Arie B. van Vugt

Outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than CT abnormalities

Mild traumatic brain injury (mTBI) is a common heterogeneous neurological disorder with a wide range of possible clinical outcomes. Accurate prediction of outcome is desirable for optimal treatment. This study aimed both to identify the demographic, clinical, and computed tomographic (CT) characteristics associated with unfavorable outcome at 6 months after mTBI, and to design a prediction model for application in daily practice. All consecutive mTBI patients (Glasgow Coma Scale [GCS] score: 13-15) admitted to our hospital who were age 16 or older were included during an 8-year period as part of the prospective Radboud University Brain Injury Cohort Study (RUBICS). Outcome was assessed at 6 months post-trauma using the Glasgow Outcome Scale-Extended (GOSE), dichotomized into unfavorable (GOSE score 1-6) and favorable (GOSE score 7-8) outcome groups. The predictive value of several variables was determined using multivariate binary logistic regression analysis. We included 2784 mTBI patients and found CT abnormalities in 20.7% of the 1999 patients that underwent a head CT. Age, extracranial injuries, and day-of-injury alcohol intoxication proved to be the strongest outcome predictors. The presence of facial fractures and the number of hemorrhagic contusions emerged as CT predictors. Furthermore, we showed that the predictive value of a scheme based on a modified Injury Severity Score (ISS), alcohol intoxication, and age equalled the value of one that also included CT characteristics. In fact, it exceeded one that was based on CT characteristics alone. We conclude that, although valuable for the identification of the individual mTBI patient at risk for deterioration and eventual neurosurgical intervention, CT characteristics are imperfect predictors of outcome after mTBI.

Fluoroscopic positioning of sacroiliac screws in 88 patients

Background Fluoroscopic placement of guided sacroiliac screws is a well-established method of fixation of the posterior pelvic ring, leading to biomechanical results similar to an intact pelvic ring. The main problem remains the risk of neurologic injury resulting from the penetration of the interve

Functional outcome of internal fixation for pelvic ring fractures.

OBJECTIVE Evaluation of the functional outcome after unstable pelvic ring fractures stabilized with internal fixation. METHODS Between January 1, 1990, and September 1, 1997, 37 patients were treated with internal fixation for unstable pelvic fracture. Demographic data, type of accident, Hospital Trauma Index-Injury Severity Score, and fracture type according to Tile classification were scored. One patient died the day after the accident from neurologic injury. A Short Form-36 health questionnaire and a form regarding functional result after pelvic trauma, adapted from Majeed et al., were returned by 31 of 36 patients (86%). Twenty-eight patients (78%) were seen for physical and radiologic examination. RESULTS Twenty-six men and 11 women, with an average age of 34.7 years (range, 15-66 years) were included. The mean Injury Severity Score reached 30.4 (range, 16-66). According to the Tile classification, there were 16 type B fractures and 21 type C fractures. Seven patients were treated with open reduction and internal fixation of the pubic arch, 10 patients were treated with a combination of anterior open reduction and internal fixation with additional external fixation to increase the stability of the posterior ring. Nineteen patients underwent internal fixation of both anterior and posterior arch. In the remaining case, percutaneous posterior screw fixation was combined with anterior external fixation, because of estimated infectious risk. The average follow-up time was 35.6 months. Patients scored 78.6 of 100 on the Majeed score. Remarkable was the reported change in sexual intercourse in 12 patients (40%). Only 12 patients (40%) did not have complaints when sitting. On the SF-36 scales physical and social functioning, role limitations due to physical problems and vitality were limited compared with the averages for the Dutch population. Patients treated with combined anterior and posterior internal fixation scored significantly better on both the Majeed score and on the categories physical functioning, pain, general health and social functioning compared with patients with similar fractures treated with a combination of anterior internal fixation with external fixation. At the physical examination, 11 of 28 patients (39%) did not have any abnormality. Nineteen patients (68%) were back at their original job, which was physically demanding in 9 cases. There was a suspicion of nonunion of the posterior arch in two patients, which could be confirmed with a computed tomographic scan. CONCLUSION In general, limitations in functioning are reported, even after long-term follow-up. In partially unstable fractures, solitary anterior fixation gives good results. In completely unstable fractures, patients treated with combined internal fixation anterior as well as posterior scored a better outcome compared with combined internal and external fixation. Therefore, this technique is recommended as treatment of first choice in completely unstable fractures.

Predictors for the selection of patients for abdominal CT after blunt trauma: a proposal for a diagnostic algorithm.

