No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Post-traumatic Cervical Spine Epidural Hematoma: Incidence and Risk Factors Ms. No. JINJ-D-17-00822R1
Abstract
Background:
The incidence and risk factors for post-traumatic cervical epidural hematoma are not well described in the current literature. Our aim was to determine the incidence and associated risk factors for post-traumatic cervical spine epidural hematoma (SEH).
Methods:
We performed a retrospective review of our institution's prospectively collected data submitted to the state trauma registry, using ICD-9 codes, for all patients activated as a trauma with cervical spine injuries, between the years 2010 and 2014. Patients with MRI available were classified based on the presence of cervical epidural hematoma (CEH) or no hematoma (NEH). For our second analysis, we classified patients with cord compression associated with an epidural hematoma (CC) and no cord compression (NCC). Potential risk factors evaluated included: INR, PTT, albumin and platelets levels, radiographic findings of Ankylosing Spondylitis (AS), and ISS. No conflicts of interest exist and/or funding was used for this study.
Results:
497 out of 1810 trauma activations met our inclusion criteria. 46 patients (2.5%) were found to have a post-traumatic cervical SEH (CEH). Of the CEH cohort, 76% were male, with 72% Caucasian, and a mean age of 55 years. 27 patients (5.4%) were found to have cervical cord compression at the level of the SEH. Of the CC arm, 78% were male, with 67% Caucasian, and a mean age of 56 years. A higher ISS and an elevated INR were found to be associated with epidural hematoma causing cord compression.
Conclusions:
An incidence of 2.5% is reported for post-traumatic cervical spine epidural hematoma. Of these, 59% had associated spinal cord compression. Patients with a higher ISS and elevated INR levels are at a higher risk for developing this potentially devastating.
... Son incidence varie entre 2,5% [1] et 7,5% [2]. Il entraine une compression médullaire dans 59% des cas [1] et est responsable de troubles neurologiques sévères parfois irréversibles. C'est une pathologie grave qui justifie plus souvent un traitement chirurgical. ...
... Le délai de résorption allait de 6 jours [3] à un mois [5;7] supérieur aux 4 jours trouvé chez notre patient. Une étude américaine en 2017 avait établi le profil du patient susceptible de présenter un hématome épidural cervical traumatique [1]. Il s'agissait d'un caucasien de sexe masculine dans la cinquantaine, victime d'un accident de la route [1]. ...
... Une étude américaine en 2017 avait établi le profil du patient susceptible de présenter un hématome épidural cervical traumatique [1]. Il s'agissait d'un caucasien de sexe masculine dans la cinquantaine, victime d'un accident de la route [1]. Plusieurs types de mécanisme de traumatisme cervical responsables d'un hématome épidural spontanément régressif ont été décrits [3; 4; 5; 6; 7]. ...
RESUME L'hématome épidural cervical isolé post traumatique est rare. C'est une affection grave qui peut être responsable de handicap sévère parfois irréversible. Le traitement est habituellement chirurgical. Dans de rare cas une abstention chirurgicale est proposée. Les limites entre la chirurgie et le traitement conservateur ne sont pas bien claires. Nous rapportons notre observation sur un cas de régression rapide et spontanée d'un hématome épidural cervical traumatique à travers laquelle nous avons effectué une revue de la littérature. Observation clinique : Il s'agissait d'un jeune patient de 17 ans, sportif et sans antécédents qui a présenté des cervicalgies survenues à la suite d'une compétition de karaté. La survenue d'une monoparésie brachiale droite avait permis de faire le diagnostic d'un hématome épidural cervical de C1 à C3. Après quatre d'hospitalisations, il a présenté une régression des symptômes cliniques avec à l'imagerie une disparition complète de l'hématome. Sur un suivi de 2 ans, l'évolution était sans particularité. Conclusion : L'indication d'une évacuation chirurgicale de l'hématome épidural cervical doit être basée sur de solides arguments cliniques et radiologiques. Bien que rare, des cas de résolution sous traitement conservateur peuvent exister.
Mots clés: rachis cervical, hématome épidural, résolution rapide, traumatisme.
Abstract The isolated cervical epidural hematoma after spine trauma is rare. It is a serious affection because it can lead to a severe handicap sometimes irreversible. The treatment is usually surgical. The frontiers between surgery and conservative treatment are not well defined. We report our observation on a case of regression of traumatic epidural hematoma through which we conducted a review of the literature. Clinical observation: We report the case of the 17-year-old male patient who had a cervical injury due to a sports accident. The cervical spine pain and neurological disorders in the right upper limb were used to diagnose a cervical epidural hematoma C1 to C3. He presented a clinical spontaneous resolution of his hematoma in 4 days confirmed by medical imagery. On a 2 years follow-up, the evolution was no particularity. Conclusion: The indication for cervical epidural hematoma surgery should be based on strong clinical and radiological evidence. Although rare, cases of resolution under conservative treatment exist.
... CEH is rare with an annual incidence of 0.1 in 100,000 patients and presents in 0.63% of trauma patients annually [1]. Presence or development of CEH does not always correlate with the severity of the injuries and may present with a delay in the onset of symptoms, often being missed on initial imaging [2][3][4][5][6][7]. In addition, there is a higher prevalence (72-78%) in males at the later part of their life with a stronger association with traumatic events [6]. ...
... Presence or development of CEH does not always correlate with the severity of the injuries and may present with a delay in the onset of symptoms, often being missed on initial imaging [2][3][4][5][6][7]. In addition, there is a higher prevalence (72-78%) in males at the later part of their life with a stronger association with traumatic events [6]. ...
... These symptoms may progress to lasting paresis or even death [2,5]. Though the incidence of cervical spinal cord compression in the setting of CEH has been reported in as low as 2.4%, patients on anticoagulants involved in traumatic injuries are more likely to sustain extensive bleeding resulting in cord compression [6]. Symptoms mimicking Brown-Sequard Syndrome have also been noticed as an initial presentation of CEH with hemiparesis, ipsilateral loss of vibratory sensation, and contralateral loss of pain sensation [8]. ...
Background
Cervical epidural hematoma (CEH) is defined as a collection of blood in the suprameningeal space. Mechanisms of this rare pathology include spontaneous, postsurgical, and traumatic as the main subtypes. This unique case of traumatic CEH represents an even smaller subset of these cases. Management varies by symptom presentation, mechanism of injury, and other contraindications.
Case presentation
This case presents a 32 year old African American female on an oral anticoagulant sustaining traumatic cervical hematoma after a motor vehicle collision. Patient complained of neck, abdominal, and back pain. Imaging revealed a cervical spinal hematoma at the level of C3–C6. This case discusses the management of CEH for the general population and in the setting of anticoagulation.
Conclusion
Management of each case of CEH must be carefully considered and tailored based on their symptom presentation and progression of disease. As the use of anticoagulation including factor Xa inhibitors becomes more prevalent, there is greater need to understand the detailed pathophysiological aspect of the injuries. Targeted reversal agents such as Prothrombin Concentrate can be used for conservative treatment. Adjunct testing such as thromboelastogram can be used to help guide management.
... Posttraumatic spinal hematomas are possible after even minor trauma. 1 In many cases, these hematomas, whether intradural or epidural, may remain asymptomatic and require no additional intervention. 2 That said, compressive hematomas of the spinal cord can have devastating neurological consequences. In the largest review to date, 4.4% of traumas involving a vertebral fracture and 5.4% of traumas without fractures were associated with spinal hematomas causing spinal cord compression. ...
... 4 Traumatic hematomas of the cervical spine are especially infrequent, with epidural hematomas found in only 2.5% of posttraumatic cervical spine injuries. 2 A prior review has shown that at least 30% to 40% of patients who experience these hematomas have an underlying coagulopathy, although the patient in our case had no prior medical conditions or medication use and no evidence of coagulopathy on his preoperative/posttraumatic laboratory tests. MRI is the ideal imaging modality for differentiating subdural and epidural spinal hematomas. ...
