Rapid, midline retroperitoneal exposure for four-level anterior lumbar interbody fusion-technical case atlas.

We describe a novel, rapid midline retroperitoneal operative technique in a patient, with multi-level degenerative scoliosis, who underwent an extensive L2-S1 anterior lumbar interbody fusion in addition to posterior instrumentation. Uniquely, our approach enables an essentially midline approach to the rectus muscle and uses the diminution of the transversalis fascia-to-peritoneum transition in the pelvis to provide expedited exposure-making it particularly helpful for ALIF exposure, retraction and intraoperative radiography. We minimize morbidity around the rectus sheath by dissecting only the medial rectus muscle and then gently, bluntly mobilizing the retroperitoneum from the deep pelvis cranially.

Hypertonic saline administration and complex traumatic brain injury outcomes: a retrospective study.

Although hypertonic saline (HTS) decreases intracranial pressure (ICP) with traumatic brain injury (TBI), its effects on survival and post-discharge neurologic function are less certain. We assessed the impact of HTS administration on TBI outcomes and hypothesized that favorable outcomes would be associated with larger amounts of 3% saline. This is a retrospective study of consecutive-patients with the following criteria: blunt trauma, age 18-70 years, intracranial hemorrhage, Glasgow Coma Scale score (GCS) 3-12, and mechanical ventilation ≥ 5 days. The need for craniotomy or craniectomy denoted surgical decompression patients. Amounts of HTS were during the first-5 trauma center days. Traits for the 112 patients during 2012-2016 were as follows: GCS, 6.8 ± 3.2; subdural hematoma, 71.4%; cerebral contusion, 31.3%, ICP device, 47.3%; surgical decompression, 51.8%; ventilator days, 14.8 ± 6.7; trauma center mortality, 13.4%; and no commands at 3 months 35.5%. In surgically decompressed patients, trauma center mortality was greater with ≤ 8.0 mEq/kg sodium (38.9%) than with > 8.0 mEq/kg (7.5%; P = 0.0037). In surgically decompressed patients, following commands at 3 months was greater with ≥ 1400 mEq sodium (76.9%) than with < 1400 mEq (50.0%; P = 0.0489). For trauma center surviving non-decompression patients with no ICP device, those following commands at 3 months received more sodium (513 ± 784 mEq) than individuals not following commands (82 ± 144 mEq; P = 0.0142). For patients with a GCS 5-8, following commands at 3 months was greater with ≥ 1350 mEq sodium (92.3%) than with < 1350 mEq (60.0%; P = 0.0214). In patients with subdural hematoma or cerebral contusion, following commands at 3 months was greater with ≥ 1400 mEq sodium (84.2%) than with < 1400 mEq (61.8%; P = 0.0333). Patients with ICP > 20 mmHg for ≤ 10 hours (mean hours 2.0) received more sodium (16.5 ± 11.5 mEq/kg) when compared to ICP elevation for ≥ 11 hours (mean hours 34) (9.4 ± 6.3 mEq/kg; P = 0.0139). These observations demonstrate that hypertonic saline administration in patients with complex traumatic brain injury is associated with 1) mitigation of intracranial hypertension, 2) trauma center survival, and 3) following commands at 3 months post-injury.

Trauma patient adverse outcomes are independently associated with rib cage fracture burden and severity of lung, head, and abdominal injuries.

