Thoracoscopic Correction of Post-traumatic Kyphosis with an Expandable Cage: Radiologic and Patient-Reported Outcomes.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To determine the long-term functional and radiological outcomes after thoracoscopic post-traumatic kyphosis (PTK) correction (PTKC). OVERVIEW OF LITERATURE: PTK after insufficient treatment of unstable fractures usually presents with pain and decreased back function. The results of PTKC using a minimally invasive thoracoscopic approach with an anterior titanium cage have not previously been reported. METHODS: Data in this study were collected from all patients who underwent thoracoscopic PTKC with an expandable cage between 2007 and 2017. Kyphosis and intervertebral body height were assessed on radiographic material. Quality of life (QOL) and functional outcome scores were determined by the Euroquol 5 dimensions (EQ5D) and the Oswestry Disability Index (ODI). Additionally, satisfaction and subjective symptom improvement were determined. RESULTS: Fourteen patients were treated for symptomatic PTK using a combined thoracoscopic anterior and posterior approach. Nine patients received initial conservative fracture treatment and five patients underwent initial posterior fracture fixation. All patients presented with pain and without neurologic injury. The mean time between injury and PTKC was 15.4 months. Cobb angle (CA) improved with 10.6° immediately after PTKC. During the first follow-up, 4.8° kyphosis correction was lost, but CAs remained stable at longer follow-up. Bony fusion was achieved in 92% of the patients after 16 months. The majority of patients reported an improvement of symptoms 85 months after surgery, satisfaction with and willingness to undergo the procedure again. The mean EQ5D index score was 0.71 and the mean ODI score was 22.3. CONCLUSIONS: The results of minimally invasive thoracoscopic PTKC using an expandable cage were satisfactory. The majority of the patients were satisfied after treatment and no neurological complications occurred. Functional and QOL scores were fairly good. Whereas some postoperative kyphosis correction was lost over time, bony fusion was achieved in the majority of the patients. The thoracoscopic approach minimizes surgical morbidity, does not lead to serious complications, and provides a good option for PTKC.

Thoracoscopic anterior stabilization for thoracolumbar fractures in patients without spinal cord injury: quality of life and long-term results.

PURPOSE: To determine the health-related quality of life (QOL), safety and radiologic parameters after thoracoscopic treatment of traumatic thoracolumbar fractures using a distractible cage in patients without spinal cord injury (SCI). METHODS: Retrospective cohort study of patients treated between 2004 and 2012 in a university level-one trauma center. Patient and treatment characteristics were collected from the hospital information system. All available radiographic material was assessed for fracture characteristics and Cobb angle at consecutive times. Patients completed the SF-36 and EQ-5D QOL questionnaires at follow-up. RESULTS: 105 patients were treated with a distractible cage, which was performed thoracoscopically in 86 cases, including 16 patients with SCI. Of 70 eligible patients, 46 were available for follow-up and completed the questionnaires at median 49 months after surgery. QOL was lower on most domains compared to the general population. Compared to patients who underwent solely posterior fixation for less severe fractures, QOL did not differ significantly. The complication rate was low (10%) with one re-operation. Mean loss of correction was 6.8° and bony fusion on CT scan was present in 98% of patients. Maintenance of kyphosis correction was significantly better for two segments anterior fixation compared to one segment. CONCLUSIONS: Thoracoscopic anterior stabilization leads to a high percentage of bony fusion in highly unstable thoracic and thoracolumbar fractures with limited post-operative loss of correction and no hardware failure. QOL of these patients does not return to normal population values but is comparable to that of patients with less severe fractures treated with solely posterior instrumentation. These slides can be retrieved under Electronic Supplementary Material.

Efficacy of oxytocin administration early after psychotrauma in preventing the development of PTSD: study protocol of a randomized controlled trial.

