The Nature and Cost of Readmissions after Work-Related Traumatic Spinal Injuries in New South Wales, Australia.

This study aimed to measure the subsequent health and health service cost burden of a cohort of workers hospitalised after sustaining work-related traumatic spinal injuries (TSI) across New South Wales, Australia. A record-linkage study (June 2013-June 2016) of hospitalised cases of work-related spinal injury (ICD10-AM code U73.0 or workers compensation) was conducted. Of the 824 individuals injured during this time, 740 had sufficient follow-up data to analyse readmissions ≤90 days post-acute hospital discharge. Individuals with TSI were predominantly male (86.2%), mean age 46.6 years. Around 8% (n = 61) experienced 119 unplanned readmission episodes within 28 days from discharge, over half with the primary diagnosis being for care involving rehabilitation. Other readmissions involved device complications/infections (7.5%), genitourinary or respiratory infections (10%) or mental health needs (4.3%). The mean ± SD readmission cost was $6946 ± $14,532 per patient. Unplanned readmissions shortly post-discharge for TSI indicate unresolved issues within acute-care, or poor support services organisation in discharge planning. This study offers evidence of unmet needs after acute TSI and can assist trauma care-coordinators' comprehensive assessments of these patients prior to discharge. Improved quantification of the ongoing personal and health service after work-related injury is a vital part of the information needed to improve recovery after major work-related trauma.

Surgical timing for cervical and upper thoracic injuries in patients with polytrauma.

OBJECTIVE Few studies have investigated the advantages of early spinal stabilization in the patient with polytrauma in terms of reduction of morbidity and mortality. Previous analyses have shown that early stabilization may reduce ICU stay, with no effect on complication rates. METHODS The authors prospectively observed 340 polytrauma patients with an Injury Severity Score (ISS) of greater than 16 at a single Level 1 trauma center who were treated in accordance with a protocol termed "early appropriate care," which emphasizes operative treatment of various fractures within 36 hours of injury. Of these patients, 46 had upper thoracic and/or cervical spine injuries. The authors retrospectively compared patients treated according to protocol versus those who were not. Continuous variables were compared using independent t-tests and categorical variables using Fisher's exact test. Logistic regression analysis was performed to account for baseline confounding factors. RESULTS Fourteen of 46 patients (30%) did not undergo surgery within 36 hours. These patients were significantly more likely to be older than those in the protocol group (53 vs 38 years, p = 0.008) and have greater body mass index (BMI; 33 vs 27, p = 0.02), and they were less likely to have a spinal cord injury (SCI) (82% did not have an SCI vs 44% in the protocol group, p = 0.04). In terms of outcomes, patients in the protocol-breach group had significantly more total ventilator days (13 vs 6 days, p = 0.02) and total ICU days (16 vs 9 days, p = 0.03). Infection rates were 14% in the protocol-breach group and 3% in the protocol group (p = 0.2) Total complications trended toward being statistically significantly more common in the protocol-breach group (57% vs 31%). After controlling for potential confounding variables by logistic regression (including age, sex, BMI, race, and SCI), total complications were significantly (p < 0.05) greater in the protocol-breach group (OR 29, 95% CI 1.9-1828). This indicates that the odds of developing "any complication" were 29 times greater if treatment was delayed more than 36 hours. CONCLUSIONS Early surgical stabilization in the polytrauma patient with a cervical or upper thoracic spine injury is associated with fewer complications and improved outcomes. Hospitals may consider the benefit of protocols that promote early stabilization in this patient population.

Femur fractures should not be considered distracting injuries for cervical spine assessment.

INTRODUCTION: The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries. OBJECTIVES: We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging. METHODS: We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated. RESULTS: Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%). CONCLUSIONS: In our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.

