Orthopaedic injuries due to electric scooter trauma presenting to a level 1 trauma centre before and after introduction of a scooter-sharing scheme.

Background: Epidemiological data from various jurisdictions has shown that electric scooters are associated with significant trauma. The Victorian state government introduced a trial scooter sharing scheme on February 1, 2022 in inner city Melbourne. This is a descriptive study from the largest trauma centre in Victoria, geographically at the heart of the government sharing scheme, investigating the "scope of the problem" before and after introduction of the ride sharing scheme. Methods: Retrospective case series. Insitutional orthopaedic department database was searched from 1 Jan 2021 to 30 June 2022 to identify all admissions, requiring orthopaedic management, associated with e-scooter trauma. Data collected included, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, injuries sustained, surgical procedures, discharge destination, and death. Results: In the 12 months prior to, and five months since introduction of the ride share scheme, 43 patients sustaining e-scooter related injuries were identified. Eighteen patients (42%) presented in the five months since ride sharing was introduced and 25 patients in the preceding 12 months. 58% of patients were found to be intoxicated. Fourteen percent required an ICU admission. Forty-four percent of patients were polytrauma admissions. The median length of stay was two days, longest individual hospital stay was 69 days. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. The mean Injury Severity Score was 17.28. Conclusion: Electric scooters are associated with a significant trauma burden. This data may be combined with other clinical services and could be used to inform policy makers.

HIP4Hips (High Intensity Physiotherapy for Hip fractures in the acute hospital setting): a randomised controlled trial.

OBJECTIVES: To investigate the effects of intensive acute hospital physiotherapy for patients with isolated hip fractures. DESIGN, SETTING: Single-institution, prospective, randomised trial at a level 1 trauma centre in Melbourne, March 2014 - January 2015. PARTICIPANTS: 92 patients aged 65 years or more with isolated hip fractures. Patients were excluded if the fracture was subtrochanteric or pathological, or if post-operative orders required the patient to be non-weight-bearing on the operated leg. INTERVENTIONS: Randomisation to usual care physiotherapy (daily; control group) or intensive physiotherapy (three times daily; intervention group). MAIN OUTCOME MEASURES: Outcomes were assessed at post-operative Day 5, at discharge, and at 6 months. The primary outcome was the modified Iowa Level of Assistance (mILOA) score, with other outcome measures including Timed Up and Go test performance and hospital length of stay (LOS). RESULTS: After controlling for sex, anaesthetic type and home setting, the between-group difference in Day 5 mILOA score favoured the intervention group (mean difference v control group, -2.7 points; P = 0.04). Hospital LOS was also shorter for the intervention group (median, 24.4 days v 35.0 days; P = 0.01). A Cox proportional hazard model that controlled for potential confounders indicated that the probability of discharge was greater for intervention group patients at all time points following surgery (P < 0.001). Re-admission and complication rates and 6-month outcomes for the two groups were not significantly different. CONCLUSIONS: Intensive acute hospital physiotherapy is safe and reduces hospital LOS after an isolated hip fracture. This has the potential to improve bed flow, given the large numbers of inpatient beds occupied by this patient population. TRIAL REGISTRATION: Clinical Trials Registry #NCT02088437.

Trampoline related injuries in adults.

