Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department

Objectives

The Canadian C-Spine Rule for imaging of the cervical spine was developed for use by physicians. We believe that nurses in the emergency department could use this rule to clinically clear the cervical spine. We prospectively evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses.

Methods

We conducted this three-year prospective cohort study in six Canadian emergency departments. The study involved adult trauma patients who were alert and whose condition was stable. We provided two hours of training to 191 triage nurses. The nurses then assessed patients using the Canadian C-Spine Rule, including determination of neck tenderness and range of motion, reapplied immobilization and completed a data form.

Results

Of the 3633 study patients, 42 (1.2%) had clinically important injuries of the cervical spine. The kappa value for interobserver assessments of 498 patients with the Canadian C-Spine Rule was 0.78. We calculated sensitivity of 100.0% (95% confidence interval [CI] 91.0%–100.0%) and specificity of 43.4% (95% CI 42.0%–45.0%) for the Canadian C-Spine Rule as interpreted by the investigators. The nurses classified patients with a sensitivity of 90.2% (95% CI 76.0%–95.0%) and a specificity of 43.9% (95% CI 42.0%–46.0%). Early in the study, nurses failed to identify four cases of injury, despite the presence of clear high-risk factors. None of these patients suffered sequelae, and after retraining there were no further missed cases. We estimated that for 40.7% of patients, the cervical spine could be cleared clinically by nurses. Nurses reported discomfort in applying the Canadian C-Spine Rule in only 4.8% of cases.

Conclusion

Use of the Canadian C-Spine Rule by nurses was accurate, reliable and clinically acceptable. Widespread implementation by nurses throughout Canada and elsewhere would diminish patient discomfort and improve patient flow in overcrowded emergency departments.Each year, Canadian emergency departments treat 1.3 million patients who have suffered blunt trauma from falls or motor vehicle collisions and who are at risk for injury of the cervical spine.¹ Most of these cases involve adults who are alert and in stable condition, and less than 1% involve fracture of the cervical spine.² Most trauma patients who have been transported in ambulances are protected by a backboard, collar and neck supports. Nurses are responsible for initial triage in the emergency department and usually send such patients to high-acuity resuscitation rooms, where they may remain fully immobilized for hours until assessment by a physician and radiography are complete. This prolonged immobilization is often unnecessary and adds considerably to patient discomfort. The delay also adds to the burden of overcrowded Canadian emergency departments in an era when they are under unprecedented pressures.^3–5 These patients occupy valuable space in resuscitation rooms, and repeated efforts to obtain satisfactory radiographs or computed tomography scans of the cervical spine use valuable time on the part of physicians, nurses and technicians.A clinical decision rule is defined as a decision-making tool incorporating three or more variables from the patient’s history, a physical examination or simple tests. Such rules are derived from original research and help clinicians with diagnostic or therapeutic decisions at the bedside. We previously developed a clinical decision rule for evaluation of the cervical spine.^6,7 The Canadian C-Spine Rule comprises simple clinical variables (Figure 1) and was designed to allow clinicians to “clear” immobilization of the cervical spine (i.e., remove neck collar and other devices) without radiography and to decrease immobilization times.⁸ We also validated the accuracy of the rule when used by physicians.⁹ We recently completed an implementation trial at 12 Canadian hospitals to evaluate the impact on patient care and outcomes of the Canadian C-Spine Rule when used by physicians.¹⁰Open in a separate windowFigure 1The Canadian C-Spine Rule to rule out cervical spine injury, adapted for use by nurses. The rule is intended for patients who have experienced trauma, who are alert (score on Glasgow Coma Scale = 15) and whose condition is stable. *The following mechanisms of injury were defined as dangerous: fall from elevation of more than 3 ft (91 cm) or five stairs, axial load to the head (e.g., diving injury), motor vehicle collision at high speed (> 100 km/h), motor vehicle collision involving a rollover or ejection, injury involving a motorized recreational vehicle, bicycle-related injury (rider struck or collision). †Simple rear-end motor vehicle collisions exclude incidents in which the patient was pushed into oncoming traffic or was hit by a bus, large truck or vehicle travelling at high speed, as well as rollovers; all such incidents would be considered high risk. ‡Neck pain with delayed onset is any pain that did not occur immediately following the precipitating incident. Adapted, with permission, from Stiell IG, Wells GA, Vandemheen K, et al. The Canadian Cervical Spine Radiography Rule for alert and stable trauma patients. JAMA 2001;286:1841–8.⁸ Copyright © 2001 American Medical Association. All rights reserved.Nurses in the emergency department usually do not evaluate the cervical spine of trauma patients, and they routinely send all immobilized patients to the emergency department’s resuscitation room. We believe that nurses could safely evaluate alert patients who have arrived by ambulance and whose condition is stable and could “clear” immobilization of the cervical spine of low-risk patients upon arrival at the triage station.¹¹ Patients could then be much more rapidly, comfortably and efficiently managed in other areas of the emergency department. An expanded decision-making role for nurses has the potential to improve the efficiency of trauma care in all Canadian hospitals. Very little research has been done to determine the ability of nurses to clear immobilization of the cervical spine.^12–15 Our objective in this study was to prospectively evaluate the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses to assess patients’ need for immobilization.     