Principais complicações do Traumatismo Raquimedularnos pacientes internados na unidade de neurocirurgiado Hospital de Base do Distrito Federal / Major complications Spinal Trauma in patients in neurosurgery unit BaseHospital Distrito Federal

Introdução: O trauma raquimedular é uma agressão à medula espinhalque pode ocasionar danos neurológicos, tais como alterações da funçãomotora, sensitiva e autônoma. Acidentes automobilísticos, queda de altura,acidente por mergulho em água rasa e ferimentos por arma de fogo têmsido as principais causas de traumatismo raquimedular.Objetivos: Levantar as principais complicações do traumatismo raquimedularnos pacientes internados na unidade de neurocirurgia do Hospitalde Base do Distrito Federal no ano de 2012.Metodologia: Trata-se de um estudo quantitativo, retrospectivo, descritivo,com corte transversal, realizado por meio de pesquisa de dados secundários.O estudo foi realizado com dados obtidos no banco de dadosdo prontuário eletrônico (TRACK CARE) do Hospital de Base do DistritoFederal.Resultado e discussão: A avaliação dos 36 prontuários eletrônicos de vítimasde traumatismo raquimedular permitiu verificar as complicações demaior incidência, sendo a bexiga neurogênica (intrínseca da patologia) e aúlcera por pressão (decorrente da internação) as mais prevalentes. Mais dametade dos pacientes apresentaram complicações durante a hospitalização,com destaque para a bexiga neurogênica, sendo que as lesões completasforam as que tiveram maior incidência de complicações relacionadasao traumatismo raquimedular.(AU)

Introduction: The spinal cord injury is an insult to the spinal cord whichcan cause neurological damage, such as changes in motor function, sensoryand autonomous. Automobile accidents, falls, accidents per dive inshallow water and injury by firearms have been the main causes of SpinalCord Trauma.Objectives: Raise the main complications of spinal cord injury in patientsadmitted to the neurosurgery unit of the Base Hospital District Federal in2012.Methodology: This is a quantitative, retrospective, descriptive, cross-sectionalstudy using secondary data research. The study was conducted withdata from the database of electronic medical records (TRACK CARE) ofthe Hospital de Base do Distrito Federal.Results and discussion: In the evaluation of the electronic medical recordsof 36 victims of spinal cord injury has shown complications, whichthe highest incidence of them was neurogenic bladder (intrinsic of the patology)and pressure ulcers (arising from hospitalization). Over half of thepatients had complications during hospitalization, especially the neurogenicbladder, more prevalent in complete lesions, which had the higherincidence of complications related to spinal cord injury.(AU)

The spine-injured patient: initial assessment and emergency treatment.

Failure to recognize spinal column or spinal cord injuries, or improper treatment of them, can have catastrophic and often irreversible neurologic consequences. Although the initial assessment is often shared with emergency care personnel, an orthopaedic surgeon's perspective can elevate the priority of spinal care to the level that is warranted. An accurate early appraisal, including complete neurologic assessment, is critical. All aspects of emergent care, including optimal immobilization precautions, resuscitation, and choice of imaging modalities, should be systematically reviewed, and practice guidelines should be adopted by each institution. Increased vigilance is required in patients with underlying ankylosing spinal conditions. The use of CT in the symptomatic patient is established, but the use of cervical MRI in the obtunded individual is contentious. By informing decisions around appropriate preliminary treatment, particularly for persons with neurologic deficits or those at high risk for developing neurologic impairment, long-term outcomes can be optimized.

Cervical spine - assessment following trauma.

BACKGROUND: Although cervical spine trauma is more common following high velocity mechanisms of injury resulting in multiple injuries, falls and low velocity mechanisms may also result in serious cervical spine injury. OBJECTIVE: This article describes the assessment and management of potential cervical spine injury in the primary care setting. DISCUSSION: Patients presenting following trauma should be assessed for risk of cervical spine injury according to one of two evidence based decision rules. If the nominated decision rule indicates high risk of injury, cervical spine imaging is indicated. An accurate history, physical examination and radiographic screening are required, preferably with computed tomography imaging, or five-view plain X-ray if computed tomography is unavailable. Magnetic resonance imaging should be considered in patients with neurologic symptoms or advanced cervical degenerative disease, as these patients are at particular risk of acute disc and ligamentous injury following trauma.

[Medicolegal assessment of post-traumatic vertigo]. / Begutachtung des posttraumatischen Schwindels.

Post-traumatic vertigo refers to a group of different disorders which occur following trauma, mainly closed head injury and whiplash injury of the cervical spine. Aside from headaches, vertigo is the most common symptom in this group of patients. In general, there are two main groups of patients with post-traumatic vertigo: those with documented vestibular dysfunctions and those without. The most common post-traumatic vestibular disorders are benign paroxysmal positioning vertigo, labyrinthine concussion, canal dehiscence and otolithic lesions. Some of these disorders are characterized by spontaneous improvement or recovery over weeks or months and some may also be treated effectively. A number of patients, however, develop phobic postural vertigo requiring psychiatric or psychosomatic exploration.

