Timothy A. Moore

Classification of lower cervical spine injuries

Study Design. Blinded assessment by multiple observers of consecutive case series. Objectives. Measure the reliability of a new system of determining stability in subaxial cervical spine injuries. Summary of Background Data. Classification is fundamental to allow communication, determine prognosis, and direct treatment. Current systems have many limitations, including difficultly of use, lack of proven reliability and validity, and no assessment of stability. A new system to assess instability is proposed. Methods. A literature review of the most commonly described classification systems is reported. The Cervical Spine Injury Severity Score was tested for reliability by 10 examiners who graded 35 consecutive cases of cervical trauma. Plain radiographs and CT were saved as read using Efilm Lite in random order. Each was scored and intraobserver and interobserver agreement was measured using intraclass correlation coefficients (ICC). Results. Intraobserver agreement was excellent with ICC ranging from 0.97 to 0.99. Interobserver agreement was also excellent with mean 0.80 ranging from 0.75 to 0.98. Conclusion. A new cervical spine classification system of injury is paramount to treatment and outcomes. A new system may increase reliability and therefore allow more accurate determination of stability and dictate treatment.

Cervical spine injury severity score. Assessment of reliability.

BACKGROUND Systems for classifying cervical spine injury most commonly use mechanistic or morphologic terms and do not quantify the degree of stability. Along with neurologic function, stability is a major determinant of treatment and prognosis. The goal of our study was to investigate the reliability of a method of quantifying the stability of subaxial (C3-C7) cervical spine injuries. METHODS A quantitative system was developed in which an analog score of 0 to 5 points is assigned, on the basis of fracture displacement and severity of ligamentous injury, to each of four spinal columns (anterior, posterior, right pillar, and left pillar). The total possible score thus ranges from 0 to 20 points. Fifteen examiners assigned scores after reviewing the plain radiographs and computed tomography images of thirty-four consecutive patients with cervical spine injuries. The scores were then evaluated for interobserver and intraobserver reliability with use of intraclass correlation coefficients. RESULTS The mean intraobserver and interobserver intraclass correlation coefficients for the fifteen reviewers were 0.977 and 0.883, respectively. Association between the scores and clinical data was also excellent, as all patients who had a score of > or =7 points had surgery. Similarly, eleven of the fourteen patients with a score of > or =7 points had a neurologic deficit compared with only three of the twenty with a score of <7 points. CONCLUSIONS The Cervical Spine Injury Severity Score had excellent intraobserver and interobserver reliability. We believe that quantifying stability on the basis of fracture morphology will allow surgeons to better characterize these injuries and ultimately lead to the development of treatment algorithms that can be tested in clinical trials.

A New Look at the Hawkins Classification for Talar Neck Fractures: Which Features of Injury and Treatment Are Predictive of Osteonecrosis?

BACKGROUND Osteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes. METHODS The cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%). RESULTS One deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01). CONCLUSIONS Following talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis.

Use of two grading systems in determining risks associated with timing of fracture fixation.

BACKGROUND The early appropriate care (EAC) protocol and clinical grading system (CGS1) propose criteria that suggest timing of definitive fracture fixation by assessing risk for complications. This study applies these criteria to a cohort of patients with orthopedic injuries and determines clinical outcomes for groups stratified by risk and timing of fracture fixation. METHODS This retrospective work was performed at a Level I trauma center. Patients with operative femur, pelvis, acetabulum, and/or thoracolumbar spine injuries were included. Fractures were treated surgically, either early or delayed. Patients were retrospectively categorized into low- or high-risk groups using the EAC protocol and described as stable, borderline, unstable, or in extremis using a modified CGS (mCGS). RESULTS In the EAC analysis, low-risk patients treated early had fewer complications compared with delayed treatment. Among high-risk patients, no significant difference was noted. With the use of the mCGS, stable patients treated early had fewer complications compared with delayed patients. No difference in complications was detected for unstable and in extremis patients. Borderline patients treated early had fewer complications compared with delayed treatment, although results were not supported by sensitivity analysis. CONCLUSION The EAC protocol can effectively distinguish patients who are at high risk for complications if treated early. Early treatment in the low-risk group was associated with fewer complications. The mCGS differentiates stable patients who benefit from early definitive treatment of fractures as well as severely injured patients (unstable or in extremis) who may benefit from damage-control orthopedics. Borderline patients may also benefit from early definitive treatment, but criteria defining borderline patients require further study. LEVEL OF EVIDENCE Prognostic study, level III.

Multiple Procedures in the Initial Surgical Setting: When Do the Benefits Outweigh the Risks in Patients With Multiple System Trauma?

