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71. The Value of Adding MRI to CT Protocols for Cervical Spine Clearance in Blunt Trauma: A Meta-Analysis
36S
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
RESULTS: There were 230 patients (57 females, 173 males), 35% were smokers. The mean age at injury was 41.8617.8 years and the mean body mass index was 25.764.2 kg/m2. The most common injury mechanism was a fall (52%) followed by MVA (36%) and sports injury (10%). The mean admission ISS was 9.267.8, mean CCI was 0.260.7, mean GCS was 14.661.6. NASCIS II & III was instituted in 15.5% & 4.2% of patients respectively; mean time from injury to surgery was 8.9659 days; surgical approach was anterior only in 30 (13%), posterior only in 154 (65%), and anteroposterior in 52 (22%) patients. The total incidence of complications was 79% (minor 30%, major 49%). The different complications are summarized in Table 1. The complications listed as ‘‘other’’ are singular incidents of a specific complication. Factors predictive of the occurrence of a major complication were administration of high dose steroids (NASCIS II)(Odds Ratio:2.3; CI: 1.1-4.8, p50.030) ASIA score (OR:0.7; CI:0.6-0.8, p50.000) and CCI (OR:1.9; CI:1.2-3.0, p50.001). CONCLUSIONS: The severity of neurologic injury, number of comorbidities and use of the high dose steroids independently increase the risk of having a major complication following surgical stabilization of thoracolumbar spine fractures. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
able to identify a clinically meaningful injury with 84 patients requiring prolonged use of a collar and 12 patients requiring surgical stabilization. The addition of MRI to a CT protocol for cervical clearance demonstrated 100% sensitivity and 94% specificity. The positive predictive value of MRI was 53%, while the negative predictive value was 100%. The false positive rate was 6%. CONCLUSIONS: The optimal imaging protocol for cervical clearance remains controversial. The risks of occult cervical injury must be weighed against the morbidities of prolonged immobilization. While CT is very sensitive in identifying osseous abnormalities, the results of this investigation demonstrate that this modality is not capable of detecting all clinically significant injuries. Indeed, in 6% of cases the addition of MRI facilitated a change in treatment protocol and, in 1%, injuries requiring surgical intervention would have been missed using CT alone. Despite recent reports advocating for the use of CT imaging alone to facilitate clearance of the cervical spine, this meta-analysis supports a continued role for MRI in evaluating patients who are obtunded, or symptomatic, despite a negative CT scan. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.086
doi: 10.1016/j.spinee.2009.08.085
71. The Value of Adding MRI to CT Protocols for Cervical Spine Clearance in Blunt Trauma: A Meta-Analysis Andrew Schoenfeld, MD1, Natalie Warholic, MA2, Christopher Bono, MD2, Kevin McGuire, MD3, Mitchel Harris, MD2; 1Harvard Combined Orthopaedic Program, Boston, MA, USA; 2Brigham and Women’s Hospital, Boston, MA, USA; 3Beth Israel Deaconess Medical Center, Boston, MA, USA BACKGROUND CONTEXT: Evaluation and clearance of the cervical spine in blunt trauma patients remains a controversial and challenging topic. While CT imaging is very sensitive for identification of osseous abnormalities, it has not been found to demonstrate similar precision in detecting ligamentous injuries. MRI has been found to be sensitive in detecting cervical injury, but many authors have questioned the potential for this imaging modality to augment the ability of CT scan to identify clinically significant injuries. PURPOSE: To quantify the ability of MRI to detect ‘‘clinically significant’’ cervical injuries in the setting of a negative CT scan. STUDY DESIGN/SETTING: Meta-analysis. PATIENT SAMPLE: 1,550 adult trauma patients. OUTCOME MEASURES: Frequency of injury detection by MRI in the setting of negative CT scan. Our outcome measure seeks to define the prevalence of occult injuries (defined as neg. CT) that required intervention after first being discovered by MRI. METHODS: A computerized search was performed for studies published in the English literature from 2000 to 2008. Inclusion criteria were prospective or retrospective investigations of patients undergoing MRI for the purposes of cervical spine clearance following a negative CT scan, reporting of the outcome of positive MRI findings (cervical clearance, surgical intervention, prolonged use of collar etc.), reporting of statistical data to facilitate calculation of true positives, true negatives, false positives and false negatives, minimum of thirty patients involved in the investigation. A true positive in this investigation was an MRI result that led to a change in management. A false positive was defined as a MRI finding that still allowed for removal of cervical spine precautions. Results of appropriate studies were then pooled and original scale meta-analyses were performed to calculate sensitivity, specificity, positive and negative predictive values. RESULTS: 11 investigations met the inclusion criteria, comprising 1,550 trauma patients with negative cervical spine CT scans. Of these, MRI detected 194 abnormalities in 182 (11.7%) patients. The majority of these were ligamentous injury (86) and degenerative changes, but fractures and dislocations were identified in 4 instances (Table). In 96 cases, MRI was