BACKGROUND: Currently few evidence based interventions are available for the prevention of PTSD within the first weeks after trauma. Increased risk for PTSD development is associated with dysregulated fear and stress responses prior to and shortly after trauma, as well as with a lack of perceived social support early after trauma. Oxytocin is a potent regulator of these processes. Therefore, we propose that oxytocin may be important in reducing adverse consequences of trauma. The 'BONDS' study is conducted in order to assess the efficacy of an early intervention with intranasal oxytocin for the prevention of PTSD. METHODS/DESIGN: In this multicenter double-blind randomized placebo-controlled trial we will recruit 220 Emergency Department patients at increased risk of PTSD. Trauma-exposed patients are screened for increased PTSD risk with questionnaires assessing peri-traumatic distress and acute PTSD symptoms within 7 days after trauma. Baseline PTSD symptom severity scores and neuroendocrine and psychophysiological measures will be collected within 10 days after trauma. Participants will be randomized to 7.5 days of intranasal oxytocin (40 IU) or placebo twice a day. Follow-up measurements at 1.5, 3 and 6 months post-trauma are collected to assess PTSD symptom severity (the primary outcome measure). Other measures of symptoms of psychopathology, and neuroendocrine and psychophysiological disorders are secondary outcome measures. DISCUSSION: We hypothesize that intranasal oxytocin administered early after trauma is an effective pharmacological strategy to prevent PTSD in individuals at increased risk, which is both safe and easily applicable. Interindividual and contextual factors that may influence the effects of oxytocin treatment will be considered in the analysis of the results. TRIAL REGISTRATION: Netherlands Trial Registry: NTR3190.

Internet-based early intervention to prevent posttraumatic stress disorder in injury patients: randomized controlled trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) develops in 10-20% of injury patients. We developed a novel, self-guided Internet-based intervention (called Trauma TIPS) based on techniques from cognitive behavioral therapy (CBT) to prevent the onset of PTSD symptoms. OBJECTIVE: To determine whether Trauma TIPS is effective in preventing the onset of PTSD symptoms in injury patients. METHODS: Adult, level 1 trauma center patients were randomly assigned to receive the fully automated Trauma TIPS Internet intervention (n=151) or to receive no early intervention (n=149). Trauma TIPS consisted of psychoeducation, in vivo exposure, and stress management techniques. Both groups were free to use care as usual (nonprotocolized talks with hospital staff). PTSD symptom severity was assessed at 1, 3, 6, and 12 months post injury with a clinical interview (Clinician-Administered PTSD Scale) by blinded trained interviewers and self-report instrument (Impact of Event Scale-Revised). Secondary outcomes were acute anxiety and arousal (assessed online), self-reported depressive and anxiety symptoms (Hospital Anxiety and Depression Scale), and mental health care utilization. Intervention usage was documented. RESULTS: The mean number of intervention logins was 1.7, SD 2.5, median 1, interquartile range (IQR) 1-2. Thirty-four patients in the intervention group did not log in (22.5%), 63 (41.7%) logged in once, and 54 (35.8%) logged in multiple times (mean 3.6, SD 3.5, median 3, IQR 2-4). On clinician-assessed and self-reported PTSD symptoms, both the intervention and control group showed a significant decrease over time (P<.001) without significant differences in trend. PTSD at 12 months was diagnosed in 4.7% of controls and 4.4% of intervention group patients. There were no group differences on anxiety or depressive symptoms over time. Post hoc analyses using latent growth mixture modeling showed a significant decrease in PTSD symptoms in a subgroup of patients with severe initial symptoms (n=20) (P<.001). CONCLUSIONS: Our results do not support the efficacy of the Trauma TIPS Internet-based early intervention in the prevention of PTSD symptoms for an unselected population of injury patients. Moreover, uptake was relatively low since one-fifth of individuals did not log in to the intervention. Future research should therefore focus on innovative strategies to increase intervention usage, for example, adding gameplay, embedding it in a blended care context, and targeting high-risk individuals who are more likely to benefit from the intervention. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 57754429; http://www.controlled-trials.com/ISRCTN57754429 (Archived by WebCite at http://webcitation.org/6FeJtJJyD).

[Surgical correction of post-traumatic kyphosis: a thoracoscopic approach]. / Operatieve correctie van posttraumatische kyfose: een thoracoscopische benadering.

