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PubMed1999

The management of acute neurotrauma in rural and remote locations: A set of guidelines for the care of head and spinal injuries.

The Neurosurgical Society of Australasia through its Trauma Committee has a long involvement in the problem of neurotrauma. The management of acute neurotrauma in rural and remote locations is of particular interest and is part of a general policy which includes education, prevention, organization of an integrated neurotrauma system and support for the Early Management of Severe Trauma (EMST) programme instituted by the Royal Australasian College of Surgeons. The management of acute neurotrauma requires a consultative approach especially in the multiple injured patient and where transfer or retrieval is necessary. As acute neurotrauma may present to general practitioners, rural surgeons or emergency departments in country hospitals, a set of guidelines has been developed to assist in the early management of acute neurotrauma. These guidelines have been previously published by the Neurosurgical Society of Australasia and the Royal Australasian College of Surgeons. They have been extensively used since 1992 by rural health and distance education groups, Royal Flying Doctor Service Emergency Management of Severe Trauma Course of the Royal Australasian College of Surgeons and by overseas education programs for neurotrauma care. This revision updates the guidelines and makes them accessible through the Journal. Reprints are available for practitioners in rural and remote settings, trauma course participants and others. Copyright 1999 Harcourt Publishers Ltd.

Journal Article↗
PubMedDate not supplied

Paramedic evaluation of clinical indicators of cervical spinal injury.

PURPOSE: Standard prehospital practice includes frequent immobilization of blunt trauma patients, oftentimes based solely on mechanism. Unnecessary cervical spine (c-spine) immobilization does have disadvantages, including morbidity such as low back pain and splinting, increased scene time and costs, and patient-paramedic conflict. Some emergency physicians (EPs) use clinical criteria to clear trauma patients of c-spine injury. If paramedics were able to apply clinical criteria in the out-of-hospital setting, then unnecessary c-spine immobilization could be safely avoided. The authors designed a prospective, randomized, simulated trial to determine the level of agreement between paramedic and EP assessments of clinical indicators of c-spine injury, hypothesizing that there would be substantial agreement between them. METHODS: A convenience sample of ten paramedics and ten attending EPs participated. Ten standardized patients, with various combinations of positive and negative findings, were examined simultaneously by EP-paramedic pairs. Each pair evaluated five randomly assigned patients for six clinical criteria: 1) alteration in consciousness, 2) evidence of intoxication, 3) complaint of neck pain, 4) cervical tenderness, 5) neurologic deficit or complaint, and 6) distracting injury. If any criterion was positive, clinical clearance was considered to have failed, and the simulated patient would have been immobilized. Fifty pairs of examinations were performed. The kappa statistic was utilized to determine level of agreement between the two groups for each criterion and for the immobilization decision. A kappa of 0.40 to 0.75 denotes good agreement and > 0.75 denotes excellent agreement. RESULTS: The kappas for the six criteria were: 1) 0.77; 2) 0.68; 3) 0.62; 4) 0.73; 5) 0.68; and 6) 0.62. The kappa statistic for the immobilization decision was 0.90. In only one case did the immobilization decisions differ; the paramedic indicated immobilization, whereas the physician did not. CONCLUSION: In this model, there was excellent agreement between paramedics and physicians when evaluating simulated patients for possible c-spine injury. No patient requiring immobilization would have been clinically cleared by paramedics. These data support the progression to a prospective field trial evaluating the use of these criteria by paramedics.

Cervical Vertebrae↗
PubMed1986

Experimental spinal injuries with vertical impact.

Fifteen fresh, intact, human male cadavers suspended head down were dropped vertically from a height of 0.9-1.5 meters. In eight specimens the heads were restrained to simulate muscle forces. The head-neck complex was oriented for maximal axial loading of the cervical and upper thoracic spine. In several cadavers, load cells were placed in cervical bodies. Head impact forces of 3,000-7,000 N in the unrestrained, and 9,800-14,600 N in the restrained, cadavers were recorded. There were more cervical and upper thoracic fractures in the restrained cadavers than in the nonrestrained subjects. The biomechanic and pathologic findings, including results of cryomicrotomography and computed tomography (CT), are discussed.