The initial assessment and management of the multiple-trauma patient with an associated spine injury.

STUDY DESIGN: Review and summary of the relevant literature from multiple disciplines. OBJECTIVE: Provide the readership with evidence-based guidelines on the initial assessment and treatment of the multiple-trauma patient with an associated spinal column injury. SUMMARY OF BACKGROUND DATA: Early operative stabilization of the isolated spinal column injury has decreased hospital and intensive care unit length of stay. Early intervention has not provided consistently improved neurologic outcomes. The timing of spinal column stabilization in the multiple-trauma patient continues to be a source of discussion. METHODS: Review of published English literature from 1990 to present using key words: spinal trauma, multiple-trauma with spinal injury; timing of spinal injury treatment; spinal fracture management; and Advanced Trauma Life Support. CONCLUSIONS: The treatment of the poly-trauma patient with an associated spinal column injury requires strict adherence to Advanced Trauma Life Support principles. Once life and limb-threatening injuries have been identified and addressed, spinal column assessment and neurologic protection must be maintained at the highest priority. Early spinal stabilization can be performed safely in the multiple-trauma patient in medical centers, in which medical and ancillary staff is available on a 24-hour basis and is familiar with these procedures.

Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria.

STUDY OBJECTIVE: We determine whether the use of an emergency medical services (EMS) protocol for selective spine immobilization would result in appropriate immobilization without spinal cord injury associated with nonimmobilization. METHODS: A 4-year prospective study examined EMS and hospital records for patients after the implementation of an EMS protocol for selective spine immobilization. EMS personnel were trained to perform and document a spine injury assessment for out-of-hospital trauma patients with a mechanism of injury judged sufficient to cause a spine injury. The assessment included these clinical criteria: altered mental status, evidence of intoxication, neurologic deficit, suspected extremity fracture, and spine pain or tenderness. The protocol required immobilization for patients with a positive assessment on any of those criteria. Outcome characteristics included the presence or absence of spine injury and spine injury management. RESULTS: The study collected data on 13,483 patients; 126 of the patients were subsequently excluded from the study because of incomplete data, leaving a study sample of 13,357 patients with complete data. Spine injuries were confirmed in the hospital records for 3% (n=415) of patients, including 50 patients with cord injuries and 128 patients with cervical injuries. Sensitivity of the EMS protocol was 92% (95% confidence interval [CI] 89.4 to 94.6%) resulting in nonimmobilization of 8% of the patients with spine injuries (33 of 415). None of the nonimmobilized patients sustained cord injuries. The specificity was 40% (95% CI 38.9 to 40.5%). CONCLUSION: The use of our selective immobilization protocol resulted in spine immobilization for most patients with spine injury without causing harm in cases in which spine immobilization was withheld.

Quantitative assessment of diffusion abnormalities in benign and malignant vertebral compression fractures by line scan diffusion-weighted imaging.

OBJECTIVE: Acute vertebral collapse is common, and it is sometimes difficult to determine whether the cause is benign or malignant. Recently, diffusion-weighted imaging has been reported to be useful for differentiating the two types. The purpose of this study was to evaluate diffusion abnormalities quantitatively in benign and malignant compression fractures using line scan diffusion-weighted imaging. SUBJECTS AND METHODS. Line scan diffusion-weighted imaging was prospectively performed in 17 patients with 20 acute vertebral compression fractures caused by osteoporosis or trauma, in 12 patients with 16 vertebral compression fractures caused by malignant tumors, and in 35 patients with 47 metastatic vertebrae without collapse. Images were obtained at b values of 5 and 1,000 sec/mm(2). The apparent diffusion coefficient (ADC) was measured in vertebral compression fractures and metastatic vertebrae without collapse. RESULTS: The ADC (mean +/- SD) was 1.21 +/- 0.17 x 10(-3) mm(2)/sec in benign compression fractures, 0.92 +/- 0.20 x 10(-3) mm(2)/sec in malignant compression fractures, and 0.83 +/- 0.17 x 10(-3) mm(2)/sec in metastatic vertebral lesions without collapse. The ADC was significantly higher in benign compression fractures than in malignant compression fractures (p < 0.01), although the two types showed considerable overlap. CONCLUSION: Although the quantitative assessment of vertebral diffusion provides additional information concerning compressed vertebrae, the benign and malignant compression fracture ADC values overlap considerably. Therefore, even a quantitative vertebral diffusion assessment may not always permit a clear distinction between benign and malignant compression fractures.

