The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients.

BACKGROUND AND OBJECTIVE: The National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients. METHODS: Patients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated. RESULTS: Over the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%-96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%-97.2%]. CONCLUSION: Compared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.

Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma.

INTRODUCTION: The incidence of ladder-related falls is increasing, and this represents a disturbing trend, particularly in the context of increased life expectancy and the impending retirement of the populous 'baby-boomer' generation. To date, there have been no critical illness-focused studies reporting on the incidence, severity and outcomes of severe ladder-related injuries requiring ICU management. METHODS: Major trauma patients admitted to ICU over a 5year period to June 2011 after ladder falls >1m were identified from prospectively collected trauma data at a Level 1 trauma service. Demographic and ICU clinical management data were collected and non-parametric statistical analyses were used to explore the relationships between variables in hospital mortality/survival. RESULTS: There were 584 ladder fall admissions, including 194 major trauma cases, of whom 29.9% (n=58) fell >1m and were admitted to ICU. Hospital mortality was 26%, and fatal cases were almost entirely older males in domestic falls of ≤3m who died as a result of traumatic brain injury. Non-survivors had lower GCS at the scene (p=0.02), higher AIS head code (p=0.01), higher heart rate and lower mean arterial pressure (p<0.01) in the initial 24h period in ICU, and were ≥55years of age (p=0.05). Only 46% of patients available for follow-up were living at home at 12months without requiring additional care. CONCLUSIONS: The incidence of ladder falls requiring ICU management is increasing, and severe traumatic brain injury was responsible for the majority of deaths and for poor outcomes in survivors. In-hospital costs attributable to the care of these patients are high, and fewer than half were living independently at home at 12months post-fall. A concerted public health campaign is required to alert the community to the potential consequences of this mechanism of injury. The use of helmets for ladder users in domestic settings, where occupational health and safety regulations are less likely to be applied, is strongly recommended to mitigate the risk of severe brain injury. The benefits of this simple strategy far outweigh any mild inconvenience for the wearer, and may prevent catastrophic injury.

Restoration of vision in blind individuals using bionic devices: a review with a focus on cortical visual prostheses.

The field of neurobionics offers hope to patients with sensory and motor impairment. Blindness is a common cause of major sensory loss, with an estimated 39 million people worldwide suffering from total blindness in 2010. Potential treatment options include bionic devices employing electrical stimulation of the visual pathways. Retinal stimulation can restore limited visual perception to patients with retinitis pigmentosa, however loss of retinal ganglion cells precludes this approach. The optic nerve, lateral geniculate nucleus and visual cortex provide alternative stimulation targets, with several research groups actively pursuing a cortically-based device capable of driving several hundred stimulating electrodes. While great progress has been made since the earliest works of Brindley and Dobelle in the 1960s and 1970s, significant clinical, surgical, psychophysical, neurophysiological, and engineering challenges remain to be overcome before a commercially-available cortical implant will be realized. Selection of candidate implant recipients will require assessment of their general, psychological and mental health, and likely responses to visual cortex stimulation. Implant functionality, longevity and safety may be enhanced by careful electrode insertion, optimization of electrical stimulation parameters and modification of immune responses to minimize or prevent the host response to the implanted electrodes. Psychophysical assessment will include mapping the positions of potentially several hundred phosphenes, which may require repetition if electrode performance deteriorates over time. Therefore, techniques for rapid psychophysical assessment are required, as are methods for objectively assessing the quality of life improvements obtained from the implant. These measures must take into account individual differences in image processing, phosphene distribution and rehabilitation programs that may be required to optimize implant functionality. In this review, we detail these and other challenges facing developers of cortical visual prostheses in addition to briefly outlining the epidemiology of blindness, and the history of cortical electrical stimulation in the context of visual prosthetics.

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.

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.

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.

Traumatic cervical discoligamentous injuries: correlation of magnetic resonance imaging and operative findings.