BACKGROUND
Posttraumatic intradural hematomas of the cervical spine are rare findings that may yield significant neurological deficits if they compress the spinal cord. These compressive hematomas require prompt surgical evacuation. In certain instances, intradural hematomas may form from avulsion of cervical nerve roots.
OBSERVATIONS
The authors present the case of a 29-year-old male who presented with right upper-extremity weakness in the setting of polytrauma after a motor vehicle accident. He had no cervical fractures but subsequently developed right lower-extremity weakness. Magnetic resonance imaging (MRI) demonstrated a compressive hematoma of the cervical spine that was initially read as an epidural hematoma. However, intraoperatively, it was found to be a subdural hematoma, eccentric to the right, stemming from an avulsion of the right C6 nerve root.
LESSONS
Posttraumatic cervical subdural hematomas require rapid surgical evacuation if neurological deficits are present. The source of the hematoma may be an avulsed nerve root, and the associated deficits may be unilateral if the hematoma is eccentric to one side. Surgeons should be prepared for the possibility of an intradural hematoma even in instances in which MRI appears consistent with an epidural hematoma.
... A spinal epidural hematoma is a collection of blood between the spinal canal dura and vertebrae. 1 death and, therefore, are a surgical emergency. 2 Occurring in 1 per 1,000,000 annually, the cause is most commonly idiopathic (29.7%) followed by anticoagulation and vascular disorders. ...
... 2,3 Given the non-specific clinical findings, spinal epidural hematomas are challenging to diagnose. 1 Non-contrast CT may show an epidural bleed as a hyperdense mass. An MRI with contrast (preferred if active extravasation or other spine pathology is suspected) or without contrast is the study of choice given the ability to estimate the location, size, and severity of compression. ...
Case PresentationAn 85-year-old male presented to the emergency department after a motor vehicle collision and developed progressive neurological deficits. CT imaging demonstrated epidural thickening from C2-C7, and MRI was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome.DiscussionCases of traumatic spinal epidural hematomas are rarely seen in the emergency department. These are part of a small subset of operative neurological emergencies that benefit from urgent operative intervention.
... 2 Spinal hematomas that occur as a result of trauma are less common. 4,5 There are only seven reported cases of traumatic cervical SAH in the literature. [6][7][8][9][10][11][12] Treatment is dependent on the patient's neurological examination as well as presence or absence of vascular pathology. ...
... 2 Spinal hematomas are frequently idiopathic, consequent of vascular malformation or tumor with trauma being cited as an etiology in only 2.5% of all cervical hemorrhages. 2,4 Hematoma formation in the subarachnoid compartment of the spine is rare and difficult to diagnose typically due to low suspicion when there is a lack of vertebral fracture or displacement on initial imaging. High suspicion is warranted avoid delay in treatment. ...
BACKGROUND
Spinal hematomas are a rare entity with broad etiologies, which stem from idiopathic, tumor-related, and vascular malformation etiologies. Less common causes include traumatic blunt nonpenetrating spinal hematomas with very few cases being reported. In the present manuscript presents a case report and review of the literature of a rare traumatic entity of a cervical subarachnoid hematoma in association with Brown-Séquard syndrome in a patient on anticoagulants. Searches were performed on PubMed and Embase for specific terms related.
OBSERVATIONS
A well-documented case of an 83-year-old female taking anticoagulants with traumatic cervical subarachnoid hematoma presenting as Brown-Séquard syndrome was reported. Six similar cases were identified, scrutinized, and analyzed in the literature review.
LESSONS
Traumatic blunt nonpenetrating cervical spine subarachnoid hematomas are a rare entity that can happen more specifically in anticoagulant users and in patients with arthritic changes and stenosis of the spinal canal. Rapid neurological deterioration and severe disability warrant early aggressive surgical treatment. This report has the intention to record this case in the medical literature for registry purposes.
... [13] Upon review of the literature, traumatic SEH is typically associated with high energy trauma, however, there are scarce reports associated with OVCF. [14,15] The exact pathophysiological mechanisms underlying OVCF accompanying SEH is still not clear. Kim et al [10] and Hirata et al [12] theorized that the instability of the fracture was a cause of hematoma. ...
... The veins in the epidural venous plexus which are vulnerable to rupture are the most likely source of SEH. [15] Historically, the mainstay of traumatic SEH management was urgent surgical decompression and evacuation of the hematoma. [16] The prognosis of SEH appears to be related to the severity of the preoperative neurological deficits and the time to intervention; early surgical treatment is crucial for good outcomes. ...
Rationale:
Osteoporotic vertebral compression fracture (OVCF) accompanying huge spinal epidural hematoma (SEH) is fairly rare. The aim of this report is to investigate the management strategies and treatment outcomes of OVCF accompanying SEH.
Patient concerns:
An 89-year-old female patient was admitted to hospital because of severe back pain and numbness of both lower limbs after a slight fall. The magnetic resonance imaging examination of the patient showed a fresh compression fracture at L2 accompanying a large dorsal SEH which extended from the T12 to L3 and deformed the spinal cord.
Diagnosis:
The patient was diagnosed with OVCF accompanying SEH.
Interventions:
Given mild neurologic deficits, the hematoma was not treated, and the patient underwent percutaneous vertebroplasty (PVP) only.
Outcomes:
After the procedure, immediate pain relief was achieved and the numbness of both lower limbs disappeared 3 days later. Three months after the procedure, the follow-up magnetic resonance imaging revealed a complete resolution of the hematoma.
Lessons:
OVCF accompanying SEH is fairly rare, and the exact pathophysiological mechanisms are still not clear. In selected patients without or with only slight neurologic symptoms, it is reasonable to perform PVP alone in OVCF accompanying SEH. Moreover, intravertebral stability after PVP might have played a role in spontaneous resolution of SEH.
... Spinal epidural hematoma (SEH) is an uncommon clinical condition, which is characterized by the collection of blood in the spinal epidural space, leading to spinal cord/roots compression and its potential neurological deficits. [1][2][3][4] We report an uncommon case of posttraumatic dorsolumbar SEH treated surgically with outcome, and discuss the characteristic imaging findings. ...
... 3 Surgery is recommended in large-size lesions with neurological deficits to achieve good functional outcome. 1,3,22 In selected cases, a conservative management has also shown to be effective with good outcome. 7,18 Conclusion SEHs are rare lesions and their diagnosis requires a high index of clinical suspicion. ...
In spite of the relative common occurrence of spinal injuries, spinal epidural hematomas (SEHs) are rare lesions. Depending on the onset, site, size, and presence of neurological deficits, they can be treated conservatively or surgically. In the presented article, we report an uncommon case of posttraumatic dorsolumbar SEH and discuss the characteristic magnetic resonance imaging (MRI) imaging findings of epidural fat in the cases of traumatic spinal hematomas.
... Cervical epidural fluid collection leading to myelopathy can result from various conditions, including vascular (idiopathic cervical epidural hematoma, traumatic cervical epidural hematoma, spinal arteriovenous malformation, spinal cord infarction), infectious (epidural abscess, infectious spondylitis, infectious discitis), neoplastic (epidural tumors, spinal cord tumors), autoimmune, post-traumatic cerebrospinal fluid (CSF) leakage, and iatrogenic causes [1][2][3][4]. In clinical practice, the most common cervical epidural fluid is hematoma. ...
Various conditions can cause myelopathy due to cervical epidural fluid collection, including idiopathic cervical epidural hematoma, traumatic cervical epidural hematoma, infectious myelitis, epidural abscess, spinal cord infarction, post-traumatic cerebrospinal fluid (CSF) leakage, and epidural tumors. While physical compression from hematoma, abscess, or epidural tumors is common, and carcinomatous meningitis can cause CSF flow obstruction and accumulation leading to myelopathy, rapid progression of serous fluid collection causing myelopathy is rare. We report a case of myelopathy caused by rapid accumulation of epidural exudate from a metastatic tumor in the cervical lamina.
