Epidemiology of non-traumatic spinal cord injury in Ireland - a prospective population-based study.

Objective: To carry out a study of non-traumatic spinal cord injury (NTSCI) epidemiology in IrelandDesign: Prospective study of all new incident cases of NTSCI during 2017Setting: Republic of IrelandParticipants: All persons with a newly acquired NTSCIInterventions: NoneOutcome measures: Crude and age/sex specific incidences; ISCoS core dataset and non-traumatic dataset; population denominator was 2016 national census figures, adjusted to 2017.Results: Overall crude incidence of NTSCI in the Republic of Ireland in 2017 was 26.9 per million per year. Mean age at onset was 56.6 (SD 17.7) years. Females accounted for 51.2% of cases. Most frequent grade of ASIA impairment scale (AIS) was AIS D. Most common etiology was degenerate conditions (48.8%) followed by neoplastic (26.4%). The most common pattern of onset (51.2%) was lengthy (greater than one month).Conclusions: Incidence of NTSCI is more than double that for traumatic SCI in the Republic of Ireland. This suggests that the delivery of rehabilitation services to patients with spinal cord injuries requires prompt review and expansion.

The Impact of COVID-19 and Lockdown on Spinal Services at a National Level: Lessons Learned and Areas of Service Improvement for Future Health Care Delivery.

The coronavirus disease 2019 (COVID-19) pandemic has had a dramatic impact on the provision of health care worldwide. The delivery of national spinal service for emergent surgery, elective surgery, and outpatient assessment has been incredibly challenging. A variety of innovative measures were undertaken to facilitate the safe provision of acute service and are outlined in this review, along with a number of key learning points which will improve the quality of health care delivered over the coming years. The challenges facing the spinal surgery community with regard the reintroduction of elective surgery is discussed, and a potential roadmap for the safe resumption of services is presented.

Instant messaging apps and data protection: combining to improve hip fracture care?

INTRODUCTION: The General Data Protection Regulation (GDPR) continues to have implications for how healthcare information is managed and shared. This presents challenges as telemedicine plays a more central role in service healthcare service provision, particularly since the beginning of 2020. We aim to measure how improved communication through a GDPR-compliant messaging app can influence time-dependent key performance indicators for hip fracture management in a tertiary-referral trauma hospital. METHODS: Using an instant messaging service, a hip fracture group was created and access was provided to all stakeholders in hip fracture care-trainee and consultant emergency physicians and orthopaedic surgeons, as well as advanced nurse practitioners, bed managers, ward managers and theatre managers. Irish Hip Fracture Database (IHFD) standard compliance was compared from April to December 2017 and April to December 2018. RESULTS: Two periods in 2017 and 2018 saw 121 and 122 hip fracture patients admitted, respectively. Mean time to admission to an orthopaedic ward in 2017 was 47 ± 42.9 h and 33.3 ± 42 h in 2018 (P = 0.5). Mean time to surgery in 2017 was 83.66 ± 53.46 h and 39.11 ± 10.84 h in 2018 (p = 0.026). CONCLUSIONS: Irish Hip Fracture Database Standards present a challenge to orthopaedic departments competing with other hospital specialties for access to beds and theatre space. The introduction of a GDPR-compliant social media messaging service has contributed to significantly reducing the time to surgery for these patients. Streamlining communication through messaging services has and continues to be vital to improving care for hip fracture patients, both in the healthcare environment and beyond.

The impact of the SARS-CoV-2 pandemic on referral characteristics in a national tertiary spinal injuries unit.