Aged↗
PubMed1990

Permanent external striated sphincter stents in patients with spinal injuries.

Nine patients with complete quadriplegia underwent external striated sphincter stenting with the Wallstent in place of an external striated sphincterotomy. Although suprapubic catheters were placed to provide an outlet should problems develop with the stent, they were successfully removed within 6 weeks in all but 1 patient. Complete bladder emptying with reduced voiding pressures was achieved, together with a significant reduction in the duration of hyper-reflexic contractions. Epithelialisation of the stent was almost complete within 3 months and intermittent catheterisation or endoscopy (and resection) is possible through the stent. Although this is a preliminary report of this new technique, it is hoped that sphincter stenting will provide a rapid, safe and effective method of treating high pressure hyper-reflexia and detrusor sphincter dyssynergia in quadriplegic patients.

Adult↗
PubMed1988

[Treatment of unstable thoracolumbar spinal injuries--determination of its present status and a preliminary report on transpedicular stabilization].

Follow-up checks were made on 19 patients with instabile injuries of the thoracolumbar spine. Poor late results were recorded from eleven of them who had undergone conservative or inadequate surgical treatment. Axial malposition of severe clinical disorders were among the findings. Transpedicular osteosynthesis of instable fractures of thoracic or lumbar regions of the spine has been practised by the authors since 1986, with plate fixation of only two vertebral segments. Pathoneurological disorders are handled by laminectomy or hemilaminectomy followed by H-shaped interspine bone grafting. Posterior rim fragments, burst off the spine, are either reduced or removed. Intraoperative perimyelography is possible. Therapeutic exercises are initiated immediately after the operation. After wound healing, the patient is allowed to get out of bed, supported by a plaster corset. Eleven patients have so far undergone the above surgical treatment. Four of them have resumed their original jobs, whereas three patients with paraplegia have been transferred to a rehabilitation centre.

Bone Plates↗
PubMed1988

[Acute management of spinal injuries. The thoracic and lumbar spine, conservative and functional therapy].

Fractures of the thoracic spine are commonly treated functionally. In the thoracolumbar and lumbar region compression fractures with angulation can be treated by closed reduction and casting according to the Boehler method. Yet, stable fractures with minor deformities may be treated with advantage by early weight bearing. Primarily unstable thoracic and lumbar vertebra fractures gradually become stable with increasing fracture healing and may also be treated functionally but with prolonged bed rest of 6-12 weeks. Thus open reduction and internal fixation achieve better anatomical alignment and also allow early mobilisation and ambulation. They are therefore recently favoured.

Fracture Fixation, Internal↗
PubMed1987

Spinal injury at the level of the third and fourth cervical vertebrae resulting from the axial loading mechanism: an analysis and classification.

The traumatic C3-C4 level injuries sustained by young athletes and documented by the National Football Head and Neck Injury Registry are discussed. Twenty-eight of 885 (2.8 per cent) injuries involved the C3-C4 vertebrae. Review of these cases reveals that the response to energy inputs at the C3-C4 level differ from that of those involving the upper (C1-C2) and lower (C5-C6) cervical segments. Specifically, these lesions appear unique with regard to infrequency of bony fracture, difficulty in effecting and maintaining reduction, and their more favorable response to early aggressive treatment. It is the authors' belief that these lesions resulting from athletic activity are due to axial loading.

Adolescent↗
PubMed1977

Spinal injury at the level of the third and fourth cervical vertebrae from football.

Acute traumatic lesions of the spine at the third and fourth cervical levels without associated fracture are not common. The eight lesions in this report occurred as a result of injuries sustained during tackle football. They included acute intervertebral disc herniation, anterior subluxation of the third cervical vertebra on the fourth, unilateral dislocation of the joint between the articular processes, and bilateral dislocation of the joints between the articular processes. The mechanism of injury was the use of the top or crown of the helmet as the primary point of contact in a high-impact collision when blocking, tackling, or head-butting. To avoid a seemingly inevitable increase in the incidence of these lesions occurring from tackle football, coaches and officials will have to modify the current techniques of blocking tackling, and head-butting.

Adolescent↗