A 59-year-old male with a history of lung cancer with metastasis to the C3 lamina, who was previously independent in activities of daily living, presented to the emergency department with progressive quadriparesis and urinary dysfunction after farming work. An acute cervical epidural hematoma was initially diagnosed, and emergency surgery was subsequently performed. Intraoperatively, no clear epidural hematoma was found, but serous, light yellow, clear fluid collection was observed in the epidural space. After drainage and partial C3, C6 laminectomy and complete C4, C5 laminectomy for decompression, neurological symptoms improved significantly. Postoperative spinal myelography showed no evident CSF leakage into the cervical epidural space. However, on postoperative day 20, bilateral lower limb weakness recurred with more fluid accumulation than preoperatively. During reoperation, exudate was observed from the remaining portion of the C3 lamina with known lung cancer metastasis. Believing the spinal cord compression from this fluid collection to be the cause of myelopathy, the metastatic C3 lamina was completely removed to prevent recurrence. No obvious dural fistula was observed. After reoperation, no significant epidural fluid collection causing spinal cord compression was observed, and the patient was discharged home with a modified Rankin scale score of 4.
... The reported incidence of posttraumatic cervical epidural hematomas from 2010 to 2014 was 2.5%, and of these, 59% were related to spinal cord compression. 11 Almost all documented cases of traumatic cervical epidural hematomas in the literature required surgical intervention. 7,12 A few cases of traumatic epidural hematoma in other regions of the spine (anterior cervical and lumbar spine) were reported to have spontaneously resolved: 1 case in the anterior cervical epidural space and 4 cases in the lumbar epidural space. ...
BACKGROUND
Cervical epidural hematomas are rare and can arise for many reasons. Patients typically present with pain and/or symptoms of spinal cord compression. Prompt surgical decompression is typically pursued when deficits are present in an effort to improve long-term neurological outcomes. However, the authors report the case of a patient with a traumatic dorsal cervical epidural hematoma with spontaneous resolution within 16 hours.
OBSERVATIONS
A 49-year-old male with a history of C5–6 anterior cervical fusion 3 years prior presented with neck pain after blunt force trauma. The exam revealed only tenderness in the cervical spine. Initial computed tomography revealed fractures of C1 and C4. Urgent magnetic resonance imaging (MRI) demonstrated a dorsal cervical epidural hematoma causing compression of the spinal cord from the occiput to C5. An operation was scheduled for the following morning; however, after he reported new symptoms, repeat MRI was performed, which confirmed no evidence of a cervical epidural hematoma.
LESSONS
This case demonstrates that a traumatic cervical epidural hematoma can resolve spontaneously within a short time frame. Close monitoring of these patients is vital, and it is important to reimage patients if new signs and/or symptoms arise to potentially change the timing and/or nature of the proposed surgery.
https://thejns.org/doi/10.3171/CASE24167
... Several case reports and even large series of post-traumatic patients with ankylosed spines describe SEHs in separate or combined groups, or even without distinction of DISH and ankylosing spondylitis [4,[14][15][16][17][18][19][20][21][22][23][24]. Those studies lack blinded retrospective review by radiologists focusing on spinal hematoma, spinal cord impingement, SCI, and distinction from other ankylosing spinal disorders. ...
Objectives:
To determine the incidence of spinal hematoma and its relation to neurological deficit after trauma in patients with spinal ankylosis from diffuse idiopathic skeletal hyperostosis (DISH).
Materials and methods:
A retrospective review of 2256 urgent or emergency MRI referrals over a period of 8 years and nine months revealed 70 DISH patients who underwent CT and MRI scans of the spine. Spinal hematoma was the primary outcome. Additional variables were spinal cord impingement, spinal cord injury (SCI), trauma mechanism, fracture type, spinal canal narrowing, treatment type, and Frankel grades during injury, before and after treatment. Two trauma radiologists reviewed MRI scans blinded to initial reports.
Results:
Of 70 post-traumatic patients (54 men, median age 73, IQR 66-81) with ankylosis of the spine from DISH, 34 (49%) had spinal epidural hematoma (SEH) and 3 (4%) had spinal subdural hematoma, 47 (67%) had spinal cord impingement, and 43 (61%) had SCI. Ground-level fall (69%) was the most common trauma mechanism. A transverse, AO classification type B spine fracture (39%) through the vertebral body was the most common injury type. Spinal canal narrowing (p < .001) correlated and spinal cord impingement (p = .004) associated with Frankel grade before treatment. Of 34 patients with SEH, one, treated conservatively, developed SCI.
Conclusions:
SEH is a common complication after low-energy trauma in patients with spinal ankylosis from DISH. SEH causing spinal cord impingement may progress to SCI if not treated by decompression.
Clinical relevance statement:
Low-energy trauma may cause unstable spinal fractures in patients with spinal ankylosis caused by DISH. The diagnosis of spinal cord impingement or injury requires MRI, especially for the exclusion of spinal hematoma requiring surgical evacuation.
Key points:
• Spinal epidural hematoma is a common complication in post-traumatic patients with spinal ankylosis from DISH. • Most fractures and associated spinal hematomas in patients with spinal ankylosis from DISH result from low-energy trauma. • Spinal hematoma can cause spinal cord impingement, which may lead to SCI if not treated by decompression.
... Using signal changes based on bone marrow edema, MRI identifies the presence and location of acute fracture or soft tissue injury and simultaneously distinguishes it from normal tissue without injury. T1-weighted imaging is useful for evaluating the integrity of ligament structures, particularly anterior and posterior longitudinal ligaments and epidural hematomas [53][54][55][56]. MRI is also used to diagnose inflammatory conditions, such as multiple sclerosis, sarcoidosis, and transverse myelitis, because it can detect swelling of the spinal cord (acute inflammation) or demyelination (chronic inflammation) [57][58][59]. ...
Diagnostic techniques for spinal pathologies have been developed in accordance with advances in technology. Accurate diagnosis of spinal pathology is essential for appropriate management of spinal diseases. Since the development of X-rays in 1895 and computed tomography (CT) in 1967, several diagnostic imaging modalities have been utilized for detecting spinal pathologies, including radiography, CT, magnetic resonance imaging, and radionuclide imaging. In addition to diagnostic imaging technologies, electrodiagnostic tests, including electromyography and nerve conduction studies, play a significant role as diagnostic tools, as spinal diseases are mostly profoundly associated with pathologies of the neural structures, such as the spinal cord and nerve root, and extent of injury at the structure cannot be adequately detected by conventional imaging techniques. In patient-specific treatment strategies, usage of diagnostic modalities is of great importance; thus, we should be aware of the basic details and approaches of the different diagnostic modalities. In this review, the authors discuss the details of the technologies that aid in the diagnosis of spinal pathologies.
... The traumatic context remains extremely rare; it could be found in isolated cervical trauma or the context of a polytrauma. An incidence of 2.5% was reported for post-traumatic cervical spine epidural hematoma [1]. We present a case of spinal cervical epidural hematoma after trauma in an adult patient. ...
Post-traumatic spinal epidural cervical hematoma is defined as a collection of blood at the level of the epidural space following a trauma. It remains a rare presentation. We report here the case of a cervical epidural hematoma extending from C3 to C5, in a 55-year-old patient victim of a public traffic accident admitted one hour after trauma. Computed Tomography (CT) scan found a compressive epidural hematoma extending C3 to C5; the patient underwent a posterior surgical approach, which allowed to evacuate the hematoma. This rare clinical entity is an emergency diagnosis and management, which needs collaboration between, Intensive Care Unit (ICU) specialists, neurosurgeons, neuroradiologists, and physiotherapists for good outcomes and follow-up.
... A spinal epidural hematoma is a collection of blood between the spinal canal dura and vertebrae. 1 death and, therefore, are a surgical emergency. 2 Occurring in 1 per 1,000,000 annually, the cause is most commonly idiopathic (29.7%) followed by anticoagulation and vascular disorders. ...
Case presentation:
An 85-year-old male who had been prescribed prasugrel presented to the emergency department (ED) after a motor vehicle collision and developed progressive neurological deficits. Computed tomography imaging demonstrated epidural thickening from the second through seventh cervical vertebrae, and magnetic resonance imaging was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome.