Single and incremental trauma models: a biomechanical assessment of spinal instability.

Biomechanical analysis of spinal injury in the laboratory requires the development of trauma models that simulate spinal instability. Current experimental trauma protocols consist of two types: single or incremental impacts. The incremental protocol has several advantages. However, the equivalence of the spinal instabilities produced by the two trauma protocols is currently unproven. The purpose of this study was to investigate whether the single and incremental trauma models produce equivalent soft tissue instabilities in the lumbar spine. Ten freshly frozen porcine lumbar spines were divided into two functional spinal units (FSUs), L2-L3 and L4-L5. FSUs were then randomized to either the single trauma (ST) or incremental trauma (IT) protocol. The IT protocol consisted of four sequentially increasing high-speed axial compression traumas, while the ST protocol was a single impact of the same magnitude as the final trauma of the IT. Before and after the final trauma, each FSU underwent flexibility testing under flexion/extension, lateral bending, and axial torsion pure moments. No significant differences were found in neutral zone or range of motion between IT and ST specimens in any of the three axes of motion, either before or after the trauma. In addition, no differences were found between the normalized motions of the IT and ST groups. The FSUs subjected to incremental trauma do not suffer greater injury than those subjected to a single impact. The data support the equivalency of the subfailure soft tissue injuries of the spine caused by the incremental and single trauma protocols respectively. This finding is important, because only with the incremental trauma protocol is one able to obtain injury threshold, study injury progression in the same specimen, produce a defined injury more accurately, and efficiently utilize scarce human cadaveric specimens.

MRI assessment of post-traumatic spinal instability.

The imaging evaluation of patients with spinal trauma has evolved over the past decades, and there has been particular interest in the concept of instability, to predict which a series of criteria have been proposed. We retrospectively evaluated the magnetic resonance imaging (MRI) findings in 50 patients with post-traumatic spinal instability according to Denis's three-column method, Daffner et al.'s radiographic criteria, and Oner et al.'s categorization of MRI findings; additionally, we evaluated the cord, the prevertebral tissue, and the epidural space. We suggest that an integrated panel of MRI information might be standardized in order to provide a more complete evaluation of spinal injury in an individual case and help planning surgical treatment.

No proof found that HIV was worsened by injury at work.

AIDS: A Louisiana appeals court ruled that [name removed], an employee at Interior Plant Designs, must return to work despite his contention that an on-the-job injury worsened his HIV infection. He suffered a spinal injury in 1994 and was on total temporary disability for 2 years. In 1996, the employer moved to have [name removed] classified as qualified for supplemental benefits, which would require his return to work in some capacity. [Name removed] opposed the change, but a workers' compensation judge backed the company's position. The appeals court later upheld that decision, ruling that [name removed] failed to prove he was unable to perform any work. His HIV specialist cautioned that the accident and related pain could worsen his HIV condition to the point where it is fatal.^ieng

Components of initial and residual disability after back injury in nurses.

STUDY DESIGN: A pre- versus postintervention with concurrent control group design was used to investigate the effect of a workplace-based early intervention program on perception of disability in nurses with low back injury. OBJECTIVES: This report examines changes over time in the components of the Oswestry Low Back Pain and Disability Questionnaire in two groups of back-injured nurses-those who received the early intervention program (study) and those who were not offered the program (control). SUMMARY OF BACKGROUND DATA: Early intervention programs can decrease morbidity, time lost from work, and compensation costs. Although perception of disability decreases, some residual disability remains, the nature of which is not clear. METHODS: The Oswestry Low Back Pain and Disability Questionnaire scores of 40 study nurses and 118 control nurses at time of injury and at 6 months after injury were examined. Analysis of variance was used to compare changes in mean overall scores over time. The proportion of nurses reporting disability on individual components of the Oswestry Low Back Pain and Disability Questionnaire at each time period was compared with the results of a chi-square test. RESULTS: Overall Oswestry Low Back Pain and Disability Questionnaire scores were similar between study and control nurses at time of injury, but were significantly lower in study nurses at 6 months after injury. However, scores of individual Oswestry Low Back Pain and Disability Questionnaire components that related to job demands increased over time; this was most apparent in lifting, particularly in study nurses. CONCLUSIONS: Although overall perception of disability decreased 6 months after injury, particularly in study nurses, disability in job-related activities persisted. Residual disability after back injury should be addressed in workplace-based prevention programs.