BACKGROUND: The SARS-CoV-2 pandemic has had profound implications on healthcare institutions. AIMS: This study aims to assess and compare referral patterns during COVID-19 to corresponding dates for the preceding 3 years (2017-2019), in order to preemptively coordinate the logistics of the surgical unit for similar future experiences. METHODS: Retrospective review for our institution, a national tertiary referral centre for spine pathology. Two distinct time-points were chosen to represent the varied levels of social restriction during the current pandemic: (i) study period 1 (SP1) from 11 November 2020 to 08 June 2020 represents a national lockdown, and (ii) study period 2 (SP2) from 09 June 2020 to 09 September 2020 indicates an easing of restrictions. Both periods were compared to corresponding dates (CP1: 11 March-08 June and CP2 09 June-09 September) for the preceding 3 years (2017-2019). Data collected included age, gender, and mechanism of injury (MOI) for descriptive analyses. MOIs were categorised into disc disease, cyclist, road-traffic-accident (RTA), falls < 2 m, falls > 2 m, malignancy, sporting injuries, and miscellaneous. RESULTS: All MOI categories witnessed a reduction in referral numbers during SP1: disc disease (-29%), cyclist (-5%), RTAs (-66%), falls < 2 m (-39%), falls > 2 m (-17%), malignancy (-33%), sporting injuries (-100%), and miscellaneous (-58%). Four of 8 categories (RTAs, falls < 2 m, malignancy, miscellaneous) showed a trend towards return of pre-lockdown values during SP2. Two categories (disc disease, falls > 2 m) showed a further reduction (-34%, -27%) during SP2. One category (sporting injuries) portrayed a complete return to normal values during SP2 while a notable increase in cyclist-related referrals was witnessed (+ 63%) when compared with corresponding dates of previous years. CONCLUSION: Spinal injury continues to occur across almost all categories, albeit at considerably reduced numbers. RTAs and falls remained the most common MOI. Awareness needs to be drawn to the reduction of malignancy-related referrals to dissuade people with such symptoms from avoiding presentation to hospital over periods of social restrictions.

The diagnostic and prognostic value of artificial intelligence and artificial neural networks in spinal surgery : a narrative review.

In recent years, machine learning (ML) and artificial neural networks (ANNs), a particular subset of ML, have been adopted by various areas of healthcare. A number of diagnostic and prognostic algorithms have been designed and implemented across a range of orthopaedic sub-specialties to date, with many positive results. However, the methodology of many of these studies is flawed, and few compare the use of ML with the current approach in clinical practice. Spinal surgery has advanced rapidly over the past three decades, particularly in the areas of implant technology, advanced surgical techniques, biologics, and enhanced recovery protocols. It is therefore regarded an innovative field. Inevitably, spinal surgeons will wish to incorporate ML into their practice should models prove effective in diagnostic or prognostic terms. The purpose of this article is to review published studies that describe the application of neural networks to spinal surgery and which actively compare ANN models to contemporary clinical standards allowing evaluation of their efficacy, accuracy, and relatability. It also explores some of the limitations of the technology, which act to constrain the widespread adoption of neural networks for diagnostic and prognostic use in spinal care. Finally, it describes the necessary considerations should institutions wish to incorporate ANNs into their practices. In doing so, the aim of this review is to provide a practical approach for spinal surgeons to understand the relevant aspects of neural networks. Cite this article: Bone Joint J 2021;103-B(9):1442-1448.

Paediatric major trauma in the setting of the Irish trauma network.

BACKGROUND: The construction of a new tertiary children's hospital and reconfiguration of its two satellite centres will become the Irish epicentre for all paediatric care including paediatric trauma. Ireland is also currently establishing a national trauma network although further planning of how to manage paediatric trauma in the context of this system is required. This research defines the unknown epidemiology of paediatric major trauma in Ireland to assist strategic planning of a future paediatric major trauma network. METHODS: Data from 1068 paediatric trauma cases was extracted from a longitudinal series of annual cross-sectional studies collected by the Trauma Audit and Research Network (TARN). All paediatric patients between the ages of 0-16 suffering AIS ≥2 injuries in Ireland between 2014-2018 were included. Demographics, injury patterns, hospital care processes and outcomes were analysed. RESULTS: Children were most commonly injured at home (45.1%) or in public places/roads (40.1%). The most frequent mechanisms of trauma were falls <2 m (36.8%) followed by RTAs (24.3%). Limb injuries followed by head injuries were the most often injured body parts. The proportion of head injuries in those aged <1 year is double that of any other age group. Only 21% of patients present directly to a children's hospital and 46% require transfer. Consultant-led emergency care is currently delivered to 41.5% of paediatric major trauma patients, there were 555 (48.2%) patients who required operative intervention and 22.8% who required critical care admission. A significant number of children in Ireland aged 1-5 years die from asphyxia/drowning. The overall mortality rate was 3.8% and was significantly associated with the presence of head injuries (p < 0.001). CONCLUSION: Paediatric Trauma represents a significant childhood burden of mortality and morbidity in Ireland. There are currently several sub-optimal elements of paediatric trauma service delivery that will benefit from the establishment of a trauma network. This research will help guide prevention strategy, policy-making and workforce planning during the establishment of an Irish paediatric trauma network and will act as a benchmark for future comparison studies after the network is implemented.