Objective:To select parameters that can predict which patients should receive abdominal computed tomography (CT) after high-energy blunt trauma. Summary Background Data:Abdominal CT accurately detects injuries of the abdomen, pelvis, and lumbar spine, but has important disadvantages. More evidence for an appropriate patient selection for CT is required. Methods:A prospective observational study was performed on consecutive adult high-energy blunt trauma patients. All patients received primary and secondary surveys according to the advanced trauma life support, sonography (focused assessment with sonography for trauma [FAST]), conventional radiography (CR) of the chest, pelvis, and spine and routine abdominal CT. Parameters from prehospital information, physical examination, laboratory investigations, FAST, and CR were prospectively recorded for all patients. Independent predictors for the presence of ≥1 injuries on abdominal CT were determined using a multivariate logistic regression analysis. Results:A total of 1040 patients were included, 309 had injuries on abdominal CT. Nine parameters were independent predictors for injuries on CT: abnormal CR of the pelvis (odds ratio [OR], 46.8), lumbar spine (OR, 16.2), and chest (OR, 2.37), abnormal FAST (OR, 26.7), abnormalities in physical examination of the abdomen/pelvis (OR, 2.41) or lumbar spine (OR 2.53), base excess <−3 (OR, 2.39), systolic blood pressure <90 mm Hg (OR, 3.81), and long bone fractures (OR, 1.61). The prediction model based on these predictors resulted in a R2 of 0.60, a sensitivity of 97%, and a specificity of 33%. A diagnostic algorithm was subsequently proposed, which could reduce CT usage with 22% as compared with a routine use. Conclusions:Based on parameters from physical examination, laboratory, FAST, and CR, we created a prediction model with a high sensitivity to select patients for abdominal CT after blunt trauma. A diagnostic algorithm was proposed.

Added Value of Routine Chest MDCT After Blunt Trauma: Evaluation of Additional Findings and Impact on Patient Management

OBJECTIVE The objective of our study was to evaluate the added value of a low-threshold routine thoracic MDCT algorithm compared with a selective MDCT algorithm in adult blunt trauma patients. SUBJECTS AND METHODS A prospective cohort study was conducted in 464 consecutive blunt trauma patients who met criteria indicative of severe blunt trauma (66% male; age range, 16-93 years; median injury severity score, 13). After clinical evaluation and conventional radiography of the chest and thoracic spine, all patients underwent routine thoracic MDCT with an IV contrast agent (routine MDCT algorithm). Within this routine MDCT group, a subgroup was prospectively defined with abnormal or inconclusive clinical or conventional radiography evaluation (selective MDCT group). Two investigators determined the type, extent, and clinical impact of additional injuries found on MDCT as compared to conventional radiography for both MDCT groups. RESULTS Of all 464 patients within the routine MDCT group, 164 patients underwent selective MDCT, which resulted in detection of additional diagnoses compared with conventional radiography in 97 (59%) patients. The routine MDCT algorithm detected additional diagnoses compared with conventional radiography in 201 of 464 patients (43%). Compared with the selective MDCT algorithm, this was an absolute increase of 104 of 464 (22%) extra patients, resulting in a change in patient management in 34 (7%; 95% CI, 5-9.7%), mostly because of additional findings of pulmonary and mediastinal injury. CONCLUSION Routine MDCT has relatively lower, though still substantial, added diagnostic value compared with selective MDCT of the chest.

Computer-Assisted versus Conventional Surgery for Insertion of 96 Cannulated Iliosacral Screws in Patients with Postpartum Pelvic Pain.

BACKGROUND The purpose of this study was to assess the value of fluoroscopy-based computer-assisted surgery (CAS) for the insertion of iliosacral screws. The results of CAS were compared with the results of a conventionally operated prospective control group. Endpoints of this study were fluoroscopy time, guide wire insertion time, operation time and complication rate. METHODS The study group consisted of 24 patients with postpartum pelvic pain syndrome. All patients were treated with a stabilization of the pelvic ring by means of an anterior plate fixation and autologous tricortical bone graft as well as two iliosacral screws bilaterally. Consequently, the results of 48 versus 48 iliosacral screw fixations could be evaluated. Conventionally operated patients were turned from the supine to the prone position intraoperatively, whereas CAS operated patients were operated in the supine position. One surgeon performed all operations. RESULTS The fluoroscopy time in the CAS group was 0.7 minutes versus 1.8 minutes in the conventionally treated group (p < 0.01). The mean insertion time for four guide wires was 20.2 minutes in the CAS versus 19.4 minutes in the conventionally operated group (p = 0.6). The mean operation time in the CAS group was 97 minutes; 116 minutes in the conventional group (p = 0.03). In the CAS group one patient had pain and a sensory deficit of S2 postoperatively. The Fishers exact test showed no difference in complication rate between the two groups (p = 0.26). CONCLUSIONS The fluoroscopy time is decreased with a factor 2.5 using CAS. Guide wire insertion time was similar in both groups. The reduction in operation time using CAS was due to fact that patients were operated in the supine position during the whole procedure. This study shows that CAS is a save technique for insertion of iliosacral screws.