Objectives: To compare single versus multiple procedures in the same surgical setting. We hypothesized that complication rates would not be different and length of stay would be shorter in patients undergoing multiple procedures. Design: Prospective, cohort. Setting: Level 1 trauma center. Patients/Participants: A total of 370 patients with high-energy fractures were treated after a standard protocol for resuscitation to lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥−5.5 mmol/L. Fractures included femur (n = 167), pelvis (n = 74), acetabulum (n = 54), and spine (n = 107). Main Outcome Measurements: Complications, including pneumonia, acute respiratory distress syndrome, infections, deep venous thrombosis, pulmonary embolism, sepsis, multiple organ failure, and death, and length of stay. Results: Definitive fixation was performed concurrently with another procedure in 147 patients. They had greater ISS (29.4 vs. 24.6, P < 0.01), more transfusions (8.9 U vs. 3.6 U, P < 0.01), and longer surgery (4:22 vs. 2:41, P < 0.01) than patients with fracture fixation only, but no differences in complications. When patients who had definitive fixation in the same setting as another procedure were compared only with other patients who required more than 1 procedure performed in a staged manner on different days (n = 71), complications were fewer (33% vs. 54%, P = 0.004), and ventilation time (4.00 vs. 6.83 days), intensive care unit (ICU) stay (6.38 vs. 10.6 days), and length of stay (12.4 vs. 16.0 days) were shorter (all P ⩽ 0.03) for the nonstaged patients. Conclusions: In resuscitated patients, definitive fixation in the same setting as another procedure did not increase the frequency of complications despite greater ISS, transfusions, and surgical duration in the multiple procedure group. Multiple procedures in the same setting may reduce complications and hospital stay versus additional surgeries on other days. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Adjacent Level Ligamentous Injury Associated with Traumatic Cervical Spine Fractures: Indications for Imaging and Implications for Treatment

BACKGROUND Magnetic resonance imaging (MRI) is a vital tool for detection of soft tissue injury (STI) after cervical spine injury (CSI). However, high cost, prolonged imaging time, and limited use in hemodynamically unstable patients necessitates that the utility of MRI in all patients with CSI be scrutinized. METHODS A retrospective review was performed of all patients treated for a CSI at a Level I trauma center between 2005 and 2010. Patient demographics, fracture characteristics, and associated STIs were collected. STIs were classified further into same level ligamentous injury, adjacent level ligamentous injury (ALLI), cord contusion, and traumatic herniated disc. ALLI was defined as anterior or posterior longitudinal ligament, ligamentum flavum, or supraspinous or interspinous ligamentous injury. RESULTS MRI was performed in 240 of 787 patients. Evidence of STI was identified in 54.6%. ALLI was the most common STI (80 of 240 patients); these injuries were subdivided into above, below, or both above and below the concurrent fracture level. Patients with ALLI were significantly more likely to have injured C3 (P < 0.01) and C5 (P < 0.03) levels, association with widened disc space (P = 0.03), and multiple CSIs (P = 0.008). The whole ALLI was included in the fixation strategy in 100% of patients with ALLI only above the concurrent fracture level and 87% of patients with ALLI only below the concurrent fracture level. CONCLUSIONS MRI detected an associated STI in about 55% of patients who underwent imaging. Injuries involving multiple fractured cervical levels, fractures at C3 and C5, and widened disc space should raise the treating physicians level of suspicion for ALLI. Our data show that treatment directed by MRI findings in select cases has substantial value.

Teamwork in Trauma: System Adjustment to a Protocol for the Management of Multiply Injured Patients.

Objectives: We developed a protocol to determine the timing of definitive fracture care based on the adequacy of resuscitation. Inception of this project required a multidisciplinary group, including physicians from anesthesiology, general trauma and critical care, neurosurgery, orthopaedic spine, and orthopaedic trauma. The purposes of this study were to review our initial experience with adherence to protocol recommendations and to assess barriers to implementation. Design: Prospective. Setting: Level 1 trauma center. Intervention: Definitive fixation of pelvis, acetabulum, spine, and femur fractures within 36 hours of injury, based on laboratory parameters for acidosis. Main Outcome Measurements: Three hundred five consecutive skeletally mature patients with Injury Severity Score ≥16 (mean, 26.4) and 346 fractures of the proximal or diaphyseal femur (n = 152), pelvic ring (n = 56), acetabulum (n = 44), and/or spine (n = 94) were treated surgically. Adherence to the protocol was defined as definitive fixation within 36 hours of injury in resuscitated patients. All patients were adequately resuscitated within that time. Patient demographic and injury characteristics, date and time of presentation, and reasons for delay were recorded. Results: Two hundred fifty-one patients (82%) with 287 fractures were treated according to the protocol, whereas 54 patients (18%) with 59 fractures were definitively stabilized on a delayed basis (mean, 90 hours). Delay was not related to patient age, Injury Severity Score, day of week, or time of presentation. Before implementation of this protocol, 76% were treated on a delayed basis, demonstrating improvement for each fracture type: spine (79% of previous patients with delay), pelvis (57%), acetabulum (72%), and femur (22%); all P < 0.0001 for more frequently delayed surgery before the protocol. Surgeon choice to delay the procedure accounted for 67% of reasons for delay. Other reasons included intensivist choice (13%), operating room availability (7.4%), patient choice (3.7%), severe head injury (5.6%), or cardiac issues (3.7%). Our trauma center and surgeons became more accustomed to the protocol and had fewer delays over time; 10% were delayed 2 years after implementation. Conclusions: Management of trauma patients with injury to multiple systems requires teamwork among providers from related specialties and hospital support, in terms of operating room access, with appropriate ancillary personnel and equipment. Our system adjusted quickly to the protocol. Surgeon preference was the most common reason for delayed fixation, but within 24 months, only 10% of fractures were treated on a delayed basis, as long as patients were resuscitated. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue.

Objectives: We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay. Design: Prospective consecutive series. Setting: Level 1 trauma center. Patients/Participants: Two hundread and fifty‐three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0. Intervention: Femur, pelvis, or spine fractures treated surgically. Main Outcome Measurements: Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded. Results: Mean charges were US

The Reliability and Validity of the Thoracolumbar Injury Classification System in Pediatric Spine Trauma.

180,145 with a mean of US

Use of patella allograft for anterior cervical diskectomy and fusion.

66,871 collected (37%). The revenue multiplier was US