STUDY DESIGN: Retrospective review using prospectively collected data. OBJECTIVE: The purpose of the study was to investigate the diagnostic properties of cervical magnetic resonance imaging (MRI) in detecting surgically verified disruptions of the anterior longitudinal ligament (ALL), intervertebral disc, and posterior longitudinal ligament (PLL). SUMMARY OF BACKGROUND DATA: Cervical MRI findings commonly provide the basis for the decision to stabilize cervical injury operatively. The correlation of cervical MRI findings with direct visualization of the cervical discoligamentous structures during operative management is a subject of debate. METHODS: The cervical spine MRI scans of patients who subsequently underwent anterior surgical stabilization after traumatic discoligamentous injury of the cervical spine were reviewed. The level and severity of ALL, disc and PLL disruption was compared with surgical findings. The sensitivity, specificity, positive and negative predictive values of MRI in the detection of surgically verified injuries were calculated. RESULTS: The MRI and surgical findings were compared on 31 consecutive patients, with the kappa values for ALL, intervertebral disc, and PLL disruption measuring 0.22, 0.25, and 0.31, respectively. MRI scans provided reasonable sensitivity to disc disruption (0.81) but poor sensitivity to ALL (0.48) and PLL (0.50) injury. Specificity for ALL and PLL disruption was 1.00 and 0.87, respectively, but 0.00 for disc disruption. The positive predictive value of MRI for ALL and intervertebral disc injury was 1.00 and 0.96, respectively, but 0.63 for PLL disruption. The false-negative rates for disruption of the ALL, disc and PLL were 0.52, 0.19, and 0.50, respectively. CONCLUSION: The ability of cervical MRI to detect surgically verified disruptions of the ALL, intervertebral disc, and PLL varied depending on the structure examined. MRI was sensitive but not specific for disc injury, and specific but not sensitive to ALL and PLL disruption. In this series, the comparison of cervical MRI and operative findings indicated that MRI was reliable only when positive for ALL and disc injury, and a reasonably reliable indicator of PLL status only when negative for PLL injury. Additionally, the high false-negative rates for ALL and PLL injury are concerning.

Occipital condyle fractures: incidence and clinical follow-up at a level 1 trauma centre.

The purpose of the study was to investigate the incidence, management, and outcomes of occipital condyle fractures at a level 1 trauma center. Blunt trauma patients with occipital condyle fracture admitted to a level 1 trauma center over a 3-year period were identified. Prospective clinical and functional follow-up was undertaken, including further radiographic imaging. The incidence of occipital condyle fracture in patients presenting to our level 1 trauma center was 1.7/1,000 per year. Twenty-four patients were followed up at a mean of 27 months post-injury. There was one case of isolated occipital condyle fracture; all other patients had sustained additional orthopedic, cervical spine, and/or head injury. Seven (29%) patients sustained unilateral Type III avulsion fractures, none of which were isolated injuries. Traumatic brain injury was detected in 46% of study patients, and 42% had cervical spine injury. External halothoracic immobilization was used in 33% of cases. Fracture union with anatomical alignment occurred in 21 patients (88%). No patient had cranial nerve deficit at admission or follow-up. Three patients (12.5%) had moderate to severe neck pain/disability at follow-up, all of whom had sustained multiple injuries. Occipital condyle fractures most frequently occur in conjunction with additional injuries, particularly head and cervical spine injuries. Most cases can be managed successfully nonoperatively. Functional outcome is generally determined by pain and disability related to other injuries, rather than occipital fracture configuration.

Nonoperative management of type II odontoid fractures in the elderly.

