Thoracolumbar injuries: prehospital and emergency management, imaging, classifications and clinical implications.

Thoracolumbar fractures are common injuries that usually result from high energy trauma. They can lead to significant morbidity due to neurologic impair - or mortality - if not managed according to strict and rapid intervention rules in terms of decompression of the spinal cord, and rigid fixation of the fracture. This manuscript reviews emergency treatment protocols, imaging modalities, and classification systems used for thoracolumbar fractures. The emergency treatment is discussed, specific classifications are compared and indications for surgeries are compared.

Thoracolumbar injuries: non operative treatment: indications, management.

INTRODUCTION: Thoracolumbar spine injuries can result from various traumatic events such as falls, motor vehicle accidents, and sports injuries. While surgical intervention is often indicated for complex fractures and in case of neurological deficits, non-operative treatment remains a viable option for certain types of injuries. AIMS: This manuscript aims to provide a comprehensive overview of the specific indications and treatment options of non-operative thoracolumbar spine injuries. It seeks to provide evidence-based recommendations for selecting patients suitable for conservative management based on fracture type and stability, absence of neurological deficits, spine deformity, integrity of the posterior ligament complex and patient specific factors.

Fractures of the thoracolumbar spine in osteoporosis.

Due to increasing life expectancy, the prevalence of fractures caused by osteoporosis is raising. These fractures significantly reduce the quality of life in the elderly population. They represent both a disease and an injury simultaneously. While they were once treated solely with conservative methods, new techniques and implants are expanding the indications for surgical treatment. This article presents the current treatment options.

Thoracolumbar injuries: operative treatment: indications, techniques, timing and implant removal. Current practice.

The operative treatment of thoracolumbar fractures is a rapidly evolving improvement in the care of patients with this injury after trauma. This article describes the different techniques and principles. Considerations and methods of treatment are scientifically addressed and illustrated according to the classification and severity of the fracture pattern. The use of computer navigation and optimisation of minimally invasive techniques is inevitable. The timing of surgery as well the removal of the material after fracture healing are also discussed. The operative treatment of spinal fractures is emerging and there is still much more knowledge to gain.

Thoracolumbar spinal cord injury: management, techniques, timing.

Acute traumatic spinal cord injury (tSCI) is a complex and heterogeneous injury, where the level of injury, injury severity, duration and degree of spinal cord compression, and blood pressure management seem to influence neurologic outcome. Although data in the literature seem to be inconsistent regarding the effectiveness of surgical decompression and spinal fixation in patients with thoracic and thoracolumbar tSCI, some single-center studies suggest that early surgical decompression may lead to a superior neurologic outcome, especially in patients with incomplete tSCI, suggesting surgical decompression to be performed as soon as possible. However, high energy injuries, especially to the upper thoracic levels, may be too severe to be influenced by surgical decompression, which may represent a critical second hit for the polytraumatized patient. Therefore, the surgeon first needs to critically evaluate the potential for neurologic recovery in each patient before determining the ideal timing of surgery. Circulatory stabilization must be achieved before surgical intervention, and minimally invasive procedures should be preferred. Invasive blood pressure monitoring should be started on admission, and maintenance of a MAP between 85 and 90 mmHg is recommended for a duration of 5-7 days, with special attention to the prevention of hypoxia, fever, acidosis and deep venous thrombosis. The role of a 24-hour infusion of high-dose MPSS is still controversial, but it may be offered at the discretion of the treating surgeon to adult patients within 8 h of acute tSCI as a treatment option, especially in the case of very early decompression or incomplete tSCI.

Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis.

INTRODUCTION: Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital. METHODS: All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint. RESULTS: Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups. CONCLUSION: Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted. LEVEL OF EVIDENCE: Level IV, meta-analysis.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition.

BACKGROUND: Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS: This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION: A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Standards of fracture care in polytrauma: results of a Europe-wide survey by the ESTES polytrauma section.