Routine Versus Selective Computed Tomography of the Abdomen, Pelvis, and Lumbar Spine in Blunt Trauma : A Prospective Evaluation

BACKGROUND Discussion still remains whether computed tomography (CT) of the abdomen, pelvis, and lumbar spine should be performed routinely after blunt trauma with high energy impact or only in restricted situations. The purpose of this study was to evaluate the additional value of a routine CT algorithm as compared with a more restricted, selective CT algorithm. MATERIALS This prospective study consisted of 465 patients that met the inclusion criteria of our high-energy trauma protocol. All patients underwent physical examination, abdominal ultrasound (AUS), and conventional radiography (CR) of the pelvis and lumbar spine and subsequently routine CT of the abdomen, pelvis, and lumbar spine. Before CT, a subgroup of patients with abnormal physical examination or CR or AUS was prospectively defined as the selective CT group. Type and extent of injuries and impact on treatment were recorded for both the routine CT group and the selective CT subgroup. RESULTS Of all patients, 42 received selective CT of the abdomen, 71 of the pelvis, and 48 of the lumbar spine. Compared with the algorithm with selective CT, routine CT revealed additional traumatic injuries in 15% of the patients in the abdomen, in 2.4% in the pelvis and in 8.2% in the lumbar spine. This resulted in an overall change of treatment in 6.4% (95% confidence interval, 3.7-9.0) of the patients who would not have received CT in a selective CT algorithm. CONCLUSIONS Compared with an algorithm with selective CT, an algorithm with routine CT finds substantially more clinically relevant diagnoses, even in patients with unsuspicious clinical examination, normal CR, and normal AUS.

Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management.

INTRODUCTION This study was performed to determine the agreement between and within surgeons concerning the influence on treatment plan of routine versus selective multidetector-row computed tomography (MDCT) findings in blunt trauma patients. PATIENTS For this study, 50 patients were randomly selected from a customized database that was originally used to compare a diagnostic algorithm with a selective use of MDCT with an algorithm with routine MDCT of the spine, chest, and abdomen within the same population. In all 50 patients, routine MDCT found additional diagnoses as compared with the selective MDCT algorithm. Of all patients, paper cases were created with detailed information on clinical parameters, findings by physical examination, and radiologic findings. The cases were independently presented to three different trauma surgeons. First, the surgeons were asked for their treatment plan based upon diagnoses found by physical examination, conventional radiography, and selective MDCT alone. Subsequently they were asked for their treatment plan with knowledge of the injuries additionally found by routine MDCT. This procedure was repeated after 3 months. The agreement between and within surgeons was determined for the change of patient management because of additional findings by routine MDCT. RESULTS The agreement on the influence of routine MDCT findings on patient management between surgeons was moderate ([kappa] = 0.46) in the first procedure and substantial in the second ([kappa] = 0.67). The agreement within surgeons ranged from moderate ([kappa] = 0.60) to excellent ([kappa] = 0.87). CONCLUSION All surgeons agreed that the traumatic injuries additionally found by routine MDCT, frequently resulted in a change of treatment plan. There was a moderate-to-excellent agreement between and within surgeons that these additional findings resulted in a change of treatment plan.

Biomechanical evaluation of the proximal femoral nail.

In 1997, the proximal femoral nail was introduced for treatment of peritrochanteric femoral fractures. Treatment results show a low complication rate. The most serious complication is cutout of the hip pin and femoral neck screw. Considerable load on the hip pin is thought to facilitate cutout. The biomechanical behavior of the hip pin and the femoral neck screw as part of the standard proximal femoral nail, and of an experimentally modified proximal femoral nail (in which the hole through the nail for the hip pin is modified to a slot) was studied. In the standard proximal femoral nail, the amount of the total load carried by the hip pin varies between 8% and 39% (mean, 21%). If the hip pin passes through a slot in the nail, it carries 2% to 8% (mean, 5%) of the load. The nonconstrained lateral end of the hip pin reduces the bending load applied to the implant. The slotted hole for the hip pin also allows the femur and the nail to medialize, even if the hip pin and femoral neck screw lose parallelism. The prevalence of cutout of the proximal femoral nail may be reduced by introduction of this mechanism.

Routine cervical spine radiography for trauma victims: Does everybody need it?

OBJECTIVE The purpose of this study was to evaluate the indication for routine cervical spine radiography in trauma patients. METHODS Prospective analysis of radiologic and clinical findings was performed during a 5-year period. Patients suitable for a clinical decision rule were reviewed separately. RESULTS Of the 1,757 consecutive patients included in the study, 38 were diagnosed with a cervical spine injury. Of the 599 patients suitable for the clinical decision rule, 62 had midline cervical tenderness, including 2 with cervical spine injury. No additional cervical spine injuries were found during follow-up. CONCLUSION It is within good practice, and it is also cost-effective, to obtain a cervical spine radiograph only on clinical parameters in trauma patients with no apparent bodily trauma and optimal parameters. With this clinical decision rule, 30.6% of all cervical spine series were redundant, and no (occult) spinal fractures would have been undetected.