonoperative death. Age and high quadriplegia were the only factors associated with mortality. CONCLUSIONS: Mortality risk in patients with deficit was associated more with age at injury than extent of anatomic injury. Spine trauma without neurologic deficit is benign in younger populations and AIS scores could be age adjusted. Mortality risk is higher in high cervical injuries with neurologic deficit and in the elderly. An incidental finding is that demographic studies based solely on discharge ICD coding may contain errors and should be considered critically.

Factors affecting survival of patients in the acute phase of upper cervical spine injuries.

INTRODUCTION: In recent years, on the one hand, the mortality rates of upper cervical spine injuries, such as odontoid fractures, were suggested to be not so high, but on the other hand reported to be significantly high. Furthermore, it has not been well documented the relationship between survival rates and various clinical features in those patients during the acute phase of injury because of few reports. This study aimed to evaluate survival rates and acute-phase clinical features of upper cervical spine injuries. METHODS: We conducted a retrospective review of all patients who were transported to the advanced emergency medical center and underwent computed tomography of the cervical spine at our hospital between January 2006 and December 2015. We excluded the patients who were discovered in a state of cardiopulmonary arrest (CPA) and could not be resuscitated after transportation. Of the 215 consecutive patients with cervical spine injuries, we examined 40 patients (18.6%) diagnosed with upper cervical spine injury (males, 28; females, 12; median age, 58.5 years). Age, sex, mechanism of injury, degree of paralysis, the level of cervical injury, injury severity score (ISS), and incidence of CPA at discovery were evaluated and compared among patients classified into the survival and mortality groups. RESULTS: The survival rate was 77.5% (31/40 patients). In addition, complete paralysis was observed in 32.5% of patients. The median of ISS was 34.0 points, and 14 patients (35.0%) presented with CPA at discovery. Age, the proportion of patients with complete paralysis, a high ISS, and incidence of CPA at discovery were significantly higher in the mortality group (p = 0.038, p = 0.038, p < 0.001, and p < 0.001, respectively). CONCLUSIONS: Elderly people were more likely to experience upper cervical spine injuries, and their mortality rate was significantly higher than that in injured younger people. In addition, complete paralysis, high ISS, a state of CPA at discovery, was significantly higher in the mortality group.

Relationship of biological factors to survival in spinal gunshot injuries.

BACKGROUND: Gunshot injuries are the third leading cause of spinal injuries, after falls from a significant height and traffic accidents. Severity of spinal damage from gunshot injury depends upon certain mechanical and biological factors. The aim of the present study was to investigate the effect of biological factors on survival in cases of spinal gunshot injury. METHODS: A total of 110 cases of spinal gunshot injury admitted multiple times to emergency services between 2012 and 2014 were included. Age, sex, region of trauma, additional organ or systemic involvement, treatment modalities (conservative, surgical), and mortality rates were analyzed. Effects of biological factors on survival were evaluated. RESULTS: Mean age of the study population was 25.51±11.74 years (min: 4; max: 55) and 95.5% of the population was male. Regions of trauma were thoracic in 50 (45.4%) subjects, cervical in 42 (38.2%), and lumbar in 18 (16.4%). Most common American Spinal Injury Association (ASIA) score was category A, as was found in 77 (70%) cases. No significant correlation was found among age, sex, ASIA score, treatment modality (conservative or surgical), and survival (p>0.05). Additional organ or systemic injury was present in 66 (60%) patients. Additional organ or systemic injury significantly affected survival, independent of the spinal region of trauma (p<0.01). CONCLUSION: Spinal gunshot injuries are complex, with unclear treatment protocol. Irrespective of the indications of spinal surgery, additional organ injuries unfavorably affect survival in cases of spinal gunshot injury. Appropriate management of all biological factors directly affects mortality rate in cases of spinal gunshot injury.

Traumatic spinal injuries in children at a single level 1 pediatric trauma centre: report of a 23-year experience.