INTRODUCTION: Fixation of major fractures plays a pivotal role in the surgical treatment of polytrauma patients. In addition to ongoing discussions regarding the optimal timing in level I trauma centers, it appears that the respective trauma systems impact the implementation of both, damage control and safe definitive surgery strategies. This study aimed to assess current standards of polytrauma treatment in a Europe-wide survey. METHODS: A survey, developed by members of the polytrauma section of ESTES, was sent online via SurveyMonkey®, between July and November 2020, to 450 members of ESTES (European Society of Trauma and Emergency Surgery). Participation was voluntary and anonymity was granted. The questionnaire consisted of demographic data and included questions about the definition of "polytrauma" and the local standards for the timing of fracture fixation. RESULTS: In total, questionnaires of 87 participants (19.3% response rate) were included. The majority of participants were senior consultants (50.57%). The mean work experience was 19 years, and on average, 17 multiple-injured patients were treated monthly. Most of the participants stated that a polytrauma patient is defined by ISS ≥ 16 (44.16%), followed by the "Berlin Definition" (25.97%). Systolic blood pressure < 90 mmHg, tachycardia or vasopressor administration (86.84%), pH deviation, base excess shift (48.68%), and lactate > 4 mmol (40.79%) or coagulopathy defined by ROTEM (40.79%) were the three most often stated indicators for shock. Local guidelines (33.77%) and the S-3 Guideline by the DGU® (23.38%) were mostly stated as a reference for the treatment of polytrauma patients. Normal coagulation (79.69%), missing administration of vasopressors (62.50%), and missing clinical signs of "SIRS" (67.19%) were stated as criteria for safe definite secondary surgery. CONCLUSION: Different definitions of polytrauma are used in the clinical setting. Indication for and the extent of secondary (definitive) surgery are mainly dependent on the polytrauma patient`s physiology. The «Window of Opportunity¼ plays a less important role in decision making.

ESTES recommendations on proximal humerus fractures in the elderly.

PURPOSE: The section for the skeletal trauma and sport's injuries of the European Society for Trauma and Emergency Surgery (ESTES) appointed a task force group to reach a consensus among European countries on proximal humeral fractures. MATERIAL/METHODS: The task force group organized several consensus meetings until a paper with final recommendations was confirmed during the ESTES Executive Board meeting in Berlin on 25 October 2018. CONCLUSION: The Recommendations compare conservative and four possible operative treatment options (ORIF, nailing, hemi- and total reverse arthroplasty) and enable the smallest common denominator for the surgical treatment among ESTES members.

Indications and interventions of damage control orthopedic surgeries: an expert opinion survey.

OBJECTIVES: The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO. BACKGROUND: The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO). METHODS: Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process. RESULTS: Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery". CONCLUSION: This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios.

Mobile wireless monitoring system for prehospital emergency care.

BACKGROUND: Latest achievement technologies allow engineers to develop medical systems that medical doctors in the health care system could not imagine years ago. The development of signal theory, intelligent systems, biophysics and extensive collaboration between science and technology researchers and medical professionals, open up the potential for preventive, real-time monitoring of patients. With the recent developments of new methods in medicine, it is also possible to predict the trends of the disease development as well the systemic support in diagnose setting. Within the framework of the needs to track the patient health parameters in the hospital environment or in the case of road accidents, the researchers had to integrate the knowledge and experiences of medical specialists in emergency medicine who have participated in the development of a mobile wireless monitoring system designed for real-time monitoring of victim vital parameters. Emergency medicine responders are first point of care for trauma victim providing prehospital care, including triage and treatment at the scene of incident and transport from the scene to the hospital. Continuous monitoring of life functions allows immediate detection of a deterioration in health status and helps out in carrying out principle of continuous e-triage. In this study, a mobile wireless monitoring system for measuring and recording the vital parameters of the patient was presented and evaluated. Based on the measured values, the system is able to make triage and assign treatment priority for the patient. The system also provides the opportunity to take a picture of the injury, mark the injured body parts, calculate Glasgow Coma Score, or insert/record the medication given to the patient. Evaluation of the system was made using the Technology Acceptance Model (TAM). In particular we measured: perceived usefulness, perceived ease of use, attitude, intention to use, patient status and environmental status. METHODS: A functional prototype of a developed wireless sensor-based system was installed at the emergency medical (EM) department, and presented to the participants of this study. Thirty participants, paramedics and doctors from the emergency department participated in the study. Two scenarios common for the prehospital emergency routines were considered for the evaluation. Participants were asked to answer the questions referred to these scenarios by rating each of the items on a 5-point Likert scale. RESULTS: Path coefficients between each measured variable were calculated. All coefficients were positive, but the statistically significant were only the following: patient status and perceive usefulness (ß = 0.284, t = 2.097), environment (both urban a nd rural) and perceive usefulness (ß = 0.247, t = 2.570; ß = 0.329, t = 2.083, respectively), and perceive usefulness and behavioral intention (ß = 0.621 t = 7.269). The variance of intention is 47.9%. CONCLUSIONS: The study results show that the proposed system is well accepted by the EM personnel and can be used as a complementary system in EM department for continuous monitoring of patients' vital signs.