Discussion:
Cases of traumatic spinal epidural hematomas are rarely seen in the ED. These are part of a small subset of operative neurological emergencies that benefit from urgent surgical intervention.
... A spinal epidural hematoma is a collection of blood between the spinal canal dura and vertebrae. 1 death and, therefore, are a surgical emergency. 2 Occurring in 1 per 1,000,000 annually, the cause is most commonly idiopathic (29.7%) followed by anticoagulation and vascular disorders. ...
Case Presentation: An 85-year-old male who had been prescribed prasugrel presented to the emergency department (ED) after a motor vehicle collision and developed progressive neurological deficits. Computed tomography imaging demonstrated epidural thickening from the second through seventh cervical vertebrae, and magnetic resonance imaging was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome. Discussion: Cases of traumatic spinal epidural hematomas are rarely seen in the ED. These are part of a small subset of operative neurological emergencies that benefit from urgent surgical intervention.
... Epidural hematomas usually show an iso-hyperintense signal on T1 weighted images and hyperintensity on T2 weighted images. The incidence of epidural hematomas after trauma has been estimated at about 2.5%, although 59% of them were associated with cord compression (49,50). Diffusion tensor imaging (DTI) with measurement of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA), as well as tractography, allow quantitative data to be obtained on the axonal integrity of the spinal cord in traumatized patients (51). ...
Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.
... 7 A recent radiographic study looking at patients with urgent and emergency MRI to evaluate spine trauma identified a rate of 68% of patients with AS who had EDHs. 8 While the relationship between spinal EDHs in patients with AS and traumatic spine fractures has been described in previous publications, [9][10][11][12] there has certainly been a paucity of literature describing this important relationship that can have dire neurological consequences if not recognized early. 13 To further evaluate and describe the incidence of this relationship, we have reviewed our institutional experience and the published literature. ...
OBJECTIVE
Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the sacroiliac joints and axial spine that is closely linked with human leukocyte antigen–B27. There appears to be an increased frequency of associated epidural hematomas in spine fractures in patients with AS. The objective was to review the incidence within the literature and a single-institution experience of the occurrence of epidural hematoma in the context of patients with AS requiring spine surgery.
METHODS
Deep 6 AI software was used to search the entire database of patients at a single level I trauma center (since the advent of the institution’s modern electronic health record system) to look at all patients with AS who underwent spinal surgery and who had a diagnosis of epidural hematoma. Additionally, a systemic literature review was performed of all papers evaluating the incidence of epidural hematoma in patients with spine fractures.
RESULTS
A single-institution, retrospective review of records from 2009 to 2020 yielded a total of 164 patients with AS who underwent spine surgery. Of those patients, 17 (10.4%) had epidural hematomas on imaging, with the majority requiring surgical decompression. These spine fractures occurred close to the cervicothoracic or thoracolumbar junction. The patients ranged in age from 51 to 88 years, and there were 14 males and 3 females in the cohort. Eight patients were administered an antiplatelet and/or anticoagulant agent, and the rest were not. All patients required surgical stabilization, with 64.7% of patients also requiring decompressive laminectomies for evacuation of the hematoma and spinal cord decompression. Only 1 death was reported in the series. There was a tendency toward neurological improvement after surgical intervention.
CONCLUSIONS
AS has been a well-described pathologic process that leads to an increased risk of three-column injury in spine fracture, with an increased incidence of symptomatic epidural hematoma compared with patients without AS. Early recognition of this entity is important to ensure that appropriate surgical management includes addressing compression of the neural elements in addition to surgical stabilization.
... One theory is that the stiffer spine is accompanied by less elastic paraspinal vasculature that can rupture easily. Also, AS patients sustain fractures typically with a transverse extension distraction mechanism, and the paraspinal vasculature can easily rupture with this highly unstable injury pattern (27). ...
Background:
Our study aimed to characterize the imaging appearance of spinal fractures in ankylosing spondylitis (AS) and identify situations in which the use of magnetic resonance imaging (MRI) is necessary.
Methods:
A total of 70 cases of spinal fractures associated with AS were retrospectively enrolled. Two radiologists independently reviewed the preoperative images. The location, type, ligament injury, neurological injury, and epidural hematoma following spinal fractures were assessed.
Results:
Only one patient had a vertebral compression fracture, and 69 patients had 77 transverse fractures involving three columns. The most frequent injuries in AS patients were type B3 (N=32, 43.8%) spine fractures, followed by type C (N= 20, 27.4%) spine fractures. There were significant differences in fracture types of the different spine regions (H=14.1, P<0.0001). Most type C spine fractures were located in the lower cervical spine, while most of the type B2 spine fractures were located in the thoracic spine. Transverse fractures were classified as shear or stress type fractures. In total, there were 62 shear fractures and 15 stress fractures. All of the transverse fractures were detected by computed tomography (CT). The accuracy of CT in the diagnosis of the exact anatomic involvement of transverse fractures was significantly higher than that of MRI (χ2=8.36, P=0.014). The anterior longitudinal ligament (ALL) was the most frequently torn ligament. Tears of ossified ligaments were best visualized by sagittal reformatted CT. Lower cervical fractures were more likely to be associated with neurological injury compared with fractures to other regions of the spine (χ2=7.24, P=0.025). There were six epidural hematoma cases, which were only detected by MRI, were found to have fractures of the lower cervical spine.
Conclusions:
We recommend a whole-spine CT examination with three-dimensional reconstruction for detecting a suspected fracture in AS patients. In cases with neurological injury, MRI examinations are always mandatory. AS patients with lower cervical spine fractures require further investigation by MRI. Patients with non-lower cervical spine fractures without any neurological deficits do not need to undergo an immediate MRI.
... Owing to its high sensitivity in identifying bone marrow edema, it is useful for detecting occult fractures, especially with additional fat suppression, such as STIR sequences (Fig. 4) [29]. A T1-weighted image helps to assess the integrity of the ligamentous structures, especially the anterior and posterior longitudinal ligaments, and the epidural hematoma [32][33][34][35]. ...
Spine diseases are common and exhibit several causes, including degeneration, trauma, congenital issues, and other specific factors. Most people experience a variety of symptoms of spine diseases during their lifetime that are occasionally managed with conservative or surgical treatments. Accurate diagnosis of the spine pathology is essential for the appropriate management of spine disease, and various imaging modalities can be used for the diagnosis, including radiography, computed tomography (CT), magnetic resonance imaging (MRI), and other studies such as EOS, bone scan, single photon emission CT/CT, and electrophysiologic test. Patient (or case)-specific selection of the diagnostic modality is crucial; thus, we should be aware of basic information and approaches of the diagnostic modalities. In this review, we discuss in detail, about diagnostic modalities (radiography, CT, MRI, electrophysiologic study, and others) that are widely used for spine disease.
... The incidence rate varies from 15 to 40 patients per 1 million inhabitants, being more prevalent in urban areas, a number that grows with each decade (Santos EAS et al., 2009;Young AJ et al., 2015;Chan CWL et al., 2016). The main causes of cervical and vertebral spine trauma are falls from their own height (63%), followed by car accidents (25%), compressive impacts, high energy trauma, impacts during sports activities and, less frequently, injuries by firearm (7%), shallow water dives (3%) and assaults (2%) (Young AJ et al., 2015;Ricart PA et al.,2017;Campos MF et al., 2008;Dowdell J et al.,2018;Whiting WC, 2015). The trauma mechanisms that lead to a cervical fracture are complex and not well understood, since mechanisms of the same nature may culminate in different injury patterns. ...