BACKGROUND: With a reported incidence of up to 10% compared to all spinal trauma, spinal injuries in children are less common than in adults. Children can have spine fractures with or without myelopathy, or spinal cord injuries without radiological abnormalities (SCIWORA). METHODS: We retrospectively reviewed the cases of children with spinal injuries treated at a level 1 pediatric trauma centre between 1990 and 2013. RESULTS: A total of 275 children were treated during the study period. The mean age at admission was 12 ± 4.5 years, and the male:female ratio was 1.4:1. Spinal injuries were more common in children of ages 12-16 years, with most injuries among ages 15-16 years. The top 3 mechanisms of spinal injury were motor vehicle-related trauma (53%), sports (28%) and falls (13%). Myelopathy occurred in 12% and SCIWORA occurred in 6%. The most common spine levels injured were L2-sacrum, followed by O-C2. Associated injuries, including head injuries (29%), and fractures/dislocations (27%) occurred in 55% of children. Overall mortality was 3%. Surgical intervention was required in 14%. CONCLUSION: The creation of a pediatric spinal injury database using this 23-year retrospective review helped identify important clinical concepts; we found that active adolescent boys had the highest risk of spine injury, that noncontiguous spine injuries occured at a rate higher than reported previously and that nonaccidental spine injuries in children are underreported. Our findings also emphasize the importance of maintaining a higher index of suspicion with trauma patients with multiple injuries and of conducting detailed clinical and radiographic examinations of the entire spine in children with a known spinal injury.

CONTEXTE: Les traumatismes médullaires sont moins fréquents chez l'enfant que chez l'adulte, avec une incidence d'au plus 10 % de tous les cas déclarés. Les enfants peuvent subir des fractures de la colonne vertébrale avec ou sans myélopathie, ou un traumatisme médullaire sans anomalie radiologique visible (SCIWORA). MÉTHODES: Nous avons effectué une analyse rétrospective des cas d'enfants atteints d'un traumatisme médullaire admis dans un centre de traumatologie spécialisé en pédiatrie de niveau 1 entre 1990 et 2013. RÉSULTATS: Au total, 275 enfants ont été traités durant la période de l'étude. L'âge moyen au moment de l'hospitalisation était de 12 ± 4,5 ans, et le ratio garçons:filles était de 1,4:1. Les adolescents de 12 à 16 ans formaient le groupe le plus représenté, et l'incidence de traumatisme la plus élevée a été observée chez les jeunes de 15 et 16 ans. Les 3 mécanismes lésionnels les plus fréquents étaient les accidents de la route (53 %), la pratique d'un sport (28 %) et les chutes (13 %). Le taux d'incidence de la myélopathie était de 12 %, et celui du SCIWORA, de 6 %. La section du rachis touchée le plus fréquemment s'étendait de L2 au sacrum, les vertèbres entre l'occiput et C2 arrivant au deuxième rang. Des lésions concomitantes, dont des blessures à la tête (29 %) et des fractures et luxations (27 %), ont été observées chez 55 % des enfants. Le taux global de mortalité était de 3 %. L'intervention chirurgicale a été nécessaire chez 14%. CONCLUSION: La création à partir de cette étude rétrospective d'une base de données sur les traumatismes médullaires chez l'enfant a mis en évidence quelques constatations cliniques dignes d'intérêt : les garçons adolescents actifs présentent le risque le plus élevé de traumatisme médullaire; les lésions médullaires non contiguës surviennent plus fréquemment que ce qui avait été rapporté précédemment; les traumatismes médullaires non accidentels chez l'enfant sont sous-déclarés. Nos conclusions viennent aussi souligner l'importance de maintenir un indice de suspicion élevé dans le cas de patients atteints de lésions multiples et d'effectuer un examen clinique et radiographique détaillé de la totalité de la colonne vertébrale des enfants ayant une lésion médullaire connue.

Perioperative morbidity and mortality after lumbar trauma in the elderly.