Sex-determining region Y (SRY) attributes to gender differences in RANKL expression and incidence of osteoporosis.

Receptor activator of nuclear factor κB ligand (RANKL) plays a crucial role in bone metabolism. RANKL gene misregulation has been implicated in several bone and cancer diseases. Here, we aimed to identify novel transcription regulators of RANKL expression. We discovered that transcription factors, sex-determining region Y (SRY) and c-Myb, regulate RANKL expression. We demonstrated that c-Myb increases and male-specific SRY decreases RANKL expression through direct binding to its 5'-proximal promoter. These results are corroborated by the gene expression in human bone samples. In osteoporotic men, expression of RANKL is 17-fold higher, which correlates with the drastically reduced expression (200-fold) of Sry, suggesting that in osteoporotic men, the upregulation of RANKL is caused by a decrease of Sry. In healthy men, the expression of RANKL is 20% higher than that in healthy women. Our data suggest that gender differences in RANKL expression and bone quality could be due to the sex-specific transcription factor SRY.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition.

BACKGROUND: Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS: Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Audit of geriatric hip fracture care - a Slovenian trauma center analysis.

BACKGROUND: The aim was to describe an audit of hip fracture patient care and outcomes in a Slovenian healthcare setting prior to the implementation of the Geriatric Fracture Center (GFC) model of care. METHODS: The Fragility Fracture Network (FFN) hip fracture audit database was used to collect data on hip fracture care in elderly patients. Epidemiological data were submitted as well as fracture type, prefracture residence and mobility prior to the fracture. The timeline of events and acute care data were also collected. Follow-up after 30 days included hip-related readmission, mobility, residence and life status. RESULTS: Included were 495 patients with a mean age of 81 years of which 20% were preoperatively seen by a physician or geriatrician, 93.1% had surgical repair, 58.5% of them within 48 h of admission. The mortality rate in hospital was 5.4% and 10.1% at follow-up, 61.8% patients were able to return to prefracture residency and 23% could walk with minor assistance. CONCLUSION: This comprehensive and detailed audit report provides baseline data on case-mix, care and outcomes following hip fractures in Slovenia, in advance of planned quality improvement work in geriatric fracture care and provides a strong basis for the assessment of the impact of the GFC model of care.

Evaluation of major trauma in elderly patients - a single trauma center analysis.

BACKGROUND: The objective of the study was to gather information about elderly major trauma patients admitted to one particular Slovenian trauma centre in Celje and examine this group of polytrauma patients, specifically with respect to mechanisms of injury, injury severity and distribution of injuries. Further on, to identify morbidity and mortality rates and compare these to the younger population and, finally, to determine the factors that have the most impact on treatment results. METHODS: The study gathered and evaluated data of 532 patients included in the Trauma Register DGU® of the German Trauma Society (TR-DGU) during a 10-year period and two distinct groups of patients were established, separated on account of age as older or younger than 65 years. The differences between these two groups were analyzed with respect to demographics, comorbidities, preclinical management, injury patterns, relevant clinical and laboratory findings. Furthermore, differences between deceased and surviving elderly patients were also analyzed. RESULTS: The majority of elderly patients suffered from a blunt mechanism of trauma (96.6%) and of these simple falls represented 47.9% within this injury mechanism. There were two body regions, which were most frequently represented, namely head and thorax injuries, accounting for 54.7% each. Complications were more frequent among the elderly, with sepsis being present in 29.9% and multiple organ failure (MOF) in 19.7% of cases. Cardiovascular failure was also high in both the elderly and young, accounting for 45.3% of the elderly and 31.3% of the younger population. The in-hospital mortality rate for the elderly group was 25.6% and was significantly higher compared to the younger counterparts (14.7%). Low fall mechanism of injury, coma and the new injury severity score (NISS) were statistically important factors for the mortality of seriously injured elderly patients during the acute phase of treatment. CONCLUSIONS: Despite advances in care, morbidity and mortality in elderly patients after major trauma remains considerably higher than in younger populations with head injuries accounting for the majority of fatalities. The elderly patient population in this study mostly suffered from blunt mechanisms of injury, with simple falls representing a high proportion of injury mechanisms. Generally, the injury severity scale (ISS) in the elderly is not statistically higher than with the younger population. Likewise, the distribution of injuries according to body regions is also similar; however, the elderly are more prone to complications (e. g. sepsis and MOF), which is likely due to a lower physiological reserves.