INTRODUCTION: Trampoline-related injuries in adults are uncommon. Participation in trampolining is increasing following its admission as a sport in the Olympics and the opening of local recreational trampoline centres. The aim of this study was to assess the number and outcomes of adult trampoline-related orthopaedic injuries presenting to four trauma hospitals in Victoria. METHODS: A cohort study was performed for the period 2007-2013. Adult patients registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who had sustained a trampolining related injury were included in this study. Descriptive analyses were used to describe the patient population, the injuries sustained and their in-hospital and 6-month outcomes. RESULTS: There was an increase in trampolining injuries from 2007 (n=3) to 2012 (n=14) and 2013 (n=18). Overall, fifty patients with a median age of 25 (range 16-66) were identified. Thirty-five patients (70%) had lower limb injuries, 20 patients (40%) had spinal injuries and one patient had an upper limb injury. Thirty-nine patients (78%) required surgery. Fractures of the tibia (n=13), ankle fractures (n=12) and cervical spine injuries (n=7) were the most common injuries; all of which required surgery. Complications included death, spinal cord injuries, compartment syndrome and open fractures. At 6 months post injury, more than half (52%) of the patients had not achieved a good recovery, 32% had some form of persistent disability, 14% did not get back to work and overall physical health for the cohort was well below population norms for the SF-12. CONCLUSION: Adult trampoline-related injuries have increased in the last few years in this cohort identified through VOTOR. Lower limb and spinal injuries are most prevalent. Public awareness and education are important to reduce the risk for people participating in this activity.

Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery.

Early decompression may improve neurological outcome after spinal cord injury (SCI), but is often difficult to achieve because of logistical issues. The aims of this study were to 1) determine the time to decompression in cases of isolated cervical SCI in Australia and New Zealand and 2) determine where substantial delays occur as patients move from the accident scene to surgery. Data were extracted from medical records of patients aged 15-70 years with C3-T1 traumatic SCI between 2010 and 2013. A total of 192 patients were included. The median time from accident scene to decompression was 21 h, with the fastest times associated with closed reduction (6 h). A significant decrease in the time to decompression occurred from 2010 (31 h) to 2013 (19 h, p = 0.008). Patients undergoing direct surgical hospital admission had a significantly lower time to decompression, compared with patients undergoing pre-surgical hospital admission (12 h vs. 26 h, p < 0.0001). Medical stabilization and radiological investigation appeared not to influence the timing of surgery. The time taken to organize the operating theater following surgical hospital admission was a further factor delaying decompression (12.5 h). There was a relationship between the timing of decompression and the proportion of patients demonstrating substantial recovery (2-3 American Spinal Injury Association Impairment Scale grades). In conclusion, the time of cervical spine decompression markedly improved over the study period. Neurological recovery appeared to be promoted by rapid decompression. Direct surgical hospital admission, rapid organization of theater, and where possible, use of closed reduction, are likely to be effective strategies to reduce the time to decompression.

Weight change following knee and hip joint arthroplasty-a six-month prospective study of adults with osteoarthritis.

BACKGROUND: Inconsistent findings of weight change following total knee (TKA) and hip (THA) arthroplasty may largely be attributable to heterogeneous cohorts and varied definitions of weight loss. This study examined weight change following TKA and THA for osteoarthritis (OA). METHODS: 64 participants with hip or knee OA were recruited from orthopaedic joint arthroplasty waiting lists at a single major Australian public hospital between March and October 2011. The Short Form (SF) 12 survey was used to assess baseline physical and mental functioning. 49 participants completed 6 month follow-up (20 from the THA group and 29 from the TKA group). RESULTS: The majority of subjects lost weight (>0 kg) 6 months following THA (70 %) and TKA (58.6 %). When at least a 5 % reduction in total body weight was used to define clinically significant weight loss, the proportion of people with weight loss was 37.9 % for TKA and 25 % for THA. Greater weight loss occurred 6 months following TKA compared with THA (7.2 % versus 3.7 % of body weight; p = 0.04). Worse pre-operative physical functioning (SF-12) was associated with greater weight loss following TKA (ß = 0.22 kg, 95 % CI 0.02-0.42 kg; p = 0.04). CONCLUSION: Most people lost weight (>0 kg) 6 months following TKA and THA and a considerable proportion of people achieved ≥5 % loss of body weight. The magnitude of weight loss was greater following TKA than THA, with worse pre-operative function being a predictor of more weight loss. Further attention to weight management is required to assist a greater number of people to achieve a larger magnitude of weight loss following knee and hip joint arthroplasty.

Incidence of acute kidney injury following total joint arthroplasty: a retrospective review by RIFLE criteria.