Locked pubis symphysis in a skeletally immature patient, a case report.

BACKGROUND: Locked symphysis pubis is an exceedingly rare pelvic injury especially in the paediatric population. This study is the first to describe this fracture in a skeletally immature patient. CASE REPORT: We report the case of a fifteen year old boy who presented to the Emergency Department (ED) after being involved in a farming injury with a left lateral compression pelvic trauma. He sustained Locked Symphysis Pubis (LSP) and internal pelvic bleeding from the right Internal Iliac Artery (IIA). He was treated successfully by selective embolization of the ILA followed by closed reduction of the LSP and percutaneous fixation of the SI joint. CONCLUSION: Locked symphysis pubis in the paediatric population is an exceedingly rare injury among lateral compression type pelvic fractures. Careful assessment and preoperative management planning are encouraged. Open packing of the pelvis in case of internal bleeding should be avoided in paediatric patients, only selective embolization is advocated. Closed reduction of the LSP by using the external fixator as a lever arm for reduction followed by percutaneous fixation of the SI joint. Moreover, changing the patient position to prone position followed by posterior lumbar spine stabilisation is our preferred method of treatment.

Crisis change management during COVID-19 in the elective orthopaedic hospital: Easing the trauma burden of acute hospitals.

INTRODUCTION: With the emergence of the 2019 novel coronavirus and its resulting pandemic status in March 2020 all routine elective orthopaedic surgery was cancelled in our institution. The developing picture in Italy, of acute hospitals becoming overwhelmed with treating patients suffering with severe and life-threatening symptoms from the disease, prompted the orthopaedic surgeons to formulate a plan to transfer trauma patients requiring surgery to the elective hospital to unburden the acute hospital system. METHODS: Under the threat of this pandemic; protocols and algorithms were established for referral, acceptance and care of trauma patients from acute hospitals in the region. Each day, as new guidance on COVID-19 emerged, our process and algorithms were adjusted to reflect pertinent change. RESULTS: The screening of all patients referred, worked well in keeping our hospital "COVID-free" with respect to patients undergoing operations. An upward trend in cases referred reflected the decreased capacity in the acute hospitals due to rising cases of COVID-19 within the hospital network. During the first 7 weeks of the pandemic 308 operations were performed, (31.1% upper limb, 33.4% lower limb, 4.1% spine, 14.1% urgent elective, 17.4% plastic surgery cases). Regular review and audit of the activity in the hospital as well as communication with the referring teams enabled appropriate planning to accommodate the increase in case-mix as the need arose. DISCUSSION: This paper details the steps that were taken in planning for such a change in management specific to the orthopaedic surgery setting and the lessons learnt during this process. The success of the development of this pathway was facilitated by clear communication channels, flexibility to adapt to changing process and feedback from all stakeholders. The implementation of this pathway allowed the unburdening of acute hospitals dealing with the pandemic that was steadily reducing access to operating theatres and anaesthetic resources.

Minimally invasive fasciotomy using a lighted retractor in the treatment of chronic exertional compartment syndrome.

