Is postoperative bracing after pedicle screw fixation of spine fractures necessary? Study protocol of the ORNOT study: a randomised controlled multicentre trial.

INTRODUCTION: The most common surgical treatment of traumatic spine fractures is through a posterior approach using pedicle screws and rods. Postoperative treatment protocols including the use of postoperative orthoses however differ between hospitals and surgeons. A three-point hyperextension orthosis is designed to support proper posture and unload the anterior column. Some motion remains when wearing an orthosis, and its main value in postoperative treatment is therefore believed to be pain relief and patient confidence. This could consequently shorten recovery time. On the other hand, an orthosis could also lead to muscle weakness and slow down recovery. Any orthosis-related complications might also be avoided. Additionally, recent studies on conservative fracture treatment show no difference in radiological outcomes with or without an orthosis. To date, no randomised studies have been performed on the use of postoperative orthoses. METHODS AND ANALYSIS: Patients undergoing posterior fixation with pedicle screws for a traumatic thoracolumbar fracture (T7-L4) will be included in this randomised controlled multicentre non-inferiority trial. Forty-six patients will be randomised 1:1 to one of the two parallel groups; one group will wear a postoperative orthosis for 6 weeks followed by 6 weeks of weaning and one group will not wear an orthosis. The primary outcome is pain at 6 weeks reported on the Numerical Rating Scale. Secondary outcomes consist of pain on other moments, analgesic use, complications and length of hospital stay, quality of life (EuroQuol 5 Dimensions), back pain-related function (Oswestry Disability Index) and radiological outcomes with a follow-up of 1 year. Orthosis compliance is monitored weekly in the orthosis group. ETHICS AND DISSEMINATION: The institutional review board (METc VUmc) approved this study on 11 October 2016 under case number 2016.389. After completion of the trial, the results will be offered to an international scientific journal for peer-reviewed publication. TRIAL REGISTRATION NUMBER: NCT03097081 and NTR6285; Pre-results.

Combined anteroposterior fixation using a titanium cage versus solely posterior fixation for traumatic thoracolumbar fractures: A systematic review and meta-analysis.

STUDY DESIGN: Systematic review with meta-analysis. OBJECTIVE: Additional anterior stabilization might prevent posterior implant failure, but over time, the disadvantageous of bone grafts have become evident. The objective of this systematic review was to compare risks and advantages of additional anterior stabilization with a titanium cage to solely posterior fixation for traumatic thoracolumbar fractures. METHODS: An electronic search was performed in the literature from 1980 to March 2016. Studies comparing only posterior with anteroposterior fixation by means of a titanium cage were included in this study. Data extraction and Cochrane risk of bias assessment were done by two independent authors. In addition, the PRISMA statement was followed, and the GRADE approach was used to present results. RESULTS: Of the 1584 studies, two randomized controlled trials (RCTs) and one retrospective cohort study were included in the meta-analysis. The RCTs reported evidence of high quality that anteroposterior stabilization maintained better kyphosis correction than posterior stabilization alone. However, these results were neutralized in the meta-analysis by the cohort study. Implant failure was reported by one study, in the posterior group. No differences in follow-up visual analog scale scores, neurologic improvement, and complications were found. Operation time, blood loss, and hospital stay all increased in the anteroposterior group. CONCLUSIONS: Patients with a highly comminuted or unstable fracture could benefit from combined anteroposterior stabilization with a titanium cage, for some evidence suggests this prevents loss of correction. However, large randomized studies still lack. There is a risk of cage subsidence, and increased perioperative risks have to be considered when choosing the optimal treatment.

National consensus on communication in prehospital trauma care, the DENIM study.

BACKGROUND: In the Netherlands prehospital trauma care is provided by emergency medical services (EMS) nurses. This care is extended by Physician staffed Helicopter Emergency Medical Services (P-HEMS) for the more severely injured patient. Prehospital communication is a factor of influence on the identification of these patients and the dispatch of P-HEMS. Though prehospital communication it is often perceived to be incomplete and unstructured. To elucidated factors of influence on prehospital triage and the identification of the severely injured patient a Delphi study was performed. METHODS: A three round modified Delphi study was designed to explore concepts amongst experts in prehospital trauma care. P-HEMS physicians/nurses, trauma surgeons, EMS nurses and dispatch center operators where asked to state their opinion regarding identification of the poly trauma patient, trauma patient characteristics, prehospital communication and prehospital handover. RESULTS: Seventy-one panellist completed all three rounds. For the first round seven cases and 13 theses were presented. From the answers/argumentation the second round was build, in which 68 theses had to be ranked within four principle themes: factors that influence prehospital communication, critical information for proper handover, factors influencing collaboration and how training/education can influence this. Out of these answers the third survey was build, focussing on determining the exact content of a prehospital trauma handover. The majority of the panellists agreed to a set of parameters resulting in a new model of inter-professional hand over regarding prehospital trauma patients. DISCUSSION: Exact identification of the poly trauma patient in need of care by P-HEMS is difficult though prehospital communication and the prehospital handover may be improved. CONCLUSION: The respondents report that prehospital communication needs to be unambiguous to improve trauma care. Consensus was reached on a set of ten parameters that should minimally be handed over with regard to a prehospital trauma patient. This to facilitate prehospital communication between the Dispatch centre, EMS, P-HEMS and the receiving hospital.

Fall-related injuries in Amsterdam: Frail older women at risk.

Unintentional falls are a common cause of injury, especially among older persons. This study evaluates risk factors such as gender and age on morbidity and mortality after unintentional falls. Data were collected retrospectively for patients with a unintentional fall who were presented to the emergency department in 2013. A total of 3,217 patients were included; the majority were female. Patients over 65 years of age had a significant higher mortality and a longer length of hospital stay. Older women are at risk for sustaining a fall-related injury. Female gender is furthermore associated with increased length of stay in the hospital. Prevention should focus especially on these frail patients.

Protocol of the DENIM study: a Delphi-procedure on the identification of trauma patients in need of care by physician-staffed Mobile Medical Teams in the Netherlands.

BACKGROUND: In The Netherlands, standard prehospital trauma care is provided by emergency medical services and can be supplemented with advanced trauma care by Mobile Medical Teams. Due to observed over and undertriage in the dispatch of the Mobile Medical Team for major trauma patients, the accuracy of the dispatch criteria has been disputed. In order to obtain recommendations to invigorate the dispatch criteria, this study aimed at reaching consensus in expert opinion on the question; which acute trauma patient is in need of care by a Mobile Medical Team? In this paper we describe the protocol of the DENIM study (a Delphi-procedure on the identification of prehospital trauma patients in need of care by Mobile Medical Teams). METHODS: A national three round digital Delphi study will be conducted to reach consensus. Literature was explored for relevant topics. After agreement on the themes of interest, the steering committee will construct questions for the first round. In total, 120 panellists with the following backgrounds; Mobile Medical Team physicians and nurses, trauma surgeons, ambulance nurses, emergency medical operators will be invited to participate. Group opinion will be fed back between each round that follows, allowing the panellists to revise their previous opinions and so, converge towards group consensus. DISCUSSION: Successful prehospital treatment of trauma patients greatly depends on the autonomous decisions made by the different professionals along the chain of prehospital trauma care. Trauma patients in need of care by the Mobile Medical Team need to be identified by those professionals in order to invigorate deployment criteria and improve trauma care. The Delphi technique is used because it allows for group consensus to be reached in a systematic and anonymous fashion amongst experts in the field of trauma care. The anonymous nature of the Delphi allows all experts to state their opinion whilst eliminating the bias of dominant and/or hierarchical individuals on group opinion.