Prehospital care of spinal injuries: a historical quest for reasoning and evidence.

PURPOSE: The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization. METHODS: An extensive search throughout historical literature and recent evidence based studies was conducted. RESULTS: The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries. CONCLUSION: Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. These slides can be retrieved under Electronic Supplementary Material.

Value of prehospital assessment of spine fracture by paramedics.

BACKGROUND: Current guidelines state that trauma patients at risk of spine injury should undergo prehospital spine immobilization to reduce the risk of neurological deterioration. Although this approach has been accepted and implemented as a standard for decades, there is little scientific evidence to support it. Furthermore, the potential dangers and sequelae of spine immobilization have been extensively reported. The role of the paramedic in this process has not yet been examined. The aim of this study was to evaluate the accuracy of prehospital evaluations for the presence of spine fractures made by paramedics. METHODS: All patients who presented with prehospital spine immobilization at our level II trauma center between January 2013 and January 2014 were prospectively included in a database. Prior to the diagnosis, paramedics recorded the probability of a spine fracture after a prehospital examination. These predictions were compared with patient outcomes. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS: One hundred and thirty-nine patients were included that positive predictive value was 22%, negative predictive value was 95%, sensitivity was 92%, specificity was 30%, and accuracy was 41%. CONCLUSIONS: The results of this study suggest that paramedics cannot accurately predict spinal fractures.

Incidence of spinal fractures in the Netherlands 1997-2012.

: To determine time trends of emergency department (ED) visits, hospitalization rates, spinal cord lesions and characteristics of patients with spinal fractures in the Netherlands. METHODS: In an observational database study we used the Dutch Injury Surveillance System to analyse spinal fracture-related ED visits, hospitalization rates and spinal cord lesions between 1997 and 2012. RESULTS: The total number of ED visits associated with spinal fractures increased from 4,507 in 1997 to 9,690 in 2012 (115% increase). The increase in the total number of fractures occurred in all age groups independently of gender. However, incidence rates increased more strongly with age and were higher in young males and ageing females. The hospitalization rate of diagnosed spinal fractures remained stable between 62 and 67%. The incidence of spinal cord lesions varied between 13.8 and 20.3 per million of the population over a period of 15 years. CONCLUSION: Spinal fracture-related ED visits are increasing in the Dutch population, independently of age or gender. The hospitalization rate and the absolute numbers of spinal cord lesions have remained stable over a period of 15 years. These findings are relevant for public health decision-making and resource allocation.

A Pulsatile Mass in the Right Buttock.

Gluteal artery pseudoaneurysms are a rare cause of buttock pain, with few cases reported in the recent literature. Although small pseudoaneurysms are usually asymptomatic, larger can be painful and require treatment. Most of these cases are pseudoaneurysms resulting from local trauma. We report in this case a patient with a gluteal artery pseudoaneurysm. The pseudoaneurysm was successfully thrombosed using ultrasound-guided thrombin injection. This article reviews the literature, discusses the imaging diagnostics and the treatment of gluteal artery aneurysms.

The use of mesh in acute hernia: frequency and outcome in 99 cases.

BACKGROUND: Incarceration of inguinal, umbilical and cicatricial hernias is a frequent problem. However, little is known about the relationship between the use of mesh and outcome after surgery. The goal of this study was to describe the relationship between the use of mesh in incarcerated hernia and the clinical outcome. PATIENTS AND METHODS: Correspondence, operation reports and patient files between January 1995 and December 2005 of patients presented at one academic and one teaching hospital in Rotterdam were searched for the following keywords: incarceration, strangulation and hernia. The patient characteristics, clinical presentation, pre-operative findings and clinical course were scored and analysed. RESULTS: A total of 203 patients could be identified: 76 inguinal, 52 umbilical, 39 incisional, 14 epigastric, 14 femoral, five trocar and three spigelian hernias. In the statistical analysis, epigastric, femoral, trocar and spigelian hernias were pooled, due to their small group sizes. One patient was excluded from the analysis because the hernia was not corrected during operation. In total, 99 hernias were repaired using mesh versus 103 primary suture repairs. Twenty-five wound infections were registered (12.3%). One mesh was removed during a reintervention for anastomotic leakage, although no signs of wound infection were present. Nine patients died, none of them due to wound-related problems [one cardiovascular, one ruptured aneurysm, two anastomotic leakage, two sepsis e causa incognita (e.c.i.), three pulmonary complications]. Univariate analysis showed that female patients (P = 0.007), adipose patients (P = 0.016), patients with an umbilical hernia (P = 0.01) and patients who underwent a bowel resection (P = 0.015) had a significantly higher rate of wound infections. The type of repair (e.g. primary suture or mesh), use of antibiotic prophylaxis, gender, ASA class and age showed no significant relation with post-operative wound infection. After logistic regression analysis, only bowel resection (P = 0.020) showed a significant relation with post-operative wound infection. CONCLUSIONS: Wound infection rates are high after the correction of acute hernia, but clinical consequences are relatively low. Mesh correction of an acute hernia seems to be safe and should be considered in every incarcerated hernia.