P4 medicine and osteoporosis: a systematic review.

BACKGROUND: Osteoporosis is the most frequent bone metabolic disease. In order to improve early detection, prediction, prevention, diagnosis, and treatment of the disease, a new model of P4 medicine (personalized, predictive, preventive, and participatory medicine) could be applied. The aim of this work was to systematically review the publications of four different types of "omics" studies related to osteoporosis, in order to discover novel predictive, preventive, diagnostic, and therapeutic targets for better management of the geriatric population. METHODS: To systematically search the PubMed database, we created specific groups of criteria for four different types of "omics" information on osteoporosis: genomic, transcriptomic, proteomic, and metabolomic. We then analyzed the intersections between them in order to find correlations and common pathways or molecules with important roles in osteoporosis, and with a potential application in disease prediction, prevention, diagnosis, or treatment. RESULTS: Altogether, 180 publications of "omics" studies in the field of osteoporosis were found and reviewed at first selection. After introducing the inclusion and exclusion criteria (the secondary selection), 46 papers were included in the systematic review. CONCLUSIONS: The intersection of reviewed papers identified five genes (ESR1, IBSP, CTNNB1, SOX4, and IDUA) and processes like the Wnt pathway, JAK/STAT signaling, and ERK/MAPK, which should be further validated for their predictive, diagnostic, or other clinical value in osteoporosis. Such molecular insights will enable us to fit osteoporosis into the P4 strategy and could increase the effectiveness of disease prediction and prevention, with a decrease in morbidity in the geriatric population.

Outcome parameters in orthogeriatric co­management - a mini-review.

Recognizing hip and other fragility fractures as an adverse event of chronic geriatric conditions led to the concept of orthogeriatric co-management (OGC). OGC today represents various forms of structural cooperation between orthopedic trauma surgeons and multiprofessional geriatric teams taking care of frail elderly patients. The models are country specific. Despite several published models there are still no clear recommendations on how this service should be best organized. The 12 outcome parameters published by the Experts' Roundtable in 2013 were recommended to be used for the further assessment of different OCG models. This literature review was prepared accordingly and showed the need for further studies to determine the best OGC model and to define a uniform set of outcome parameters for use in future clinical studies.

Education in Disaster Management: What Do We Offer and What Do We Need? Proposing a New Global Program.

OBJECTIVE: Although there is a significant willingness to respond to disasters, a review of post-event reports following incidents shows troubling repeated patterns with poorly integrated response activities and response managers inadequately trained for the requirements of disasters. This calls for a new overall approach in disaster management. METHODS: An in-depth review of the education and training opportunities available to responders and disaster managers has been undertaken, as well as an extensive review of the educational competencies and their parent domains identified by subject matter experts as necessary for competent performance. RESULTS: Seven domains of competency and competencies that should be mastered by disaster mangers were identified. This set of domains and individual competencies was utilized to define a new and evolving curriculum. In order to evaluate and assess the mastery of each competency, objectives were more widely defined as activities under specific topics, as the measurable elements of the curriculum, for each managerial level. CONCLUSIONS: This program enables interagency cooperation and collaboration and could be used to increase and improve decision-makers' understanding of disaster managers' capabilities; at the strategic/tactical level to promote the knowledge and capability of the disaster managers themselves; and as continuing education or further career development for disaster managers at the operational level. (Disaster Med Public Health Preparedness. 2016;10:854-873).

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition.

BACKGROUND: Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS: The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.