Manuela Jaindl

Thromboembolic complications after spinal surgery in trauma patients.

Background Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease. Patients and methods We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem. Results The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities. Interpretation We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.

Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis

Clearing the cervical spine in polytrauma patients still presents a challenge to the trauma team. The risk of an overlooked cervical spine injury is substantial since these patients show painful and life-threatening injuries to one or more organ systems so that clinical examination is usually not reliable. A generally approved guideline to assess the cervical spine in polytrauma patients might significantly reduce delays in diagnosis, but a consistent protocol for evaluating the cervical spine has not been uniformly accepted or followed by clinicians. One purpose of this study was to analyse the common methods for cervical spine evaluation in critically injured patients and its safety and efficacy at this trauma centre. The second purpose was to present a comprehensive diagnostic C-spine protocol, based on the authors’ experiences with documented cases. From a prospectively gathered polytrauma database, we retrospectively analysed the clinical records of all polytrauma patients, with skeletal and/or non-skeletal cervical spine injuries, who were admitted to this level I trauma centre between 1980 and 2004. All patients were assessed following the trauma algorithm of our unit (modified by Nast-Kolb). Standard radiological evaluation of the cervical spine consisted of either a single lateral view or a three-view cervical spine series (anteroposterior, lateral, odontoid). Further radiological examinations (functional flexion/extension views, oblique views, CT scan, MRI) were carried out for clinical suspicion of an injury or when indicated by the standard radiographs. Sixteen patients (14%) had a single cross-table lateral view for radiological assessment of the cervical spine during initial trauma evaluation, Twenty-nine patients had a three-view cervical spine series (anteroposterior, lateral, odontoid) and 81 patients underwent extended radiological examinations by cervical CT scan (n=52), functional flexion/extension views (n=26) or MRI (n=3). Correct diagnosis was made in 107 patients (91%) during primary trauma evaluation, whereas in 11 patients (9%) our approach to clear the cervical spine failed to detect significant cervical spine injuries. In six patients skeletal injuries were missed by a single lateral view and in two patients by a three-view standard series because inadequate radiographs with poor technical quality or incomplete visualization of the cervical spine did not show the extent of the injury. In three cases ligamentous injuries were missed despite complete sets of standard radiographs and cervical CT scan, but without functional radiography. Common methods for cervical spine evaluation in critically injured patients were plain radiographs, cervical CT scan and functional flexion/extension views. Cervical CT scan was the most efficient imaging tool in detecting skeletal injuries, showing a sensitivity of 100%. A single cross-table lateral view appeared to be insufficient, as we found a sensitivity of only 63%. Functional radiography or MRI was also necessary, as plain radiographs and CT scan failed to detect significant ligamentous injuries in 6% of the patients. For more comprehensive assessment of the C-spine, we presented a new C-spine protocol based on the authors’ experiences, with the aim to avoid unnecessary delays in diagnosis.

Spine injuries in polytraumatized pediatric patients: characteristics and experience from a Level I trauma center over two decades.

BACKGROUND Spine injuries, a common component in polytrauma, are relatively rare in pediatric patients. Previous studies mainly described injuries to the cervical region, whereas information of injury patterns to the thoracic and lumbosacral region lack in the current literature. The aim of this study was to determine the incidence and characteristics of polytraumatized children and associated spine injuries in different pediatric development ages. METHODS A cohort review of all pediatric patients with the diagnosis of polytrauma and associated spine injury, admitted to a urban Level I trauma center, was conducted over an 18-year period from January 1992 to December 2010. Patients were stratified into four developmental age groups: infants/toddlers (age 0–4 years), preschool/young children (age 5–9 years), preadolescents (age 10–14 years), and adolescents (age 15–17 years). Demographics, clinical injury data, patterns of spine injuries, associated injuries, treatment, and outcome were abstracted and analyzed. RESULTS From a database of 897 severely (Injury Severity Score ≥ 16) injured pediatric patients, 28 children met the inclusion criteria. The mean age was 12.7 years (range, 1.3–16.7 years), and there were 18 males and 10 females. Younger children (age 0–9 years) sustained more injuries to the upper spine region, whereas injuries to the lumbar region were only seen in adolescents. Nine (32%) patients received surgical treatment for spine fracture or subluxation, and 15 (54%) were treated by nonoperative means. Four patients (14%) received only palliative treatment due to medical futility. Overall, the most commonly associated injury was thoracic injury (89%) followed by traumatic brain injury (64%). CONCLUSION The age-related anatomy and physiology predispose younger children to upper spine injuries in contrast to lower spine injuries seen in adolescents. Predictors of mortality include pathologic pupillary light reflex, high Injury Severity Score and Abbreviated Injury Scale score, and a low Glasgow Coma Scale score at admission. Thoracic injuries were the most common associated injuries followed by traumatic brain injury. LEVEL OF EVIDENCE Prognostic study, level III.

