Nonoperative trauma management: has the pendulum swung too far? The distinguished Dr. William Matory lecture.
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Over the last decade, the role of nonoperative management has revolutionized the specialty of trauma. However, this management paradigm has generated substantial controversy in several areas, including penetrating neck and abdominal trauma. Evidence-based analysis will be the ultimate guideline to determine what is optimal management. To prevent the pendulum from swinging too far, there should always exist a high index of suspicion to possible complications associated with the nonoperative approach. Also, the specific choice of management should be institution- and resource dependent. (+info)
Soccer causes degenerative changes in the cervical spine.
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BACKGROUND: Radiological changes and degeneration of the cervical spine have been previously described in soccer players. The onset of such changes was 10-20 years earlier than that of the normal population. The aim of this study was to assess these early degenerative changes in amateur active and veteran soccer players in a cross-sectional descriptive study using biomechanical, radiological, and magnetic resonance measures. METHODS: The subjects were active (<30 years; n=15) and veteran (>30 years; n=15) male amateur soccer players, and their age-matched controls ( n=13 and n=15). Biomechanical measurements were made on a cervical dynamometer. Dynamic radiological and magnetic resonance findings were also obtained and evaluated. RESULTS: The normalized mean extension moment was higher in the active soccer players, but the mean range of motion was lower. Degenerative changes were prominent in veteran players, and the sagittal diameter of their spinal canal at C2 to C6 was lower when compared to active players and controls. Magnetic resonance findings of degeneration were more prominent in soccer players when compared to their age-matched controls. CONCLUSION: A tendency towards early degenerative changes exists in soccer players most probably due to high- and/or low-impact recurrent trauma to the cervical spine caused by heading the ball. (+info)
Snowblading injuries in Eastern Canada.
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OBJECTIVES: To evaluate injury patterns of snowbladers and compare them with those of skiers and snowboarders. To determine possible effects of helmet use in these sports on injury to the head and neck. METHODS: This prospective case series observational study was conducted by collecting the injury reports from the ski patrol during the 1999-2000 season at Mont Tremblant ski resort, Quebec. All participants in downhill winter sports who presented themselves to the ski patrol with traumatic injury related to their sport were included. A concussion was defined as any loss of consciousness, amnesia, confusion, disorientation, vertigo, or headache that resulted from injury. The ski patroller reported helmet use on the accident report at the time of injury. RESULTS: Snowbladers present with a unique pattern of injury compared with skiers and snowboarders. The incidence of leg, knee, and ankle/foot injuries were 20.5%, 25.6%, and 10.3% respectively. Concussions represented 11% of all injuries. There was no increase in other injury, including neck injury, related to helmet use. CONCLUSIONS: Unique injury patterns in snowbladers warrant reconsideration of equipment design. Concussion is a common injury on the ski slope. Although the effects of helmet use on concussion rate are inconclusive based on this study, helmet use did not increase the rate of neck injury, even when adjusted for age. (+info)
The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.
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BACKGROUND: The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients with trauma. It is unclear how the two decision rules compare in terms of clinical performance. METHODS: We conducted a prospective cohort study in nine Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition. The CCR and NLC were interpreted by 394 physicians for patients before radiography. RESULTS: Among the 8283 patients, 169 (2.0 percent) had clinically important cervical-spine injuries. In 845 (10.2 percent) of the patients, physicians did not evaluate range of motion as required by the CCR algorithm. In analyses that excluded these indeterminate cases, the CCR was more sensitive than the NLC (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 percent vs. 66.6 percent, P<0.001). In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 percent and 40.4 percent, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 percent (P=0.09 for the comparison with the NLC) and 50.7 percent (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries. CONCLUSIONS: For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography. (+info)
Isolated contralateral vertebral artery injury in a stab wound to the neck.
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Ipsilateral vertebral artery injuries are a rare entity following trauma to the neck. We discuss the first case of an isolated right vertebral artery injury in a patient with a left stab wound. The patient required bilateral neck explorations and, due to massive bleeding, a median sternotomy in order to obtain control of the proximal segment of the right vertebral artery. We emphasize the importance for trauma surgeons to be familiar with basic but important vascular exposures. The anatomy, surgical exposure, and management of these rare injuries are discussed. (+info)
Pedestrian crashes: higher injury severity and mortality rate for light truck vehicles compared with passenger vehicles.
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INTRODUCTION: During the last two decades changes in vehicle design and increase in the number of the light truck vehicles (LTVs) and vans have led to changes in pedestrian injury profile. Due to the dynamic nature of the pedestrian crashes biomechanical aspects of collisions can be better evaluated in field studies. DESIGN AND SETTING: s: The Pedestrian Crash Data Study, conducted from 1994 to 1998, provided a solid database upon which details and mechanism of pedestrian crashes can be investigated. RESULTS: From 552 recorded cases in this database, 542 patients had complete injury related information, making a meaningful study of pedestrian crash characteristics possible. Pedestrians struck by LTVs had a higher risk (29%) of severe injuries (abbreviated injury scale >/=4) compared with passenger vehicles (18%) (p = 0.02). After adjustment for pedestrian age and impact speed, LTVs were associated with 3.0 times higher risk of severe injuries (95% confidence interval (CI) 1.26 to 7.29, p = 0.013). Mortality rate for pedestrians struck by LTVs (25%) was two times higher than that for passenger vehicles (12%) (p<0.001). Risk of death for LTV crashes after adjustment for pedestrian age and impact speed was 3.4 times higher than that for passenger vehicles (95% CI 1.45 to 7.81, p = 0.005). CONCLUSION: Vehicle type strongly influences risk of severe injury and death to pedestrian. This may be due in part to the front end design of the vehicle. Hence vehicle front end design, especially for LTVs, should be considered in future motor vehicle safety standards. (+info)
Neck pain and disability following motor vehicle accidents--a cohort study.
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The primary aim of the study was to compare the prevalence of neck pain and disability in a group exposed to motor vehicle accidents (MVAs) with those in the general population. The secondary aim was to assess the prevalence of a past history of exposure to an MVA with sequelae of neck pain in the general population. The exposed group consisted of 121 patients with neck complaints following an MVA in 1983. The control group, consisting of 1,491 subjects, was randomly selected, with attention to the distribution of age and gender in the exposed group. A neck-pain questionnaire was mailed to the subjects. In the control group, it included enquiry about a history of exposure to an MVA with sequelae of neck pain. The Neck Disability Index (NDI) was used to assess neck-related disability. In the exposed group 108 subjects (89%) responded, and in the control group 931 (62%) did. Seventeen years after the MVA, 59 subjects (55%) reported neck pain in the exposed group, with no gender differences. In the control group 270 (29%) reported neck pain with a higher frequency among women (34%) than men (19%) (p<0.01). There was a significant difference between the exposed group and the control group regarding the occurrence of neck pain (p<0.001). In the control group 34% recalled a history of an MVA, among whom one-third reported neck pain in connection with the accident and 28% had persistent neck pain referable to the accident. The exposed group scored significantly higher on the NDI (p<0.001) and reported significantly higher neck pain intensity than did the control group (p<0.001). In conclusion, a past history of exposure to an MVA with sequelae of neck pain appears to have a substantial impact on future persistent neck pain and associated disability. (+info)
A pain in the back case.
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I This article discusses a Supreme Court case involving a patient who was referred to a chiropractor for treatment of neck pain. The case highlights some important issues, including the: importance of good medical record keeping, duty to read patient documentation, including previous medical records, duty to perform a physical examination, and duty to consider if a referral is appropriate (+info)