Conservative treatment of an unstable spinal fracture can give lead to post-traumatic kyphosis, and may give rise to serious back pain. Surgical correction can alleviate the problem in patients with this deformity. Operative correction of kyphotic deformities of the thoracic spine and deformities at the level of the thoracolumbar junction are often performed via a thoracotomy or a thoraco-phrenico-laparotomy, respectively. There are also some correction techniques that are only performed via a posterior approach. In accordance with general surgical trends, spinal surgery tries to use minimally invasive intervention in order to reduce operative trauma, postoperative pain and complications. In the authors' hospital, patients with unstable spinal fractures have been undergoing surgery using a thoracoscopic approach for the past few years; now patients with post-traumatic kyphosis are also being treated using a minimally invasive approach. The thoracoscopic approach has been used in major centres abroad for some time, but has not previously been described in the Netherlands.

Helicopter Emergency Medical Services save lives: outcome in a cohort of 1073 polytraumatized patients.

BACKGROUND: In many Western countries, Helicopter Emergency Medical Services (HEMS) have become standard in the prehospital care of severely injured patients. Several studies have shown that HEMS have a positive effect on patient's outcome, although it remains unclear which specific patients benefit most from its care. The aim of this study was to assess the effect of HEMS on the outcome of a large polytraumatized (Injury Severity Score≥16) population. METHODS: All polytraumatized patients treated at the scene of the accident by EMS and/or HEMS and presented in the VU University Medical Center during a period of 6 years were included and retrospectively analyzed. The total population was divided into two groups according to the presence of HEMS on-scene. Prehospital, in-hospital, and outcome parameters were compared. The Trauma Injury Severity Score method was used to calculate the probability of survival. RESULTS: Almost 60% of all included patients (n=1073) were treated only by an EMS crew on-scene. The remaining 446 patients received additional HEMS care. Significant differences between these two groups were observed in the demographic characteristics, showing that the HEMS group was more severely injured. The predicted survival was calculated using the Trauma Injury Severity Score method, as well as the observed survival, both showing a significantly higher outcome for the EMS group (0.88 vs. 0.66% and 87.7 vs. 71.3%). However, the Z-statistic showed a significant positive difference between the predicted and the observed survival for the HEMS group (P<0.005) and no significant differences for the EMS group (P>0.1), indicating that the chance of surviving in the HEMS group was higher. Per 100 HEMS dispatches, 5.4 additional lives were saved. A correlation of the observed survival with the first measured Revised Trauma Score on-scene showed a positive effect for the HEMS group when the Revised Trauma Score reached a value of 9 or lower. CONCLUSION: On-scene HEMS care has a positive effect on the survival of polytraumatized patients, saving 5.4 additional lives per 100 HEMS deployments. This positive effect is especially observed in patients with abnormal vital signs (respiratory and hemodynamically). Research and revision of dispatch criteria are important to reach patients that benefit most from HEMS care.

The effect of tertiary surveys on missed injuries in trauma: a systematic review.

BACKGROUND: Trauma tertiary surveys (TTS) are advocated to reduce the rate of missed injuries in hospitalized trauma patients. Moreover, the missed injury rate can be a quality indicator of trauma care performance. Current variation of the definition of missed injury restricts interpretation of the effect of the TTS and limits the use of missed injury for benchmarking. Only a few studies have specifically assessed the effect of the TTS on missed injury. We aimed to systematically appraise these studies using outcomes of two common definitions of missed injury rates and long-term health outcomes. METHODS: A systematic review was performed. An electronic search (without language or publication restrictions) of the Cochrane Library, Medline and Ovid was used to identify studies assessing TTS with short-term measures of missed injuries and long-term health outcomes. 'Missed injury' was defined as either: Type I) any injury missed at primary and secondary survey and detected by the TTS; or Type II) any injury missed at primary and secondary survey and missed by the TTS, detected during hospital stay. Two authors independently selected studies. Risk of bias for observational studies was assessed using the Newcastle-Ottawa scale. RESULTS: Ten observational studies met our inclusion criteria. None was randomized and none reported long-term health outcomes. Their risk of bias varied considerably. Nine studies assessed Type I missed injury and found an overall rate of 4.3%. A single study reported Type II missed injury with a rate of 1.5%. Three studies reported outcome data on missed injuries for both control and intervention cohorts, with two reporting an increase in Type I missed injuries (3% vs. 7%, P<0.01), and one a decrease in Type II missed injuries (2.4% vs. 1.5%, P=0.01). CONCLUSIONS: Overall Type I and Type II missed injury rates were 4.3% and 1.5%. Routine TTS performance increased Type I and reduced Type II missed injuries. However, evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias. Future studies should address these issues to allow for the use of missed injury rate as a quality indicator for trauma care performance and benchmarking.