Incidence and analysis of radial head and neck fractures

AIM To investigate several complications like persistent radial head dislocation, forearm deformity, elbow stiffness and nerve palsies, associated with radial head fractures. METHODS This study reviewed the clinical records and trauma database of this level I Trauma Center and identified all patients with fractures of the radial head and neck who where admitted between 2000 and 2010. An analysis of clinical records revealed 1047 patients suffering from fractures of the radial head or neck classified according to Mason. For clinical examination, range of motion, local pain and overall outcome were assessed. RESULTS The incidence of one-sided fractures was 99.2% and for simultaneous bilateral fractures 0.8%. Non-operative treatment was performed in 90.4% (n = 947) of the cases, surgery in 9.6% (n = 100). Bony union was achieved in 99.8% (n = 1045) patients. Full satisfaction was achieved in 59% (n = 615) of the patients. A gender related significant difference (P = 0.035) in Mason type distribution-type III fractures were more prominent in male patients vs type IV fractures in female patients-was observed in our study population. CONCLUSION Mason type I fractures can be treated safe conservatively with good results. In type II to IV surgical intervention is usually considered to be indicated.

Basal haemoglobin levels as prognostic factor for early death in elderly patients with a hip fracture--A twenty year observation study.

INTRODUCTION Hip fractures are a significant cause of mortality and morbidity in the elderly. This study investigated the relationship between initial haemoglobin (Hb) levels and a prognostic parameter for outcome in those patients. PATIENTS AND METHODS A total of 3595 consecutive patients with diagnosed hip fractures were included in our study (72.2% females). Anaemia was defined according to WHO criteria, with according subgroups mild, moderate and severe anaemia. Data collection was performed prospectively and statistical evaluation was performed retrospectively. RESULTS Mean follow up in our study group was 11.2 ± 0.3 months. The mean age of our study group was 78.5 years (SEM ± 0.2 years). To facilitate analysis, patients were divided in two groups: ≤ 84 years (60.1%) and ≥ 85 years (39.9%). Mortality <12 months was 12.2% (n = 439). In our study population lower Hb levels ad admission were associated with a markedly elevated short-term mortality. In a multivariate logistic regression model adjusted for age and sex, mild anaemia at admission caused a 1.5 (CI: 1.1-1.9), moderate anaemia a 2.6 (95 CI: 2.0-3.4), and severe anaemia a 3.6 (CI: 1.8-6.9) fold increase in three months mortality compared to patients without anaemia. Total lymphocyte count (1.2 ± 0) did not show any differences between the subgroups. CONCLUSION Those findings in our study population with 3595 patients over a period of twenty years have proven that initial Hb levels are a useful and cost effective parameter to predict mortality in elderly patients with a hip fracture. This prognostic factor may help to increase the outcome of elderly patients with a hip fracture.

Vascular Injury in Obese Patients after Ultra-Low-Velocity Trauma

Background: Traumatic Knee Dislocation (KD) is a serious and potentially limb threatening injury, albeit a relatively rare condition. Knee dislocation, defined as a complete disruption of the integrity of the tibia-femoral articulation, is uncommon, representing 0.001% to 0.013% of orthopedic injuries. Male:Female ratio is 4:1, and nearly 10% are caused by ultra-low-velocity dislocations. These injuries have historically been attributed to High Velocity Impacts (HVKD) however more recently they are being noted in Low Velocity Incidents (LVKD), particularly involving morbidly obese people. An increase in LVKD in the morbidly obese from 17%, between 1995-2000 to 53% in 2007-2012 was reported in the literature. Methods: In our case series of two female patients vascular injury occurred after an ultra low velocity trauma in the domestic environment. Case 1 was a 72-year old female, BMI 28 kg/m2, with diabetes mellitus Type II, arterial hypertension, and obesity. Case 2 was a 57-year old female, BMI 44 kg/m2, with diabetes mellitus Type II, psychosis, and obesity. Vascular surgery was performed to maintain blood supply for the injured limb. Results: In one case full weight-bearing was achieved and the other case resulted in an above the knee amputation, due to severe soft tissue damage. Conclusion: Knee dislocation is a rare albeit a serious and potentially limb threatening condition. Expediancy in reducing the acutely dislocated knee is vital to prevent neurovascular damage and potential for compartement syndrome and limb amputation. Based on our observation, the knowledge of potentially serious adverse outcomes in obese patients with ultra-low-velocity trauma and vascular injury should increase our awareness in these patients with knee pain even after marginal trauma. X-rays, and if suspicion is raised, a CT-scan usually leads to a detailed and profound diagnosis, enabling immediate surgical intervention to save the affected limb.