Cervical spine injury complicating facial trauma: incidence and management.

PURPOSE: To review the impact of concomitant cervical spine injury on the management of facial fractures in a tertiary care institution via a retrospective chart review. PATIENTS AND METHODS: Within the past 10 years, 1,750 consecutive patients presented to our institution with facial fractures. Thirty-two had concomitant cervical spine injury. Five were transferred or died before treatment. The remaining 27 charts were reviewed in detail. RESULTS: The incidence of cervical spine injury among patients with facial fractures in our study was 1.8%. There were no treatment delays attributed to these injuries. Of note was the inaccuracy of lateral cervical spine films in 9 of 27 cases (33%). CONCLUSION: Although uncommon, cervical spine injury must be thoroughly ruled out before evaluation and management of facial trauma. Concomitant cervical spine injury should not delay appropriate and timely treatment of facial fractures because adequate means of intraoperative stabilization are readily available.

Congenital spine deformity, congenital stenosis, diastematomyelia, and tight filum terminale in a workmen's compensation patient: a case report.

STUDY DESIGN: This case report concerns a patient injured at work who was denied adequate evaluation and treatment by a Workman's Compensation Commission, resulting in nearly complete paraplegia. OBJECTIVES: For a patient with a congenital spine deformity, a diastematomyelia, a tight filum terminale, and a congenital stenosis, denial of magnetic resonance imaging evaluation and appropriate surgery cannot be justified. SUMMARY OF BACKGROUND DATA: This 35-year-old man injured his knee and back in a fall at work but was able to work for 1 week. Progressive neurologic deterioration was documented, but magnetic resonance imaging evaluation was denied. When it finally obtained and the lesion identified, appropriate neurosurgery was denied. METHODS: When seen by the authors more than 3 years after his injury, he had a nearly complete paraplegia. Despite neurosurgical decompression and spine stabilization, no significant recovery occurred. RESULTS: A nearly complete paraplegia resulted from this combination of lesions coupled with intolerable delay in diagnosis and therapy, both the result of "foot-dragging" by a Workmen's Compensation Commission. CONCLUSIONS: In an effort to be "cost-conscious" and to avoid "unnecessary low back surgery," a Workmen's Compensation Commission has caused a patient to become paraplegic. Such management is neither cost-effective nor of adequate quality.

Is routine cervical spine radiographic evaluation indicated in patients with mandibular fractures?

Fractures of the mandible are commonly seen in most urban trauma centers. Over the past decade, the authors have seen a rise in these injuries secondary to an increase in drug and alcohol abuse, violent crime, and high-speed motor vehicle accidents. Several reports have described an association between mandibular fractures and cervical spine injuries and recommend routine cervical spine radiographs in all patients with mandibular injuries. These studies have failed to show a "cause and effect" relationship because of concomitant injuries found in these patients. This study reviews mandibular fractures and cervical spine injury retrospectively and prospectively over a 3-year period. The retrospective study included patients with isolated mandibular fractures who came to Cooper Hospital/University Medical Center Emergency Room in 1987. Thirty patients were identified, 18 of whom had cervical spine x rays. No patients had a significant radiologic or clinical cervical spine injury. The prospective study included all patients with mandibular fractures seen in the emergency room during 1988 and 1989. Seventy-three patients were identified, 44 of whom had mandibular and cervical spine radiographs. None had a significant radiologic or clinical cervical spine injury. The authors conclude that routine cervical spine x rays are costly and unnecessary. Also, any patient with a suspicion of concomitant cervical spine injury (i.e., patients with a loss of consciousness, multi-organ system injury, cervical pain or tenderness, or intoxication from alcohol use) should have cervical spine x rays, including anteroposterior, lateral, and open-mouth odontoid views.