Criteria for cancelling helicopter emergency medical services (HEMS) dispatches.

INTRODUCTION: In The Netherlands there is no consensus about criteria for cancelling helicopter emergency medical services (HEMS) dispatches. This study assessed the ability of the primary HEMS dispatch criteria to identify major trauma patients. The predictive power of other early prehospital parameters was evaluated to design a safe triage model for HEMS dispatch cancellations. METHODS: All trauma-related dispatches of HEMS during a period of 6 months were included. Data concerning prehospital information and inhospital treatment were collected. Patients were divided into two groups (major and minor trauma) according to the following criteria: injury severity score 16 or greater, emergency intervention, intensive care unit admission, or inhospital death. Logistic regression analysis was used to design a prediction model for the early identification of major trauma patients. RESULTS: In total, 420 trauma-related dispatches were evaluated, of which 155 concerned major trauma patients. HEMS was more often cancelled for minor trauma patients than for major trauma patients (57.7% vs 20.6%). Overall, HEMS dispatch criteria had a sensitivity of 87.7% and a specificity of 45.3% for identifying major trauma patients. Significant differences were found for vital sign abnormalities, anatomical components and several parameters of the mechanism of injury. A triage model designed for cancelling HEMS correctly identified major trauma patients (sensitivity 99.4%). CONCLUSION: The accuracy of the current HEMS dispatch criteria is relatively low, resulting in high cancellation rates and low predictability for major trauma. The new HEMS cancellation triage model identified all major trauma patients with an acceptable overtriage and will probably reduce unjustified HEMS dispatches.

Effect of secondary prehospital risk factors on outcome in severe traumatic brain injury in the context of fast access to trauma care.

BACKGROUND: Prevention of secondary prehospital risk factors such as hypoxia and hypotension is likely to improve patient prognosis in severe traumatic brain injury (TBI). Because the Dutch trauma care organization is characterized by fast access to specialized trauma care due to the geographical situation, we investigated whether and to what extend secondary risk factors, such as hypoxia and hypotension, and measures, such as endotracheal intubation, affect outcome in severe TBI in the context of a region with fast access to trauma care. METHODS: The medical records of 339 subsequent computed tomography-confirmed patients with TBI with a Glasgow coma scale (GCS) score≤8 who were primarily referred to a Level I trauma center in Amsterdam or Nijmegen in the Netherlands were retrospectively analyzed. RESULTS: Multinomial logistic regression revealed that the strongest outcome predictors in our population were a disturbed pupillary reflex (odds ratio [OR], 5.8), a GCS score of 3 (OR, 4.9), and arterial hypotension (OR, 3.5). Interestingly, we observed no differences between intubated and nonintubated patients with respect to metabolic and respiratory parameters or mortality whereby the injury severity score was slightly higher in endotracheally intubated patients (32 [25-41]) versus nonintubated patients (25 [22-29]). CONCLUSION: In agreement with others, GCS, a disturbed pupil reflex, and arterial hypotension were predictive for the prognosis of primarily referred patients with severe TBI in the Netherlands. In contrast, in the perspective of slightly higher injury scores in intubated patients, prehospital endotracheal intubation was not predictive for patient outcome.

Is a maximum Revised Trauma Score a safe triage tool for Helicopter Emergency Medical Services cancellations?