Basal elevated serum calcium phosphate product as an independent risk factor for mortality in patients with fractures of the proximal femur-A 20 year observation study.

INTRODUCTION Fractures of the proximal femur are a significant cause of mortality and morbidity in the elderly population. Yet predictive marker of unfavourable prognosis are still lacking. Calcium phosphate product is a marker of osteo-renal dysregulation. This study investigated the role of serum calcium phosphate product (SCPP) levels as a prognostic parameter for outcome in those patients. PATIENTS AND METHODS A total of 3577 consecutive patients with diagnosed fractures of the proximal femur were included in our study (72.5% females). SCPP was divided into tertiles: <1.92mmol(2)/l(2), 1.93-2.38mmol(2)/l(2) and >2.39mmol(2)/l(2). Data collection was performed prospectively and statistical evaluation was performed retrospectively. RESULTS Mean follow up in our study group was 11.0±0.3 months. The mean age of our study group was 79.0 years (SEM ±14 years). To facilitate analysis, patients were divided in two groups: ≤84 years (64.4%) and ≥85 years (35.6%), and mortality <12 months was 12.4% (n=445). In our study population higher SCPP levels ad admission were associated with a markedly elevated mortality. In a multivariate logistic regression model adjusted for age and sex, plasma creatinine and haemoglobin at admission caused a 1.3 (CI: 1.01-1.6) for SCPP 1.93-2.38mmol(2)/l(2), and a 1.6 (CI: 1.2-2.0) for SPP >2.39mmol(2)/l(2) fold increase in overall mortality compared to patients with baseline SCPP levels (<1.92mmol(2)/l(2)) as reference category. CONCLUSION Those findings in our study population with 3577 patients over a period of 20 years proved to be, that serum Ca levels may be a good predictor for mortality in patients with fracture of the proximal femur. Further studies are required to evaluate whether these high risk patients might benefit from specific therapeutic measurements. This prognostic factor may help to increase the outcome of elderly patients with a fracture of the proximal femur.

Clearing the Cervical Spine in Polytrauma Patients: Current Standards in Diagnostic Algorithm

Introduction:Clearing the cervical spine in polytrauma patients still presents a challenge for the trauma team. The risk of an overlooked cervical spine injury is substantial since these patients show painful and lifethreatening injuries to one or more organ systems so that clinical examination is usually not reliable. A generally approved guideline to assess the cervical spine in polytrauma patients might significantly reduce delays in diagnosis, but a consistent protocol for evaluating the cervical spine has not been uniformly accepted or performed by clinicians. The aim of this study was to assess the safety and efficacy of the diagnostic algorithm at this trauma center and to propose a possible consensus of the optimal method for clearing the cervical spine in polytrauma patients.Materials and Methods:This study retrospectively analyzed the clinical records of all polytrauma patients with cervical spine injuries (n = 118) who were admitted to this level-I trauma center between 1980 and 2004. All patients were assessed following the trauma algorithm of our unit (modified by Nast-Kolb). Standard radiological evaluation of the cervical spine consisted of a single lateral view or a three-view cervical spine series. Further radiological examinations (functional flexion/extension views, oblique views, CT-scan, MRI) were performed by clinical suspicion of an injury or when indicated by the standard radiographs.Results:Correct diagnosis was made in 107 patients (91%) during primary trauma evaluation, whereas in 11 patients (9%) our approach to clear the cervical spine failed to detect significant cervical spine injuries: In six cases skeletal injuries were missed because only a lateral view of the cervical spine was performed during primary trauma evaluation and in one case because a three-view cervical spine series did not show the extent of the injury. In four cases discoligamentous injuries were missed despite complete sets of standard radiographs and a CT-scan, but missing functional flexion/ extension views.Conclusion:For assessment of the cervical spine in poly-trauma patients we recommend a three-view trauma series as minimum to clear the cervical spine and the more liberal use of CT-scan as standard diagnostic tool in a specific subset of patients with clinically suspected cervical spine injuries and significant trauma history. In those patients also, passive functional flexion/ extension views should be considered as obligate in later stages of diagnostic algorithm.