The trauma mechanisms that lead to a cervical fracture are complex and not well understood, since mechanisms of the same nature may culminate in different injury patterns. This study aimed to review the current literature about the biomechanical factors that contribute to cervical fractures trauma. The search was conducted in databases PubMed, LILACS, SciELO and Cochrane Library platforms. We used the descriptors "Biomechanical Phenomena", "Cervical Vertebrae" and "Fractures, Bone". Found 185 articles, of which 183 were from the Pubmed platform and two from Cochrane Library platforms, in the other search platforms studies were not found. The inclusion criteria were: studies published in the last 5 years that were fully available on the web. After using these filters, 16 studies were found, all from the Pubmed platform only. Exclusion of 11 studies. Selected 5 articles to compose the review sample. They were divided into 3 categories to be discussed more closely, namely: injury mechanism, musculature influence to the injury and impact site as fracture determinants. Cervical fractures traumas occurs through indirect mechanisms where the most common mechanisms are flexion, extension, compression and dissociation. Moreover, it is observed that the cervical muscles behave as a protective factor for cervical fractures trauma. Copyright © 2020, Thiago Maciel Valente et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
... Studies of nonfatal UIs are an important part of the overall picture of UIs [6,7]. Although much is known about fatal injuries via the vital registry system, there are limited data on nonfatal injuries in LMICs, with most information being based on questionnaire surveys and trauma registries or focused on a select group of injuries or population [8][9][10][11][12]. Although the National Injury Surveillance System (NISS) was built in China since 2006, it includes only 126 hospitals with limited representation and collects information using hard-copy forms, which leads to poor availability of real-time data [13]. ...
Introduction:
Unintentional injuries (UIs) impose a significant burden on low- and middle-income countries (LMICs). However, available UI epidemiological data are limited for LMICs, including China. This article aimed to provide an overview of the UI hospitalization profile, identify risk factors for in-hospital mortality and provide diagnosis-specific survival risk ratios (SRRs) for reference by LMICs using hospital discharge abstract data (DAD) from Beijing, China.
Patients and methods:
A cross-sectional study was conducted for patients sustaining UIs requiring admission. Information was retrieved from 138 hospitals in Beijing to describe the demographics, injury nature, mechanisms, severity and hospital outcomes. Multivariate logistic regression was performed to identify and evaluate risk factors for in-hospital mortality for UIs.
Results:
Falls (57.1%), transport accidents (19.9%) and exposure to inanimate mechanical forces (16.4%) were the leading causes of UI hospitalization. Falls and transport accidents were responsible for 94.2% of the in-hospital deaths caused by UIs. Injury mechanisms differed among sex (χ2 = 5322.1, P < 0.001) and age (χ2 = 24,143.3, P < 0.001) groups. Male sex (OR: 1.50, 95% confidence interval (CI): 1.23-1.79), age ≥ 85 years (OR: 16.39, 95% CI: 7.46-36.00), Barthel Index at admission ≤ 60 (OR: 25.78, 95% CI: 13.30-49.95), modified Charlson comorbidity index ≥ 6 (OR: 2.60, 95% CI: 1.91-3.55), International Classification of Diseases-based injury severity score (ICISS) < 0.85 (OR: 15.17, 95% CI: 12.57-18.30), sustaining injuries to the head/neck (OR: 23.20, 95% CI: 7.31-73.64), injuries caused by foreign body entering through natural orifice (OR: 34.00, 95%CI: 6.37-181.54) and injuries resulting from transport accidents (OR: 1.71, 95% CI: 1.41-2.07) were important risk factors for in-hospital mortality for UIs.
Conclusions:
Hospital DAD are an objective and cost-effective data source that allows for a hospital-based perspective of UI epidemiology. Sex, age, functional status at admission, comorbidities, injury nature, severity and mechanism are significantly associated with the in-hospital mortality of UIs in China. This study generates a reference dataset of diagnosis-specific SRRs from a large trauma population in China, which may be more applicable in injury severity estimation using ICISS in LMICs.
A BSTRACT
Spinal epidural hematoma (SEH) is a rare but critical cause of spinal cord compression, especially in children. Chronic SEH (CSEH) is rarer and difficult to define, with varying timeframes used in literature. Its rarity makes diagnosis challenging. This case report describes a 10-year-old female with a 3-month history of progressive neck pain and bilateral hand weakness following a rolling exercise. On physical examination, motor strength was graded 3/5 in the distal upper extremities, whereas the lower extremities exhibited normal strength. Magnetic resonance imaging revealed a C5-Th2 extradural lesion compressing the spinal cord, consistent with CSEH. Traditional laminectomy carries risks like postoperative kyphosis, particularly in young patients. Therefore, an en bloc laminoplasty (EBL) was performed in this patient. Postoperatively, the patient demonstrated significant clinical improvement. This case highlights the successful application of EBL for CSEH in a pediatric patient, emphasizing its potential to minimize complications compared to laminectomy. Laminoplasty, indicated for cervical stenosis, aims to decompress the spinal cord while preserving posterior structures and maintaining spinal mobility. EBL, a specific laminoplasty technique, may offer biomechanical advantages. This case demonstrates the potential benefits of EBL in managing CSEH in pediatric patients, contributing to better outcomes compared to traditional methods.
Objective
This study aimed to evaluate the efficacy and safety of different stem cell types for spinal cord injury (SCI) therapy and find out the superior treatment for SCI.
Methods
A systematic literature search was performed using PubMed, Embase, the Cochrane Library, Web of Science, VIP, CNKI, and Wan Fang from database initiation to January 30, 2021. A Bayesian network meta-analysis was performed using ADDIS software. The PROSPERO registration number was CRD42020129635.
Results
Twelve studies with 642 patients were enrolled in this study. Network meta-analysis revealed that bone mesenchymal stem cells combined with rehabilitation training (BMSCs + R) were significantly more effective than rehabilitation training alone (R) in improving American Spinal Injury Association (ASIA) impairment scale (AIS)-grading improvement rate (OR=94.25, 95% CI: 6.71 to 9321.95), ASIA motor score (WMD=6.67, 95% CI: 0.83 to 12.73), ASIA Sensory Functional score (WMD=12.41, 95%CI: 3.42 to 21.72), and Barthel Index (BI) score (WMD=7.24, 95% CI: 0.21 to 14.30). However, no statistically significant differences were observed between marrow mononuclear cells combined with rehabilitation training (MNCs + R), umbilical cord-derived mesenchymal stem cells combined with rehabilitation training (UCMSCs + R), or UCMSCs alone and R on all indicators. In terms of safety, there were no serious and permanent adverse effects after transplantation of BMSCs, MNCs, or UCMSCs.
Conclusion
BMSCs + R may be superior to the other stem cell treatments for SCI in improving AIS grading, ASIA motor score, ASIA Sensory Functional score, and BI score. The therapeutic effects of UCMSCs and MNCs remain to be confirmed.
OBJECTIVE
Ankylosing spondylitis, the most common spondyloarthritis, fuses individual spinal vertebrae into long segments. The unique biomechanics of the ankylosed spine places patients at unusually high risk for unstable fractures secondary to low-impact mechanisms. These injuries are unique within the spine trauma population and necessitate thoughtful management. Therefore, the authors aimed to present a richly annotated data set of operative AS spine fractures with a significant portion of patients with simultaneous dual noncontiguous fractures.
METHODS
Patients with ankylosing spondylitis with acute fractures who received operative management between 2012 and 2020 were reviewed. Demographic, admission, surgical, and outcome parameters were retrospectively collected and reviewed.
RESULTS
In total, 29 patients were identified across 30 different admissions. At admission, the mean age was 71.7 ± 11.8 years. The mechanism of injury in 77% of the admissions was a ground-level fall; 30% also presented with polytrauma. Of admissions, 50% were patient transfers from outside hospitals, whereas the other half presented primarily to our emergency departments. Fifty percent of patients sustained a spinal cord injury, and 35 operative fractures were identified and treated in 32 surgeries. The majority of fractures clustered around the cervicothoracic (C4–T1, 48.6%) and thoracolumbar (T8–L3, 37.11%) junctions. Five patients (17.2%) had simultaneous dual noncontiguous operative fractures; these patients were more likely to have presented with a higher-energy mechanism of injury such as a bicycle or motor vehicle accident compared with patients with a single operative fracture (60% vs 8%, p = 0.024). On preoperative MRI, 56.3% of the fractures had epidural hematomas (EDHs); 25% were compressive of the underlying neural elements, which dictated the number of laminectomy levels performed (no EDH, 2.1 ± 2.36; noncompressive EDH, 2.1 ± 1.85; and compressive EDH, 7.4 ± 4 [p = 0.003]). The mean difference in instrumented levels was 8.7 ± 2.6 with a mean estimated blood loss (EBL) of 1183 ± 1779.5 mL. Patients on a regimen of antiplatelet therapy had a significantly higher EBL (2635.7 mL vs 759.4 mL, p = 0.015). Overall, patients had a mean hospital length of stay of 15.2 ± 18.5 days; 5 patients died during the same admission or after transfer to an outside hospital. Nine of 29 patients (31%) had died by the last follow-up (the mean follow-up was 596.3 ± 878.9 days).