72. Lumbosacral Dissociation Injuries in High Energy Blast Injuries Ronald Lehman, Jr., MD1, Melvin Helgson, MD1, Romney Andersen2, Carlo Bellabarba, MD3, H. Michael Frisch2; 1Washington, DC, USA; 2 Walter Reed Army Medical Center, Washington, DC, USA; 3University of Washington, Seattle, WA, USA BACKGROUND CONTEXT: Lumbosacral dissociation (LSD) injuries are defined by an anatomic separation of the pelvis from the spinal column usually as a result of high-energy trauma. In the last five years, we have seen a large volume of these injuries in young, healthy combat casualties subjected to high-energy blast trauma and helicopter crashes. PURPOSE: We set out to retrospectively evaluate our patients’ who sustained lumbopelvic dissociations in order to quantify/classify their injuries, evaluate the treatment methods and ascertain their clinical outcomes. STUDY DESIGN/SETTING: We reviewed the inpatient/outpatient medical records and radiographs for all patients treated at our institution with combat-related lumbosacral dissociations. Included were all patients with radiographic evidence of a zone III sacral fracture, with associated lumbar fractures indicating loss of the iliolumbar ligamentous complex integrity. PATIENT SAMPLE: In our database review of over 250 spinal columntype injuries, twenty-three (23) patients met our inclusion criteria and had at least 1 yr follow-up after sustaining lumbopelvic dissociations. OUTCOME MEASURES: Outcome measures included clinical and radiographic followup at interval time points. Physical Exam, Visual Analog Scores (VAS), radiographs and computerized tomography (CT) were utilized to evaluate patients. METHODS: We reviewed the inpatient/outpatient medical records and radiographs for all patients treated at our institution with combat-related lumbosacral dissociations. Included were all patients with radiographic evidence of a zone III sacral fracture, with associated lumbar fractures indicating loss of the iliolumbar ligamentous complex integrity. RESULTS: Twenty-three (23) patients met our inclusion criteria and had at least 1 yr follow-up. In 15 patients, the sacral fracture could be classified as a H or U type zone II fracture, while in the remaining 9 patients the sacral fracture was severely comminuted and unable to classify. Six patients sustained open sacral fractures. Patients were treated as follows: no fixation – 9, sacroiliac screw fixation – 8, posterior spinal fusion – 5, sacral plate – 1. One patient treated non-operatively with a severely comminuted LSD died three weeks later due to other associated injuries and was not included in the study. At a mean follow-up of 1.71 years (range 1 to 4.5 years), 11 (48%) still reported residual pain and mean visual analog score at latest follow-up averaged 1.7 (range 0 to 7). There was no difference in VAS between different treatment modalities. Two open injuries treated
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
RESULTS: There were 230 patients (57 females, 173 males), 35% were smokers. The mean age at injury was 41.8617.8 years and the mean body mass index was 25.764.2 kg/m2. The most common injury mechanism was a fall (52%) followed by MVA (36%) and sports injury (10%). The mean admission ISS was 9.267.8, mean CCI was 0.260.7, mean GCS was 14.661.6. NASCIS II & III was instituted in 15.5% & 4.2% of patients respectively; mean time from injury to surgery was 8.9659 days; surgical approach was anterior only in 30 (13%), posterior only in 154 (65%), and anteroposterior in 52 (22%) patients. The total incidence of complications was 79% (minor 30%, major 49%). The different complications are summarized in Table 1. The complications listed as ‘‘other’’ are singular incidents of a specific complication. Factors predictive of the occurrence of a major complication were administration of high dose steroids (NASCIS II)(Odds Ratio:2.3; CI: 1.1-4.8, p50.030) ASIA score (OR:0.7; CI:0.6-0.8, p50.000) and CCI (OR:1.9; CI:1.2-3.0, p50.001). CONCLUSIONS: The severity of neurologic injury, number of comorbidities and use of the high dose steroids independently increase the risk of having a major complication following surgical stabilization of thoracolumbar spine fractures. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
able to identify a clinically meaningful injury with 84 patients requiring prolonged use of a collar and 12 patients requiring surgical stabilization. The addition of MRI to a CT protocol for cervical clearance demonstrated 100% sensitivity and 94% specificity. The positive predictive value of MRI was 53%, while the negative predictive value was 100%. The false positive rate was 6%. CONCLUSIONS: The optimal imaging protocol for cervical clearance remains controversial. The risks of occult cervical injury must be weighed against the morbidities of prolonged immobilization. While CT is very sensitive in identifying osseous abnormalities, the results of this investigation demonstrate that this modality is not capable of detecting all clinically significant injuries. Indeed, in 6% of cases the addition of MRI facilitated a change in treatment protocol and, in 1%, injuries requiring surgical intervention would have been missed using CT alone. Despite recent reports advocating for the use of CT imaging alone to facilitate clearance of the cervical spine, this meta-analysis supports a continued role for MRI in evaluating patients who are obtunded, or symptomatic, despite a negative CT scan. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.086
doi: 10.1016/j.spinee.2009.08.085