BACKGROUND: Total joint arthroplasty (TJA) is a common procedure with demand for arthroplasties expected to increase exponentially. Incidence of acute kidney injury (AKI) following TJA is reportedly low, with most studies finding an incidence of <2%, increasing to 9% when emergency orthopaedic patients are included. METHODS: Retrospective medical record review of consecutive primary, elective TJA procedures was undertaken at a large tertiary hospital (Alfred). Demographic, peri-operative and post-operative data were recorded. Factors associated with AKI (based on RIFLE criteria) were determined using multiple logistic regression. RESULTS: Between January 2011 and June 2013, 425 patients underwent TJA; 252 total knee replacements (TKR) and 173 total hip replacements (THR). Sixty-seven patients (14.8%) developed AKI, including 51 TKR. Factors associated with AKI (adjusting for known confounders) include increasing body mass index [adjusted odds ratio (AOR) 1.14; 95% CI: 1.07, 1.21], older age (AOR 1.07; 95% CI 1.02, 1.13) and lower pre-operative glomerular filtration rate (AOR 0.97; 95% CI 0.96, 0.99) and taking angiotensin-converting enzyme inhibitors (AOR 2.70; 95% CI 1.12, 6.48) and angiotensin-II receptor blockers (AOR 2.64; 95% CI 1.18, 5.93). In most patients, AKI resolved by discharge, however, only 62% of patients had renal function tests after discharge. CONCLUSIONS: This study showed a rate of AKI of nearly 15% in our TJA population, substantially higher than previously reported. Given that AKI and long-term complications are associated, prospective research is needed to further understand the associated factors and predict those at risk of AKI. There may be opportunities to maximize the pre-operative medical management and mitigate risk.

Early predictors of functional disability after spine trauma: a level 1 trauma center study.

STUDY DESIGN: Retrospective review on prospective cohort and explicit chart review. OBJECTIVE: To identify early spine trauma predictors of functional disability and to assess management compliance to established spine trauma treatment algorithms. SUMMARY OF BACKGROUND DATA: Identification of early (within 48 hours) spine trauma predictors of functional disability is novel and may assist in the management of patients with trauma. Also, with significant global variation, spine trauma treatment algorithms are essential. METHODS: Analysis was performed on patients with spine trauma from May 1, 2009, to January 1, 2011. Functional outcomes were determined using the Glasgow Outcome Scale (GOS) at 1 year. Univariate and multivariate regressions were applied to investigate the effects of the injury severity score, age, blood sugar level, vital signs, traumatic brain injury, comorbidities, coagulation profile, neurology, and spine injury characteristics. A compliance study was performed using the SLIC and TLICS spine trauma algorithms. RESULTS: The completion rate for the GOS was 58.8%. The completed GOS cohort was 4.2 years younger in terms of mean age, had more number of patients with severe polytrauma, but less number of patients with severe spinal cord injuries (ASIA [American Spinal Injury Association] A, B, and C) in comparison with the uncompleted GOS cohort. Multivariate logistic regression revealed 3 independent early spine trauma predictors of functional disability with statistical significance (P < 0.05). They were (1) hypotension (OR [odds ratio] = 1.98; CI [confidence interval] = 1.13-3.49), (2) hyperglycemia (OR = 1.67; CI = 1.09-2.56), and (3) moderate/severe traumatic brain injury (OR = 5.88; CI = 1.71-20.16). There were 305 patients with subaxial cervical spine injuries and 653 patients with thoracolumbar spine injuries. The subaxial cervical spine injury classification and thoracolumbar injury classification and severity score compliance studies returned agreements of 96.1% and 98.9%, respectively. CONCLUSION: Early independent spine trauma predictors of functional disability identified in a level 1 trauma center with high compliance to the subaxial cervical spine injury classification and thoracolumbar injury classification and severity score algorithms were hypotension, hyperglycemia, and moderate or severe traumatic brain injury. Spine trauma injury variables alone were shown not to be predictive of functional disability. LEVEL OF EVIDENCE: 3.

Evidence-based guideline for the written radiology report: methods, recommendations and implementation challenges.