Die verletzte Halswirbelsäule bei Kindern und Jugendlichen

SummaryTrauma of the infant or juvenile spine is a very rare occurrence (less than 2%). Nevertheless, it is almost always dramatic. In 21 years 1630 patients with spinal cord injuries were treated. Of these, 21.7% (357 patients) had injuries in the area of the cervical spine. 23 patients (1.4%) were younger than 17.5 years, 8 of them were younger than 10 years. In 10 cases the cause was a traffic accident, in 7 cases it was a jump in too shallow water. In 4 times other leisure activities were the cause. A fall from a window sill and a falling tree were further reasons. Neck segment C0 to C3 was involved eight times, segment C3 to C7/Th 1 was involved 15 times. The average age of the group with injuries in C0 to C3 was 5.6 years, in the group with injuries of segments C3 to C7/Th1 it was 15.8 years. In 11 cases the trauma caused complete tetraplegia, in six cases the paralysis was partial. In six further cases no neurological deficit occurred. 14 cases were treated surgically, six were treated conservatively. Four children younger than 10 years with complete tetraplegia died. In seven cases tetraplegia persisted; out of six patients with incomplete neurological deficit three improved and three patients recovered completely.ZusammenfassungVerletzungen der kindlichen wie der jugendlichen Halswirbelsäule stellen ein rares (unter 2%), in der Regel aber äußerst dramatisches Geschehen dar. In 21 Jahren wurden 1630 Patienten mit Verletzungen, die gesamte Wirbelsäule betreffend, versorgt. 21,7% (357) davon entfielen auf die Halswirbelsäule. Insgesamt 23 Patienten (1,4%) von 1630 waren unter 17,5 Jahren, acht davon (0,5%) unter 10 Jahren. Ursache für die Verletzungen war in 10 Fällen der Straßenverkehr, in sieben Fällen eine Sprung in zu seichtes Wasser, in vier Fällen Aktivitäten in der Freizeit; ein Sturz aus dem Fenster und ein umstürzender Baum waren weitere Verletzungsursachen.Die Segmente C0 bis C3 waren 8-mal, die Segmente C3 bis C7/Th 1 waren 15-mal betroffen. Das Alter in der Segmentgruppe C0 bis C3 betrug im Median 5,6 Jahre, bei den Segmenten C3 bis C7/Th1 rund 15,8 Jahre. Folge des Traumas war in 11 Fällen ein kompletter Querschnitt, in sechs Fällen ein inkompletter Status und in sechs Fällen kein fassbares neurologisches Defizit. Operativ wurde in 14 Fällen interveniert, konservativ kamen ein Minervagips und fünf Schanzkrawatten zur Anwendung. Vier Kinder unter 10 Jahren mit komplettem Querschnitt verstarben (drei davon am Aufnahmetag), in sieben Fällen persistierte der komplette Querschnitt. Von den sechs Patienten mit inkompletter Neurologie zeigten drei eine deutliche Besserung, bei den drei anderen kam es zur Restitutio ad integrum.Trauma of the infant or juvenile spine is a very rare occurrence (less than 2%). Nevertheless, it is almost always dramatic. In 21 years 1630 patients with spinal cord injuries were treated. Of these, 21.7% (357 patients) had injuries in the area of the cervical spine. 23 patients (1.4%) were younger than 17.5 years, 8 of them were younger than 10 years. In 10 cases the cause was a traffic accident, in 7 cases it was a jump in too shallow water. In 4 times other leisure activities were the cause. A fall from a window sill and a falling tree were further reasons. Neck segment C0 to C3 was involved eight times, segment C3 to C7/Th1 was involved 15 times. The average age of the group with injuries in C0 to C3 was 5.6 years, in the group with injuries of segments C3 to C7/Th1 it was 15.8 years. In 11 cases the trauma caused complete tetraplegia, in six cases the paralysis was partial. In six further cases no neurological deficit occurred. 14 cases were treated surgically, six were treated conservatively. Four children younger than 10 years with complete tetraplegia died. In seven cases tetraplegia persisted; out of six patients with incomplete neurological deficit three improved and three patients recovered completely.