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Purpose Spinal injuries resulting in neurological damage cause significant morbidity. Swift neurosurgical intervention can mitigate negative outcomes. However, variable mechanisms of injury may be associated with inappropriate transport (IAT), which may delay necessary surgical interventions. Patients with near shore spinal injuries (NSSI) presented with unique mechanisms, so we investigated factors associated with IAT in patients with NSSI. Methods We performed a multicenter retrospective study of all adult patients transported from a beach resort to 3 hospitals for suspected NSSI between 2006 - 2017. We excluded patients transferred to other facilities, and those not injured in the water. Primary outcome was IAT, defined as patients with NSSI requiring transfer to another trauma center. To avoid heterogeneity in our analysis, we further excluded patients without NSSI who were inappropriately transported to a level I trauma center. We used multivariable logistic regression to assess association of independent variables (such as demographic, environmental, and clinical factors) with outcome. Results We analyzed 278 patients with suspected NSSI, and found 14 (5.0%) had IAT. Compared to appropriately transported patients, diving was associated with higher percentages of IAT (28.6% vs. 3.9%, p = 0.014) and more were transported by air (50.0% vs. 20.6%, p = 0.01). In multivariable regression, patients’ oxygenation saturation (odds ratio [OR] = 0.8, 95% confidence intervals [CI]: 077–0.98) and diving (OR = 7.5, 95% CI: 1.2–46) were significantly associated with IAT. Conclusion Rate of IAT for patients with NSSI was low. However, first responders and emergency medicine providers should be aware that diving is associated with a higher likelihood of IAT.

We studied the risk of associated spinal and nonspinal injuries (NSIs) in the setting of observed thoracolumbar transverse process fracture (TPF) and examined the clinical management of TPF.Patients treated at a Level I trauma center over a 5-year period were screened for thoracolumbar TPF. Prevalence of associated spinal fractures and NSIs as well as relationship to level of TPF was explored. Clinical management and follow-up outcomes were reviewed.A total of 252 patients with thoracolumbar TPFs were identified. NSIs were commonly observed (70.6%, n = 178); however, associated spinal fractures were more rarely seen (24.6%, n = 62, P0.0001). No patients had neurological deficits attributable to TPFs, and only 3 patients with isolated TPFs were treated with orthosis. Among patients with outpatient follow-up (70.6%, n = 178), none developed delayed-onset neurological deficits or spinal instability. Thoracic TPFs (odds ratio = 3.56, 95% confidence interval = 1.20-10.56) and L1 TPFs (odds ratio = 2.48, 95% confidence interval = 1.41-4.36) were predictive of associated thoracic NSIs. L5 TPF was associated with pelvic fractures (odds ratio = 6.30, 95% confidence interval = 3.26-12.17). There was no difference in rate of NSIs between isolated TPF (70.0%) and TPF with associated clinically relevant spinal fracture (72.6%, P = 0.70).NSIs are nearly 3 times more common in patients with thoracolumbar TPFs than associated clinically relevant spinal fractures. Spine service consultation for TPF may be unnecessary unless fracture is associated with a clinically relevant spinal injury, which represents a minority of cases. However, detection of TPF should raise suspicion for high likelihood of associated NSIs.

A spinal injury leads to complex reactions by glial, immune and other non-neural cells. In mammals these reactions are thought to prevent regeneration of axons and neuronal replacement. Here we review recent insights into how different cell types may cooperate to allow functional regeneration in zebrafish.

Introduction and purpose: Falling from a tree is a common cause of injury in and around the Karabük province. Such injuries can impair the quality of life by causing permanent damage and can increase morbidity and mortality. This study aimed to reveal the patterns of spinal and cranial injuries in patients admitted to the hospital. Methods: Patients who were admitted to the emergency department after falling from a tree in the Karabük province over a 2-year period and were diagnosed with injuries caused by falling from a tree were included. The parameters of age, sex, type of tree which the patient fell from, spinal and cranial fracture patterns and pain scores during follow-up were evaluated. Results: We studied 98 patients over a 2-year period. Of these, 5 (5.10%) patients were aged

Background Seat belt marks are seen frequently on occupants after motor vehicle accidents. Over the years, the clinical significance of these marks has changed as restraint systems have evolved. With modern restraint systems, signs of a compromised occupant–restraint relationship are an important and easily identified bedside finding. Objectives We sought to learn to recognize seat belt marks that demonstrate an abnormal occupant–restraint system relationship and to cultivate an understanding of significant soft tissue biomechanical loading associated with marks caused by a compromised occupant–restraint relationship. Discussion A review of case studies from the literature combined with forensic work demonstrate a strong correlation between significant injury and improper seatbelt use. When evidence of a compromised occupant–restraint relationship exists, incorporating computed tomography angiography and observation may be clinically indicated. Conclusion The recognition of seat belt marks made by a compromised occupant–restraint relationship is an important finding that allows risk stratification of the patient at the bedside. Further investigation with a prospective trial at a trauma center is warranted.

Objective Nanotechnology is a promising field with numerous applications across various branches of medicine. The unique innate physical, chemical, and biological properties of nanoparticles enable them to serve as appropriate agents performing diverse functions at cellular and subcellular levels. Spinal pathologies constitute one major field where its applications are being explored. Methods A critical review of literature was performed to identify the current role of nanotechnology in spine surgery. A PubMed search was done using the following key words: “nanotechnology in neurosurgery,” “nanotechnology in surgery,” “nanotechnology in spine,” “nanotechnology in spine surgery,” “nanotechnology in disc regeneration,” “nanotechnology in spinal injury,” “nanotechnology in spinal cord regeneration,” “nanotechnology in spine fusion,” “nanotechnology in osteoporosis,” “nanotechnology in spinal drug delivery,” and “nanotechnology in spinal infection.” Initial search revealed 347 articles. Articles were further screened. Duplicate articles, articles on nonnanotechnologic topics, nonspine articles, or articles with details not pertaining to the current field of interest and non-English language studies were excluded. Results A total of 76 articles were finally included. Nanotechnologic advancements in spine surgery include applications in spinal fusion, central nervous system drug delivery, neuronal regeneration, disk regeneration, spinal infection prophylaxis, management of osteoporosis, sutureless vascular anastomosis, molecular imaging, and theranostic medicine. Conclusions Nanotechnology in spine surgery is still in its early stages. Eventually, we may see the implementation of nanotechnology as an alternative to existing treatment options. Concerns regarding safety of this technology need to be addressed through future research projects. Although promising, the exact role of nanotechnology in spine surgery remains to be seen.