The written radiology report is the dominant method by which radiologists communicate the results of diagnostic and interventional imaging procedures. It has an important impact on decisions about further investigation and management. Its form and content can be influential in reducing harm to patients and mitigating risk for practitioners but varies markedly with little standardisation in practice. Until now, the Royal Australian and New Zealand College of Radiologists has not had a guideline for the written report. International guidelines on this subject are not evidence based and lack description of development methods. The current guideline seeks to improve the quality of the written report by providing evidence-based recommendations for good practice. The following attributes of the report are addressed by recommendations: Content Clinical information available to the radiologist at the time the report was created Technical details of the procedure Examination quality and limitations Findings (both normal and abnormal) Comparison with previous studies Pathophysiological diagnosis Differential diagnoses Clinical correlation and/or answer to the clinical question Recommendations, particularly for further imaging and other investigations Conclusion/opinion/impression Format Length Format Language Confidence and certainty Clarity Readability Accuracy Communication of discrepancies between an original verbal or written report and the final report Proofreading/editing of own and trainee reports.

Early predictors of mortality after spine trauma: a level 1 Australian trauma center study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To identify early independent mortality predictors after spine trauma. SUMMARY OF BACKGROUND DATA: Spine trauma consists of spinal cord and spine column injury. The ability to identify early (within 24 hours) risk factors predictive of mortality in spine trauma has the potential to reduce mortality and improve spine trauma management. METHODS: Analysis was performed on 215 spine column and/or spinal cord injured patients from July 2008 to August 2011. Univariate and multivariate logistic regression models were applied to investigate the effects of the Injury Severity Score, age, mechanism of injury, blood glucose level, vital signs, brain trauma severity, morbidity before trauma, coagulation profile, neurological status, and spine injuries on the risk of in-hospital death. RESULTS: Applying a multivariate logistic regression model, there were 7 independent early predictive factors for mortality after spine injury. They were (1) Injury Severity Score more than 15 (odds ratio [OR] = 3.67; P = 0.009), (2) abnormal coagulation profile (OR = 6; P < 0.0001), (3) patients 65 years or older (OR = 3.49; P = 0.007), (4) hypotension (OR = 2.9; P = 0.033), (5) tachycardia (OR = 4.04; P = 0.005), (6) hypoxia (OR = 2.9; P = 0.033), and (7) multiple comorbidities (OR = 3.49; P = 0.007). Severe traumatic brain injury was also associated with mortality but was excluded from multivariate analysis because there were no patients with this variable in the comparison group. CONCLUSION: Mortality predictors for spine trauma patients are similar to those for general trauma patients. Spine injury variables were shown not to be independent predictors of spine trauma mortality.

Outcomes at 12 months after early magnetic resonance imaging in acute trauma patients with persistent midline cervical tenderness and negative computed tomography.

STUDY DESIGN: A prospective observational cohort study of alert, neurologically intact trauma patients presenting to the emergency department with midline cervical tenderness. Screening cervical magnetic resonance imaging (MRI) had been conducted after negative computed tomography (CT) when tenderness was persistent. OBJECTIVE: To determine the association of acute findings and demographic characteristics with any long-term neck disability, and with time to return to work in such patients. SUMMARY OF BACKGROUND DATA: The relationship between acute findings and outcomes in these patients is unknown, and we hypothesized that outcomes at 12 months would correlate with acute clinical signs and symptoms, MRI findings, and mechanisms of injury. METHODS: Patients at a Level 1 trauma center with persistent midline cervical tenderness in the absence of evidence of intoxication, painful distracting injury, persistently abnormal neurology, or acute CT findings, who underwent early cervical MRI under the institutional protocol, were reviewed in the outpatient spine clinic after discharge. In addition, the factors associated with neck disability and time to return to work were examined at follow-up at 12 months after presentation. RESULTS: There were 162 of 178 patients available for follow-up at 12 months (91%). Of these, 46% had MRI-identified cervical spine injury at their initial examination, and 22% had required clinical management, including 2.5% with operative stabilization. Neck disability was present in 43% of patients and was associated with depressive symptoms, workers' compensation, and low annual income. Delay in return to work was associated with the presence of minor limb/other fractures and depressive symptoms, whereas patients on high annual incomes were found to return to work more quickly. CONCLUSION: Surprisingly in these acute trauma patients, MRI-detected injury, clinical factors, and injury mechanism were not found to be associated with long-term patient outcomes. As a result, a trial of a more targeted, individual return to work plan, including strategies aimed at improving physical and psychological function, may now be justified to optimize long-term recovery, reduce health resource costs, and maximize economic productivity through early return to work.

