Publications (10)11.45 Total impact
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Article: The impact of a standardized "spine damage-control" protocol for unstable thoracic and lumbar spine fractures in severely injured patients: A prospective cohort study.
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ABSTRACT: In contrast to the established principles of "damage-control orthopedics" for temporary external fixation of long bone or pelvic fractures, the "ideal" timing and modality of fixation of unstable spine fractures in severely injured patients remains controversial. A prospective cohort study was designed to evaluate the safety and efficacy of a standardized "spine damage-control" (SDC) protocol for the acute management of unstable thoracic and lumbar spine fractures in severely injured patients. A total of 112 consecutive patients with unstable thoracic or lumbar spine fractures and Injury Severity Score (ISS) of greater than 15 were prospectively enrolled in this study from October 1, 2008, to December 31, 2011. Acute posterior spinal fixation within 24 hours was performed in 42 patients (SDC group), and 70 patients underwent definitive operative spine fixation in a delayed fashion ("delayed surgery"[DS] group). Both cohorts were prospectively analyzed for baseline demographics, length of operative time, amount of intraoperative blood loss, total hospital length of stay, number of ventilator-dependent days, and incidence of early postoperative complications. The mean time to initial spine fixation was significantly decreased in the SDC group (8.9 [1.7] hours vs. 98.7 [22.4] hours, p < 0.01). The SDC cohort had a reduced mean length of operative time (2.4 [0.7] hours vs. 3.9 [1.3] hours), length of hospital stay (14.1 [2.9] days vs. 32.6 [7.8] days), and number of ventilator-dependent days (2.2 [1.5] days vs. 9.1 [2.4] days), compared with the DS group (p < 0.05). Furthermore, the complication rate was decreased in the SDC group with regard to wound complications (2.4% vs. 7.1%), urinary tract infections (4.8% vs. 21.4%), pulmonary complications (14.3% vs. 25.7%), and pressure sores (2.4% vs. 8.6%), compared with the DS cohort (p < 0.05). A standardized SDC protocol represents a safe and efficient treatment strategy for severely injured patients with associated unstable thoracic or lumbar fractures. Therapeutic study, level III.The journal of trauma and acute care surgery. 02/2013; 74(2):590-6. -
Article: A cost-minimization analysis of phenytoin versus levetiracetam for early seizure pharmacoprophylaxis after traumatic brain injury.
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ABSTRACT: Recent data indicate comparable efficacy and safety for levetiracetam (LEV) when compared with phenytoin (PHT) for prophylaxis of early seizures after traumatic brain injury. The purpose of this study was to conduct a cost-minimization analysis, from the perspective of both the acute care institution (cost) and patient (charges), comparing these two strategies. A decision tree was constructed to include baseline event probabilities obtained from detailed literature review, costs, and charges. Monte Carlo simulation was used to derive the mean costs and charges per patient treated with the LEV when compared with the PHT strategy. Adverse event probabilities, costs, charges, and frequency of laboratory determination for the PHT group were varied in sensitivity analyses. Literature review indicated equal efficacy of PHT versus LEV for early seizure prevention. The PHT strategy was superior to the LEV strategy from both the institutional (mean cost per patient $151.24 vs. $411.85, respectively) and patient (mean charge per patient $2,302.58 vs. $3,498.40, respectively) perspectives. Varying both baseline adverse event probabilities and frequency of laboratory testing did not alter the superiority of the PHT strategy. LEV replaced PHT as the dominant strategy only when the cost/charge of treating mental status deterioration was increased markedly above baseline. From both institutional and patient perspectives, PHT is less expensive than LEV for routine pharmacoprophylaxis of early seizures among traumatic brain injury patients. Pending compelling efficacy data, LEV should not replace PHT as a first-line agent for this indication.The journal of trauma and acute care surgery. 01/2012; 72(1):276-81. -
Article: Fatal gunshot wounds to the head: a critical appraisal of organ donation rates.