INTRODUCTION: The Revised Trauma Score is used worldwide in the prehospital setting and provides a snapshot of patient's physiological state. Several studies have shown that the reliability of the RTS is high in trauma outcomes. In the Netherlands, Helicopter Emergency Medical Services (HEMS) are mostly used for delivery of specialized trauma teams on-scene and occasionally for patient transportation. In our trauma system, the Emergency Medical Services crew performs triage after arrival on-scene and cancels the HEMS-dispatch if deemed unnecessary. In this study we assessed the ability of a maximum on-scene Revised Trauma Score (RTS=12) to be used as a triage tool for HEMS cancellation. METHODS: All patients with a maximum on-scene RTS after blunt trauma (with or without receiving HEMS care) who were presented in the trauma resuscitation room of two Level-1 trauma centers during a period of 6 months, were included. Information concerning prehospital and in-hospital vital parameters, severity and localization of the injuries, and the in-hospital course were analyzed. Major trauma patients were classified using the following parameters: Injury Severity Score of at least 16, emergency intervention, Intensive Care Unit admission, and in-hospital death. RESULTS: Four-hundred and forty blunt trauma patients having a maximum RTS were included between 1 July and 31 December 2006. Eighty patients received on-scene HEMS care. Almost 16% of the total population concerned major trauma patients, of which only 25 (36%) received HEMS care. In 17 patients (3.9%), the RTS deteriorated during transportation. Major trauma patients sustained more injuries to the chest, abdomen, and lower extremities. CONCLUSION: The RTS alone is not a reliable triage tool for HEMS cancellations in our trauma system and will lead to a considerable rate of undertriage with one in every six cancellations being incorrect. Other criteria based on patient's vital signs, combined with anatomical and mechanism of injury parameters should be developed to safely minimize triage errors.

An evaluation of a Shockroom located CT scanner: a randomized study of early assessment by CT scanning in trauma patients in the bi-located trauma center North-West Netherlands (REACT trial).

BACKGROUND: Trauma is a major source of morbidity and mortality, especially in people below the age of 50 years. For the evaluation of trauma patients CT scanning has gained wide acceptance in and provides detailed information on location and severity of injuries. However, CT scanning is frequently time consuming due to logistical (location of CT scanner elsewhere in the hospital) and technical issues. An innovative and unique infrastructural change has been made in the AMC in which the CT scanner is transported to the patient instead of the patient to the CT scanner. As a consequence, early shockroom CT scanning provides an all-inclusive multifocal diagnostic modality that can detect (potentially life-threatening) injuries in an earlier stage, so that therapy can be directed based on these findings. METHODS/DESIGN: The REACT-trial is a prospective, randomized trial, comparing two Dutch level-1 trauma centers, respectively the VUmc and AMC, with the only difference being the location of the CT scanner (respectively in the Radiology Department and in the shockroom). All trauma patients that are transported to the AMC or VUmc shockroom according to the current prehospital triage system are included. Patients younger than 16 years of age and patients who die during transport are excluded. Randomization will be performed prehospitally. Study parameters are the number of days outside the hospital during the first year following the trauma (primary outcome), general health at 6 and 12 months post trauma, mortality and morbidity, and various time intervals during initial evaluation. In addition a cost-effectiveness analysis of this shockroom concept will be performed. Regarding primary outcome it is estimated that the common standard deviation of days spent outside of the hospital during the first year following trauma is a total of 12 days. To detect an overall difference of 2 days within the first year between the two strategies, 562 patients per group are needed. (alpha 0.95 and beta 0.80). DISCUSSION: The REACT-trial will provide evidence on the effects of a strategy involving early shockroom CT scanning compared with a standard diagnostic imaging strategy in trauma patients on both patient outcome and operations research. TRIAL REGISTRATION: ISRCTN55332315.

Cost-effectiveness of the SEN-concept: Specialized Emergency Nurses (SEN) treating ankle/foot injuries.