Epidemiology and Risk Factors of Cervical Spine Injury during Heating Season in the Patients with Cervical Trauma: A Cross-Sectional Study

Purpose

The purpose of this study was to describe the epidemiology of cervical spine injury in the patients with cervical trauma and analyze its associated risk factors during the special heating season in North China.

Methods

This cross-sectional study investigated predictors for cervical spine injury in cervical trauma patients using retrospectively collected data of Hebei Provincial Orthopaedic Hospital from 11/2011 to 02/2012, and 11/2012 to 02/2013. Binary logistic regression analysis was used to determine risk factors for cervical fractures/dislocations or cord injury.

Results

A total of 106 patients were admitted into this study. Of all, 34 patients (32.1%) were treated from 11/2011 to 02/2012 and 72 patients (67.9%) from 11/2012 to 02/2013. The mean age was 41.9±13.3 years old; 85 patients (80.2%) were male and 82 (77.4%) from rural areas. Eighty patients (75.5%) were caused by fall including 45 (42.5%) by severe fall (>2 m). Sixty-five patients (61.3%) of all suffered injuries to other body regions and 32 (30.2%) got head injury. Thirty-one patients (29.2%) sustained cervical cord injury with cervical fractures/dislocations. Twenty-six (83.9%) of cervical cord injury patients were from rural areas and 24 (77.4%) of those resulted from fall including 15 (48.4%) from severe fall (>2 m). Logistic regression displayed that age (OR, 1.47; 95% CI, 1.05–2.07), head injury (OR, 5.63; 95% CI, 2.23–14.26), were risk factors for cervical cord injury and snowing (OR, 8.25; 95% CI, 2.26–30.15) was a risk factor for cervical spine injury due to severe fall (>2 m).

Conclusions

The elder male patients and patients with head trauma are high-risk population for cervical cord injury. As a seasonal factor, snowing during heating season is of note a risk factor for cervical spine injury resulting from severe fall (>2 m) in the patients with cervical trauma in North China.     

Haemodynamic changes in patients with whiplash injury measured by transcranial Doppler sonography (TCD)

The daily increasing number of cervical whiplash injuries presents ever-greater requirement for vertebrobasilar diagnostics. A cervical spine injury, which is quite frequent injury, may occur during a fall, or industrial, traffic, sport or war injury. Transcranial Doppler (TCD) sonography with Transcan 3-D EME device and 2 MHz probe was used for the assessment of vertebrobasilar circulation in patients with a whiplash injury of the cervical spine, that occurred mostly in car accident. This study includes 47 patients with clinically verified cervical spine trauma with x-ray evidence of no bone lesion. The patients were examined by TCD within a month, and then six months following the accident. The obtained values were compared to normal blood flow velocities and correlated with the severity of clinical picture. During the first month after the injury, statistically significant disturbances in the vertebrobasilar circulation were recorded, such as the increase in mean blood flow velocities in AVL (68%), AVR (62%) and BA (51%) (mostly as spasam). Six months later, normal findings were obtained in about 50% of the vessels, whereas in rest of the patients vasospasam persisted in one, two or all examined blood vessels. TCD of the vertebrobasilar circulation was found to be a very useful method in the diagnostics and follow-up of patients with a whiplash injury.     