This study aims to determine spinal injury patterns and identify crash factors commonly associated with serious spinal injury as a result of motorcycle crashes. Data was retrospectively collected from motorcyclists sustaining spinal injuries from road crashes treated at Kuala Lumpur Hospital, Malaysia, over the 5-year period from 2005 to 2009. Each patient's injuries were analyzed by reviewing his or her medical records for radiographic imaging and computed tomography scans.A total of 151 patients were included in this study, of which, males accounted for over 87%. The first lower lumbar (L1) was the most commonly injured vertebral level, followed by the adjacent thoracic vertebra (T12). Fracture to the vertebral body without dislocation was found to be the most frequently observed spinal injury pattern. Injury severities for a majority of patients (65%) were measured at Maximum Abbreviated Injury Scale (MAIS) of 2. Serious spinal injury was associated with thorax or upper-extremity injury.Prevalence of lumbar spinal injury in the study reflects a predominantly low-speed crash among the motorcyclist in the region. Motorcyclists are at greater odd to sustain severe spinal injury when directly striking an object compare to striking the ground during the crash event. Keywords: Spinal injury, Motorcycle crash, Mechanism of injury, Vertebral fracture

Background Nurses are involved in delivering care for patients following acute traumatic spinal cord injury throughout the entire care journey. An injury of this type is significant for the individual and their family and can be challenging for nurses delivering care for patients with life changing injuries, especially for nurses new to this setting. There is a lack of research that examines the experience of nurses caring for these patients in the acute setting. Method A hermeneutic phenomenological approach was used to understand the experience of nurses caring for patients in the acute setting who had sustained a traumatic spinal injury with associated neurological deficit. Using the phenomenological approach guided by the insight of Gadamer and Max Van Manen, participants with a broad range of experience were recruited and interviewed. The responses were transcribed into a text and subjected to hermeneutic analysis. Burnard's (1991) 14-step process and the hermeneutic approach were used to interpret and understand the phenomenon of interest. Conclusion The study highlights the experience and challenges of providing care to these individuals. Although patients had significant physical disabilities and were often dependent physically, the nurses' concerns were directed more towards fulfilling their psychological needs. Nurses identified grieving patients and felt their role was to provide realistic hope to motivate them. They felt an internal tension regarding desensitisation towards their patients, but this was often an internal protective mechanism to deal with the significance of the events surrounding these patients. Nurses new to this setting took time to learn the routines and manage the unique challenges effectively. Caring for these patients gave the nurses the opportunity to understand their patients and their families, and appreciate that both groups will fluctuate in their behavior throughout the acute process, as they adjust to grief and loss.

Background Traumatic spinal injury (TSI) results from injury to bony, ligamentous, and/or neurologic structures of the spinal column and can cause significant morbidity and mortality. The global burden of TSI is poorly understood, so we performed a systematic review and meta-analysis to estimate the global volume of TSI. Methods We performed a systematic review through PubMed, Embase, and Cochrane Databases on TSI studies reported from 2000 to 2016. Collected data were used to perform a meta-analysis to estimate the annual incidence of TSI across World Health Organization regions and World Bank income groups using random-effect models. Incorporating global population figures, the annual worldwide volume of TSI was estimated. Results A total of 102 studies were included in the systematic review and 19 studies in the meta-analysis. The overall global incidence of TSI was 10.5 cases per 100,000 persons, resulting in an estimated 768,473 [95% confidence interval, 597,213–939,732] new cases of TSI annually worldwide. The incidence of TSI was higher in low- and middle-income countries (8.72 per 100,000 persons) compared with high-income countries (13.69 per 100,000 persons). Road traffic accidents, followed by falls, were the most common mechanism of TSI worldwide. Overall, 48.8% of patients with TSI required surgery. Conclusions TSI is a major source of morbidity and mortality throughout the world. Largely preventable mechanisms, including road traffic accidents and falls, are the main causes of TSI globally. Further investigation is needed to delineate local and regional TSI incidences and causes, especially in low- and middle-income countries.

To clarify the differences between postmortem CT (PMCT) and autopsy findings in the postmortem detection of cervical spine injuries (CSIs).Our department's forensic pathology database was searched for CSI cases. In each case, the autopsy data and radiologists' interpretations were reviewed for the presence of bone fractures and intervertebral injuries.The study included 42 cases. For both bone fractures and intervertebral injuries, no substantial concordance between PMCT and autopsy findings was observed (McNemar's test: p0.001 and p0.001, respectively). Regarding bone fractures, more injuries were detected with CT than with autopsy (CT: 74, autopsy: 23). The percentage of CT-detected fractures that were missed at autopsy (77.0%, 57/74) was higher than the percentage of autopsy-detected fractures missed with CT (26.1%, 6/23). Regarding intervertebral injuries, fewer injuries were detected with CT than with autopsy (CT: 40, autopsy: 80). The percentage of CT-detected injuries that were missed at autopsy (35.0%, 14/40) was lower than the percentage of autopsy-detected injuries that were missed with CT (67.5%, 54/80).A substantial number of CSIs were detected by either PMCT or autopsy alone. Accurate evaluation for CSI requires the use of both methods.

Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.