Nutritional status and short-term outcome of hip arthroplasty.

PURPOSE: To review nutritional status and outcome of 90 patients who underwent total hip arthroplasty (THA) or hemiarthroplasty. METHODS: Records of 51 women and 39 men aged 26 to 96 (median, 71) years who underwent elective THA (n=48) for osteoarthritis, or trauma-related THA (n=10) or hemiarthroplasty (n=32) for subcapital femoral neck fractures using an uncemented femoral stem were retrospectively reviewed. Patient demographics and intra- and post-operative complications were recorded. Patient co-morbidities were assessed according to the Charlson grading system. Nutritional status was assessed using haematological markers of serum albumin (ALB) level and total lymphocyte count (TLC). Samples were taken on the day of the operation and within 24 hours of operation. Suboptimal nutrition was defined as a serum ALB level of <3.5 g/dl and a TLC of <1.50 cells/mm. RESULTS: 86% of trauma patients and 30% of elective patients were malnourished preoperatively (p<0.001). Preoperatively, more males than females had suboptimal ALB levels (28% vs. 8%, p=0.033) and TLC (82% vs. 31%, p<0.001). Age was inversely proportional to preoperative ALB and TLC values; patients older than 75 years had significantly lower values. Of those staying >7 days in hospital, 67% were aged >75 years as opposed to 31% were aged ≤ 75 years (p=0.001). Male gender, old age, and presentation with trauma were risk factors for suboptimal nutritional parameters (p<0.001 for all). Patients with suboptimal ALB and TLC values had a significantly longer stay in hospital (p=0.032 and p=0.021, respectively). CONCLUSION: The rate of malnourishment was significantly higher in patients having trauma-related surgery than in those having elective surgery. Malnourished patients are at greater risk of prolonged hospital stay. Preoperative nutritional assessment may be useful in predicting patients at high surgical risk.

Pulmonary embolism and the use of vena cava filters after major trauma.

BACKGROUND: Major trauma patients are at significant risk of developing pulmonary embolism (PE). We aimed to (i) analyse the current incidence and timing of PE after injury; (ii) identify risk factors that predispose major trauma patients to the occurrence of PE; and (iii) describe the use of vena cava filters (VCFs) following major trauma. METHODS: Prospectively collected data from The Alfred Hospital's Trauma Registry were used to identify all major trauma patients admitted over a 7-year period. A multivariable logistic regression model was used to identify factors associated with the occurrence of PE. A similar model was developed to identify factors associated with the use of VCFs inserted at the discretion of the treating clinician. RESULTS: A total of 6344 major trauma patients were treated during this period, with 73.2% male, mean age of 44.2, 90.2% with a blunt mechanism of injury and mean injury severity score of 24.3. Prophylactic VCFs were inserted in 511 patients (8.1%), with a mean time to insertion of 3.6 days after injury. There were 45 PE, 2 of which were fatal. The mean time to PE was 12 days post-injury. Three variables were independently associated with the occurrence of PE: the absence of a VCF; number of injuries to the lower limb; and central venous catheterization. CONCLUSION: The PE rate was 0.71%. Lower limb injuries and central venous catheterization are independently associated with a higher risk of PE after major trauma and VCFs are associated with a reduced risk.

Health resource utilisation costs in acute patients with persistent midline cervical tenderness following road trauma.