Patterns of Cervical Spine Injury and Their Associated Lesions

Motorcycle riding and diving into shallow water continue to present a high risk of cervical spine injury, often complicated by spinal cord damage. In patients with high cervical cord trauma, differentiation of arterial hypotension due to losing vasomotor control from the effects of internal hemorrhage can cause difficulty. In a series of 123 consecutive cases of cervical spine injury, no evidence was found that either early surgical treatment or steroid administration exert a favorable influence on recovery from traumatic myelopathy. When compared with other series, differences were found in the nature, frequency and severity of both spinal and associated injuries, resulting from the relative frequency among the population studied of trauma due to a particular mechanism—traffic accident, diving, industrial injury—and the special functions and location of the hospital from which information is gathered.     

Discontinuation of cervical spine immobilisation in unconscious patients with trauma in intensive care units--telephone survey of practice in south and west region.

OBJECTIVE: To study how the cervical spine is assessed before discontinuation of cervical spine immobilisation in unconscious trauma patients in intensive care units. DESIGN: Telephone interview of consultants responsible for adult intensive care units. SETTING: All 25 intensive care units in the South and West region that admit victims of major trauma. MAIN OUTCOME MEASURES: The clinical and radiological basis on which the decision is made to stop cervical spine immobilisation in unconscious patients with trauma. RESULTS: In 19 units cervical spine immobilisation was stopped in unconscious patients on the basis of radiology alone, and six units combined radiology with clinical examination after the patient had regained consciousness. Sixteen units relied on a normal lateral radiological view of the cervical spine alone, five required a normal lateral and anteroposterior view, and four required a normal lateral, anteroposterior, and open mouth peg view. CONCLUSIONS: There are inconsistencies in the clinical and radiological approach to assessing the cervical spine in unconscious patients with trauma before the removal of immobilisation precautions. There is an overreliance on the lateral cervical spine view alone, which has been shown to be insensitive in this setting.     

Severe neurologic manifestations from cervical spine instability in spondylo-megaepiphyseal-metaphyseal dysplasia

Spondylo-megaepiphyseal-metaphyseal dysplasia (SMMD; OMIM 613330) is a dysostosis/dysplasia caused by recessive mutations in the homeobox-containing gene, NKX3-2 (formerly known as BAPX1). Because of the rarity of the condition, its diagnostic features and natural course are not well known. We describe clinical and radiographic findings in six patients (five of which with homozygous mutations in the NKX3-2 gene) and highlight the unusual and severe changes in the cervical spine and the neurologic complications. In individuals with SMMD, the trunk and the neck are short, while the limbs, fingers and toes are disproportionately long. Radiographs show a severe ossification delay of the vertebral bodies with sagittal and coronal clefts, missing ossification of the pubic bones, large round "balloon-like" epiphyses of the long bones, and presence of multiple pseudoepiphyses at all metacarpals and phalanges. Reduced or absent ossification of the cervical vertebrae leads to cervical instability with anterior or posterior kinking of the cervical spine (swan neck-like deformity, kyknodysostosis). As a result of the cervical spine instability or deformation, five of six patients in our series suffered cervical cord injury that manifested clinically as limb spasticity. Although the number of individuals observed is small, the high incidence of cervical spine deformation in SMMD is unique among skeletal dysplasias. Early diagnosis of SMMD by recognition of the radiographic pattern might prevent of the neurologic complications via prophylactic cervical spine stabilization.     

Cancer screening practices among primary care physicians serving Chinese Americans in San Francisco

Previous research has reported a lack of regular cancer screening among Chinese Americans. The overall objectives of this study were to use a mail survey of primary care physicians who served Chinese Americans in San Francisco to investigate: a) the attitudes, beliefs, and practices regarding breast, cervical, and colon cancer screening and b) factors influencing the use of these cancer screening tests. The sampling frame for our mail survey consisted of: a) primary care physicians affiliated with the Chinese Community Health Plan and b) primary care physicians with a Chinese surname listed in the Yellow Pages of the 1995 San Francisco Telephone Directory. A 5-minute, self-administered questionnaire was developed and mailed to 80 physicians, and 51 primary care physicians completed the survey. A majority reported performing regular clinical breast examinations (84%) and teaching their patients to do self-breast examinations (84%). However, the rate of performing Pap smears was only 61% and the rate of ordering annual mammograms for patients aged 50 and older was 63%. The rates of ordering annual fecal occult blood testing and sigmoidoscopy at regular intervals of three to five years among patients aged 50 and older were 69% and 20%, respectively. Barriers (patient-specific, provider-specific, and practice logistics) to using cancer screening tests were identified. The data presented in this study provide a basis for developing interventions to increase performance of regular cancer screening among primary care physicians serving Chinese Americans. Cancer screening rates may be improved by targeting the barriers to screening identified among these physicians. Strategies to help physicians overcome these barriers are discussed.     