BACKGROUND CONTEXT Diffuse idiopathic skeletal hyperostosis (DISH) makes the spine prone to unstable fractures with neurological deterioration. The patients with DISH spinal fractures often complained minimal symptoms, which may lead to delayed diagnosis. PURPOSE This prospective study was conducted to evaluate the association between delayed diagnosis and delayed paralysis in DISH spinal injury. STUDY DESIGN/SETTING The study design was prospective multicenter study. Twelve institusions participated into this study. PATIENT SAMPLE This study included 69 patients with DISH (44 males, 25 females; mean age 75.2±11.4years). OUTCOME MEASURES Delayed diagnosis, dates of medical presentation, dates for correct diagnosis, name of diagnosis, neurological status at injury (Frankel grade), and delayed paralysis were evaluated. METHODS Patients were eligible for this study if they 1) had DISH, defined as flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies, and 2) had an injury in the ankylosing spine. RESULTS Delayed diagnosis was observed in 55.1% of the subjects. The reason of delayed diagnosis was doctor's delay in 55.3% and patient's delay in 44.7%. All patients without delayed diagnosis were made correct diagnosis by first medical institution within 24 hours after injury, however, patients with delayed diagnosis spent 11.3 days (0-180 days). Before correct diagnosis, 19 different diagnosis was made, osteoporotic vertebral fracture (57.9%) was the most frequent diagnosis. At the time of injury, Frankel B was observed in 2.9%, C in 7.2%, D in 15.9%, E in 73.9%, respectively. Delayed paralysis was observed in 17.2%. Correct diagnosis within 14 days after injury significantly associated with delayed paralysis (p=.049). CONCLUSIONS Delayed diagnosis was observed more than 50% of the patients, and most reason was doctor's delay (55.3%). To avoid delayed paralysis and improve clinical symptom, correct diagnosis at initial presentation is essential. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background The demand for neurosurgical procedures increased drastically in the late 19th century owing to advances in ballistics during the American Civil War and Crimean War. Methods and Results Surgical care for a gunshot wound to the spine relied on skilled identification and removal of the fractured bone. Hemorrhage control and infection prevention were also imperative for improving survival rates. Conclusions Although new techniques were implemented, the mortality rate from spinal injuries during this period was staggering. Nevertheless, those 19th century procedural methods provided the basis for present-day treatment for spinal injury patients.

The attacks on humans by big captive felids has been an issue of concern for the administration of zoological parks and wildlife conservationists. The theme of human-animal conflict takes a new dimension for the wild animals kept in zoos, circuses, exotic animal farms, and private custody. Despite the potential dangers involved, the zookeepers have to closely interact with the captive tigers for catering to the needs of food, general health, and wellbeing. The literature has described cases of attacks by captive tigers resulting in the death of the primary caretaker. The injuries present on such bodies include multiple punctured lacerations, traumatic amputations, damage to the vital organs of the neck, fracture-dislocation of cervical vertebrae, and abrasions secondary to the dragging of the body. We present a rare fatal case of an attack of a tiger on keeper during the night hours while he entered the cage to look after the tiger who was suffering from gastroenteritis for a few days and was not taking his feed aptly. The keeper had a twelve-year long relation with the tiger, and the discovery of his death was an astonishment for zoo administration. This case describes the autopsy findings emphasizing the distribution of injuries, along with inquiring into the scene of the incident. The details about the predatory behaviour of tigers and stereotypic behaviours in captivity have been discussed.

Objectives To investigate seasonal injury incidence and musculoskeletal screening as a predictor of injury in elite Olympic class sailors. Design Prospective cohort study. Methods A 12-month analysis of injury surveillance data was performed for elite Australian sailors (age = 16–30 years, N = 22). Pre-season musculoskeletal screening (incorporating mobility, stability and neural tests) and seasonal injury data were analysed for predictive relationships, and associations between potential predictor variables and injury status. Results Injuries requiring medical attention occurred at a rate of 3.6 injuries/athlete, while injuries resulting in disability occurred at a rate of 0.6 injuries/athlete, with the lumbar spine the main site of injury (23% and 33%, respectively). Wrist and hand injury resulted in the highest number of days of disability (110 days), followed by injury to the lumbar spine (87 days). Across the season 75% of injuries to the lumbar spine occurred in the latter half of the season. The only screening measure predictive of injured/uninjured status was better left-sided single-leg decline-squat performance (OR = 0.29; 95% CI = 0.09–0.88; p = 0.03), while increasing age was significantly (p = 0.03) associated with thoracic (OR = 1.48; 95% CI = 1.03–2.12) and lumbar spine (OR = 1.46; 95% CI = 1.04–2.04) injury. Conclusions Though clinically useful, current screening protocols do not adequately assess the risk of seasonal injury in elite Olympic class sailors, and should be revised. Due to the increased risk of spinal injury and potential lost/modified participation in older Olympic class sailors, injury prevention activities should be individualised and age appropriate.

Summary Purpose The purpose of the study was to determine the frequency, location, type and severity of injuries to segmental regions of spine sustained by international luge athletes and conservative musculoskeletal approaches used to treat their injuries. Methods Retrospective, self-reported injury and treatment data related to the purpose of this study were collected using a multi-language survey distributed to international luge athletes. Using Facebook contacts of luge athletes known to the principal investigator, Internet links to the survey (Qualtrics L.L.C., Provo, UT) were distributed to 150 athletes who were at least 18 years old and competed in the general class of luge (100 men, 50 women) via e-mail. Results There were 64 respondents (42.7%). The annual rate of musculoskeletal injuries of the spine was 0.13 injuries per athlete per year. The most common musculoskeletal spinal injuries were sprains/strains (n = 24, 47.1%) and intervertebral disc injuries (n = 22, 43.1%). The majority of musculoskeletal spinal injuries were rated as mild to moderate in severity (69.1%) and persisted for more than 6 months (87.3%), making them chronic in nature. At least two-thirds of the injured athletes reported using massage, physical therapy, exercise or a form of complementary and alternative medicine (chiropractic or acupuncture) for their musculoskeletal spinal injuries. Of those athletes receiving chiropractic care for their musculoskeletal spinal injuries, perceived effectiveness of symptom relief for cervical and thoracic treatments was 100%, while perceived effectiveness of symptom relief for lumbar treatments was 86.7%. Conclusion The majority of responding luge athletes (51.6%) experienced a musculoskeletal spinal injury during their career. Musculoskeletal spinal injuries were chronic in nature, mild to moderate in severity and predominately occurred in the lumbar and cervical spinal segments. Sprain/strain and intervertebral disc injures were the most commonly reported musculoskeletal spinal injuries. The role of chiropractic care as a cost-effective, conservative treatment modality for luge athletes requires further research and clinical consideration.