OBJECTIVE: We hypothesized that lung injury and rib cage fracture quantification would be associated with adverse outcomes. SUBJECTS AND METHODS: Consecutive admissions to a trauma center with Injury Severity Score ≥ 9, age 18-75, and blunt trauma. CT scans were reviewed to score rib and sternal fractures and lung infiltrates. Sternum and each anterior, lateral, and posterior rib fracture was scored 1 = non-displaced and 2 = displaced. Rib cage fracture score (RCFS) = total rib fracture score + sternal fracture score + thoracic spine Abbreviated Injury Score (AIS). Four lung regions (right upper/middle, right lower, left upper, and left lower lobes) were each scored for % of infiltrate: 0% = 0; ≤ 20% = 1, ≤ 50% = 2, > 50% = 3; total of 4 scores = lung infiltrate score (LIS). RESULTS: Of 599 patients, 193 (32%) had 854 rib fractures. Rib fracture patients had more abdominal injuries (p < 0.001), hemo/pneumothorax (p < 0.001), lung infiltrates (p < 0.001), thoracic spine injuries (p = 0.001), sternal fractures (p = 0.0028) and death or need for mechanical ventilation ≥ 3 days (Death/Vdays ≥ 3) (p < 0.001). Death/Vdays ≥ 3 was independently associated with RCFS (p < 0.001), LIS (p < 0.001), head AIS (p < 0.001) and abdominal AIS (p < 0.001). Of the 193 rib fracture patients, Glasgow Coma Score 3-12 or head AIS ≥ 2 occurred in 43%. A lung infiltrate or hemo/pneumothorax occurred in 55%. Thoracic spine injury occurred in 23%. RCFS was 6.3 ± 4.4 and Death/Vdays ≥ 3 occurred in 31%. Death/Vdays ≥ 3 rates correlated with RCFS values: 19% for 1-3; 24% for 4-6; 42% for 7-12 and 65% for ≥ 13 (p < 0.001). Death/Vdays ≥ 3 was independently associated with RCFS (p = 0.02), LIS (p = 0.001), head AIS (p < 0.001) and abdominal AIS (p < 0.001). Death/Vdays ≥ 3 association was better for RCFS (p = 0.005) than rib fracture score (p = 0.08) or number of fractured ribs (p = 0.80). CONCLUSION: Rib fracture patients have increased risk for truncal injuries and adverse outcomes. Adverse outcomes are independently associated with rib cage fracture burden. Severity of head, abdominal, and lung injuries also influence rib fracture outcomes.

Timing for deep vein thrombosis chemoprophylaxis in traumatic brain injury: an evidence-based review.

Multiple studies have addressed deep vein thrombosis chemoprophylaxis timing in traumatic brain injuries. However, a precise time for safe and effective chemoprophylaxis is uncertain according to experts. A comprehensive literature review on brain injuries was performed to delineate temporal proportions for 1) spontaneous intracranial hemorrhage (ICH) progression, 2) post-chemoprophylaxis ICH expansion, and 3) post-chemoprophylaxis deep vein thrombosis. Twenty-three publications were found including more than 5,000 patients. Spontaneous ICH expansion at 24 hours was 14.8% in 1,437 patients from chemoprophylaxis studies and 29.9% in 1,257 patients not in chemoprophylaxis studies (P < 0.0001). With low-risk ICH (n = 136), 99% of spontaneous ICH expansion occurred within 48 hours. In moderate or high-risk ICH (n = 109), 18% of spontaneous ICH expansion occurred after day 3. If patients with pre-chemoprophylaxis ICH expansion are included, the post-chemoprophylaxis ICH expansion proportion was 5.6% in 1,258 patients with chemoprophylaxis on days 1 to 3 and was 1.5% in 401 with chemoprophylaxis after day 3 (P = 0.0116). If patients with pre-chemoprophylaxis ICH expansion were excluded, the post-chemoprophylaxis ICH expansion proportion was 3.1% in 1,570 patients with chemoprophylaxis on days 1 to 3 and was 2.8% in 582 with chemoprophylaxis after day 3 (P = 0.7769). In diffuse axonal injury (n = 188), the post-chemoprophylaxis ICH expansion proportion was 1.6% with chemoprophylaxis after day 3. The deep vein thrombosis proportions were as follows: chemoprophylaxis on days 1 to 3, 2.6% in 2,384 patients; chemoprophylaxis on days 4 or 5, 2.2% in 831; and chemoprophylaxis on day 8, 14.1% in 99 (P < 0.0001). Spontaneous ICH expansion proportions at 24 hours substantially vary between chemoprophylaxis and non-chemoprophylaxis studies. Chemoprophylaxis should not be given within 3 days of injury for moderate-risk or high-risk ICH. Chemoprophylaxis is reasonable when low-risk patients have not developed ICH expansion within 48 hours post-injury. Chemoprophylaxis is also acceptable after day 3, when low-risk patients develop ICH expansion within 48 hours post-injury. In diffuse axonal injury patients who have not developed ICH within 72 hours, chemoprophylaxis is reasonable. Deep vein thrombosis proportions significantly increase when chemoprophylaxis is withheld for greater than 7 days.