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Blunt Cervical Spine Trauma and Distracting Injuries
The Journal of Emergency Medicine, Vol. 41, No. 6, pp. 743–747, 2011 Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Abstracts , BLUNT CERVICAL SPINE TRAUMA AND DISTRACTING INJURIES. Konstantinidis A, Demetriades D, Plurad D, et al. J Trauma 2011;71:528–32. Evaluation of the cervical spine (c-spine) is a key part of the initial evaluation of trauma patients in the emergency department. Although multiple guidelines have been presented in the literature to assist the emergency physician in determining whether imaging is needed in the assessment of the cervical spine, there is continued controversy on this subject. This study aimed to clarify the role of distracting injuries in the evaluation of cervical spine injuries. The authors collected prospective data on over 9000 blunt trauma patients admitted to the trauma surgery service at an academic medical center. Of these patients, 119 (1.3%) had a cervical spine injury, either bony or ligamentous, found on imaging, but 15% of these patients were excluded from the study because their physical examination was limited by intoxication or altered mental status. Of the 101 evaluable patients with confirmed c-spine injury, 96% (all but 4 patients) had midline neck pain or tenderness during their initial physical examination. These included 88 patients with injuries that have previously been described as ‘‘distracting,’’ including pelvic fractures and long bone fractures. The one finding that the authors found in common among the 4 patients with c-spine injuries but negative physical examination was bruising and tenderness of the upper anterior chest (with or without rib fracture). Based on these findings, the authors argued that current practice guidelines might result in overuse of c-spine imaging, and that a narrower definition of ‘‘distracting injuries’’ should be developed. [Nir Harish, MD Denver Health Medical Center, Denver, CO]
A considerable body of literature has demonstrated gender discrepancies in overall mortality after acute myocardial infarction (AMI). This study assessed age-stratified mortality rates among men and women undergoing coronary angiography for AMI to determine whether gender discrepancies are age specific. The retrospective observational study included 2677 consecutive patients at a single tertiary care center who presented with chest pain, and subsequently were found to have electrocardiographic changes and biomarker changes consistent with an MI, and underwent angiography before revascularization therapy. Patients were divided by gender and by age; > or < 70 years old. Consistent with prior data, women had MIs at older ages within both of these age groups (> 70 years old age group: women 77.1 6 5.5 years vs. men 75.4 6 4.6 years old; p < 0.001, < 70 years old age group: women 60.4 6 8.2 years old vs. men 56.4 6 8.5 years old; p < 0.001). In both age groups, women had a statistically significant increased number of medical problems, including diabetes and hypertension, although men in both age groups had a statistically significant increased incidence of cigarette smoking and higher incidence of prior myocardial infarctions. Overall MI characteristics, including location of event, evidence of collateral circulation on angiography, and multi-vessel disease, demonstrated no difference between genders in either age group. Overall treatment, including angioplasty, use of stents, use of thrombolysis, and coronary artery bypass surgery rates, were not different between the genders in either age group. The primary outcome, overall survival to hospital discharge, was significantly different between men and women in the > 70-year-old age group (women 11.7% vs. men 5.0%), although in the < 70-year-old age group, no difference was found (women 5.7% vs. men 4.9%). In a multivariate logistic regression model that included past medical history, risk factors, MI characteristics, and treatment characteristics, female age was positively predictive of in-hospital mortality for patients > 70 years of age (odds ratio [OR] 1.78, 95% confidence interval [CI] 1.05–3.00), whereas in patients < 70 years of age, female gender was not associated with increased in-hospital mortality (OR 1.09, 95% CI 0.53–2.24). [Austin Johnson, MD Denver Health Medical Center, Denver, CO]
Comments: This interesting study raises questions about the traditional concept of distracting injuries making examination of the cervical spine unreliable. Although not definitive, the authors suggest that even when significant injuries are present, cervical spine imaging may be omitted if the examination is benign. Clearly, most emergency physicians will have difficulty accepting these conclusions, and until a larger study can validate these findings, it would be prudent to continue imaging those patients that the physician judges to be unreliable due to an injury that, in their judgment, is distracting.
Comment: Although primarily limited by its retrospective design, this study found that gender differences in mortality seem to be important only in older patients. However, there seem to be important confounders of associated comorbidities that are difficult to interpret. Nonetheless, the magnitude of the findings would seem to suggest that as patients age, gender seems to play a role in outcome, although the reasons for this remain unclear.