CONCLUSIONS
Patients with AS who have been found to have unstable spine fractures warrant a thorough diagnostic evaluation to identify secondary fractures as well as compressive EDHs. These patients experienced prolonged inpatient hospitalizations with significant morbidity and mortality.
Purpose:
The purpose of this study is to examine the incidence, location, and magnetic resonance imaging (MRI) features of spinal epidural hematoma (SEH) and spinal subdural hematoma (SSH) in post-traumatic ankylosing spondylitis (AS) patients.
Methods:
A total of 2256 consecutive referrals for urgent and emergency MRI scans of the spine over a period of eight years and nine months were manually reviewed for any mentions indicating axial ankylosis and post-traumatic spinal hematoma. We found 164 patients with ankylosed spines complicated by spinal fracture, of whom 32 had AS. Of the 132 excluded patients, 80 had diffuse idiopathic skeletal hyperostosis (DISH). The primary outcome was the presence of spinal hematoma, and the secondary outcome was spinal canal narrowing and spinal cord impingement. Two musculoskeletal radiologists and one fellow in musculoskeletal radiology reviewed the images for the presence of spinal hematoma and related signal characteristics, blinded to one another and initial reports.
Results:
Of 28 post-traumatic AS patients, 19 had SEHs and five had spinal SSHs. There was a statistically significant difference between Frankel grades before and after surgery in respect of neurological improvement (p = 0.008). Patients who had radiologically proven spinal cord impingement showed more severe neurological deficits (p = 0.012). Hematomas with T1 heterogeneity showed a significantly increased delay (p = 0.047) between injury and imaging, while other signal characteristics were only approximate.
Conclusions:
Both SEH and SSH are common complications in post-traumatic AS patients. Patients benefit from surgery, but the relevance of spinal hematoma as a separate factor causing neurological deficit remains unclear.
Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.
The present study investigates the effect of albumin levels in patients who have developed heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia-thrombosis (HITT). A retrospective observational cohort study was conducted at King Abudlaziz Medical City (KAMC), a university teaching hospital, on patients diagnosed with HIT between June 2013 and December 2014. Clinical and laboratory findings were used to confirm HIT. Albumin levels were reported on admission as baseline and during HIT occurrence. Twenty-eight patients were identified as HIT positive by enzyme-linked immunosorbent assay (ELISA), with a cutoff value of ≥1 optical density units and pretest probability “4Ts” score of ≥4. Of the 28 patients, nine (32%) developed HITT. Demographic characteristics of the patients who developed HIT and HITT were similar. The mean albumin level for patients who developed HITT was significantly lower than that for patients who developed HIT (p < 0.001). Our findings suggest that patients with low serum albumin levels are at greater risk of developing HITT. This finding awaits confirmation in larger prospective clinical trials.
Full recovery from tetraplegia is uncommon in cervical spine injury. This has not being reported for cervical spine fracture in a patient with ankylosing spondylitis causing spinal epidural hematoma. We report on a case of cervical spine fracture in a patient with ankylosing spondylitis who came with tetraplegia. He underwent a two stage fixation and fusion. He had a complete recovery. Two hours after the operation he regained full strength in all the limbs while in the Intensive Care Unit. He went back to full employment. There are only two other reports in the literature where patients with ankylosing spondylitis and extradural hematoma who underwent treatment within 12 h and recovered completely from tetraparesis and paraplegia respectively. Patient with ankylosing spondylitis has a higher incidence of spinal fracture and extradural hematoma. Good outcome can be achieved by early diagnosis and treatment. This can ensure not only a stable spine, but also a rapid and complete recovery in a tetraplegic patient.
This project describes a morphology-based subaxial cervical spine traumatic injury classification system. Using the same approach as the thoracolumbar system, the goal was to develop a comprehensive yet simple classification system with high intra- and interobserver reliability to be used for clinical and research purposes.
A subaxial cervical spine injury classification system was developed using a consensus process among clinical experts. All investigators were required to successfully grade 10 cases to demonstrate comprehension of the system before grading 30 additional cases on two occasions, 1 month apart. Kappa coefficients (κ) were calculated for intraobserver and interobserver reliability.
The classification system is based on three injury morphology types similar to the TL system: compression injuries (A), tension band injuries (B), and translational injuries (C), with additional descriptions for facet injuries, as well as patient-specific modifiers and neurologic status. Intraobserver and interobserver reliability was substantial for all injury subtypes (κ = 0.75 and 0.64, respectively).
The AOSpine subaxial cervical spine injury classification system demonstrated substantial reliability in this initial assessment, and could be a valuable tool for communication, patient care and for research purposes.
The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients with trauma. It is unclear how the two decision rules compare in terms of clinical performance.
We conducted a prospective cohort study in nine Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition. The CCR and NLC were interpreted by 394 physicians for patients before radiography.
Among the 8283 patients, 169 (2.0 percent) had clinically important cervical-spine injuries. In 845 (10.2 percent) of the patients, physicians did not evaluate range of motion as required by the CCR algorithm. In analyses that excluded these indeterminate cases, the CCR was more sensitive than the NLC (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 percent vs. 66.6 percent, P<0.001). In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 percent and 40.4 percent, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 percent (P=0.09 for the comparison with the NLC) and 50.7 percent (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries.
For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography.
The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine's poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment.
Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior-posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed. Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences.
The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior-posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10--a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.
Background:
Antiplatelet therapy (APT) after percutaneous coronary intervention (PCI) prevents ischemic events with increased risk of bleeding. Little is known about the relationship between hypoalbuminemia and bleeding risk in patients receiving APT after PCI. This study investigated the association between serum albumin level and bleeding events in this population.Methods?and?Results:We enrolled 438 consecutive patients who were prescribed dual APT (DAPT; aspirin and thienopyridine) beyond 1 month after successful PCI without adverse events. The patients were divided into 3 groups according to serum albumin tertile: tertile 1, ?3.7 g/dL; tertile 2, 3.8-4.1 g/dL; and tertile 3, ?4.2 g/dL. Adverse bleeding events were defined as Bleeding Academic Research Consortium criteria types 2, 3, and 5. During the median follow-up of 29.5 months, a total of 30 adverse bleeding events were observed. Median duration of DAPT was 14 months. The tertile 1 group had the highest risk of adverse bleeding events (event-free rate, 83.1%, 94.3% and 95.8%, respectively; P<0.001). On Cox proportional hazards modeling, serum albumin independently predicted adverse bleeding events (HR, 0.10, 95% CI: 0.027-0.39, P=0.001, for tertile 3 vs. tertile 1).
Conclusions:
Decreased serum albumin predicted bleeding events in patients with APT after PCI.
Study design:
Agreement study.
Objective:
To perform an independent inter-observer and intra-observer agreement assessment of the AOSpine subaxial cervical spine injury classification system.
Summary of background data:
The AOSpine subaxial cervical spine injury classification system was recently described. It showed substantial inter- and intra-observer agreement in the study describing it; however, an independent evaluation has not been performed.
Methods:
Anteroposterior and lateral radiographs, computed tomography scans and magnetic resonance imaging of 65 patients with acute traumatic subaxial cervical spine injuries were selected and classified using the morphologic grading of the subaxial cervical spine injury classification system by six evaluators (three spine surgeons and three orthopaedic surgery residents). After a six-week interval, the 65 cases were presented to the same evaluators in a random sequence for repeat evaluation. The Kappa coefficient (κ) was used to determine the inter- and intra-observer agreement.
