Update: Spine injury

Spine injury

Controversies

At this moment there is persistent controversy within the spinal trauma community, which can be grouped under 6 headings:

First of all there is still no unanimity on the role and timing of medical and surgical interventions for patients with associated neurologic injury.

Type and timing of surgical intervention in multiply injured patients.

In some common injury types like odontoid fractures and thoracolumbar burst fracture, there is wide variation in practice between operative versus nonoperative management without clear reasons.

The role of different surgical approaches and techniques in certain injury types are not clarified yet.

Methods of nonoperative management and care of elderly patients with concurrent complex disorders are also areas where there is no consensus1).

Types

Spinal cord injury

Whiplash-associated disorders

Pediatric spine injury

Cervical spine injury

Thoracolumbar spine fracture

Sacral fracture

Osteoporotic vertebral fracture

Spinal gunshot wound

Penetrating neck trauma


Traumatic spine injuries are often transferred to regional tertiary trauma centers from OSH and subsequently discharged from the trauma center’s emergency department (ED) suggesting secondary overtriage of such injuries.

A study to investigate interfacility transfers with spine injuries found high rate of secondary overtriage of neurologically intact patients with isolated spine injuries. Potential solutions include increasing spine coverage in community EDs, increasing direct communication between the OSH and spine specialist at the tertiary center, and utilization of teleradiology 2).

Complications

Hydrocephalus is a rare complication of traumatic spine injury. A literature review reflects the rare occurrence with cervical spine injury.

Dragojlovic et al present a case of traumatic injury to the lumbar spine from a gunshot wound, which caused communicating hydrocephalus. The patient sustained a gunshot wound to the lumbar spine and had an L4-5 laminectomy with exploration and removal of foreign bodies. At the time of surgery, the patient was found to have dense subarachnoid hemorrhage in the spinal column. He subsequently had intermittent headaches and altered mental status that resolved without intervention. The headaches worsened, so a computed tomography scan of the brain was obtained, which revealed hydrocephalus. A ventriculoperitoneal shunt was placed, and subsequent computed tomography scan of the brain showed reduced ventricle size. The patient returned to rehabilitation with complete resolution of hydrocephalus symptoms. Intrathecal hemorrhage with subsequent obstruction or decreased absorption of cerebrospinal fluid at the distal spinal cord was thought to lead to communicating hydrocephalus in this case of lumbar penetrating trauma. In patients with a history of hemorrhagic, traumatic spinal injury who subsequently experience headaches or altered mental status, hydrocephalus should be included in the differential diagnosis and adequately investigated 3).

Assessment

ATLS® algorithm and spine trauma assessment. In Step „A“ cervical spine (C-Spine) protection is indispensable. Every unconscious patient is stabilized by stiff-neck. Patients with signs of chest injury in step „B” and abdominal injury in step „C“, especially retroperitoneal are highly suspicious for thoracic (T-) and/or (L-) lumbar spine injury. Normal motor exam and reflexes do not rule out significant spine injury in the comatose patient. Abnormal neurologic exam is a sign for substantial spinal column injury including spinal cord injury (SCI). Log roll in step „E” is important to assess the dorsum of the cervical to the sacral spine and to look out for any signs of bruising, open wounds, tender points and to palpate the paravertebral tissue and posterior processus in search for distraction injury. Spine precautions should only be discontinued when patients gain back consciousness and are alert to communicate sufficiently on spinal discomfort or neurologic sensations before the spine is cleared 4).

Data on all patients with traumatic spine injuries admitted to the Alfred Hospital, Melbourne between May 1, 2009, and January 1, 2011, were collected:

There were 965 patients with traumatic spine injuries with 2,333 spine trauma levels. The general cohort showed a trimodal age distribution, male-to-female ratio of 2:2, motor vehicle accidents as the primary spine trauma mechanism, 47.7% patients with severe polytrauma as graded using the Injury Severity Score (ISS), 17.3% with traumatic brain injury (TBI), the majority of patients with one spine injury level, 7% neurological deficit rate, 12.8% spine trauma operative rate, and 5.2% mortality rate. Variables with statistical significance trending toward mortality were the elderly, motor vehicle occupants, severe ISS, TBI, C1-2 dissociations, and American Spinal Injury Association (ASIA) A, B, and C neurological grades. Variables with statistical significance trending toward the elderly were females; low falls; one spine injury level; type 2 odontoid fractures; subaxial cervical spine distraction injuries; ASIA A, B, and C neurological grades; and patients without neurological deficits. Of the general cohort, 50.3% of spine trauma survivors were discharged home, and 48.1% were discharged to rehabilitation facilities. This study provides baseline spine trauma epidemiological data. The trimodal age distribution of patients with traumatic spine injuries calls for further studies and intervention targeted toward the 46- to 55-year age group as this group represents the main providers of financial and social security. The study’s unique feature of delineating variables with statistical significance trending toward both mortality and the elderly also provides useful data to guide future research studies, benchmarking, public health policy, and efficient resource allocation for the management of spine trauma 5).