The concepts of spinal stability are central to the decision-making processes following spinal trauma. In order to completely understand spinal stability knowledge of the local anatomy and basic biomechanics of the spine is required. This article aims to revise these concepts and discuss their impact on stability of the spine. Mechanisms of injury in the cervical, thoracic and lumbar spine are discussed alongside the biomechanics of structural failure at each level. The basic concepts of clinical spinal stability are explored with comment on the biomechanical considerations for specific fracture patterns.

Summary Background and aim Pressure sore treatment in spinal injury patients is challenging. A multidisciplinary approach with joint management by the plastic surgery and spinal injury teams was initiated at our institution in 2005 to improve patient care and surgical outcomes following reconstruction. This study assessed the surgical outcomes following reconstruction using the team approach and to compare inpatient stay and readmissions for complications before and after the multidisciplinary protocol was introduced. Methods A retrospective review of consecutive patients in the multidisciplinary pressure sore clinic was performed. Data were collected on patient demographics, reconstructive techniques, surgical outcomes and readmission for any complications. Results In total, 45 patients with 60 pressure sores (grade 3 or 4) were reviewed in the joint clinic between 2005 and 2011. The majority of patients were paraplegic (78%), while the remaining 22% were tetraplegic. Ischial sores were the most common (45%) followed by trochanteric (23%) and sacral (20%) sores. Multiple sores were noted in 44% of patients. Flap reconstruction was required in 32 patients (71%); after a mean follow-up time of 33 months (range 25–72 months), there were three (9%) major complications (two recurrences of pressure sores and one sinus) and seven (22%) minor complications. After introduction of patient care pathways through the multidisciplinary approach, the rate of readmission for complications decreased from 14% to 5.5% and inpatient stay upon readmission reduced from 65 to 45 days. Conclusions Implementation of a multidisciplinary approach was key to optimising surgical outcomes, achieving a low recurrence rate (6%) and reducing readmissions.

The purpose of this investigation was to delineate whether elderly patients with spinal injuries benefit from transfers to higher level trauma centers.Retrospective review of the National Trauma Data Bank 2007 to 2011, including patients65 (y) with any spinal fracture and/or spinal cord injury from a blunt mechanism. Patients who were transferred to level I and II centers from other facilities were compared to those admitted and received their definitive treatment at level III or other centers.Of 3,313,117 eligible patients, 43,637 (1.3%) met inclusion criteria: 19,588 (44.9%) were transferred to level I-II centers, and 24,049 (55.1%) received definitive treatment at level III or other centers. Most of the patients (95.8%) had a spinal fracture without a spinal cord injury. Transferred patients were more likely to require an intensive care unit admission (48.5% versus 36.0%, P0.001) and ventilatory support (16.1% versus 13.3%, P0.001). Mortality for the entire cohort was 7.7% (8.6% versus 7.1%, P0.001) and significantly higher, at 21.7% for patients with a spinal cord injury (22.3% versus 21.0%, P0.001). After adjusting for all available covariates, there was no difference in the adjusted mortality between patients transferred to higher level centers and those treated at lower level centers (adjusted odds ratio [95% confidence interval]: 1.05 [0.95-1.17], P = 0.325).Transfer of elderly patients with spinal injuries to higher level trauma centers is not associated with improved survival. Future studies should explore the justifications used for these transfers and focus on other outcome measures such as functional status to determine the potential benefit from such practices.

Frontal vehicle crashes have been a leading cause of spinal injuries in recent years. Reconstruction of frontal crashes using computational models and spinal load analysis helps us understand the patterns of injury and load propagation during frontal crashes. By reconstructing a real crash test and using a viscoelastic crash dummy model, spinal injury patterns were analyzed. The results indicated that a moderate crash with an impact speed of 56 km/h leads to injuries in L1-L2 and L5-S1 levels (L for lumbar and S for sacral vertebrae). The largest spinal loads and injuries were mainly observed immediately after the airbag deployment when the peak of the crash acceleration transpires. Also, the effects of impulse magnitude on the spinal loads and head injury criterion (HIC) showed that HIC is more sensitive than compressive forces to the magnitude of impulse. Moreover, the effects of disc preconditioning as a major factor in the risk of injury was evaluated. The results demonstrate that as the lumbar spine is subjected to a longer preloading, it will be more vulnerable to injury; preconditioning of the discs more adversely affected the risk of injury than a 10% increase in the crash impulse. Overall the results highlight the importance of spinal injury prevention in frontal crashes.