Results:
The inter-observer agreement was substantial when considering the fracture main types (A, B, C or F), with κ= 0.61 (0.57 - 0.64), but moderate when considering the sub-types: κ= 0.57 (0.54 - 0.60). The intra-observer agreement was substantial considering the fracture types, with κ= 0.68 (0.62 - 0.74) and considering sub-types, κ= 0.62 (0.57 - 0.66). No significant differences were observed between spine surgeons and orthopaedic residents in the overall inter- and intra-observer agreement, or in the inter- and intra-observer agreement of specific A, B, C or F type of injuries.
Conclusion:
This classification allows adequate agreement among different observers and by the same observer on separate occasions. Future prospective studies should determine whether this classification allows surgeons to decide the best treatment for patients with subaxial cervical spine injuries.
Level of evidence:
3.
MRI plays a critical role in all orthopaedic practices. A basic working knowledge of the most commonly used pulse sequences in musculoskeletal imaging and the appearance of normal tissues on those sequences is critical to confident MRI interpretation. The orthopaedic surgeon should be familiar with appropriate use of intravenous and intra-articular contrast and its limitations. Concepts key to MRI interpretation include image contrast and resolution, signal, noise, and pulse sequence. Recent advances in anatomic and functional imaging highlight the robust potential of MRI for musculoskeletal evaluation. As MRI technology evolves, the orthopaedic surgeon must stay current on these technologic advances to use this tool to its fullest potential.
Spinal epidural hematoma is a rare condition that usually presents with acute, severe pain at the location of the hemorrhage, with radiation to the extremities. It can rapidly develop to include progressive and severe neurologic deficit. The pathophysiology often remains unclear. However, epidural hematoma in the lumbar spine is best described as the result of internal rupture of the Batson vertebral venous plexus. Clinical evaluation of pain control and neurologic deficit is the most important tool in early diagnosis. Currently, MRI is the diagnostic method of choice. Regardless of the setting, symptomatic spinal epidural hematoma is typically managed with urgent surgical decompression of the spinal canal.
Retrospective review.
To describe the spine fracture characteristics, current treatments, and their results in patients with ankylosing spinal disorders (ASD), such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), with the hypothesis that complication and mortality rates are high.
Spine fractures in patients with ASD are unique and have only been described in relatively small case series.
Retrospective review of a large consecutive series of patients with spine fractures and ASD over a 7-year period. Complications were stratified according to parameters such as type and number of comorbidities, patient age, and mechanism of injury. Predictors of mortality were analyzed by linear regression. Similarities between patients with AS and DISH were evaluated by chi analysis.
Of the 122 spine fractures in 112 consecutive patients with ASD, the majority were transdiscal extension injuries, most commonly affecting C6-C7. Eighty-one percent of the patients had at least 1 major medical comorbidity. Spinal cord injury was present in 58% of the patients, 34% of whom improved by at least 1 American Spinal Injury Association grade. Nineteen percent of patients had delayed diagnosis of their spine fracture, 81% of whom had resulting neurologic compromise. Surgery was performed on 67% of patients, consisting primarily of multilevel posterior instrumentation 3 levels above and below the injury. Eighty-four percent of all patients had at least 1 complication. Mortality was 32% and correlated with age > or =70 (P < 0.0001), number of comorbidities (P < 0.0001), and low-energy mechanism of injury (P = 0.009). AS patients were younger (P = 0.03) and had a higher risk of delayed fracture diagnosis (P = 0.012), but were otherwise similar to DISH patients.
Patients with spine fractures and ASD are at high risk for complications and death and should be counseled accordingly. Multilevel posterior segmental instrumentation allows effective fracture healing. AS and DISH patients represent similar patient populations for the purpose of treatment and future research.
Of 300 patients who were hospitalized for acute cervical injuries, 216 lived, fifty-one died within four months of injury, and thirty-three were lost to follow-up. The important findings in a retrospective review were that laminectomy resulted in a high mortality rate and loss of motor function and that steroids did not improve neural recovery in quadriplegics and their use was associated with gastrointestinal hemorrhage. Closed or open reduction followed by posterior fusion for subluxations or dislocations, and anterior decompression and fusion for vertebral compression fractures, offered the best chance for recovery of neural function and restoration of stability. Massive epidural hemorrhage was found only in patients with ankylosing spondylitis.
An example of a traumatic extradural hematoma of the cervical spine that occurred in a 32-year-old man who suffered from chronic ankylosing spondylitis is reported. Progressive sensory and motor deficit ensued some 3 hours after the patient fell from a standing position. The patient landed on his back, striking his head on the floor. After being helped up, he was able to walk unassisted to a nearby chair, where he sat down until his left lower extremity--and shortly afterwards, the right one--became numb and weak. On admission, the patient was found to have tetraparesis that was more pronounced in the lower extremities and associated with incomplete sensation to pinprick at level T7-T10. He also had painless distention of the urinary bladder. After a few hours, the weakness in his limbs increased and his sensory level rose to C5 bilaterally. A horizontal diastatic fracture across the vertebral body of C7 was discovered on plain x-ray films of the spine, and an extradural hematoma extending dorsally from C5 to T1 was revealed by emergency magnetic resonance imaging. After an emergency decompressive cervical laminectomy and removal of the clot, the patient rapidly regained complete neurological function, except with regard to both the urinary bladder and the rectum, which remained abnormal for almost 7 weeks after the operation.
A traumatic epidural hematoma of the cervical spine is reported in a 13-year-old girl. The patient recovered spontaneously over several days without surgical intervention. The diagnosis was made on magnetic resonance (MR) imaging, which also demonstrated subsequent resolution of the hematoma. The etiological factors of spinal epidural hematomas are reviewed and the utility of MR imaging in differentiating other causes of acute spinal cord injury is emphasized.
Five patients with vertebral fracture and spinal epidural hematoma (SEH) are described. Another 58-year-old man developed a post-traumatic SEH without bony damage. From the literature, 38 patients (31 male, 4 female, and 3 unknown) were collected. Ankylosing spondylitis or rheumatoid arthritis was noted in 9 of 12 subjects between 50 and 75 years of age. Two groups of patients were identified: Group 1--16 patients with spinal fracture (aged 23 to 63 years), and Group 2--22 patients without spinal fracture (the age was less than 18 years in 12 subjects). In Group 2, a coagulation defect or spinal epidural vascular malformation resulted in a SEH in 6 patients. The preoperative myelopathy was complete in 3 patients each from Group 1 (23.1%) and Group 2 (16.7%). Of the 31 patients operated upon, 9 of the 13 from Group 1 (69.3%) and 6 of the 18 from Group 2 (33.3%) underwent laminectomy within 1 week after the onset of symptoms. Postoperative neurological return was observed in 38.5% (5 of 13) and 88.9% (16 of 18) of these two groups of patients, respectively. Post-traumatic SEHs, predominant in the male population, are often associated with vertebral disease in elderly patients. In the very young patient, there is usually no fracture/dislocation of the spine. A predisposing lesion may be present when spinal fracture is not evident. The prognosis after surgical intervention is better in patients without spinal fracture than in those with vertebral damage, probably because of less contusion to the spinal cord and the presence of very young subjects in the former group of patients.
The authors report a retrospective review of 105 patients with ankylosing spondylitis (AS) diagnosed over a 6-year period in Tucson, Arizona. In the series, there were 13 patients with spinal fractures and eight with severe spinal cord injury. Two patients with central cord contusion had no demonstrable cervical spine fracture. Injury was often trivial and dislocation at fractures sites was minimal, demonstrating the extreme fragility of these patients. Spinal stenosis, which has not previously been associated with AS, was documented in three cases. Pseudarthrosis, a destructive vertebral lesion that does not require surgical decompression or fusion, was found in four patients; this entity is believed to originate as a pathological or traumatic fracture. Atlanto-axial subluxation and basilar invagination associated with spinal ankylosis occurred in one patient. The study emphasizes the value of computerized tomography scanning of the spine for diagnosis, and halo-vest application as a nonoperative treatment for cervical immobilization. Early diagnosis and appropriate therapy to decompress, reduce, and immobilize unstable spinal lesions may result in reduction of the 29% mortality rate and 45% permanent neurological morbidity rate observed after spinal fracture in this series of AS patients. Because of the high operative complication rate observed, nonsurgical immobilization is the recommended treatment unless spinal dislocation or bone fragment displacement has occurred at the fracture site.