Outcome

There is no universally accepted outcome instrument available that is specifically designed or validated for spinal trauma patients, contributing to controversies related to the optimal treatment and evaluation of many types of spinal injuries. Therefore, the AOSpine Knowledge Forum Trauma aims to develop such an instrument using the International Classification of Functioning Disability and Health (ICF) as its basis.

Experts from the 5 AOSpine International world regions were asked to give their opinion on the relevance of a compilation of 143 ICF categories for spinal trauma patients on a 3-point scale: “not relevant,” “probably relevant,” or “definitely relevant.” The responses were analyzed using frequency analysis. Possible differences in responses between the 5 world regions were analyzed with the Fisher exact test and descriptive statistics.

Of the 895 invited AOSpine International members, 150 (16.8%) participated in this study. A total of 13 (9.1%) ICF categories were identified as definitely relevant by more than 80% of the participants. Most of these categories were related to the ICF component “activities and participation” (n = 8), followed by “body functions” (n = 4), and “body structures” (n = 1). Only some minor regional differences were observed in the pattern of answers.

More than 80% of an international group of health care professionals experienced in the clinical care of adult spinal trauma patients indicated 13 of 143 ICF categories as definitely relevant to measure outcomes after spinal trauma. This study creates an evidence base to define a core set of ICF categories for outcome measurement in adult spinal trauma patients 6).

Early independent risk factors predictive of suboptimal physical health status identified in a level 1 trauma center in polytrauma patients with spine injuries were tachycardia, hyperglycemia, multiple chronic medical comorbidities, and thoracic spine injuries. Early spine trauma risk factors were shown not to predict suboptimal mental health status outcomes 7).

References

1)

Oner C, Rajasekaran S, Chapman JR, Fehlings MG, Vaccaro AR, Schroeder GD, Sadiqi S, Harrop J. Spine Trauma-What Are the Current Controversies? J Orthop Trauma. 2017 Sep;31 Suppl 4:S1-S6. doi: 10.1097/BOT.0000000000000950. PubMed PMID: 28816869.
2)

Bible JE, Kadakia RJ, Kay HF, Zhang CE, Casimir GE, Devin CJ. How often are interfacility transfers of spine injury patients truly necessary? Spine J. 2014 Apr 14. pii: S1529-9430(14)00379-9. doi: 10.1016/j.spinee.2014.01.065. [Epub ahead of print] PubMed PMID: 24743061.
3)

Dragojlovic N, Stampas A, Kitagawa RS, Schmitt KM, Donovan W. Communicating Hydrocephalus Due to Traumatic Lumbar Spine Injury: Case Report and Literature Review. Am J Phys Med Rehabil. 2016 Jun 17. [Epub ahead of print] PubMed PMID: 27323322.
5)

Tee JW, Chan CH, Fitzgerald MC, Liew SM, Rosenfeld JV. Epidemiological trends of spine trauma: an Australian level 1 trauma centre study. Global Spine J. 2013 Jun;3(2):75-84. doi: 10.1055/s-0033-1337124. Epub 2013 Mar 19. PubMed PMID: 24436855; PubMed Central PMCID: PMC3854579.
6)

Oner FC, Sadiqi S, Lehr AM, Aarabi B, Dunn RN, Dvorak MF, Fehlings MG, Kandziora F, Post MW, Rajasekaran S, Vialle L, Vaccaro AR. Toward Developing a Specific Outcome Instrument for Spine Trauma: An Empirical Cross-sectional Multicenter ICF-Based Study by AOSpine Knowledge Forum Trauma. Spine (Phila Pa 1976). 2015 Sep 1;40(17):1371-1379. PubMed PMID: 26323025.
7)

Tee JW, Chan CH, Gruen RL, Fitzgerald MC, Liew SM, Cameron PA, Rosenfeld JV.Early predictors of health-related quality of life outcomes in polytrauma patients with spine injuries: a level 1 trauma center study. Global Spine J. 2014 Feb;4(1):21-32. doi: 10.1055/s-0033-1358617. Epub 2013 Nov 6. PubMed PMID: 24494178.

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