BACKGROUND: Emergency Departments (EDs) are confronted with progressive overcrowding. As a consequence, the workload for ED physicians increases and waiting times go up with the risk of unnecessary complications and patient dissatisfaction. To cope with these problems, Specialized Emergency Nurses (SENs), regular ED-nurses receiving a short, injury-specific course, were trained to assess and treat minor injuries according to a specific protocol. METHODS: An economic evaluation was conducted alongside a randomized controlled trial comparing House Officers (HOs) and SENs in their assessment of ankle and foot injuries. Cost prices were established for all parts of healthcare utilization involved. Total costs of health care utilization were computed per patient in both groups. Cost-effectiveness was investigated by comparing the difference in total cost between groups with the difference in sensitivity and specificity between groups in diagnosing fractures and severe sprains. Finally, cost-effectiveness ratios were calculated and presented on a cost-effectiveness plane. RESULTS: No significant differences were seen between treatment groups for any of the health care resources assessed. However, the waiting times for both first assessment by a treatment officer and time spent waiting between hearing the diagnosis and final treatment were significantly longer in the HO group. There was no statistically significant difference in costs between groups. The total costs were euro 186 (SD euro 623) for patients in the SEN group and euro 153 (SD euro 529) for patients in the HO group. The difference in total costs was euro 33 (95% CI: - euro 84 to euro 155). The incremental cost-effectiveness ratio was euro 27 for a reduction of one missed diagnosis and euro 18 for a reduction of one false negative. CONCLUSION: Considering the benefits of the SEN-concept in terms of decreased workload for the ED physicians, increased patient satisfaction and decreased waiting times, SENs appear to be a useful solution to the problem of ED crowding.

Specialized emergency nurses treating ankle and foot injuries: a randomized controlled trial.

OBJECTIVE: To cope with emergency departments (EDs) being progressively overcrowded, the concept of specialized emergency nurses (SENs) was conceived. In this study, the ability of SENs to treat ankle/foot injuries was assessed. METHODS: Regular emergency nurses were trained in a 2-day session that addressed all aspects of ankle/foot injuries. A randomized controlled trial was set up in which the diagnostic accuracy of SENs was compared with that of house officers (HOs). Secondary outcome parameter was patient satisfaction measured by a standardized questionnaire. RESULTS: In total, 512 consecutive patients were included. The sensitivity of SENs was 0.94 (95% confidence interval [CI], 0.78-0.99) compared with 0.78 (95% CI, 0.57-0.91) of HOs. Specificity was 0.94 (95% CI, 0.90-0.97) for SENs compared with 0.95 (95% CI, 0.91-0.98) for HOs. The delivered care by SENs was found to be significantly better and the median waiting time at the ED was significantly reduced (21 minutes for SENs vs 32 minutes for HOs). CONCLUSIONS: Specialized emergency nurses are capable of assessing and treating ankle/foot injuries accurately with excellent patient satisfaction and with a reduction of waiting times. Other injury-specific courses are now developed for this approach.

Cost-effectiveness of the treatment of traumatic thoracolumbar spine fractures: Nonsurgical or surgical therapy?

BACKGROUND: Spinal fractures can be an important cause for disabling back pain. Therefore, in judging the cost-effectiveness of nonsurgical or surgical therapy, not only direct costs but also the indirect costs should be calculated. In this prospective randomized study, the costs incurred by nonsurgically and surgically treated patients with a traumatic thoracolumbar spine fracture without neurological involvement were analysed. MATERIALS AND METHODS: 32 patients with a traumatic thoracolumbar spine fracture were prospectively randomized for operative or nonsurgical treatment. Patients were sent a questionnaire every three months to inquire about work-status, additional health costs and doctor visits. The patients who have minimum followup of two years were included. RESULTS: Of thirty-two patients, 30 met the criterion of the followup period of at least two years. Fourteen patients received nonsurgical therapy, while 16 received surgical treatment. Direct costs of the treatment of nonsurgically treated patients were €10,608 ($12,730). For the operatively treated group, these costs were €18,769 ($22,523). Indirect costs resulted in a total of €219,187 ($263,025) per nonoperatively treated patient. In the operatively treated group, these costs were €66,004 ($79,206). CONCLUSION: In the treatment of traumatic thoracolumbar spine fractures, the indirect costs exceed the direct costs by far and make up 95.4% of the total costs for treatment in nonsurgically treated patients and 71.6% of the total costs in the operative group. In view of cost-effectiveness, the operative therapy of traumatic thoracolumbar spine fractures is to be preferred.