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ABSTRACT: Patients sustaining fatal gunshot wounds to the head are often young, without associated comorbidities, and are potentially ideal transplantation candidates. A 5-year review of a level I trauma center's prospective database was performed for all patients sustaining fatal gunshot wounds to the head. Demographic, physiologic, anatomic, and laboratory variables were collected. Sixty-eight patients were identified, of whom 10 (14.7%) were organ donors. Of 25 admitted to the intensive care unit who eventually did not become donors, 15 (60%) were due to lack of consent. Despite frequent intensive care unit admissions, organ donation is infrequent following fatal gunshot wounds to the head, primarily because of lack of consent. Improved communication with next of kin could improve organ recovery and reduce futile care in this group.American journal of surgery 12/2010; 200(6):728-33; discussion 733. · 2.36 Impact Factor -
Article: Advocating "spine damage control" as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis.
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ABSTRACT: BACKGROUND: The "ideal" timing and modality of fracture fixation for unstable thoracolumbar spine fractures in multiply injured patients remains controversial. The concept of "damage control orthopedics" (DCO), which has evolved globally in the past decade, provides a safe guidance for temporary external fixation of long bone or pelvic fractures in multisystem trauma. In contrast, "damage control" concepts for unstable spine injuries have not been widely implemented, and the scarce literature in the field remains largely anecdotal. The current practice standards are reflected by two distinct positions, either (1) immediate "early total care" or (2) delayed spine fixation after recovery from associated injuries. Both concepts have inherent risks which may contribute to adverse outcome. PRESENTATION OF HYPOTHESIS: We hypothesize that the concept of "spine damage control" - consisting of immediate posterior fracture reduction and instrumentation, followed by scheduled 360 degrees completion fusion during a physiological "time-window of opportunity" - will be associated with less complications and improved outcomes of polytrauma patients with unstable thoracolumbar fractures, compared to conventional treatment strategies. TESTING OF HYPOTHESIS: We propose a prospective multicenter trial on a large cohort of multiply injured patients with an associated unstable thoracolumbar fracture. Patients will be assigned to one of three distinct study arms: (1) Immediate definitive (anterior and/or posterior) fracture fixation within 24 hours of admission; (2) Delayed definitive (anterior and/or posterior) fracture fixation at > 3 days after admission; (3) "Spine damage control" procedure by posterior reduction and instrumentation within 24 hours of admission, followed by anterior 360 degrees completion fusion at > 3 days after admission, if indicated. The primary and secondary endpoints include length of ventilator-free days, length of ICU and hospital stay, mortality, incidence of complications, neurological status and functional recovery. IMPLICATIONS OF HYPOTHESIS: A "spine damage control" protocol may save lives and improve outcomes in severely injured patients with associated spine injuries.Journal of Trauma Management & Outcomes 05/2009; 3:6. -
Article: Fatal outcome after insufficient spine fixation for pyogenic thoracic spondylodiscitis: an imperative for 360 degrees fusion of the infected spine.
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ABSTRACT: Pyogenic spondylodiscitis represents a potentially life-threatening condition. Due to the low incidence, evidence-based surgical recommendations in the literature are equivocal, and the treatment modalities remain controversial. A 59 year-old patient presented with a history of thoracic spondylodiscitis resistant to antibiotic treatment for 6 weeks, progressive severe back pain, and a new onset of bilateral lower extremity weakness. Clinically, the patient showed a deteriorating spastic paraparesis of her lower extremities. An emergent MRI revealed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression, paravertebral and epidural abscess, and signs of myelopathy. The patient underwent surgical debridement with stabilization of the anterior column from T6-T9 using an expandable titanium cage, autologous bone graft, and an anterolateral locking plate. The patient recovered well under adjunctive antibiotic treatment. She presented again to the emergency department 6 months later, secondary to a repeat fall, with acute paraplegia of the lower extremities and radiographic evidence of failure of fixation of the anterior T-spine. She underwent antero-posterior revision fixation with hardware removal, correction of kyphotic malunion, evacuation of a recurrent epidural abscess, decompression of the spinal canal, and 360 degrees fusion from T2-T11. Despite the successful salvage procedure, the patient deteriorated in the postoperative phase, when she developed multiple complications including pneumonia, acute respiratory distress syndrome, bacterial meningitis, abdominal compartment syndrome, followed by septic shock with multiple organ failure and a lethal outcome within two weeks after revision surgery. This catastrophic example of a lethal outcome secondary to failure of anterior column fixation for pyogenic thoracic spondylodiscitis underlines the notion that surgical strategies for the infected spine must be aimed at achieving absolute stability by a 360 degrees fusion. This aggressive - albeit controversial - concept allows for an adequate infection control by adjunctive antibiotics and reduces the imminent risk of a secondary loss of fixation due to compromises in initial fixation techniques.Patient Safety in Surgery 03/2009; 3(1):4. -
Article: Absence of the complement regulatory molecule CD59a leads to exacerbated neuropathology after traumatic brain injury in mice.
