Thoracolumbar spine trauma: review of the evidence.

AIM: The aim of this paper was to provide a comprehensive review of literature regarding the classification systems and surgical management of thoracolumbar spine trauma. METHODS: A Pubmed search of thoracolumbar , spine , fracture was used on January 05, 2013. Exclusionary criteria included non-Human studies, case reports, and non-clinical papers. RESULTS. One thousand five hundred twenty manuscripts were initially returned for the combined search string; 150 were carefully reviewed, and 48 manuscripts were included in the review. DISCUSSION: Traumatic spinal cord injury (SCI) has a high prevalence in North America. The thoracolumbar junction is a point of high kinetic energy transfer and often results in thoracolumbar fractures. New classification systems for thoracolumbar spine fractures are being developed in an attempt to standardize evaluation, diagnosis, and treatment as well as reporting in the literature. Earlier classifications such as the Denis 3-column model emphasized anatomic divisions to guide surgical planning. More modern classification systems such as the Thoracolumbar injury classification system (TLICS) emphasize initial neurologic status and structural integrity of the posterior ligamentous complex as a guide for surgical decision making and have demonstrated a high intra- and interobserver reliability. Other systems such as the Load-Sharing Classification aid as a useful tool in planning the extent of instrumentation and fusion. CONCLUSION: There is still much controversy over the surgical management of various thoracolumbar fractures. Level I data exists supporting the nonsurgical management of thoracolumbar burst fractures without neurologic compromise. However, for the majority of fracture types in this region, more randomized controlled trials are necessary to establish standards of care

Complications of Decompressive Craniectomy

Introduction: Persistent elevation of intracranial pressure (ICP), if untreated, may lead to brain ischemia or lack of brain oxygen and even brain death.1-6,10 When standard treatments for elevated ICP are exhausted without any signs of improvement, decompressive craniectomy can be an effective alternative solution.7,19 Decompressive craniectomies (DC) have been used as a method of controlling intracranial pressure in patients with cerebral edema secondary to cerebral ischemia, subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI), among others. 8-10 Several studies over the years have demonstrated the efficacy of this procedure.7-9,11,35,36 However, consensus is still lacking in the utility of DC as an effective first tier treatment for intractable intracranial pressure due to the rudimentary neurological outcome assessments, and the many complications associated with this procedure.11,12,59 There are a limited number of studies that have looked at complications secondary to the procedure itself.13-18 The majority of these studies only investigated the impact of this procedure in patients with traumatic brain injury. The purpose of this study is to investigate the rates of various complications associated with the decompressive craniectomy procedure in patients that did not suffer from traumatic brain injury, and to determine whether the same associations between preoperative parameters and development of complications can be made

Emergency reversal of antiplatelet agents in patients presenting with an intracranial hemorrhage: A clinical review

Abstract Objective: Prehospital use of antiplatelet agents has been associated with an increased risk for ICH as well as a secondary increase in ICH volume after the initial hemorrhage. Strategies to reestablish platelet aggregation are used in clinical practice, but without any established guidelines or recommendations. This article serves to evaluate the literature regarding “reversal” of antiplatelet agents in neurosurgical populations. Methods: PUBMED and MEDLINE databases were searched for publications from 1966 to 2009 relating to intracranial hemorrhage and antiplatelet agents. The reference sections of recent articles, guidelines and reviews were reviewed and pertinent articles identified. Studies were classified by two broad subsets; those describing intracranial hemorrhage relatable to a traumatic mechanism and those with a spontaneous intracranial hemorrhage. Two independent auditors recorded and analyzed study design and the reported outcome measures. Results: For the spontaneous intracranial hemorrhage group, 9 reports assessing antiplatelet effects on various outcome measures were identified. Eleven studies evaluating the use of prehospital antiplatlets prior to a traumatic intracranial hemorrhage were examined. Conclusion: The data assessing the relationship between outcome and prehospital antiplatelet agents in the setting of ICH is conflicting in both the trauma and the stroke literature. Only one retrospective review specifically addressed outcomes after attempted reversal with platelet transfusion. Further study is needed to determine whether platelet transfusion ameliorates hematoma enlargement and/or improves outcome in the setting of acute ICH

Outcomes in Traumatic Brain Injury Patients on Preinjury Anticoagulation and Antiplatelet Agents