INTRODUCTION: The costs associated with patients discharged with isolated clinician-elicited persistent midline tenderness and negative computed tomography (CT) findings have not been reported. Our aim was to determine the association of acute and post-acute patient and injury characteristics with health resource costs in such patients following road trauma. METHODS: In a prospective cohort study, road trauma patients presenting with isolated persistent midline cervical tenderness and negative CT, who underwent additional acute imaging with MRI, were recruited. Patients were reviewed in the outpatient spine clinic following discharge, and were followed up at 6 and 12 months post-trauma. Multivariate linear regression was used to assess the association of injury mechanism, clinical assessment, socioeconomic factors and outcome findings with health resource costs generated in the acute hospital and post-acute periods. RESULTS: There were 64 patients recruited, of whom 24 (38%) had cervical spine injury detected on MRI. Of these, 2 patients were managed operatively, 6 were treated in cervical collars and 16 had the cervical spine cleared and were discharged. At 12 months, there were 25 patients (44%) with residual neck pain, and 22 (39%) with neck-related disability. The mean total cost was AUD $10,153 (SD=10,791) and the median was $4015 (IQR: 3044-6709). Transient neurologic deficit, which fully resolved early in the emergency department, was independently associated with higher marginal mean acute costs (represented in the analysis by the ß coefficient) by $3521 (95% CI: 50-6880). Low education standard (ß coefficient: $5988, 95% CI: 822-13,317), neck pain at 6 months (ß coefficient: $4017, 95% CI: 426-9254) and history of transient neurologic deficit (ß coefficient: $8471, 95% CI: 1766-18,334) were associated with increased post-acute costs. CONCLUSION: In a homogeneous group of road trauma patients with non fracture-related persistent midline cervical tenderness, health resource costs varied considerably. As long term morbidity is common in this population, a history of resolved neurologic deficit may require greater intervention to mitigate costs. Additionally, adequate communication between acute and community care providers is essential in order to expedite the recovery process through early return to normal daily activities.

Rest easy? Is bed rest really necessary after surgical repair of an ankle fracture?

INTRODUCTION: Bed rest with elevation of the affected limb is commonly prescribed postoperatively following ankle fracture fixation although there is no evidence that this is necessary. AIM: The aim of this prospective, randomised study was to investigate the effects of early mobilisation following surgical fixation of an ankle fracture on wound healing and length of stay (LOS). METHOD: A total of 104 patients underwent primary internal fixation of an ankle fracture at The Alfred hospital, Melbourne between July 2008 and January 2010. INTERVENTION: The strategy included either early mobilisation group (first day post surgery) or control group (bed rest with elevation until day 2 post surgery). OUTCOME MEASURES: Data collected included demographic, injury type and surgical procedure. Outcome data included inpatient LOS, wound condition at 10-14 days, opioid use and re-admission rate. RESULTS: Groups were comparable at baseline. Wound breakdown rate was 2.9% (3 patients in the control group). Median LOS of the early mobilisation group was 55 h compared with 71 h in the control group (p<0.0001). Opioid use for the control group was an average of 90 mg morphine equivalent in the first 24 h post surgery compared with 67 mg morphine equivalent for the early mobilisation group (p=0.32). CONCLUSION: This study indicates that early mobilisation following surgical fixation of an ankle fracture results in a shorter hospital stay without evidence of an increased risk of re-admission or wound complication.

Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results.