Chronic exertional compartment syndrome can be a debilitating cause of lower leg pain that typically affects young, healthy people during a variety of aerobic activities. Conservative management has produced a poor success rate and numerous techniques for surgical decompression have been described. Many of these, however, involve blind fascial dissection which increases the risk of direct nerve injury or insufficient fascial release. We describe a novel technique of mini-open fasciotomy using a lighted retractor which enables direct visualization of the fascia and the superficial peroneal nerve using a single, small incision. By the use of a 3- to 4-cm laterally based incision, a lighted retractor with fiber-optic illumination is introduced into the subcutaneous plane and advanced distally and proximally. The retractor gently elevates the subcutaneous tissues while focusing light directly into the surgical area and a long Metzenbaum scissors is then used to release the fascia under direct vision. Fasciotomy using this technique avoids the risks of blind fascial release and is a straightforward, safe, and effective method for compartment decompression.

Prospective epidemiological update on traumatic spinal cord injury in Ireland.

Study design: Prospective population-based epidemiological study on traumatic spinal cord injury in Ireland. Objectives: To provide updated data for the global TSCI repository. Setting: Republic of Ireland. Methods: All cases of TSCI acquired during 2016 were included. ISCoS core dataset was collected on all cases. Descriptive statistics are reported. Results: Overall crude incidence of TSCI was 12.8 per million (61 cases). Males accounted for 75.4%. Mean age at onset was 52.8 (19.9) years. Falls was the most common aetiology, 60.7% and AIS D was the most common injury level/AIS classification, 32.8%. The majority of patients (59%) were discharged home. Conclusions: Overall incidence of TSCI has changed very little since 2000 but many aspects of injury such as age and aetiologies are different. This data can now be included in the next TSCI global mapping update. Sponsorship: Health Research Board, Ireland.

Metastasis Affecting Craniocervical Junction: Current Concepts and an Update on Surgical Management.

STUDY DESIGN: Literature review. OBJECTIVES: Metastatic disease affecting the craniovertebral junction (CVJ) only accounts for 0.5% of all spine metastases. The management of these disease processes is complex, which involves multimodality radiological studies and various surgical approaches. We aimed to review the available evidence and summarize the findings in this review. METHODS: The authors conducted search of PubMed and Google Scholar with the following search terms: metastasis, craniovertebral junction (CVJ), occipitocervical, approaches, stability, and radiotherapy. Articles were reviewed by the authors and determined for inclusion based on relevance and level of evidence. RESULTS: The majority of relevant research reviewed composed of literature reviews of particular aspects regarding metastatic disease affecting the craniovertebral junction, including diagnosis, surgical approach, and radiotherapy. CONCLUSIONS: Prompt evaluation of rotational neck pain with or without occipital neuralgia may reveal early metastatic disease within a stable CVJ. Magnetic resonance imaging appears to be the gold standard imaging modality in detecting this pathology, with nuclear bone scan playing a role in distinguishing benign and malignant processes. Unfortunately, no level 1 evidence exists for use of either radiotherapy or surgery in these cases; however, from the available literature, spinal instability and evidence of progressive neurology are relative indications for operative intervention.

Epidemiology of Traumatic Spinal Cord Injury in Ireland, 2010-2015.

BACKGROUND: The International Spinal Cord Society and World Health Organisation recommend the collection of epidemiological data on traumatic spinal cord injury (TSCI). A 1-year prospective study is ongoing in Ireland. While the results of this study are awaited, it was concluded from a feasibility exercise that a complete retrospective dataset, 2010-2015, could be obtained and would be useful for service planning. METHODS: All patients with TSCI discharged from the national SCI acute and rehabilitation centres were included. Data was collected on gender, age, aetiology, level of injury, American Spinal Injuries Association impairment scale, length of rehabilitation admission and discharge destination. Population denominators were national census figures 2006 and 2011, rolled forward. RESULTS: The incidence of TSCI remained constant throughout the study period, 11.5-13.3 per million per year. The mean age of injury onset was 48.9 (SD 19.8) years. Males accounted for 71.5%. The most common injury level/AIS was incomplete tetraplegia, accounting for 43.2% of all TSCI. Leading aetiology was falls, accounting for 53.3% of injuries. Patients with incomplete tetraplegia were older than those with all other injuries (p < 0.001). CONCLUSIONS: The epidemiological trends identified are similar to those prevalent elsewhere in the developed world. More incomplete tetraplegia among an older patient population necessitates a review of how acute care and rehabilitation services are delivered.