Background Driving a quad bike in a rural occupational setting is likely to expose the driver to various physical stimuli including whole-body vibration (WBV). These exposures may be linked to post-driving postural alterations which in turn could lead to an increased risk of spinal injury while undertaking manual material handling activities immediately following driving or falls while exiting from a vehicle. Purpose The purpose of this study was to use a battery of postural tasks namely; bipedal and unipedal stance, limits of stability (LOS) and lifting task to assess how quad bike driving alters the postural control (PC) in a group of rural workers. Methods The PC, determined from centre of pressure (COP) displacements in a group of rural workers (n = 34), was evaluated at three time (T) periods, once (T-I) before the 30 min quad bike driving session on a typical New Zealand farm terrain and twice (T-II and T-III) immediately following driving, each time period lasted approximately 10 min later. Results The results demonstrated a significant (p Conclusions These results demonstrate both immediate and sustained alterations in the PC following a period of occupational vehicle driving. Also, the results demonstrate both a worsening and improvement in postural control during the performance of a battery of tasks. Observed adverse or facilitatory postural effects will require further laboratory based investigations in order to determine how such disparity can best be explained or challenged. Relevance to industry The findings will inform ergonomists about the potential risk involved in carrying out physically demanding occupational tasks following vehicle driving. This putative situation could be prevented by adopting behavioural strategies by drivers, and engineered interventions designed to reduce WBV exposure.

Clinicians make decisions about patient management on a daily basis and are required to act in a way that is both legally and ethically correct. To act legally requires compliance with a set of rules which reflect the values and interests of society. Ethical decisions are based on what we believe as a group to be morally right. Morals are, however, unique to the individual. Balancing the legal, ethical and moral dimensions of clinical decisions has the potential, therefore, to generate conflict for the individual practitioner. In this paper we report a case study of a patient with a high cervical spine injury resulting in quadriplegia, without prospect of a ventilator independent life. The patient, who was assessed as having capacity to make decisions, subsequently elected to have treatment withdrawn. In this case, withdrawal of treatment constituted removal of mechanical ventilation which ultimately resulted in death. The patient also requested for his organs to be donated after he was deceased. This case study, to our knowledge, is the first report of donation after cardiac death following a high cervical spinal injury in a cognitively intact patient. As such, this case study allows us to discuss the moral, ethical and legal implications of donation after cardiac death following withdrawal of medical treatment.

This study assesses the etiology, clinical management, and outcome of patients with spontaneous spinal epidural hematoma (SSEH). SSEH is an uncommon neurosurgical emergency. We analyzed data from 10 patients (six women, four men) treated for SSEH (mean age, 63.5 years). Five patients had bleeding disorders due to anticoagulant therapy at the time of diagnosis. The initial clinical symptom in most patients was severe pain (n=8). Spinal injury was assessed using the American Spinal Injury Association (ASIA) scale, with six Grade A, one Grade C, and three Grade D patients. Lesions were in the cervicothoracic (n=4), thoracic (n=5), and thoracolumbar regions (n=1). Location was dorsal in seven patients and ventral in three. SSEH extension ranged from three to 15 spinal levels (mean, 6.9 levels). ASIA scale outcomes for the entire group were Grade A, n=2; Grade B, n=1; Grade C, n=1; Grade D, n=2; and Grade E, n=4. Outcomes for patients with no bleeding disorders (n=5) were Grade D, n=1; and Grade E, n=4. Outcomes for patients with bleeding disorders (n=5) were Grade A, n=2; Grade B, n=1; Grade C, n=1; and Grade D, n=1. After surgical treatment, patients improved by at least by one ASIA grade. The patients with mild neurological deficit who were treated conservatively also improved. Emergent spinal cord decompression is the only way to preserve spinal cord function in patients with severe deficit. Coagulation disorders were related to poor neurological status at admission and with poor neurological outcome. Conservative treatment was acceptable in patients with minimal neurological deficit.

We describe the case of a trauma patient who presented to our emergency department with signs and symptoms suggestive of cervical cord injury. The patient had an underlying ossification of the posterior longitudinal ligament with multiple cervical disc prolapses from C3 to C7. The presence of these two factors increased the impact of the traumatic cervical cord injury. The patient underwent spinal decompression via laminectomy. Unfortunately, his neurological status did not show any significant improvement after the surgery.Our aim is to highlight the association between ossification of the posterior longitudinal ligament and spinal cord injury in trauma patients. Keywords: Ossification of posterior longitudinal ligament, OPLL, Trauma, Cord injury, Rta, Road traffic accident, Cervical cord injury, Spinal injury

In an effort to produce best practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several parameters related to spinal immobilization. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented. This is an updated version of original WMS Practice Guidelines for Spine Immobilization in the Austere Environment published in Wilderness & Environmental Medicine 2013;24(3):241–252.

In the treatment of severely injured patients, the term 'damage control radiology' has been used to parallel the modern concept of damage control surgery and the allied development of continuous damage control resuscitation from patient retrieval, through all transfers, to appropriate primary treatment. The aims of damage control radiology are (i) rapid identification of life-threatening injuries including bleeding sites, (ii) identification or exclusion of head or spinal injury, and (iii) prompt and accurate triage of patients to the operating theatre for thoracic, abdominal, or both surgeries or the angiography suite for endovascular haemorrhage control. If we are to achieve these aims, patients must have immediate access to modern multidetector computed tomography (MDCT) which is without doubt the most potent weapon in the diagnostic armamentarium. The most severely injured patients are those who have the most to benefit from early diagnosis and life-saving therapies. The traditional teaching that these patients should go immediately to surgery is challenged by technological developments in MDCT and recent clinical evidence.

Spinal injuries are common and are often associated with other injuries, therefore should always be suspected in the polytrauma victim. Spinal cord injury resulting from trauma can be compounded by errors in handling, therefore the safe handling of the potentially spinal cord injured patient is of paramount importance at all stages preceding and during hospital care. The early detection of spinal injury is possible using a combination of clinical and radiological criteria, whilst safe initial management before transfer to a designated spinal injury unit consists of spinal immobilisation using recommended protocols.

Non- missile penetrating spinal injury (NMPSI) is a rare entity in North America and as a result there is no clear treatment paradigm. According to the literature, NMPSI causes serious acute neurological deficits and can also lead to devastating delayed complications in cases of untreated retained foreign bodies (RFB). In this report we present an acute case of NMPSI to the thoracic spine resulting in RFB treated by operative removal using minimally invasive fluoroscopic technique. While in prior published cases of NMPSI operative intervention was accomplished through laminectomy, our case presents an alternative, less invasive approach which may results in shorter recovery time. We also review the literature on NMPSI, including reports on both acute cases and chronic presentation due to RFBs. Based on this review, we conclude that NMPSI associated with RFB should be managed with operative intervention.