Traumatic brain injury (TBI) affects an estimated 1.7 million people a year. Around 75% of these cases are mild. Falls and motor vehicle accidents are among the leading causes for TBI, with falls accounting for 60.7% of occurrences in populations 65 years or older1. As the general population continues to expand both in age and in size, the risk of falls will increase. This poses a problem particularly in light of the pervasive use of anticoagulants and antiplatelet agents for this population, both of which increase the bleeding risk. Anticoagulants and antiplatelet agents are used for a variety of conditions, including deep venous thrombosis, atrial fibrillation, pulmonary embolism and coronary artery disease. They are also given postoperatively for prosthetic heart valves or stent placement. An estimated 597,689 deaths in 2010 were due to cardiovascular disease, with 80% above the age of 652. Stroke caused 129,476 deaths. The use of anticoagulants and antiplatelet agents for prevention of cardiovascular and cerebrovascular events is irrefutable, but little literature has touched on its effects on morbidity and mortality in those with traumatic brain injury. This article summarizes the current literature on the pre-TBI use of anticoagulants and antiplatelet agents and the associated morbidity and mortality

Avoiding Antiplatelet Reversal in Non-Operative Intracranial Hemorrhages: Functional Outcomes of Guideline-Based Practice

Introduction: Intracranial hemorrhage (ICH) is a common, life-threatening neurological pathology in aging patients, many of whom take antiplatelet medications with potential to worsen the hemorrhage. In the event of ICH, Thomas Jefferson University Hospital (TJUH) follows a protocol modeling the 2016 Neurocritical Care Society (NCS) joint guidelines for antiplatelet medication reversal. We analyzed pre- and post-NCS guideline data from TJUH for outcomes of non-operative ICH patients in order to tease out the potential benefits of this protocol. Methods: This retrospective cohort study took place from January 2016 – Jan. 2018 at a tertiary care center: TJUH. Patients included were ³18 y.o., on antiplatelet therapy who, had CTs available for evaluation of expansion, and did not undergo surgical management. The primary outcomes measured for comparison were both the admission and discharge Glasgow Coma Scores (GCS), admission and discharge modified Rankin Scores (mRS), time to death, hematoma expansion, and in-hospital mortality. T-tests, the Kolmogorov-Smirnov-test, and Chi-Square test for independence were used. Results: For pre- and post-protocol groups, no significant difference existed for GCS or mRS, at admission and discharge. There were no significant findings for in-hospital mortality and hemorrhage expansion. Discussion: TJUH established a protocol in line with the 2016 NCS joint guidelines for managing ICH in patients on antiplatelet therapies. This protocol recommends discontinuing antiplatelet therapy and not transfusing platelets in patients not receiving surgical management. We examined the protocol efficacy have found no significant differences in the pre- and post-protocol groups, indicating patient outcomes may be equivalent

Intraoperative Vancomycin Use in Spinal Surgery: Single Institution Experience and Microbial Trends.

Study Design. Retrospective Case Series.Objective. To demonstrate the microbial trends of spinal surgical site infections(SSI) in patients who had previously received crystallized vancomycin in the operative bed.Summary of Background Data. Prior large, case control series demonstrate the significant decrease in SSI with the administration of vancomycin in the wound bed.Methods. A single institution, electronic database search was conducted for all spinal surgery patients who had received prophylactic crystalline vancomycin powder in the wound bed. Patient\u27s with a prior history of wound infection, intrathecal pumps, or spinal stimulators were excludedResults. 981 consecutive patients (494 male, 487 female, mean age 59.4 years, range 16-95 years) were identified from January 2011 to June 2013. The average dose of vancomycin powder was 1.13 grams(range: 1-6 grams). 66 patients (6.71%) were diagnosed with a SSI of which 51 patients had positive wound cultures (5.2%). Of the 51 positive cultures the most common organism was Staphylococcus aureus. The average dose of vancomycin was 1.3 grams in the 38 cases where a gram-positive organism was cultured. A number of gram-negative infections were encountered such as Serratia marcescens, Enterobacter aerogenes, Bacteroides fragilis, Enterobacter cloacae, Citrobacter koseri and Pseudomonas aeruginosa. The average dose of vancomycin was 1.2 grams in 23 cases where a gram negative infection was cultured. 15 of the 51 (29.4%) positive-cultures were polymicrobial. 8 (53%) of these 15 polymicrobial cultures contained three or more distinct organisms.Conclusion. Prophylactic intraoperative vancomycin use in the wound bed in spinal surgery may increase the incidence of gram-negative or polymicrobial spinal infections. The use of intraoperative vancomycin may correlate with postoperative seromas, due to the high incidence of non-positive cultures. Large, randomized, prospective trials are needed to demonstrate causation and dose-response relationship