Advances in Point-of-Care Thoracic Ultrasound.

Pulmonary ultrasound continues to develop and is ideally suited for the evaluation and treatment of respiratory emergencies. It is portable, can be performed rapidly, has no ionizing radiation, and is highly sensitive and specific for the diagnosis of pneumothorax, pneumonia, pulmonary edema, and free fluid in the chest.

Emergency and critical care imaging.

Care for patients who have time-sensitive disease processes in the emergency department and critical care settings is optimized with rapid diagnosis and intervention. Recent advances in medical imaging have increased portability, decreased image acquisition time, improved data resolution, and increased use of noninvasive studies. This article discusses the use of portable imaging techniques such as bedside ultrasound and radiography as well as CT and CT angiography in the diagnosis and care of critically ill patients.

Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine.

STUDY DESIGN: Survey-based descriptive study. OBJECTIVE: To study relationships between surgeon-specific factors and surgical approach to degenerative diseases of the lumbar spine. SUMMARY OF BACKGROUND DATA: Geographic variations in the rates of lumbar spine surgery are significant within the United States. Although surgeon density correlates with the rates of spine surgery, other reasons for variation such as surgeon age and training background are poorly understood. METHODS: A total of 22 orthopedic surgeons and 8 neurosurgeons of varied ages and geographic regions answered questions regarding the need for surgery, surgical approach, and use of fusion and instrumentation for 5 simulated cases. Cases included: (1) multilevel stenosis without deformity or instability, (2) degenerative spondylolisthesis with stenosis, (3) isthmic (spondylolytic) spondylolisthesis with foraminal stenosis, (4) degenerative scoliosis with stenosis, and (5) recurrent stenosis following prior laminectomy without deformity or instability. The effects of surgeon age and training background on surgical decision making were analyzed using an independent samples t test and Fisher exact test, respectively. RESULTS: Significant variation in treatment approach among surgeons was noted for all cases except the patient with lytic spondylolisthesis, for whom all surgeons recommended fusion. Orthopedists recommended fusion and instrumentation more often than neurosurgeons for all cases, reaching significance for degenerative scoliosis with stenosis (P = 0.02 for both fusion and instrumentation). Younger surgeons were generally more likely to recommend instrumentation than their older peers, reaching significance for multilevel stenosis without deformity or instability and recurrent stenosis following prior laminectomy without deformity or instability (P = 0.05 and 0.01, respectively). CONCLUSIONS: Variations in surgical approach to lumbar degenerative diseases may depend on a patient's clinical condition. This study found strong agreement in the approach to lytic spondylolisthesis but significant variation for other degenerative conditions of the lumbar spine. In addition, recommendation for fusion and instrumentation varied with surgeon age and training background. Previously documented geographic variations may result in part from a lack of consensus on appropriate treatment techniques for specific lumbar degenerative conditions, as well as surgeon-specific factors.

Variation in surgical decision making for degenerative spinal disorders. Part II: cervical spine.

STUDY DESIGN: Survey-based descriptive study. OBJECTIVE: To study relationships between surgeon-specific factors and surgical approach to degenerative diseases of the cervical spine. SUMMARY OF BACKGROUND DATA: Geographic variations in the rates of cervical spine surgery are significant within the United States. Although surgeon density correlates with the rates of spinal surgery, other reasons for variation such as surgeon-specific factors are poorly understood. METHODS: A total of 22 orthopedic surgeons and 8 neurosurgeons of varied ages and geographic regions answered questions regarding the need for surgery, surgical approach, and use of fusion and instrumentation for 5 simulated cases. Cases included: (1) single-level disc herniation with osteophyte and radiculopathy, (2) single-level pseudarthrosis with axial neck pain, (3) multilevel stenosis with radiculopathy and neutral lordosis, (4) multilevel stenosis with myelopathy and neutral lordosis, and (5) multilevel stenosis with myelopathy and marked kyphosis. The effects of surgeon age and training background on surgical decision making were analyzed using an independent samples t test and Fisher exact test, respectively. RESULTS: The greatest agreement occurred for the single-level disc herniation, with all surgeons choosing an anterior discectomy, and 28 of the 29 respondents recommending fusion. Younger surgeons recommended instrumentation more often for all cases, reaching significance for the case of multilevel stenosis with myelopathy and neutral lordosis (Fisher exact test P = 0.02). Differences in recommendation for fusion, instrumentation, and the use of a posterior approach between orthopedic and neurosurgeons were limited. CONCLUSIONS: Variations in surgical procedures for cervical degenerative disease may depend on the clinical condition. Although this study found strong agreement in treatment approach to single-level disc herniation, significant variation was seen for the other degenerative conditions of the cervical spine. While differences in recommendation for fusion were not clearly associated with surgeon age, there was a trend toward the higher use of instrumentation by younger surgeons. Previously documented geographic variation may result in part from a lack of consensus regarding appropriate treatment techniques for certain degenerative conditions of the cervical spine, as well as surgeon-specific factors.

Variations in injury patterns, treatment, and outcome for spinal fracture and paralysis in adult versus geriatric patients.

STUDY DESIGN: Retrospective cohort analysis of hospital discharge and mortality data for spinal fracture and spinal cord injury patients in a single state from 1990 to 1995. OBJECTIVES: Population-based review of preinjury patient factors, injury and treatment patterns, and in-hospital versus 60-day mortality in adult and geriatric spinal injury patients. SUMMARY OF BACKGROUND DATA: While population-based analyses of hospitalized injured patients indicate that geriatric patients are at higher risk for adverse outcome, less is known about the specific subset of patients with spinal fracture and spinal cord injury. A specific knowledge gap exists regarding factors that influence survival after hospital discharge of spine-injured patients. METHODS: Patients with cervical, thoracic, or lumbar spinal fracture were identified by ICD-9-CM discharge diagnosis codes. Age, gender, preexisting conditions, and injury severity were determined, and patients were divided into adult (ages 16-64 years; n = 6,029) and geriatric (ages >or=65 years; n = 3,973) groups. In-hospital and 60-day mortality rates and odds ratios of 60-day mortality were calculated relative to patient and injury characteristics, level of treating hospital, and surgical treatment. RESULTS: Increased 60-day mortality was associated with preexisting medical conditions, increased injury severity, and paralysis but reduced with surgical treatment. Geriatric patients had fewer cervical injures, lower force injuries, less severe overall injuries, decreased paralysis, increased preexisting conditions, decreased treatment at level 1 and 2 treatment centers, and decreased odds of surgical treatment. Geriatric patients also had increased 60-day versus in-hospital mortality and increased mortality associated with cervical spine injury. DISCUSSION: Differences exist in preinjury patient factors, injury and treatment patterns, and mortality between adult and geriatric patients following spinal injuries. The increased 60-day versus in-hospital mortality for the geriatric population suggests that 60-day mortality may be a better measure of outcome for these patients. While the possibility of selection bias exists, both geriatricand adult patients had reduced 60-day mortality associated with surgical intervention.