Objectives To test the hypothesis that the firing rates and discharge variability of human muscle spindles are not affected by spinal cord injury. Methods Tungsten microelectrodes were inserted into muscle fascicles of the peroneal nerve in six individuals with complete paralysis of the lower limbs following spinal cord injury: 12 afferents were spontaneously active at rest and 7 were recruited during passive muscle stretch. For comparison, recordings were made from 17 spontaneously active and 9 stretch-recruited afferents in 12 intact subjects. Results Firing rates for the spontaneously active muscle spindles were not significantly different between the spinal (9.8 ± 1.6 Hz) and intact (10.2 ± 1.3 Hz) subjects; the same was true for the stretch-recruited afferents – static firing rates, measured over the final 1 s of a ramp-and-hold stretch, were not different between the spinal and intact groups (13.1 ± 3.1% vs 10.0 ± 2.5 Hz). There were also no differences in discharge variability between the spinal and intact subjects, either for the spontaneously active spindles (8.1 ± 2.0% vs 5.7 ± 0.9%) or for the stretch-activated spindles, calculated over the final 1 s of static stretch (19.7 ± 5.6% vs 17.0 ± 1.9%). In addition, the responses to stretch imposed manually by the experimenter provided no evidence for an increase in the dynamic response to stretch in the patients. Conclusions The static stretch sensitivity of human muscle spindles is not affected by chronic spinal cord injury, suggesting that there is no difference in static (and possibly dynamic) fusimotor drive to paralyzed muscles in chronic spinal cord injury. Significance This study provides no evidence for an increase in fusimotor drive as a mechanism for the spasticity associated with chronic spinal injury, though further studies using controlled stretch would be required before it can be concluded that dynamic fusimotor drive is “normal” in these patients.

Spinal trauma is 1 of the major causes of disability that commonly affects young adults, and radiologists play a crucial role in the evaluation of acutely traumatized patients. With the advent of multidetector computed tomography (MDCT), the algorithm of imaging of spinal trauma has changed dramatically and MDCT is now established as the imaging modality of choice for the diagnosis of spinal trauma. The appearance on MDCT of the spinal injury depends on the mechanism of the injury, which also determines the stability of the injury. This pictorial essay describes the MDCT appearances, mechanism, and stability of commonly encountered traumatic spinal injuries.

This case report presents a case of a Fielding and Hawkins Type I AARF in an adult following trauma. It is presented to draw attention to the medical and technical details associated with the management of this rare spinal injury. The importance of imaging in the diagnosis and management of AARF is discussed. Early recognition and treatment of AARF is paramount in the avoidance of subsequent deformity and instability in these patients and are the key to the prevention of operable treatment.

Given the increasing incidence and severity of obesity in the adult population, orthopaedic surgeons are evaluating and treating more acutely injured obese patients. Management of obese patients is complicated given their body habitus and associated medical comorbidities. Although evaluation and treatment are almost the same as for nonobese patients, some special considerations are necessary to prevent errors in diagnosis and treatment of obese trauma patients. This article focuses on spine injuries in obese patients. Predisposition to spinal injury, effective evaluation and early management, principles of treatment planning, operative technical pearls, and postoperative management are discussed.

Introduction Buccodental infection is a frequent cause for hematogenous infection of a hip prosthesis. Common symptoms in these cases are pain and functional impotence of the hip, occasionally associated to fever and generalized discomfort. Normally the infection evolves towards cutaneous fistulization. Clinical case We present the case of a 62-year-old male with a hip prosthesis admitted for atypical lumbar pain irradiated to the thigh. Once spinal injury was ruled out, the pain was found to stem from an abscess in the iliac muscle associated with an infection in the patient's hip prosthesis. The patient had sustained a buccodental infection one month before. Discussion Hematogenous infection of a buccodental origin constitutes a frequent cause of late prosthetic infection. Fistulization in the retroperitoneal area is uncommon, as is acute presentation with few infection indicators.

Objective Because there is no consensus about the best method for the evaluation of ligamental injury we determined the accuracy of computed tomography in comparison to the accuracy of magnetic resonance imaging to detect ligamental injury in adults with a vertebral corpus fracture. Methods A literature search was conducted in MEDLINE, EMBASE and Cochrane Library databases to retrieve relevant articles. Title and abstract of these articles were screened on in- and exclusion criteria. Remaining articles were read and critically appraised on relevance and validity. Results Three articles were selected that compromised the best available evidence. Two studies stated that computed tomography is not an effective modality for detecting cervical ligamental injury which means that magnetic resonance imaging is clearly superior to computed tomography for detecting ligamental injury. The third study described that if findings at multi-detector row computed tomography are negative in detecting ligamental injury, there is no need for magnetic resonance imaging. Conclusion Best evidence shows magnetic resonance imaging is more sensitive for detecting ligamental injury than computed tomography. However the use of magnetic resonance imaging as a standard screening method is not necessary in all patients with spinal injury. Best available evidence concludes that magnetic resonance imaging has limited clinical value when used in combination with computed tomography. Magnetic resonance imaging should probably only be used when there is doubt regarding the diagnosis of ligamental injury after computed tomography.

This article describes the anatomy of the cervical spine and the most common types of fractures associated with the cervical spine. Cervical spinal cord syndromes are also reviewed because such syndromes discovered during neurologic examinations frequently provide the first clue that there is an underlying spinal cord injury. Because most associated maxillofacial and spinal injuries occur in the setting of motor vehicle accidents, it is particularly important for the maxillofacial surgeon to be cognizant of the injuries, particularly in the context of the need for facial/cranial surgery. Appropriate measures are necessary to immobilize or fixate the spine before surgery to avoid exacerbating the spinal injury.