Application of Cervical Collars – An Analysis of Practical Skills of Professional Emergency Medical Care Providers

Background/Objective

The application of a cervical collar is a standard procedure in trauma patients in emergency medicine. It is often observed that cervical collars are applied incorrectly, resulting in reduced immobilization of the cervical spine. The objective of this study was to analyze the practical skills of trained professional rescue personnel concerning the application of cervical collars.

Material and Methods

Within emergency medical conferences, n = 104 voluntary test subjects were asked to apply a cervical collar to a training doll, wherein each step that was performed received an evaluation. Furthermore, personal and occupational data of all study participants were collected using a questionnaire.

Results

The test subjects included professional rescue personnel (80.8%) and emergency physicians (12.5%). The average occupational experience of all study participants in pre-clinical emergency care was 11.1±8.9 years. Most study participants had already attended a certified training on trauma care (61%) and felt "very confident" in handling a cervical collar (84%). 11% applied the cervical collar to the training doll without errors. The most common error consisted of incorrect adjustment of the size of the cervical collar (66%). No association was found between the correct application of the cervical collar and the occupational group of the test subjects (trained rescue personnel vs. emergency physicians) or the participation in certified trauma courses.

Conclusion

Despite pronounced subjective confidence regarding the application of cervical collars, this study allows the conclusion that there are general deficits in practical skills when cervical collars are applied. A critical assessment of the current training contents on the subject of trauma care must, therefore, be demanded.     

Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review

Background:

There is uncertainty about the optimal approach to screen for clinically important cervical spine (C-spine) injury following blunt trauma. We conducted a systematic review to investigate the diagnostic accuracy of the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) criteria, 2 rules that are available to assist emergency physicians to assess the need for cervical spine imaging.

Methods:

We identified studies by an electronic search of CINAHL, Embase and MEDLINE. We included articles that reported on a cohort of patients who experienced blunt trauma and for whom clinically important cervical spine injury detectable by diagnostic imaging was the differential diagnosis; evaluated the diagnostic accuracy of the Canadian C-spine rule or NEXUS or both; and used an adequate reference standard. We assessed the methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies criteria. We used the extracted data to calculate sensitivity, specificity, likelihood ratios and post-test probabilities.

Results:

We included 15 studies of modest methodologic quality. For the Canadian C-spine rule, sensitivity ranged from 0.90 to 1.00 and specificity ranged from 0.01 to 0.77. For NEXUS, sensitivity ranged from 0.83 to 1.00 and specificity ranged from 0.02 to 0.46. One study directly compared the accuracy of these 2 rules using the same cohort and found that the Canadian C-spine rule had better accuracy. For both rules, a negative test was more informative for reducing the probability of a clinically important cervical spine injury.

Interpretation:

Based on studies with modest methodologic quality and only one direct comparison, we found that the Canadian C-spine rule appears to have better diagnostic accuracy than the NEXUS criteria. Future studies need to follow rigorous methodologic procedures to ensure that the findings are as free of bias as possible.A clinically important cervical spine injury is defined as any fracture, dislocation or ligamentous instability detectable by diagnostic imaging and requiring surgical or specialist follow-up.^1,2 These injuries can have disastrous consequences including spinal cord injury and death if the diagnosis is delayed or missed.³ Despite the low prevalence (< 3%) of clinically important cervical spinal injury following blunt trauma (e.g., motor vehicle collision), accurate diagnosis is imperative for safe, effective management.⁴ Currently, uncertainty exists about the optimal diagnostic approach. Some guidelines^5,6 advocate using screening tools to identify patients with a higher likelihood of clinically important cervical spinal injury; these patients are then sent for imaging to establish the diagnosis. In other more conservative settings, all patients with blunt trauma are sent for imaging. The first approach, involving screening, is arguably preferable because it optimizes resources and time, while reducing unnecessary costs, radiation exposure and psychological stress for the patient.⁷ For screening to be safe and effective, the screening tools must have high sensitivity, a low negative likelihood ratio and a low rate of false positives. This assures clinicians that a clinically important cervical spine injury is unlikely and reduces the number of referrals for imaging.Clinical decision rules synthesize 3 or more findings from the patient’s history, physical examination or simple diagnostic tests to guide diagnostic and treatment decisions.^8,9 Two clinical decision rules, the Canadian C-spine rule² and the National Emergency X-Radiography Utilization Study (NEXUS; Box 1),¹⁰ are available to assess the need for imaging in patients with cervical spine injury following blunt trauma. These rules aim to reduce unnecessary imaging by reserving these investigations for patients with a higher likelihood of clinically important cervical spinal injury. Developed independently and validated using large cohorts of patients, these 2 decision rules are recommended in many international guidelines.^5,11,12 However, no consensus exists as to which rule should be endorsed.^12–14 Therefore, the purpose of our systematic review was to describe the quality of research evaluating the Canadian C-spine rule and NEXUS; describe the diagnostic accuracy of the Canadian C-spine rule and NEXUS; and compare the diagnostic accuracy of the Canadian C-spine rule to that of NEXUS.