STUDY OBJECTIVE: We aim to determine the prevalence and factors associated with cervical discoligamentous injuries detected on magnetic resonance imaging (MRI) in acute, alert, neurologically intact trauma patients with computed tomography (CT) imaging negative for acute injury and persistent midline cervical spine tenderness. We present the cross-sectional analysis of baseline information collected as a component of a prospective observational study. METHODS: Alert, neurologically intact trauma patients presenting to a Level I trauma center with CT negative for acute injury, who underwent MRI for investigation of persistent midline cervical tenderness, were prospectively recruited. Deidentified images were assessed, and injuries were identified and graded. Outcome measures included the presence and extent of MRI-detected injury of the cervical ligaments, intervertebral discs, spinal cord and associated soft tissues. RESULTS: There were 178 patients recruited during a 2-year period to January 2009. Of these, 78 patients (44%) had acute cervical injury detected on MRI. There were 48 single-column injuries, 15 two-column injuries, and 5 three-column injuries. Of the remaining 10 patients, 6 had isolated posterior muscle edema, 2 had alar ligamentous edema, 1 had epidural hematoma, and 1 had atlanto-occipital edema. The injuries to 38 patients (21%) were managed clinically; 33 patients were treated in cervical collars for 2 to 12 weeks, and 5 patients (2.8%) underwent operative management, 1 of whom had delayed instability. Ordinal logistic regression revealed that factors associated with a higher number of spinal columns injured included advanced CT-detected cervical spondylosis (odds ratio [OR] 11.6; 95% confidence interval [CI] 3.9 to 34.3), minor isolated thoracolumbar fractures (OR 5.4; 95% CI 1.5 to 19.7), and multidirectional cervical spine forces (OR 2.5; 95% CI 1.2 to 5.2). CONCLUSION: In patients with cervical midline tenderness and negative acute CT findings, we found that a subset of patients had MRI-detected cervical discoligamentous injuries and that advanced cervical spine degeneration evident on CT, minor thoracolumbar fracture, and multidirectional cervical spine forces were associated with increased injury extent. However, a larger study is required to validate which variables may reliably predict clinically important injury in such patients, thereby indicating the need for further radiographic assessment.

A synthetic haemoglobin-based oxygen carrier and the reversal of cardiac hypoxia secondary to severe anaemia following trauma.

We report a case of compassionate use of a haemoglobin-based oxygen carrier in a severely injured Jehovah's Witness patient, for whom survival was considered unlikely. Severe anaemia and cardiac hypoxia were reversed after slow infusion of this agent. No vasoactive side effects were associated with the treatment, possibly due to the slow infusion, and the patient survived.

Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion.

STUDY DESIGN: The correlation between magnetic resonance imaging and discography of the cervical spine in degenerative disc disease was studied. In addition, the results of cervical discectomy and fusion were evaluated. OBJECTIVES: To compare the value of cervical magnetic resonance imaging versus discography in selecting the level for discectomy and fusion and to evaluate the surgical outcome. SUMMARY OF BACKGROUND DATA: The value of magnetic resonance imaging and discography in patients with cervical discogenic pain is less clear. Also, the status of a hypointense signal (dark) cervical disc and/or a small herniated disc on magnetic resonance imaging has not been determined. METHODS: The magnetic resonance imaging studies and discography followed by computed tomography in 55 patients with cervical discogenic pain were evaluated. Surgical planning was based on the complete information of clinical symptoms, magnetic resonance imaging, and discography as well as computed tomography discography. Anterior cervical discectomy and keystone fusion was performed. Postoperative pain relief was assessed by the patients, and the follow-up radiographs were viewed by an independent reviewer. The overall surgical outcome was evaluated using Odom's criteria. RESULTS: There were 161 disc levels that successfully underwent cervical discography with 79 positive levels. A positive discography result was found in 63% of dark (hypointense signal) discs and 45% of speckled discs. Fifty-nine percent of small herniated discs and 59% of torn discs had a positive discography, respectively. There were 100 abnormal cervical discs on magnetic resonance imaging. Magnetic resonance imaging had a false-positive rate of 51% and a false-negative rate of 27%. Successful cervical fusion was achieved in 95% of patients, and the overall satisfactory result was 76%. CONCLUSIONS: Magnetic resonance imaging can identify most of the painful discs but still has relatively high false-negative and false-positive rates. There is a high chance that hypointense signal and small herniated discs are the pain generators, but they are not always symptomatic. Discography can save the levels from being unnecessarily fused. The combination of clinical symptoms, magnetic resonance imaging, and discography provides the most information for decision making and can improve the management of cervical discogenic pain.