STUDY DESIGN: Retrospective case series of elderly patients with Type II odontoid fractures, with prospective functional follow-up. OBJECTIVE: We aimed to investigate the functional outcomes after nonoperative management of Type II odontoid fractures in elderly patients at a Level 1 trauma center. SUMMARY OF BACKGROUND DATA: Controversy exists regarding the most appropriate method of treatment of Type II odontoid fractures in the elderly population. The primary aim of management has generally been considered to be the achievement of osseous fusion. METHODS: Patients >or=65 years of age presenting to a Level 1 trauma center with Type II odontoid fractures were identified retrospectively from a prospective neurosurgery database. Those initially treated operatively, or who died before follow-up were excluded. Long-term pain and functional outcomes were assessed. RESULTS: Forty-two patients were followed up at a median of 24 months post injury. Ten patients (24%) were treated in cervical collars alone and 32 patients (76%) were managed in halothoracic braces. Radiographically demonstrated osseous fusion occurred in 50% of patients treated in collars and in 37.5% of patients managed in halothoracic bracing. However, fracture stability was achieved in 90% and 100% of cases respectively. In patients treated in collars, 1 patient had severe residual neck pain, severe disability, and poor functional outcome. There were no cases of severe pain or disability, or poor functional outcome in patients managed in halothoracic orthoses. There was no difference in outcome in those achieving osseous union compared with stable fibrous union. CONCLUSION: The nonoperative management of Type II odontoid fractures in elderly patients results in fracture stability, by either osseous union or fibrous union in almost all patients. Long-term clinical and functional outcomes seem to be more favorable when fractures have been treated with halothoracic bracing in preference to cervical collars. Stable fibrous union may be an adequate aim of management in elderly patients.

Factors predicting cervical collar-related decubitus ulceration in major trauma patients.

STUDY DESIGN: Retrospective medical record and electronic database audit to ascertain the incidence and predictors of cervical collar-related decubitus ulceration (CRU). OBJECTIVE: To determine the incidence and risk factors associated with the development of CRU in major trauma patients immobilized in Philadelphia cervical collars. SUMMARY OF BACKGROUND DATA: Cervical spine immobilization requires the utilization of a cervical collar before spinal clearance, which may be complicated by CRU and increased morbidity. METHODS: From a trauma registry database at a level 1 trauma center, 299 major trauma patients admitted over a 6-month period were identified. Predictors of CRU were retrospectively examined and assessed for relative importance using medical records and prospective infection control and radiology databases. RESULTS: Clinically significant predictors of CRU were ICU admission (P = 0.007), mechanical ventilation (P = 0.005), the necessity for cervical MRI (P < or = 0.001), and time to cervical spine clearance (P < or = 0.001). Time to cervical spine clearance was the major indicator, such that the risk of CRU increased by 66% for every 1 day increase in cervical collar time. CONCLUSION: In major trauma patients at a level 1 trauma center, the risk of CRU development increased significantly for every day of Philadelphia cervical collar time. Associated increased morbidity may be reduced by measures aimed at earlier cervical spine clearance.

Cervical spine clearance in unconscious traumatic brain injury patients: dynamic flexion-extension fluoroscopy versus computed tomography with three-dimensional reconstruction.

BACKGROUND: An optimal protocol for clearing the cervical spine in unconscious patients with traumatic brain injury remains controversial. Protocols include plain radiographs and computed tomography (CT), and ligamentous injury may be identified with flexion-extension radiographs. We questioned whether cervical CT with three-dimensional (3D) reconstructions may obviate the need for flexion-extension radiology in the detection of occult ligamentous injury. METHODS: Between July 1999 and November 2001, 276 unconscious traumatic brain injured patients admitted to The Alfred Hospital received cervical spine plain radiographs, CT with 3D reconstructions, and dynamic flexion-extension X-ray studies with fluoroscopy as part of a routine protocol. These patients were identified from a prospective intensive care unit database and all radiology reports were reviewed. RESULTS: Dynamic flexion-extension X-ray studies with fluoroscopy identified no new fractures or instability; there were no instances of true-positive results. Dynamic flexion-extension was true-negative in 260 of 276 (94%) patients, falsely positive in six patients (2.2%) and falsely negative in one (0.4%) patient. In nine patients, dynamic flexion-extension was inadequate. CONCLUSION: Dynamic flexion-extension X-ray studies with fluoroscopy delayed cervical spine clearance and were almost always reported as normal. In a cervical spine clearance protocol for unconscious traumatic brain injury patients, dynamic flexion-extension X-ray studies with fluoroscopy did not identify any patients with cervical fracture or instability not already identified by plain radiographs and fine-cut CT (C0 to T2) with 3D reconstructions.