Box 1:

National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria¹⁰

Cervical spine radiography is indicated for patients with neck trauma unless they meet ALL of the following criteria:

• No posterior midline cervical-spine tenderness
• No evidence of intoxication
• A normal level of alertness (score of 15 on the Glasgow Coma Scale)
• No focal neurologic deficit
• No painful distracting injuries

     

Factors influencing recovery from headache after common whiplash.

OBJECTIVE--To assess the relation between pretraumatic and trauma related headache in patients suffering from whiplash. DESIGN--Follow up study of patients examined a mean (SD) of 7.4 (4.2) days after trauma and again at three and six months. SETTING--Patients referred from primary care. SUBJECTS--117 patients (mean age 30.8 (9.5) years. MAIN OUTCOME MEASURES--Prevalence of trauma related headache and the predictive relation by multiple logistic regression between different somatic and psychological variables and trauma related headache at each examination. RESULTS--Prevalence of trauma related headache decreased from 57% to 27%. History of pretraumatic headache proved a significant risk factor for presenting with trauma related headache. A significant relation between trauma related headache and the following variables was found: at seven days the initial wellbeing score, early onset of neck pain, depression scale from the personality inventory, and the initial intensity of neck pain; at three months, intensity of neck pain, and history of pretraumatic headache; and at six months neck pain, pain intensity, and history of pretraumatic headache. CONCLUSIONS--History of pretraumatic headache significantly increases the likelihood of presenting with trauma related headache but only in combination with findings indicative of clinically important injury to the cervical spine.     

X-ray signs of ligamentous cervical injuries from joint manual therapy

X-ray study was conducted in 40 patients undergoing joint manual therapy (MT) to study its impact on the ligamentous apparatus of the cervical spine. The patients who had received rotational manual therapeutic techniques were found to have statodynamic dysfunction (100%), x-ray signs of ligamentous cervical injury (62%), or intervertebral disk protrusions (67%). An algorithm for cervical spine x-ray study in the frontal and lateral projections was compiled to perform after MT in the early and late periods.     

Ossification of the posterior longitudinal ligament]

The authors described 21 patients aged 37 to 83 with ossification of the posterior longitudinal ligament (10 with ischemic myelopathy, 6 with aftermaths of a trauma of the cervical spine, and 5 with the radicular syndrome on the basis of vertebral osteochondrosis. X-ray signs of three types of ossification of the posterior longitudinal ligament were defined and specified: linear, curved and mixed. The linear type was more frequently observed in the cervical spine whereas the curved type was more frequent in the lumbar spine.     

Discrete morphological variants of human cervical vertebrae: Exploring pattern of distribution and biological significance

Studies on discrete traits of the human cervical vertebrae, appearing at certain intervals during the last century, posed some questions regarding evolutionary processes that human cervical spine underwent during phylogenesis. To address questions of significance of these morphological traits we need first a good knowledge of the extent of their variation in modern humans. The aim of the current work was to integrate available data on the occurrence of various non-metric traits in the human cervical spine and search for the pattern of their distribution on intra- and inter-population levels. The study was based on data from five osteological samples from North America (Terry and Grant collections) and Russia (mid 20th c. and 18th c.); and data taken from literature. Traits were categorized into rare (<3%), low frequency (up to 10%), often encountered (10–30%) and characteristic for modern humans (>50% on average). Several traits showed mild to strong association with each other indicating interrelation between various spine characteristics. Of the traits analyzed, the following had consistent pattern of sex-related variability: complete dorsal ponticle, bifid spinous processes and cervical ribs; and ancestry-related variability: dorsal ponticle and bifid spinous processes. Each ancestry group (European, African, Asian and North American) had its specifics regarding the latter two traits which might be related to genetic isolation. Most of the traits, however, showed relatively similar pattern of distribution among various populations, including the pattern of within-spine variability. This suggests a common intraspecific pattern and a possible link to some fundamental characteristics of the human vertebral column.     