, COMPARISON OF GENDER-SPECIFIC MORTALITY IN PATIENTS < 70 YEARS VERSUS $ 70 YEARS OLD WITH ACUTE MYOCARDIAL INFARCTION. Ishihara M, Inoue I, Kawagoe T, et al. Am J Cardiol 2011;108: 772–5. 743
Abstracts , BLUNT CERVICAL SPINE TRAUMA AND DISTRACTING INJURIES. Konstantinidis A, Demetriades D, Plurad D, et al. J Trauma 2011;71:528–32. Evaluation of the cervical spine (c-spine) is a key part of the initial evaluation of trauma patients in the emergency department. Although multiple guidelines have been presented in the literature to assist the emergency physician in determining whether imaging is needed in the assessment of the cervical spine, there is continued controversy on this subject. This study aimed to clarify the role of distracting injuries in the evaluation of cervical spine injuries. The authors collected prospective data on over 9000 blunt trauma patients admitted to the trauma surgery service at an academic medical center. Of these patients, 119 (1.3%) had a cervical spine injury, either bony or ligamentous, found on imaging, but 15% of these patients were excluded from the study because their physical examination was limited by intoxication or altered mental status. Of the 101 evaluable patients with confirmed c-spine injury, 96% (all but 4 patients) had midline neck pain or tenderness during their initial physical examination. These included 88 patients with injuries that have previously been described as ‘‘distracting,’’ including pelvic fractures and long bone fractures. The one finding that the authors found in common among the 4 patients with c-spine injuries but negative physical examination was bruising and tenderness of the upper anterior chest (with or without rib fracture). Based on these findings, the authors argued that current practice guidelines might result in overuse of c-spine imaging, and that a narrower definition of ‘‘distracting injuries’’ should be developed. [Nir Harish, MD Denver Health Medical Center, Denver, CO]
A considerable body of literature has demonstrated gender discrepancies in overall mortality after acute myocardial infarction (AMI). This study assessed age-stratified mortality rates among men and women undergoing coronary angiography for AMI to determine whether gender discrepancies are age specific. The retrospective observational study included 2677 consecutive patients at a single tertiary care center who presented with chest pain, and subsequently were found to have electrocardiographic changes and biomarker changes consistent with an MI, and underwent angiography before revascularization therapy. Patients were divided by gender and by age; > or < 70 years old. Consistent with prior data, women had MIs at older ages within both of these age groups (> 70 years old age group: women 77.1 6 5.5 years vs. men 75.4 6 4.6 years old; p < 0.001, < 70 years old age group: women 60.4 6 8.2 years old vs. men 56.4 6 8.5 years old; p < 0.001). In both age groups, women had a statistically significant increased number of medical problems, including diabetes and hypertension, although men in both age groups had a statistically significant increased incidence of cigarette smoking and higher incidence of prior myocardial infarctions. Overall MI characteristics, including location of event, evidence of collateral circulation on angiography, and multi-vessel disease, demonstrated no difference between genders in either age group. Overall treatment, including angioplasty, use of stents, use of thrombolysis, and coronary artery bypass surgery rates, were not different between the genders in either age group. The primary outcome, overall survival to hospital discharge, was significantly different between men and women in the > 70-year-old age group (women 11.7% vs. men 5.0%), although in the < 70-year-old age group, no difference was found (women 5.7% vs. men 4.9%). In a multivariate logistic regression model that included past medical history, risk factors, MI characteristics, and treatment characteristics, female age was positively predictive of in-hospital mortality for patients > 70 years of age (odds ratio [OR] 1.78, 95% confidence interval [CI] 1.05–3.00), whereas in patients < 70 years of age, female gender was not associated with increased in-hospital mortality (OR 1.09, 95% CI 0.53–2.24). [Austin Johnson, MD Denver Health Medical Center, Denver, CO]
Comments: This interesting study raises questions about the traditional concept of distracting injuries making examination of the cervical spine unreliable. Although not definitive, the authors suggest that even when significant injuries are present, cervical spine imaging may be omitted if the examination is benign. Clearly, most emergency physicians will have difficulty accepting these conclusions, and until a larger study can validate these findings, it would be prudent to continue imaging those patients that the physician judges to be unreliable due to an injury that, in their judgment, is distracting.
Comment: Although primarily limited by its retrospective design, this study found that gender differences in mortality seem to be important only in older patients. However, there seem to be important confounders of associated comorbidities that are difficult to interpret. Nonetheless, the magnitude of the findings would seem to suggest that as patients age, gender seems to play a role in outcome, although the reasons for this remain unclear.
, COMPARISON OF GENDER-SPECIFIC MORTALITY IN PATIENTS < 70 YEARS VERSUS $ 70 YEARS OLD WITH ACUTE MYOCARDIAL INFARCTION. Ishihara M, Inoue I, Kawagoe T, et al. Am J Cardiol 2011;108: 772–5. 743