Resume Cet article est un etat des lieux sur les connaissances des traumatismes du rachis cervical en France. Le rachis cervical d’un joueur de rugby est soumis a des contraintes mecaniques importantes au cours de phases de jeu specifiques aux regles de ce sport, avec des situations de contact individuel ou collectif. Trois elements ont oriente notre analyse : la description des traumatismes aigus, la description des lesions degeneratives et les recommandations pratiques issues de notre activite clinique. Les traumatismes aigus ont ete decrits par les etudes retrospectives et prospectives de la Federation francaise de rugby (FFR). Ces travaux ont analyse les facteurs de risque de lesions graves, leur mecanisme de survenue, les postes exposes, les phases de jeu et leur incidence par saison au cours des dix dernieres annees. Cinq pour cent des traumatismes du rugbyman concernent le rachis cervical. Deux a trois accidents par saison avec lesions medullaires graves entrainent des sequelles fonctionnelles severes. L’amenagement de la melee et la reconnaissance d’une aptitude specifique a jouer en premiere ligne ont reduit de moitie les accidents. Par ailleurs, la pratique du rugby predispose a un risque de degenerescence arthrosique precoce, notamment pour les joueurs de premiere ligne. Enfin, des recommandations ont ete enoncees pour des situations courantes auxquelles est confronte un traumatologue du sport : le certificat de non contre-indication a la pratique du rugby et l’autorisation de rejouer apres un traumatisme du rachis cervical. Des exemples de cas cliniques illustrent nos indications.

We studied whether laryngoscopy and tracheal intubation were easier when using the Pentax-AWS (Tokyo, Japan), a new videolaryngoscope, than when applying the Macintosh laryngoscope, during manual in-line neck stabilization.In 203 anaesthetized patients with manual in-line neck stabilization, we inserted the Pentax-AWS and a Macintosh laryngoscope, in turn, and recorded the view of the glottis and time taken to laryngoscopy. The success rate of tracheal intubation (within 120 s) and time to intubation were also recorded.The view of the glottis was significantly better with the Pentax-AWS than with the Macintosh laryngoscope (P0.001). For the Macintosh laryngoscope, the view was obscured in 22 of 203 patients (11%) (Grade 3 in 21 patients and Grade 4 in one patient), whereas for the Pentax-AWS, the glottis was always clearly seen (Grade 1). Time taken to see the glottis with the Pentax-AWS [mean (sd): 6.0 (3.1) s] was significantly shorter than with the Macintosh laryngoscope [11.0 (5.0) s] (95% CI for difference: 4-6 s). The success rate of tracheal intubation with the Pentax-AWS (all of 99 patients) was significantly higher than with the Macintosh laryngoscope (93 of 104 patients) (P=0.001). Time taken for intubation was similar between the Macintosh laryngoscope [51 (27) s] and the Pentax-AWS [54 (14) s] (95% CI for difference: -9 to 3 s).In patients with stabilized neck, the Pentax-AWS provided a better view of the glottis and a higher success rate of tracheal intubation, compared with the conventional Macintosh laryngoscope.

OBJECTIVE: To evaluate the sensitivity and reproducibility of the Basso, Beattie, Bresnahan functional scale in the assessment of the locomotor capacity of rats after spinal cord injury. METHODS: Thirty male Wistar rats underwent laminectomy and mild, moderate or severe spinal cord contusions using the New York University Weight Drop Impactor. The mice were followed for 28 days, after which time each rat was placed in an 80x80x30 cm³ clear box lined with a blue non-slippery material and stimulated to move. Their movement was video-recorded by three digital cameras operating simultaneously. Identical copies of the edited videos were given to six independent evaluators who were blinded with regards to the degree of injury severity. Each evaluator made a determination of the locomotor capacity of the rats using the Basso, Beattie, Bresnahan functional scale. RESULTS: We determined the sensitivity of the method to differences among the evaluators as well as between the results achieved on the left and right hind paws of rats subjected to either mild, moderate or severe injuries by comparing the functional outcomes and reproducibility using non-parametric correlation tests. CONCLUSIONS: The Basso, Beattie, Bresnahan scale showed high reproducibility and satisfactory sensitivity for identifying mild injuries; satisfactory reproducibility and non-satisfactory sensitivity for moderate injuries; and reduced reproducibility and non-satisfactory sensitivity for severe injuries.

Geriatric spinal injury has unique mechanisms, confounding treatment factors, and outcomes. Mechanisms of injury frequently involve low velocity falls, as opposed to the high velocity traumas responsible for most other spinal cord injuries. Age-related comorbidities such as cervical spondylosis, osteoporosis, osteoarthritis, and neuromuscular disorders play into the pathophysiology of injury in this population. Three common injuries encountered include central cord injury, cervical extension distraction injuries, and odontoid fractures. Treatment is aimed at balancing safety of surgery with risks of nonoperative management. Understanding features unique to geriatric spinal injury is important in maximizing recovery.

Spinal injuries are very common among professional or amateur athletes. Spinal sport lesions can be classified in overuse and acute injuries. Overuse injuries can be found after years of repetitive spinal load during sport activity; however specific overuse injuries can also be found in adolescents. Acute traumas are common in contact sports. Most of the acute injuries are minor and self-healing, but severe and catastrophic events are possible. The aim of this article is to review the wide spectrum of spinal injuries related to sport activity, with special regard to imaging finding.

Spinal injury often affects young adults and results in debilitating neurological status, which in turn places a significant burden on society. This review article describes the current practice and controversies surrounding the management of spinal injury. General principles of pre-hospital management, resuscitation, medical treatment, surgical intervention and future advancement are reviewed.