Posters for accident departments: simple method of sustaining reduction in x ray examinations.

OBJECTIVE--To assess whether a simple strategy would sustain a reduction in the number of unnecessary x ray examinations. DESIGN--Use of posters to display guidelines encouraging the more effective use of radiology in patients with head injuries, twisted ankles, neck injuries, and abdominal pain. SETTING--Accident department of a large metropolitan district general hospital. PATIENTS--15,875 patients attending the accident department over two years. MAIN OUTCOME MEASURE--Proportion of patients having radiography. RESULTS--Referrals for skull radiography fell from 56% to 20% and those for abdominal radiography fell from 31% to 7%. Referral patterns for adults attending with twisted ankles and cervical spine injuries did not change. Reductions were sustained over two years. CONCLUSION--Carefully designed posters provide a simple method of reducing unnecessary x ray examinations.     

Reducing Inappropriate Serum T3 Laboratory Test Ordering in Patients with Treated Hypothyroidism

Objective: Choosing Wisely is a campaign of the American Board of Internal Medicine that aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. As part of this campaign, the Endocrine Society advises against ordering a serum total or free triiodothyronine (T3) level when assessing levothyroxine dosing in hypothyroid patients. This study was performed to assess and reduce inappropriate laboratory ordering practices among providers who manage patients with hypothyroidism within a large U.S. academic health system.Methods: A best practice alert (BPA) in the health record was developed and implemented following the collection of baseline data. This alert consisted of a popup window that was triggered when a serum T3 laboratory test was ordered for patients prescribed levothyroxine. The alert required user acknowledgement before the serum T3 laboratory test could be ordered.Results: During the 6-week period prior to launching the BPA, serum T3 tests were ordered a mean of 162.3 ± 15.4 (standard deviation) occurrences per 10,000 patients per week. Over a 15-week period following implementation of the BPA, the frequency of serum T3 orders steadily decreased and resulted in >44% fewer inappropriate tests being ordered.Conclusion: Although national societal guidelines recommend against ordering serum T3 concentrations while monitoring patients with hypothyroidism managed with levothyroxine, these laboratory tests are frequently ordered. Development of a triggered alert in the health record may reduce inappropriate monitoring practices, decrease costs, and improve utilization of limited health-care resources for this common clinical condition.Abbreviations: ATA = American Thyroid Association; BPA = best practice alert; T3 = triiodothyronine; TSH = thyroid-stimulating hormone     

Contemporary management of renal trauma

In the management of renal trauma, surgical exploration inevitably leads to nephrectomy in all but a few specialized centers. With current management options, the majority of hemodynamically stable patients with renal injuries can be successfully managed nonoperatively. Improved radiographic techniques and the development of a validated renal injury scoring system have led to improved staging of injury severity that is relatively easy to monitor. This article reviews a multidisciplinary approach to facilitate the care of patients with renal injury.     

A new method for measuring torsional deformity in scoliosis

Background

This study evaluates the outcome and complications of decompressive cervical Laminectomy and lateral mass screw fixation in 110 cases treated for variable cervical spine pathologies that included; degenerative disease, trauma, neoplasms, metabolic-inflammatory disorders and congenital anomalies.

Methods

A retrospective review of total 785 lateral mass screws were placed in patients ages 16-68 years (40 females and 70 males). All cases were performed with a polyaxial screw-rod construct and screws were placed by using Anderson-Sekhon trajectory. Most patients had 12-14-mm length and 3.5 mm diameter screws placed for subaxial and 28-30 for C1 lateral mass. Screw location was assessed by post operative plain x-ray and computed tomography can (CT), besides that; the facet joint, nerve root foramen and foramen transversarium violation were also appraised.

Results

No patients experienced neural or vascular injury as a result of screw position. Only one patient needed screw repositioning. Six patients experienced superficial wound infection. Fifteen patients had pain around the shoulder of C5 distribution that subsided over the time. No patients developed screw pullouts or symptomatic adjacent segment disease within the period of follow up.