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ABSTRACT: Complement represents a crucial mediator of neuroinflammation and neurodegeneration after traumatic brain injury. The role of the terminal complement activation pathway, leading to generation of the membrane attack complex (MAC), has not been thoroughly investigated. CD59 is the major regulator of MAC formation and represents an essential protector from homologous cell injury after complement activation in the injured brain. Mice deleted in the Cd59a gene (CD59a-/-) and wild-type littermates (n = 60) were subjected to focal closed head injury. Sham-operated (n = 60) and normal untreated mice (n = 14) served as negative controls. The posttraumatic neurological impairment was assessed for up to one week after trauma, using a standardized Neurological Severity Score (NSS). The extent of neuronal cell death was determined by serum levels of neuron-specific enolase (NSE) and by staining of brain tissue sections in TUNEL technique. The expression profiles of pro-apoptotic (Fas, FasL, Bax) and anti-apoptotic (Bcl-2) mediators were determined at the gene and protein level by real-time RT-PCR and Western blot, respectively. Clinically, the brain-injured CD59a-/- mice showed a significantly impaired neurological outcome within 7 days, as determined by a higher NSS, compared to wild-type controls. The NSE serum levels, an indirect marker of neuronal cell death, were significantly elevated in CD59a-/- mice at 4 h and 24 h after trauma, compared to wild-type littermates. At the tissue level, increased neuronal cell death and brain tissue destruction was detected by TUNEL histochemistry in CD59a-/- mice within 24 hours to 7 days after head trauma. The analysis of brain homogenates for potential mediators and regulators of cell death other than the complement MAC (Fas, FasL, Bax, Bcl-2) revealed no difference in gene expression and protein levels between CD59a-/- and wild-type mice. These data emphasize an important role of CD59 in mediating protection from secondary neuronal cell death and further underscore the key role of the terminal complement pathway in the pathophysiology of traumatic brain injury. The exact mechanisms of complement MAC-induced secondary neuronal cell death after head injury require further investigation.Journal of Neuroinflammation 02/2009; 6:2. · 3.83 Impact Factor -
Article: Pharmacology of traumatic brain injury: where is the "golden bullet"?
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ABSTRACT: Traumatic brain injury (TBI) represents a major health care problem and a significant socioeconomic challenge worldwide. In the United States alone, approximately 1.5 million patients are affected each year, and the mortality of severe TBI remains as high as 35%-40%. These statistics underline the urgent need for efficient treatment modalities to improve posttraumatic morbidity and mortality. Despite advances in basic and clinical research as well as improved neurological intensive care in recent years, no specific pharmacological therapy for TBI is available that would improve the outcome of these patients. Understanding of the cellular and molecular mechanisms underlying the pathophysiological events after TBI has resulted in the identification of new potential therapeutic targets. Nevertheless, the extrapolation from basic research data to clinical application in TBI patients has invariably failed, and results from prospective clinical trials are disappointing. We review the published prospective clinical trials on pharmacological treatment modalities for TBI patients and outline future promising therapeutic avenues in the field.Molecular Medicine 09/2008; 14(11-12):731-40. · 3.76 Impact Factor -
Article: Unilateral cervical facet fractures with subluxation: injury patterns and treatment.