The Oswestry Spinal Risk Index (OSRI): an external validation study.

PURPOSE: The Oswestry Spinal Risk Index (OSRI) was recently reported as an adjunct in the management of metastatic spinal disease. Based on the tumour type and a general condition score, survivorship is predicted. We aimed to externally validate this new score. METHODS: We assessed the survivorship of 121 patients identified from a prospectively collated database in the National Spinal Injuries Unit in the Republic of Ireland. Actual survivorship was calculated according to the tumour subtype and general conditioning, according to the Karnofsky Performance Score (OSRI = Primary Tumour Pathology + (2-General Conditioning Score)). Our results were then compared to those previously published. RESULTS: 45.5 % were female (n = 55). The mean age at presentation was 61.5 years (range 23-85). Breast and prostate cancers were the most frequent diseases encountered. The actual survival in our cohort closely mirrored the predicted survival, according to the equation used to calculate the OSRI with an overall strong correlation found (r = 0.798, p = 0.001). CONCLUSION: We found that the OSRI is a simple to use scoring system. We found a strong correlation in our results with the predicted survivorship based on the OSRI. The OSRI can be used as a useful adjunct in the management of patient with metastatic disease of the spine.

Road collisions as a cause of traumatic spinal cord injury in ireland, 2001-2010.

BACKGROUND: Road collisions remain the leading cause of traumatic spinal cord injury (TSCI) in the world. Half of all TSCIs in Ireland in 2000 were caused by road collisions. Since then, there has been a downward trend in road fatalities coincident with implemented road safety strategies. OBJECTIVE: To examine the incidence of TSCI resulting from road collisions from 2001 to 2010. METHOD: This is a retrospective study using the hospital inpatient enquiry database of the tertiary referral center, which houses the national spinal injuries unit. Information retrieved included total numbers of patients with TSCI and number of TSCIs due to road collisions from 2001 through 2010, age groups affected, and the gender balance. RESULTS: Over the 10-year period studied, the incidence rate of TSCI due to road collisions declined, although this did not reach statistical significance. The largest numbers of all TSCIs and TSCIs due to road collisions were in the 20- to 29-year age category and the male gender. CONCLUSIONS: As mortality due to road collisions declined, so did the number of TSCIs from the same etiology. An impactful road safety campaign is likely to have influenced these trends.

Cauda equina syndrome: assessing the readability and quality of patient information on the Internet.

STUDY DESIGN: A readability and quality control Internet-based study using recognized quality scoring systems. OBJECTIVE: To assess the readability and quality of Internet information relating to cauda equina syndrome accessed through common search engines. SUMMARY OF BACKGROUND DATA: Access to health-related Internet information has increased dramatically during the past decade. A significant proportion of this information has been demonstrated to be set at too high a level for general comprehension. Despite this, searching for health-related information is now the third most popular online activity. METHODS: A total of 125 cauda equina syndrome Web sites were analyzed from the 5 most popular Internet search engines: Google, Bing, Yahoo, Ask, and AOL. Web site authorship was classified: academic, physician, medico-legal, commercial, or discussion/social media. Readability of each Web site was assessed using the Flesch Reading Ease score, the Flesch-Kincaid grade level, and the Gunning Fog Index. Quality was calculated using the DISCERN instrument and The Journal of the American Medical Association benchmark criteria. The presence of HON-code certification was also assessed. RESULTS: Fifty-two individual Web sites were identified and assessed. The majority of Web sites were academic or physician compiled (53.8%; 28/52); however, a significant minority of Web sites were medico-legal related (19.2%; 10/52). Just 13.5% (7/52) of Web sites were at or below the recommended sixth-grade readability level. HON-code certified Web sites achieved significantly greater DISCERN (P = 0.0006) and The Journal of the American Medical Association (P = 0.0002) scores. CONCLUSION: Internet information relating to cauda equina syndrome is of variable quality and largely set at an inappropriate readability level. Given this variability in quality, health care providers should direct patients to known sources of reliable, readable online information. Identification of reliable sources may be aided by known markers of quality such as HON-code certification.