A case-control retrospective analysis comparing patients who developed a postoperative spinal epidural hematoma with patients who did not develop this complication.
To identify risk factors for the development of an epidural hematoma following spinal surgery.
Neurologic deterioration following spinal surgery is a rare but devastating complication. Epidural hematomas should be suspected in the patient who demonstrates a new postoperative neurologic deficit. The risk factors that predispose a patient to a postoperative spinal epidural hematoma have not been identified.
Patients who underwent spinal surgery at a single institution over a 10-year period were retrospectively reviewed. Twelve patients who demonstrated neurologic deterioration after surgery and required surgical decompression because of an epidural hematoma were identified. All cases involved lumber laminectomies. A total of 404 consecutive patients that underwent lumbar decompression and did not develop an epidural hematoma formed the control group. Factors postulated to increase the risk of postoperative spinal epidural hematoma were compared between the two groups using logistic regression.
Multilevel procedures (P = 0.037) and the presence of a preoperative coagulopathy (P < 0.001) were significant risk factors. Age, body mass index, perioperative durotomies, and postoperative drains were not statistically significant risk factors.
Patients who require multilevel lumbar procedures and/or have a preoperative coagulopathy are at a significantly higher risk for developing a postoperative epidural hematoma.
Spinal hematoma has been described in autopsies since 1682 and as a clinical diagnosis since 1867. It is a rare and usually severe neurological disorder that, without adequate treatment, often leads to death or permanent neurological deficit. Epidural as well as subdural and subarachnoid hematomas have been investigated. Some cases of subarachnoid spinal hematoma may present with symptoms similar to those of cerebral hemorrhage. The literature offers no reliable estimates of the incidence of spinal hematoma, perhaps due to the rarity of this disorder. In the present work, 613 case studies published between 1826 and 1996 have been evaluated, which represents the largest review on this topic to date. Most cases of spinal hematoma have a multifactorial etiology whose individual components are not all understood in detail. In up to a third of cases (29.7%) of spinal hematoma, no etiological factor can be identified as the cause of the bleeding. Following idiopathic spinal hematoma, cases related to anticoagulant therapy and vascular malformations represent the second and third most common categories. Spinal and epidural anesthetic procedures in combination with anticoagulant therapy represent the fifth most common etiological group and spinal and epidural anesthetic procedures alone represent the tenth most common cause of spinal hematoma. Anticoagulant therapy alone probably does not trigger spinal hemorrhage. It is likely that there must additionally be a "locus minoris resistentiae" together with increased pressure in the interior vertebral venous plexus in order to cause spinal hemorrhage. The latter two factors are thought to be sufficient to cause spontaneous spinal hematoma. Physicians should require strict indications for the use of spinal anesthetic procedures in patients receiving anticoagulant therapy, even if the incidence of spinal hematoma following this combination is low. If spinal anesthetic procedures are performed before, during, or after anticoagulant treatment, close monitoring of the neurological status of the patient is warranted. Time limits regarding the use of anticoagulant therapy before or after spinal anesthetic procedures have been proposed and are thought to be safe for patients. Investigation of the coagulation status alone does not necessarily provide an accurate estimate of the risk of hemorrhage. The most important measure for recognizing patients at high risk is a thorough clinical history. Most spinal hematomas are localized dorsally to the spinal cord at the level of the cervicothoracic and thoracolumbar regions. Subarachnoid hematomas can extend along the entire length of the subarachnoid space. Epidural and subdural spinal hematoma present with intense, knife-like pain at the location of the hemorrhage ("coup de poignard") that may be followed in some cases by a pain-free interval of minutes to days, after which there is progressive paralysis below the affected spinal level. Subarachnoid hematoma can be associated with meningitis symptoms, disturbances of consciousness, and epileptic seizures and is often misdiagnosed as cerebral hemorrhage based on these symptoms. Most patients are between 55 and 70 years old. Of all patients with spinal hemorrhage, 63.9% are men. The examination of first choice is magnetic resonance imaging. The treatment of choice is surgical decompression. Of the patients investigated in the present work, 39.6% experienced complete recovery. The less severe the preoperative symptoms are and the more quickly surgical decompression can be performed, the better are the chances for complete recovery. It is therefore essential to recognize the relatively typical clinical presentation of spinal hematoma in a timely manner to allow correct diagnostic and therapeutic measures to be taken to maximize the patient's chance of complete recovery.
Electronic Supplementary Material is available if you access this article at http://dx.doi.org/10.1007/s10143-002-0224-y. On that page (frame on the left side), a link takes you directly to the supplementary material.
In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.
Spinal fractures in ankylosing spondylitis (AS) were difficult to diagnose before CT and MR imaging were available. The purpose of our investigation was to characterize spinal fractures and determine the value of different imaging modalities in AS.
Twelve successive cases of spinal fractures were identified in MR imaging files of AS patients. Conventional radiographs were available for 12, CT scans for 7, and 3D-CT scans for 4. We carefully reviewed clinical histories and imaging presentations.
Fractures were found in the cervical spine in 3 patients and in the thoracolumbar spine in 9. The 3 columns of the spine were involved in 11 patients. A routine 4-mm axial CT was not enough to demonstrate all fractures and ligament tears. The sensitivities of 3D-CT scans for demonstration of the following problems were similar to that of MR imaging and were better than that of conventional radiographs: tearing of the posterior longitudinal ligament, the thoracic spinous process fracture, and the facet fracture. MR imaging depicted these following findings that usually were not shown on conventional radiographs or 3D-CT scans: cord deformity, soft tissue disruption, and ligament tears in the posterior column. MR imaging also showed avascular necrosis and occult fractures better than conventional radiographs or CT scans.
MR imaging shows abnormalities in AS that may not be clear or even detectable by using other imaging methods. With the capability to show lesions in the posterior column, MR imaging can serve to evaluate AS patients with spinal fracture for the possibility of 3-column involvement.
Prospective clinical series.
To determine the incidence, volume, and extent of postoperative epidural hematoma resulting in thecal sac compression, and to identify risk factors correlated with measured hematoma volumes.
Risk factors for postoperative hematoma development have been retrospectively determined in small populations of symptomatic patients. A prospective study of hematoma characteristics and associated risk factors in a consecutive series of patients could significantly enhance our understanding of postoperative hematoma.
Preoperative magnetic resonance imaging and clinical data on 13 pre- and intraoperative risk factors were prospectively collected on 50 consecutive patients undergoing lumbar decompression surgery with or without fusion. Postoperative magnetic resonance imagings were performed within 2 to 5 days of surgery. Thecal sac cross-sectional area was calculated at each disc space. Relative thecal sac compression due to hematoma was calculated at all levels where postoperative cross-sectional area was smaller than preoperative. Hematoma volumes were calculated. Multivariate analysis identified risk factors associated with postoperative hematoma volume.
After decompression, 58% of patients developed epidural hematoma of sufficient magnitude to compress the thecal sac beyond its preoperative state at one or more levels. None developed new postoperative neurologic deficits. A mean of 1.4 levels were decompressed. Hematoma extended over a mean of 1.9 levels. Maximal thecal sac compression due to hematoma occurred at an adjacent, nondecompressed level in 28% of patients. Multivariate analysis found age greater than 60, multilevel procedures, and preoperative international normalized ratio to be associated with larger hematoma volumes.
Lumbar decompression surgery results in a 58% incidence of asymptomatic compressive postoperative epidural hematoma. Adjacent level compression by hematoma occurs in 28% of patients. Advanced age, multilevel procedures, and international normalized ratio are independently associated with postoperative hematoma volume.