OBJECT Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal trauma. Lumbar spine trauma in the elderly is a growing public health problem with relatively little evidence to guide clinical management. The authors sought to characterize the complications, morbidity, and mortality associated with surgical and nonsurgical management in elderly patients with traumatic fractures of the lumbar spine. METHODS Using the National Sample Program of the National Trauma Data Bank, the authors performed a retrospective analysis of patients ≥ 55 years of age who had traumatic fracture to the lumbar spine. This group was divided into middle-aged (55-69 years) and elderly (≥ 70 years) cohorts. Cohorts were subdivided into nonoperative, vertebroplasty or kyphoplasty, noninstrumented surgery, and instrumented surgery. Univariate and multivariable analyses were used to characterize and identify predictors of medical and surgical complications, mortality, hospital length of stay, ICU length of stay, number of days on ventilator, and hospital discharge in each subgroup. Adjusted odds ratios, mean differences, and associated 95% CIs were reported. Statistical significance was assessed at p < 0.05, and the Bonferroni correction for multiple comparisons was applied for each outcome analysis. RESULTS Between 2003 and 2012, 22,835 people met the inclusion criteria, which represents 94,103 incidents nationally. Analyses revealed a similar medical and surgical complication profile between age groups. The most prevalent medical complications were pneumonia (7.0%), acute respiratory distress syndrome (3.6%), and deep venous thrombosis (3%). Surgical site infections occurred in 6.3% of cases. Instrumented surgery was associated with the highest odds of each complication (p < 0.001). The inpatient mortality rate was 6.8% for all subjects. Multivariable analyses demonstrated that age ≥ 70 years was an independent predictor of mortality (OR 3.16, 95% CI 2.77-3.60), whereas instrumented surgery (multivariable OR 0.38, 95% CI 0.28-0.52) and vertebroplasty or kyphoplasty (OR 0.27, 95% CI 0.17-0.45) were associated with decreased odds of death. In surviving patients, both older age (OR 0.32, 95% CI 0.30-0.34) and instrumented fusion (OR 0.37, 95% CI 0.33-0.41) were associated with decreased odds of discharge to home. CONCLUSIONS The present study confirms that lumbar surgery in the elderly is associated with increased morbidity. In particular, instrumented fusion is associated with periprocedural complications, prolonged hospitalization, and a decreased likelihood of being discharged home. However, fusion surgery is also associated with reduced mortality. Age alone should not be an exclusionary factor in identifying surgical candidates for instrumented lumbar spinal fusion. Future studies are needed to confirm these findings.

Outcome in patients undergoing surgery for spinal injury in an Ethiopian hospital.

OBJECT: The objective of this study was to investigate epidemiology and outcome after surgical treatment for spinal injuries in Ethiopia. METHODS: Medical records of patients who underwent surgery for spine injuries at Myungsung Christian Medical Center in Addis Ababa, Ethiopia, between January 2008 and September 2012 were reviewed retrospectively. Assessment of outcome and complications was determined from patient consultations and phone interviews. RESULTS: A total of 146 patients were included (129 males, 17 females). Their mean age was 31.7 years (range 15-81 years). The leading cause of injury was motor vehicle accidents (54.1%), and this was followed by falls (26.7%). The most common injury sites were lumbar (41.1%) and cervical (34.2%) regions of the spine. In 21.2% of patients, no neurological deficit was present before surgery, 46.6% had incomplete spinal cord injury (American Spinal Injury Association [ASIA] Impairment Scale [AIS] Grade B-D), and 32.2% had complete spinal cord injury (AIS Grade A). Follow-up was hampered by suboptimal infrastructure, but information regarding outcome was successfully obtained for 110 patients (75.3%). At follow-up (mean 22.9 months; range 2-57 months), 25 patients (17.1%) were confirmed dead and 85 patients (58.2%) were alive; 49 patients (33.6%) underwent physical examination. At least 8 of the 47 patients (17.0%) with a complete injury and 29 of the 68 patients (42.6%) with an incomplete injury showed neurological improvement. The reported incidences of pressure wounds, recurrent urinary tract infections, pneumonia, and thromboembolic events were 22.5%, 13.5%, 5.6%, and 1.1%, respectively. CONCLUSIONS: Patients showed surprisingly good recovery considering the limited resources. Surgical treatment for spine injuries in Ethiopia is considered beneficial.

Traumatic spondyloptosis: a series of 20 patients.

OBJECT Spondyloptosis represents the most severe form of spondylolisthesis, which usually follows high-energy trauma. Few reports exist on this specific condition, and the largest series published to date consists of only 5 patients. In the present study the authors report the clinical observations and outcomes in a cohort of 20 patients admitted to a regional trauma center for severe injuries including spondyloptosis. METHODS The authors performed a retrospective chart review of patients admitted with spondyloptosis at their department over a 5-year period (March 2008-March 2013). Clinical, radiological, and operative details were reviewed for all patients. RESULTS In total, 20 patients with spondyloptosis were treated during the period reviewed. The mean age of the patients was 27 years (range 12-45 years), and 17 patients were male (2 boys and 15 men) and 3 were women. Fall from height (45%) and road traffic accidents (35%) were the most common causes of the spinal injuries. The grading of the American Spinal Injury Association (ASIA) was used to assess the severity of spinal cord injury, which for all patients was ASIA Grade A at the time of admission. In 11 patients (55%), the thoracolumbar junction (T10-L2) was involved in the injury, followed by the dorsal region (T1-9) in 7 patients (35%); 1 patient (5%) had lumbar and 1 patient (5%) sacral spondyloptosis. In 19 patients (95%), spondyloptosis was treated surgically, involving the posterior route in all cases. In 7 patients (37%), corpectomy was performed. None of the patients showed improvement in neurological deficits. The mean follow-up length was 37.5 months (range 3-60 months), and 5 patients died in the follow-up period from complications due to formation of bedsores (decubitus ulcers). CONCLUSIONS To the authors' best knowledge, this study was the largest of its kind on traumatic spondyloptosis. Its results illustrate the challenges of treating patients with this condition. Despite deformity correction of the spine and early mobilization of patients, traumatic spondyloptosis led to high morbidity and mortality rates because the patients lacked access to rehabilitation facilities postoperatively.