Treatment of traumatic thoracolumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment.

STUDY DESIGN: Multicenter prospective randomized trial. OBJECTIVE: To test the hypotheses that thoracolumbar AO Type A spine fractures without neurologic deficit, managed with short-segment posterior stabilization will show an improved radiographic outcome and at least the same functional outcome as compared with nonsurgically treated thoracolumbar fractures. SUMMARY OF BACKGROUND DATA: There are various opinions regarding the ideal management of thoracolumbar Type A spine fractures without neurologic deficit. Both operative and nonsurgical approaches are advocated. METHODS: Patients were randomized for operative or nonsurgical treatment. Data sampling involved demographics, fracture classifications, radiographic evaluation, and functional outcome. RESULTS: Sixteen patients received nonsurgical therapy, and 18 received surgical treatment. Follow-up was completed for 32 (94%) of the patients after a mean of 4.3 years. At the end of follow-up, both local and regional kyphotic deformity was significantly less in the operatively treated group. All functional outcome scores (VAS Pain, VAS Spine Score, and RMDQ-24) showed significantly better results in the operative group. The percentage of patients returning to their original jobs was found to be significantly higher in the operative treated group. CONCLUSIONS: Patients with a Type A3 thoracolumbar spine fracture without neurologic deficit should be treated by short-segment posterior stabilization.

Spine fractures caused by horse riding.

STUDY DESIGN: Retrospective study and review of literature. OBJECTIVES: Study of demographic data concerning spinal fractures caused by horse riding, classification of fractures according to the AO and Load Sharing classifications, evaluation of mid-term radiological results and long-term functional results. METHODS: A review of medical reports and radiological examinations of patients presented to our hospital with horse riding-related spine fractures over a 13-year period; long-term functional follow-up is performed using the Roland Morris Disability Questionnaire (RMDQ-24). RESULTS: Thirty-six spine fractures were found in 32 patients. Male to female ratio is 1:7. Average age is 33.7 years (8-58 years). The majority of the fractures (78%) are seen at the thoracolumbar junction Th11-L2. All but two patients have AO type A fractures. The average Load Sharing Classification score is 4.9 (range 3-9). Neurological examinations show ASIA/Frankel E status for all patients. Surgical treatment is performed on ten patients. Mean follow-up for radiological data is 15 months (range 3-63). Functional follow-up times range from 1 to 13 years with an average follow-up of 7.3 years. Mean RMDQ-24 score for all patients is 5.5 (range: 0-19), with significantly different scores for the non-operative and surgical group: 4.6 vs 8.1. Twenty-two percent of the patients have permanent occupational disabilities and there is a significant correlation between occupational disability and RMDQ-24 scores. CONCLUSIONS: Not only are short-term effects of spine fractures caused by horse riding substantial but these injuries can also lead to long-term disabilities.

Diagnostic accuracy of lower extremity X-ray interpretation by 'specialized' emergency nurses.

OBJECTIVES: In the quest for a cost-effective and quality-preserving solution to manage crowding in the emergency department, the possibility of deploying regular emergency nurses for the treatment of acute ankle injuries was investigated. The aim of this study is to compare the diagnostic accuracy of emergency nurses with that of senior house officers in interpreting ankle and foot radiographs. METHODS: A prospective study comparing the assessment of 60 radiographs (30 feet and 30 ankles) by 16 emergency nurses before and after an educational session was performed. Each subset of 30 radiographs contained 12 fractures, hand-picked by a radiologist to represent everyday traumatology in the emergency department. The control group consisted of eight senior house officers representing everyday expertise. The outcome of the diagnostic assessment, represented as the pooled sensitivity and specificity for both groups, was compared using Z-statistics. RESULTS: Before the training session, the specialized emergency nurse group showed a sensitivity of 0.87 (confidence interval 0.83-0.91) compared with 0.93 (confidence interval 0.88-0.96) for the control group (P = 0.05). The specificity of specialized emergency nurses was 0.87 (confidence interval 0.81-0.92) compared with 0.93 (confidence interval 0.89-0.95) for the senior house officers (P < 0.05). After the training session, specialized emergency nurse diagnostic parameters did not differ significantly from the control group, displaying a sensitivity of 0.89 (confidence interval 0.86-0.92) and specificity of 0.92 (confidence interval 0.87-0.95). CONCLUSION: Before the training session, the specialized emergency nurse group showed a significantly lower accuracy than the SHO group. After training, however, the diagnostic accuracy did not differ significantly between groups. Therefore, we conclude that emergency nurses are able to accurately interpret foot and ankle radiographs after a short educational session.