Conclusion

decompressive cervical spine laminectomy and Lateral mass screw stabilization is a technique that can be used for a variety of cervical spine pathologies with safety and efficiency.     

Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study.

OBJECTIVE--To measure the effectiveness of management of major trauma in the United Kingdom. DESIGN--Review of the care of all seriously injured patients seen over two years. SETTING--33 hospitals which receive patients who have sustained major trauma. SUBJECTS--14,648 injured patients admitted for more than three days, transferred or admitted into an intensive care bed, or dying from their injuries. MAIN OUTCOME MEASURE--Death or survival in hospital within three months of the injury. RESULTS--21% of seriously injured patients (1299) took longer than one hour to reach hospital. Time before arrival at hospital was not related to severity of injury. A senior house officer was in charge of initial hospital resuscitation in 57% (826/1445) of patients with an injury severity score > or = 16. More senior staff were commonly responsible for definitive operations, but only 46% (165/355) of patients judged to require early operation arrived in theatre within two hours. Mortality for 6111 patients sustaining blunt trauma and treated in the 14 busiest hospitals was significantly higher (actual 408, predicted 295.6, p < 0.001) than in a comparable North American dataset. Large differences in the 14 hospitals assessed could not be explained by variations in case load or facilities. In contrast, the outcome of the 4.1% (597) of patients with penetrating injuries was better than that of a comparable group in the United States. Analysis of the 415 penetrating injuries with complete data showed that 15 patients died (19.3 predicted; p = 0.04). CONCLUSIONS--The initial management of major trauma in the United Kingdom remains unsatisfactory. There are delays in providing experienced staff and timely operations. Mortality varies inexplicably between hospitals and, for blunt trauma, is generally higher than in the United States.     

DR全脊柱摄影技术在脊柱侧弯中的应用与优势

目的:探讨数字化X线摄影(DR)全脊柱摄像技术在脊柱侧弯中的应用和优势。方法:收集2012年2月至2013年6月于本院进行治疗的脊柱侧弯病例88例,应用数字化X线摄影(DR)技术对脊柱由上至下进行正位和侧位的扫描,均进行3次曝光,每两次曝光间隔均为9秒,曝光后通过图像拼接技术将患者脊柱图像进行拼接和重叠,形成全景图像,对全部患者的图像质量进行观察和评估。结果:所有入选病例中有84例患者图像清晰显示了脊柱侧弯的方向和角度、椎体和椎间隙、对称的椎弓根、根间距及对脏器的影响程度。其中1例因运动不合作出现伪影,3例曝光不足。全脊柱图像质量正位优秀率为92.43%,侧位优秀率为85.92%;全脊柱图像拼接正位优秀率为83.44%,侧位优秀率为86.58%。结论:数字化X线摄影(DR)技术应用上方便快捷,患者配合时间较短,图像质量较好,能够满足临床医生进行诊断和治疗,有助于患者预后康复情况的评估,值得在临床诊断中推广应用。     

Effectiveness of a regional trauma system in reducing mortality from major trauma: before and after study.

OBJECTIVE: To assess the effect of the development of an experimental trauma centre and regional trauma system on the survival of patients with major trauma. DESIGN: Controlled before and after study examining outcomes between 1990 and 1993, spanning the introduction of the system in 1991-2. SETTING: Trauma centre in North Staffordshire Royal Infirmary and five associated district general hospitals in the North West Midlands regional trauma system, and two control regions in Lancashire and Humberside. SUBJECTS: All trauma patients taken by the ambulance services serving the regions or arriving other than by ambulance with injury severity scores > 15, whether or not they had vital signs on arrival at hospital. MAIN OUTCOME MEASURES: Survival rates standardised for age, severity of injury, and revised trauma score. RESULTS: In 1990, 33% of major trauma patients in the experimental region were taken to the trauma centre, and by 1993 this had risen to only 39%. Crude death rates changed by the same amount in the control regions (46.5% in 1990-1 to 44.4% in 1992-3) as in the experimental region (44.8% to 41.3%). After standardisation, the estimated change in the probability of dying in the experimental region compared with the control regions was -0.8% per year (95% confidence interval -3.6% to 2.2%); for out of hours care, the change was 1.6% per year (-2.3% to 5.6%), and, for multiply injured patients, the change was -1.6% (-6.1% to 2.6%). CONCLUSION: Any reductions in mortality from regionalising major trauma care in shire areas of England would probably be modest compared with reports from the United States.