Ischemic stroke after cervical spine injury: analysis of 11,005 patients using the Japanese Diagnosis Procedure Combination database.

BACKGROUND CONTEXT: The incidence and relevant risk of ischemic stroke after cervical spine trauma remain unknown. PURPOSE: To examine the incidence of ischemic stroke during hospitalization in patients with cervical spine injury, and analyze the impact of different types of cervical spine injuries on the occurrence of ischemic stroke. STUDY DESIGN: Retrospective analysis of data abstracted from the Diagnosis Procedure Combination database, a nationally representative database in Japan. PATIENT SAMPLE: We included all patients hospitalized for any of the following traumas: fracture of cervical spine (International Classification of Diseases, 10th Revision codes: S120, S121, S122, S127, S129); dislocation of cervical spine (S131, S133); and cervical spinal cord injury (SCI) (S141). OUTCOME MEASURES: Outcome measures included all-cause in-hospital mortality and incidence of ischemic stroke (I63) during hospitalization. METHODS: We analyzed the effects of age, sex, comorbidities, smoking status, spinal surgery, consciousness level at admission, and type of cervical spine injury on outcomes. RESULTS: We identified 11,005 patients with cervical spine injury (8,031 men, 2,974 women; mean [standard deviation] age, 63.5 [18] years). According to the types of cervical spine injury, we stratified the patients into three groups: cervical fracture and/or dislocation without SCI (2,363 patients); cervical fracture and/or dislocation associated with SCI (1,283 patients); and cervical SCI without fracture and/or dislocation (7,359 patients). Overall, ischemic stroke occurred in 115 (1.0%) patients during hospitalization (median length of stay, 26 days). In-hospital death occurred in 456 (4.1%) patients. Multivariate analyses showed that ischemic stroke after cervical spine injury was significantly associated with age, diabetes, and consciousness level at admission. The highest in-hospital mortality was observed in patients with cervical fracture and/or dislocation associated with SCI (7.6%), followed by cervical SCI without fracture and/or dislocation (4.0%), and cervical fracture and/or dislocation without SCI (2.6%). Unlike mortality, risks of stroke did not vary significantly among the three groups. CONCLUSIONS: This analysis revealed that ischemic stroke after cervical spine injury was not uncommon and was associated with increased mortality and morbidity. Occurrence of ischemic stroke was significantly associated with age, comorbidities such as diabetes, and consciousness level at admission, but not with the type of spine injury.

Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients.

BACKGROUND: Because of a lack of evidence, the appropriate timing of surgical stabilization of thoracic and lumbar spine injuries in severely injured patients is still controversial. Data of a large international trauma register were analyzed to investigate the medical care situation of unstable spinal column fractures in patients with multiple injuries, so as to examine the outcome related to timing of surgical stabilization. METHODS: Data sets of the Trauma Registry of German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (1993-2010) were analyzed. The Trauma Registry of DGU is a prospective, multicenter register that provides information on severely injured patients. All patients with an Injury Severity Score (ISS) of 16 or greater caused by blunt trauma, subsequent treatment of 7 days or more, 16 years or older, and thoracic or lumbar spine injuries (spine Abbreviated Injury Scale [AIS] score ≥ 2) were included in our analysis. Patients with relevant spine injuries classified as having a spine AIS score of 3 or greater were further analyzed in terms of whether they got early (<72 hours) or late (>72 hours) surgical treatment due to unstable spinal column fractures. RESULTS: Of 24,974 patients, 8,994 (36.0%) had documented spinal injuries (spine AIS score ≥ 2). A total of 1,309 patients who sustained relevant thoracic spine injuries (spine AIS score ≥ 3) and 994 patients who experienced lumbar spine trauma and classified as having spine AIS score of 3 or greater were more precisely analyzed. Of these, 68.2% and 71.0%, respectively, received an early thoracic or lumbar spine fixation. With an increase in spinal injury severity, an increase in early stabilization in the thoracic and lumbar spine was seen. In the group of patients with early surgical stabilization, significantly shorter hospital stays, shorter intensive care unit stays, fewer days on mechanical ventilation, and lower rates of sepsis were seen. In the case that additional body regions were affected, for example, when patients were critically ill, a delayed spinal stabilization was more often performed. CONCLUSION: A spinal stabilization at an early stage (<72 hours) is presumed to be beneficial. Although some patients may require delay due to necessary medical improvement, every reasonable effort should be made to treat patients with instable spinal column fractures as soon as possible. If an early surgical treatment is feasible, severely injured patients may benefit from a shorter period of hospital treatment and a lower rate of complications. LEVEL OF EVIDENCE: Therapeutic study, level III.