Cervical epidural abscess following an Escherichia coli urinary tract infection.

A previously healthy 64-year-old man developed an Escherichia coli spinal epidural abscess (SEA) isolated to the cervical vertebrae posturinary tract infection 9 days previously. He subsequently underwent emergent surgical decompression followed by a prolonged course of intravenous antibiotics. He is symptom free at 1-year follow-up. SEA is an uncommon condition. Even with modern surgical techniques and antimicrobial agents, the mortality remains significant. Intravenous drug use, spinal procedures and medical conditions such as diabetes, Crohn's disease and chronic renal failure are all known risk factors for SEA and the majority of cases are associated with at least one of these risk factors. The case report highlights the importance of maintaining a high index of suspicion for this condition even in patients without established risk factors who present with red flag symptoms: back pain, fever and neurological deficit, as the consequences of a delayed diagnosis can be severe.

The 100 most cited papers in spinal deformity surgery: a bibliometric analysis.

Spinal deformity is a condition that has been recognized for many millennia. There have been major advances in the treatment of spinal deformity in recent years and studies outlining new ideas can inspire others to further advance the speciality. The number of citations a paper receives may indicate the influence of that paper. It is therefore important that we evaluate and analyze the most cited works in our field. The aim of this study is to identify the 100 most cited papers relevant to spinal deformity surgery in the literature. A search through the Thomson Reuters Web of Science™ for citations related to spinal deformity surgery was performed. The number of citations, mean citation number (total number citations/years since publication), journal, authors, year of publication and country of origin of the top 100 papers was recorded. The top 100 papers were cited a combined 17,646 times, ranging from 453 to 112. The majority of papers originated from the United States (71) and were published in 20 different journals. The decade 1990-1999 was the most prolific, with 36 of the 100 papers published during this time. Papers pertaining to the management of scoliosis (49) were the most common. This study identifies the top 100 most cited papers in the field of spinal deformity surgery. While citation is not a specific marker of the scientific quality of a paper, it is a surrogate for the influence a paper has had on the orthopedic community. This list of papers provides an invaluable resource for both those in training and those actively practicing and involved in the further development of spinal deformity surgery.

Management of simultaneous bilateral neck of femur fractures in an elderly patient.

Simultaneous bilateral neck of femur fracture is rare. There have been few reports of such a condition in the literature. This uncommon pattern of injury has been associated with high-energy trauma, underlying bone disease, and seizure disorders. We describe our experience of such a condition involving an elderly patient with significant cardiovascular comorbidity. The operative approach involved single-stage repair of both the involved joints. Bilateral uncemented hemi-arthroplasty was performed using a single tray of sterile surgical instruments and 2 sterile drapes. We report a satisfactory outcome. Uncemented arthroplasty should be considered in such a case so as to minimize the risk of a possible bone cement implantation syndrome.

Acute traumatic spinal injury following bicycle accidents: a report of three cases.

Although the vast majority of injuries suffered while cycling are minor, acute spinal injuries have been reported. We describe three cases of acute spinal injury occurring while cycling. All three patients reported being thrown over the handlebars, while travelling downhill at speed. Two of the cases resulted in profound neurological deficit. These cases show that there is a spectrum of spinal injury due to bicycle accidents, ranging from no neurological deficit to profound insult, and from high cervical injury to mid-thoracic spinal injury. In cases of bicycle accidents, increased awareness of the possibility of such spinal injury is advisable.