Background context Methylprednisolone has evolved during the 1990s, through the results obtained from the National Acute Spinal Cord Injury Studies NASCIS II and III, as a standard treatment in acute spinal injury. Purpose To evaluate the scientific basic for the use of methylprednisolone in acute spinal cord injury. Study desing Systematic review of the accumulated literature. Methods Critical evaluation of the data obtained in the NASCIS II and III studies plus other accumulated literature. Results Analyses have been made on subgroups of the study populations, and the results were based on statistical artefacts. Furthermore, improved functional recovery shown by these studies was not clinically significant. Conclusion There is insufficient evidence to support the use of methylprednisolone as a standard treatment in acute spinal cord injury.

Resume Introduction. – La prescription d'un programme de reentrainement individualise chez le blesse medullaire a prouve son efficacite, aussi bien pour l'amelioration de la capacite physique des individus, que pour la prevention des risques de survenue des maladies cardiovasculaires. Cependant, si les necessites d'un reconditionnement physique ont largement fait leurs preuves, les modalites pratiques de son application sont mal codifiees, aucun consensus n'existant quant a l'intensite de l'entrainement a appliquer, son type, sa duree ou sa frequence. Objectif. – Realiser une revue de la litterature afin de repertorier les differents programmes de reentrainement en endurance mis en place, ainsi que d'evaluer leur efficacite, leurs limites, leurs resultats, dans le but de creer un consensus et de formuler des recommandations. Methode. – Apres consultation des bases de donnees et de la litterature concernee, 99 references ont ete relevees : d'une part, les etudes ayant analysees les reponses physiologiques a l'exercice chez le blesse medullaire ; d'autre part, les etudes cliniques ayant mis en place des protocoles de reentrainement a l'effort. Resultats. – On releve une grande diversite des caracteristiques des protocoles au niveau des outils utilises de l'intensite, du type, de la duree ou de la frequence appliques. Quelles que soient les specificites de chaque programme, 35 etudes mettent en evidence une augmentation de la consommation maximale d'oxygene de 9 a 99 %, de la puissance de 19 a 118 %, et une diminution des variables cardiovasculaires sous maximales, a la suite d'une programme d'entrainement allant de 4 a 36 semaines, selon les etudes. Discussion – Conclusion. – Il ressort qu'un reentrainement effectue sur un ergometre pour fauteuil roulant est profitable puisqu'il permet une meilleure maitrise et utilisation du fauteuil, ainsi qu'une adaptation des reglages de maniere individualisee. Les exercices continus ou en creneaux entrainent tous deux des ameliorations sur l'adaptation a l'effort. Cependant, les exercices en creneaux paraissent plus benefiques car ils reproduisent la nature intermittente des activites de la vie quotidienne et sont mieux toleres par les sujets. Ainsi, les resultats observes dans les etudes repertoriees, nous permettent d'enoncer qu'un reentrainement a une intensite d'au moins 70 % de la FCmax, au cours d'une seance de 30 minutes, trois jours par semaine, pendant huit semaines, peut etre la base d'un programme de reentrainement en endurance optimale chez le blesse medullaire.

The aim of our research was to develop the neurophysiological criteria for testing the end of spinal shock. Patients (18 male and 12 women, age 18-33 y.o) with spinal cord injury at the C4-C7 level were investigated 5-7 days (First point) and 2 months (Second point) after trauma. The F-waves were tested bilaterally in nn. medianus, ulnaris, peroneus, tibialis in every patient; the central motor conduction was tested with the transcranial magnetic stimulation (TMS) for mm. Abd.Poll.Brevis and Add.Hallucis. At the First point F-waves were absent in all patients and TMS revealed conduction block (CB) at the cervical level. At the second point in 28 patients the F-waves reappeared only for n.tibialis, with CB in 26 cases and restored conduction in 2 patients from Add.Hallucis on one side; in 2 patients at the Second point here were persistent absence of F-waves and full CB. The reappearance of F-waves in n.Tibialis can be used as a criteria for testing the end of spinal shock and restoration of segmental motor neurons excitability.

The concept of the manipulable spinal lesion — a musculoskeletal disturbance that can be detected with manual palpation and corrected with manipulation — is examined and evidence for the theories of the dysfunction is discussed. A model for intervertebral dysfunction is presented that describes both mechanical and neurological sequelae to spinal injury, leading to a deficit in regional proprioception, changes in segmental and polysegmental muscle activity and motor control, and predisposing the segment to further strain. The evidence for the proposed model and mechanisms of manual treatment is discussed. Recommendations and directions are outlined for future research.

Recruitment of inflammatory leukocytes to the injured spinal cord is a physiological response that is associated with the production of cytokines and proteinases that are involved in host defense and wound repair. Cells in the spinal cord are mainly post-mitotic and tissue regeneration is poor; thus, these inflammatory mediators can exacerbate the damage to spared tissue and thereby impair spontaneous functional recovery. Although several aspects of immune function might benefit the CNS, experimental studies indicate that acute neuroinflammation aggravates tissue injury. Until the timing and nature of the molecular signals that govern leukocyte recruitment and activation after spinal injury are defined, clinical therapies designed to boost immune cell function should be avoided.

Traumatic duodenal injuries are a rare and complex challenge. The surgeon facing such an injury has several options to repair this injury: primary repair with or without a serosal patch, performing a pyloric exclusion, adding a gastrostomy and/or feeding jejunostomy, and performing a gastro-enterostomy in order to bypass the duodenum. All of these options have a significant failure rate with persisting duodenal leakage and long-term morbidity. An often overlooked insult is concomitant spinal injury that may lead to a distal duodenal obstruction due to compression by the superior mesenteric artery (SMAS). This combined injury is noted when the mechanism is a high velocity blunt trauma such as seat belt injury during a motor vehicle accident. The contribution of this obstruction to the failure rate of the duodenal repair has not been addressed yet. We describe a case in which this event was foreseen and a Ladd’s procedure was added to the duodenal repair. It is our impression that avoiding SMAS may enhance the chances of a successful duodenal repair.