71. The Value of Adding MRI to CT Protocols for Cervical Spine Clearance in Blunt Trauma: A Meta-Analysis Andrew Schoenfeld, MD1, Natalie Warholic, MA2, Christopher Bono, MD2, Kevin McGuire, MD3, Mitchel Harris, MD2; 1Harvard Combined Orthopaedic Program, Boston, MA, USA; 2Brigham and Women’s Hospital, Boston, MA, USA; 3Beth Israel Deaconess Medical Center, Boston, MA, USA BACKGROUND CONTEXT: Evaluation and clearance of the cervical spine in blunt trauma patients remains a controversial and challenging topic. While CT imaging is very sensitive for identification of osseous abnormalities, it has not been found to demonstrate similar precision in detecting ligamentous injuries. MRI has been found to be sensitive in detecting cervical injury, but many authors have questioned the potential for this imaging modality to augment the ability of CT scan to identify clinically significant injuries. PURPOSE: To quantify the ability of MRI to detect ‘‘clinically significant’’ cervical injuries in the setting of a negative CT scan. STUDY DESIGN/SETTING: Meta-analysis. PATIENT SAMPLE: 1,550 adult trauma patients. OUTCOME MEASURES: Frequency of injury detection by MRI in the setting of negative CT scan. Our outcome measure seeks to define the prevalence of occult injuries (defined as neg. CT) that required intervention after first being discovered by MRI. METHODS: A computerized search was performed for studies published in the English literature from 2000 to 2008. Inclusion criteria were prospective or retrospective investigations of patients undergoing MRI for the purposes of cervical spine clearance following a negative CT scan, reporting of the outcome of positive MRI findings (cervical clearance, surgical intervention, prolonged use of collar etc.), reporting of statistical data to facilitate calculation of true positives, true negatives, false positives and false negatives, minimum of thirty patients involved in the investigation. A true positive in this investigation was an MRI result that led to a change in management. A false positive was defined as a MRI finding that still allowed for removal of cervical spine precautions. Results of appropriate studies were then pooled and original scale meta-analyses were performed to calculate sensitivity, specificity, positive and negative predictive values. RESULTS: 11 investigations met the inclusion criteria, comprising 1,550 trauma patients with negative cervical spine CT scans. Of these, MRI detected 194 abnormalities in 182 (11.7%) patients. The majority of these were ligamentous injury (86) and degenerative changes, but fractures and dislocations were identified in 4 instances (Table). In 96 cases, MRI was
72. Lumbosacral Dissociation Injuries in High Energy Blast Injuries Ronald Lehman, Jr., MD1, Melvin Helgson, MD1, Romney Andersen2, Carlo Bellabarba, MD3, H. Michael Frisch2; 1Washington, DC, USA; 2 Walter Reed Army Medical Center, Washington, DC, USA; 3University of Washington, Seattle, WA, USA BACKGROUND CONTEXT: Lumbosacral dissociation (LSD) injuries are defined by an anatomic separation of the pelvis from the spinal column usually as a result of high-energy trauma. In the last five years, we have seen a large volume of these injuries in young, healthy combat casualties subjected to high-energy blast trauma and helicopter crashes. PURPOSE: We set out to retrospectively evaluate our patients’ who sustained lumbopelvic dissociations in order to quantify/classify their injuries, evaluate the treatment methods and ascertain their clinical outcomes. STUDY DESIGN/SETTING: We reviewed the inpatient/outpatient medical records and radiographs for all patients treated at our institution with combat-related lumbosacral dissociations. Included were all patients with radiographic evidence of a zone III sacral fracture, with associated lumbar fractures indicating loss of the iliolumbar ligamentous complex integrity. PATIENT SAMPLE: In our database review of over 250 spinal columntype injuries, twenty-three (23) patients met our inclusion criteria and had at least 1 yr follow-up after sustaining lumbopelvic dissociations. OUTCOME MEASURES: Outcome measures included clinical and radiographic followup at interval time points. Physical Exam, Visual Analog Scores (VAS), radiographs and computerized tomography (CT) were utilized to evaluate patients. METHODS: We reviewed the inpatient/outpatient medical records and radiographs for all patients treated at our institution with combat-related lumbosacral dissociations. Included were all patients with radiographic evidence of a zone III sacral fracture, with associated lumbar fractures indicating loss of the iliolumbar ligamentous complex integrity. RESULTS: Twenty-three (23) patients met our inclusion criteria and had at least 1 yr follow-up. In 15 patients, the sacral fracture could be classified as a H or U type zone II fracture, while in the remaining 9 patients the sacral fracture was severely comminuted and unable to classify. Six patients sustained open sacral fractures. Patients were treated as follows: no fixation – 9, sacroiliac screw fixation – 8, posterior spinal fusion – 5, sacral plate – 1. One patient treated non-operatively with a severely comminuted LSD died three weeks later due to other associated injuries and was not included in the study. At a mean follow-up of 1.71 years (range 1 to 4.5 years), 11 (48%) still reported residual pain and mean visual analog score at latest follow-up averaged 1.7 (range 0 to 7). There was no difference in VAS between different treatment modalities. Two open injuries treated