Complications associated with surgical treatment of traumatic spinal fractures: a review of the scoliosis research society morbidity and mortality database.

OBJECTIVE: Traumatic spinal fracture is a common indication for surgery, with an associated high incidence of perioperative complications. The literature provides a wide range in the incidence of complications. We seek to assess the perioperative morbidity and mortality of surgery for traumatic spinal fractures and to identify predictors of their occurrence. METHODS: We performed a retrospective analysis of all traumatic spinal fracture cases submitted by members of the Scoliosis Research Society from 2004 to 2007. RESULTS: A total of 108,478 cases were submitted from 2004 through 2007, with 6,706 (6.2%) performed for treatment of traumatic fracture. Twenty-two percent of patients had preoperative neurological deficits. Intraoperative neuromonitoring was used in 58% of cases. The overall incidence of complications was 6.9%. The perioperative mortality was 0.5%. There were 59 (0.9%) new postoperative neurological deficits. Multivariate analysis demonstrated preoperative neurological deficit (P = .001; odds ratio [OR] 1.449, 95% confidence interval [CI] [1.156 to 1.817]) and fusion (P =.001; OR 1.12, 95% CI [1.072 to 1.168]) as predictors of complications and use of intraoperative neuromonitoring (P = .016; OR 1.949, 95% CI [1.13 to 3.361]), and preoperative neurological deficit (P < .001; OR 2.964, 95% CI [1.667 to 5.271]) as predictors of new postoperative neurological deficits (P < .001). CONCLUSIONS: Overall, surgery for the treatment of spinal fractures was performed with relatively low incidences of perioperative complications (6.9%) and mortality (0.5%). These data may prove useful for patient counseling and ongoing efforts to improve the safety of operative care for patients with spinal fracture.

Motorised two-wheeler crash and helmets: injury patterns, severity, mortality and the consequence of gender bias.

BACKGROUND: India records the maximum number of deaths from motorised two-wheeler vehicle (MTV) accidents in the world with mandatory helmet laws for males but not females. This study was designed to investigate injury patterns, severity, mortality, and helmet usage among hospital admitted victims of a MTV crash with a paired subgroup analyses on female victims. METHODS: Hospital trauma registry from January 2011 to July 2012 for all adult victims of a MTV crash was analysed for outcomes of mortality, serious head injury, severe facial injury, and cervical spine injury while adjusting for age, gender, use of alcohol/drugs, injury severity score, and presence of shock by multivariable logistic regression model. Groups of helmeted victims (HV) and nonhelmeted victims (NHV) were identified. RESULTS: A total of 2,718 victims were included. HV suffered maximum injuries to the lower extremity (29.04 %) and had reduced adjusted odds of death (odds ratio (OR) 0.65; 95 % confidence interval (CI) 0.48-0.86), serious head injury (OR 0.34; CI 0.26-0.45), cervical spine injury (OR 0.74; CI 0.54-1.06), and serious facial injury (OR 0.87; CI 0.57-1.26) compared with NHV who suffered maximum injuries to the head (24.49 %). Compliance with helmet use was 52.91 and 7.94 % among males and females respectively. A total of 224 pairs of male driver and female pillion involved in same MTV crash were identified, and the predominantly helmeted male had reduced odds of death (OR 0.44; CI 0.21-0.84) and severe head injury (OR 0.42; CI 0.24-0.72) compared with overwhelmingly nonhelmeted females. CONCLUSIONS: Helmet laws must be strictly enforced, and society should think about the cost being born by its fairer counterpart by the gender-based differential law.