Direct medical costs of traumatic thoracolumbar spine fractures.

BACKGROUND: The costs and cost-effectiveness of treatment of thoracolumbar fractures are poorly known. METHODS: We estimated the costs of hospital care and outpatient visits for patients with traumatic thoracolumbar spine fractures. RESULTS: Stable fractures without neurological deficits were treated nonoperatively and the costs were EUR 5,100. Unstable fractures without neurological deficits were treated either nonoperatively, with an average of 29 hospitalization days and average cost of EUR 12,500 (86% of which represented hospitalization costs), or operatively with 24 hospitalization days and average cost of EUR 19,700 (48% of which represented hospitalization costs and 42% surgery costs). Unstable fractures with neurological deficits were usually operated (average costs EUR 31,900). INTERPRETATION: For all patients, the costs of hospitalization days were the main cost driver. Although the length of stay for patients with unstable fractures and without neurological deficit who were treated operatively was shorter than for patients treated nonoperatively, the total costs were higher due to the additional costs of surgery. Surgical treatment must therefore be shown to give a better outcome in order to outweigh the costs. Future research should focus on the cost-effectiveness of operative and nonoperative treatment of patients with unstable vertebral fractures who have no neurological deficits, and take indirect costs and quality of life into account.

Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses.

OBJECTIVES: The ED is often confronted with long waiting periods. Because of the progressive shortage in general practitioners, further growth is expected in the number of patients visiting the ED without consulting a general practitioner first. These patients mainly present with minor injuries suitable for a standardized diagnostic protocol. The question was raised whether these injuries can be treated by trained ED nurses (specialized emergency nurses [SENs]). The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules (OAR) and Ottawa Foot Rules (OFR). METHODS: In a prospective study, all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor (house officer [HO]) randomized for first observer. Before the study, SENs were trained in applying OAR and OFR. In all patients, radiography was performed (gold standard). The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics. Furthermore, from the paired results, reproducibility was calculated using kappa statistics. RESULTS: In total, 106 injuries were assessed in pairs, of which 14 were ultimately found to concern acute fractures (prevalence, 13%). The sensitivity for the SEN group was 0.93 (95% confidence interval [CI], 0.64-1.00) compared with 0.93 (95% CI, 0.64-1.00) for the HO group (no significance [ns]). The specificity of the nurses was 0.49 (95% CI, 0.38-0.60) compared with 0.39 (95% CI, 0.29-0.50) for the doctors (ns). The positive predictive value for the SEN group was 0.22 (95% CI, 0.13-0.35) compared with 0.19 (95% CI, 0.11-0.31) for the HO group (ns). The negative predictive value for the nurses was 0.98 (95% CI, 0.87-1.00) compared with 0.97 (95% CI, 0.84-1.00) for the doctors (ns). The interobserver agreement for the OAR and OFR subsets was kappa = 0.38 for the lateral malleolus; kappa = 0.30, medial malleolus; kappa = 0.50, navicular; kappa = 0.45, metatarsal V base; and kappa = 0.43, weight-bearing. The overall interobserver agreement for the OAR was kappa = 0.41 and kappa = 0.77 for the OFR. CONCLUSION: Specialized emergency nurses are able to assess ankle and foot injuries in an accurate manner with regard to the detection of acute fractures after a short, inexpensive course.