Saskya Byerly

Clinical Relevance of Magnetic Resonance Imaging in Cervical Spine Clearance: A Prospective Study

IMPORTANCE A missed cervical spine (CS) injury can have devastating consequences. When CS injuries cannot be ruled out clinically using the National Emergency X-Radiography Utilization Study low-risk criteria because of either a neurologic deficit or pain, the optimal imaging modality for CS clearance remains controversial. OBJECTIVE To investigate the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) for CS clearance. DESIGN, SETTING, AND PARTICIPANTS A prospective observational study was conducted from January 1, 2010, through May 31, 2011, at a level I trauma center. Participants included 830 adults who were awake, alert, and able to be examined who experienced blunt trauma with resultant midline CS tenderness and/or neurologic deficits and were undergoing CT of the CS. Initial examinations, all CS imaging results, interventions, and final CS diagnoses were documented. The criterion standard for the sensitivity and specificity calculations was final diagnosis of CS injury at the time of discharge. MAIN OUTCOMES AND MEASURES Clinically significant CS injuries, defined as injuries requiring surgical stabilization or halo placement. RESULTS Overall, 164 CS injuries (19.8%) were diagnosed, and 23 of these (2.8%) were clinically significant. All clinically significant injuries were detected by CT. Fifteen of 681 patients (2.2%) with a normal CT scan had a newly identified finding on MRI; however, none of the injuries required surgical intervention or halo placement. There was no change in management on the basis of MRI findings. The sensitivity and specificity of CT for detecting CS injury was 90.9% and 100%, respectively. For clinically significant CS injuries, the sensitivity was 100% and specificity was 100%. CONCLUSIONS AND RELEVANCE Computed tomography is effective in the detection of clinically significant CS injuries in adults deemed eligible for evaluation who had a neurologic deficit or CS pain. Magnetic resonance imaging does not provide any additional clinically relevant information.

The role of margins in extremity soft tissue sarcoma.

For extremity soft tissue sarcomas, limb salvage is now standard of care. The extent of surgical margins is balanced with functionality of the resected limb. Although negative margins are the goal, the necessary width is unclear. Additional considerations for margin adequacy include presence of anatomic barriers such as fascia and periosteum, proximity of critical structures, receipt of adjuvant and neoadjuvant therapies, and histologic subtype. Multidisciplinary team discussion is critical for treatment planning. J. Surg. Oncol. 2016;113:333–338.

Cervical Spinal Clearance: A Prospective Western Trauma Association Multi-Institutional Trial.

BACKGROUND For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury. METHODS This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings. RESULTS Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18–110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14–15); Injury Severity Score, 9 (IQR, 4–16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease. CONCLUSIONS For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted. LEVEL OF EVIDENCE Diagnostic tests, level II.

Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey

BACKGROUND Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice. METHODS A prospective multicenter study (2013–2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered. RESULTS Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data. CONCLUSION For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers. LEVEL OF EVIDENCE Diagnostic tests or criteria, level II.

The impact of pre-injury controlled substance use on clinical outcomes after trauma

BACKGROUND A disproportionately high percentage of trauma patients use controlled substances, and they often co-ingest multiple drugs. Previous studies have evaluated the effect of individual drugs on clinical outcomes after trauma. However, the impact of all drugs included in a comprehensive screening panel has not yet been compared in a single cohort of patients. METHODS All trauma patients who underwent urine drug screens after admission to the LAC + USC Medical Center (January 2008–June 2015) were identified retrospectively. Univariable and multivariable regression analyses determined the significance of all drugs tested in the hospital’s standard toxicology screen (amphetamine, barbiturate, benzodiazepine, cocaine, opiate, phencyclidine) on clinical outcomes. RESULTS A total of 10,166 patients who underwent admission toxicology screening were identified. Although 5,621 patients had completely negative screens, 3,292 patients tested positive for only one drug and 1,253 patients tested for multiple drugs. Univariable analysis indicated that patients who tested positive for multiple drugs had higher rates of operative intervention (p < 0.001), longer hospital stay (p < 0.001), and longer ICU stays (p < 0.001). Multivariable analysis indicated that phencyclidine was associated with higher rates of mortality (p = 0.025) whereas amphetamine was associated with lower rates of mortality (p = 0.012). Higher rates of operative intervention were observed in patients testing positive for amphetamine (p < 0.001), benzodiazepine (p < 0.001), or opiate (p < 0.001). Benzodiazepine use was associated with higher rates of mechanical ventilation (p < 0.001), but use of amphetamines (p = 0.021) or opiates (p < 0.001) was associated with lower rates. CONCLUSIONS Pre-injury use of amphetamine, barbiturate, benzodiazepine, cocaine, opiate, and PCP has a significant and variable impact on clinical outcomes after trauma. Comparing the relative effect of each drug class can help clinicians risk-stratify all trauma patients, including those who test positive for multiple substances. LEVEL OF EVIDENCE Epidemiologic study, level III.