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ABSTRACT: This is a retrospective study of patients with unilateral cervical facet fractures from a Level I academic trauma center. We sought to examine fracture patterns involving only the facets, to examine the incidence of associated neurologic and vascular injuries, and to determine optimum management strategies for these injuries. Most of the literature regarding unilateral cervical facet injuries has resulted from studies evaluating dislocated locked facets, "fracture-dislocations," or fractures of the lateral mass and pedicle. We retrospectively reviewed our experience with unilateral fractures of the facets, identifying 25 cases over a 5-year period. Presenting history, neurologic examination, imaging findings, method of reduction, interval to surgery, type of surgery, and evaluation for vascular injuries were recorded. Fusion was assessed by plain radiographs and computed tomography scans at follow-up. All 25 patients were treated operatively. Ten of the fractures involved the superior articular process, 13 involved the inferior articular process, and 2 cases involved both. The most commonly affected level was at C6/7. Twenty-one of the 25 patients underwent anterior stabilization, 3 underwent posterior stabilization, and 1 underwent anterior-posterior stabilization. Eleven patients underwent diagnostic 4-vessel angiography, revealing 2 patients with vertebral artery injuries. Average follow-up was 11.5 months. There were no identifiable nonunions. We conclude the following: (a) anterior discectomy and fusion with a static (constrained) plating system is appropriate treatment for this type of injury, (b) in the absence of significant neurologic deficit with residual canal or foraminal stenosis, preoperative closed reduction is not necessary, (c) a small percentage of these patients will have vertebral artery injury, thus warranting screening with 16-slice computed tomographic angiography.Journal of Spinal Disorders & Techniques 09/2007; 20(6):416-22. · 1.50 Impact Factor -
Article: Are upright lateral cervical radiographs in the obtunded trauma patient useful? A retrospective study.
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ABSTRACT: The best method for radiographic "clearance" of the cervical spine in obtunded patients prior to removal of cervical immobilization devices remains debated. Dynamic radiographs or MRI are thought to demonstrate unstable injuries, but can be expensive and cumbersome to obtain. An upright lateral cervical radiograph (ULCR) was performed in selected patients to investigate whether this study could provide this same information, to enable removal of cervical immobilization devices in the multiple trauma patient. We retrospectively reviewed our experience with ULCR in 683 blunt trauma victims who presented over a 3-year period, with either a Glasgow Coma Score <13 or who were intubated at the time of presentation. ULCR was performed in 163 patients. Seven patients had studies interpreted to be abnormal, of which six were also abnormal, by either CT or MRI. The seventh patient's only abnormality was soft tissue swelling; MRI was otherwise normal. Six patients had ULCR interpreted as normal, but had abnormalities on either CT or MRI. None of the missed injuries required surgical stabilization, although one had a vertebral artery injury demonstrated on subsequent angiography. ULCR had an apparent sensitivity of 45.5% and specificity of 71.4%. ULCR are inferior to both CT and MRI in the detection of cervical injury in patients with normal plain radiographs. We therefore cannot recommend the use of ULCR in the obtunded trauma patient.World Journal of Emergency Surgery 02/2007; 2:4. -
Article: Are upright lateral cervical radiographs in the obtunded trauma patient useful? A retrospective study
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ABSTRACT: Abstract Background The best method for radiographic "clearance" of the cervical spine in obtunded patients prior to removal of cervical immobilization devices remains debated. Dynamic radiographs or MRI are thought to demonstrate unstable injuries, but can be expensive and cumbersome to obtain. An upright lateral cervical radiograph (ULCR) was performed in selected patients to investigate whether this study could provide this same information, to enable removal of cervical immobilization devices in the multiple trauma patient. Methods We retrospectively reviewed our experience with ULCR in 683 blunt trauma victims who presented over a 3-year period, with either a Glasgow Coma Score <13 or who were intubated at the time of presentation. Results ULCR was performed in 163 patients. Seven patients had studies interpreted to be abnormal, of which six were also abnormal, by either CT or MRI. The seventh patient's only abnormality was soft tissue swelling; MRI was otherwise normal. Six patients had ULCR interpreted as normal, but had abnormalities on either CT or MRI. None of the missed injuries required surgical stabilization, although one had a vertebral artery injury demonstrated on subsequent angiography. ULCR had an apparent sensitivity of 45.5% and specificity of 71.4%. Conclusion ULCR are inferior to both CT and MRI in the detection of cervical injury in patients with normal plain radiographs. We therefore cannot recommend the use of ULCR in the obtunded trauma patient.World Journal of Emergency Surgery. 01/2007;
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2008
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University of Colorado Denver
- Department of Neurosurgery
Denver, CO, USA
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