Background: It is very difficult to ascertain how much of the degeneration seen in a post-traumatic spine was due to pre-existing disease and how much was due to the trauma. The aim of the current study was to determine the prevalence of pre-existing disc degeneration on MRI in a region of the spine injured by spinal trauma. Methods: Prospective whole spine MRI study in 118 patients with spinal trauma. One hundred and eighteen consecutive patients (79M:39F, mean age 36years, range 13 – 90 yrs) admitted to our spinal unit for treatment of their acute spinal trauma were investigated with whole spine magnetic resonance imaging (MRI). Whole spine MRI was already the standard protocol for all patients admitted with spinal trauma to rule out co-existing pathology and multiple spinal fractures. 1. Patient data, including age, sex, and mechanism of injury was recorded prospectively onto a spinal injury database. We divided the spine into cervical (C1–C7), thoracic (T1–T12), and lumbosacral (L1–S1) regions. For the purpose of this study we documented the presence or absence of pre-existing degenerative disc disease in all regions of the spine. Of particular interest was any pre-existing degenerative disc disease in the region affected by the spinal trauma. The number of spinal levels affected by pre-existing disc disease within each region was also detailed. Results: The two most common mechanisms of injury were flexion-compression (68 patients) and flexion-distraction (24 patients). Seventy-one of the patients sustained burst fractures and the vast majority of these were in the thoracolumbar region. Thirty-seven patients (31%) had degenerative disc disease in the same region of the spine that was injured in the spinal trauma. Seven patients had pre-existing cervical degeneration in the presence of cervical spine trauma and thirty had pre-existing lumbosacral degeneration in patients that had lumbosacral trauma. Twenty four patients (20%) had more than one level of degenerative change within the same region as their spinal trauma. Eighteen patients (15%) had degeneration in a different region of the spine to the one that was injured. Conclusion: Thirty one percent of the patients in our study had pre-existing degenerative disc disease in the same region as their spinal trauma despite the average age of our patients being only 36yrs. This has important medicolegal implications because it means that a large % of patients who sustain spinal trauma have pre-existing degenerative changes which are not the result of their injury

Objective. To determine the incidence, distribution and associated organ damage in patients that sustained multilevel spinal injuries presenting to a level 1 trauma unit. Is the standard trauma series adequate?. Methodology. A retrospective, chart review of all spinal injury patients that were admitted to the spinal unit from March 2007 to May 2011 was performed. Patients with multilevel spinal injuries were isolated from paediatric, single level, and gunshot injuries. All Trauma unit patients undergo a full body C.T scan with angiography. Using the radiologist's reports the incidence, mechanism of injury, distribution patterns and associated organ damage sustained by this subset of patients was tabulated and reported on. Results. Of the 825 patients that were admitted to the unit, 141 patients had sustained some form of spinal injury. 13 paediatric and 21 gunshot wound spinal patients were excluded. 107 adult blunt force spinal injuries were identified of which 39 fulfilled the multilevel spinal injury criteria. Conclusion. The Incidence of multilevel spinal trauma is higher than previously reported. Distribution patterns found on this C.T scan based study differ from the older x-ray based studies. Distinct patterns of associated organ damage exist with specific spinal injury levels. The dorso- lumbar spine is the most common secondary level involved and it should be included in the trauma series X-ray evaluation of high risk polytrauma patients. NO DISCLOSURES

Injuries to the spinal cord are rarely isolated problems. Multiple trauma patients with spinal injuries can face significant long-term disability. In this retrospective, descriptive study we investigated the relationship between the level of spinal trauma and the injuries associated with this. We aimed to define the populations at risk and highlight trends identified. METHODS: Analysis of 1500 trauma patients admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) over 6 years was undertaken. 265 patients of these patients had spinal cord injuries (SCI). Data was obtained from the HEMS trauma registry, patient records and interviews with patients. RESULTS: 265 patients sustained SCI (mean age: 38 25% female). The most common mechanisms of injury were motor vehicle accidents (46%) and falls (29%) Attempted suicide was a common cause of SCI in our study group (mean age 32. M:F ratio 2:1) The most common associated injuries were limb and head trauma. C-spine injuries were the most common spinal injury and were associated with the highest mortality rates (37%). C-injuries presented with a bimodal age distribution, 84% had head trauma and 30% had significant chest injuries. In patients who sustained thoracic spinal injuries 71% had severe chest injuries and 34% had head injuries. The most common associated injury in lumbar spine trauma was injuries to the limbs or pelvis (68%). Injuries to the lumbar spine occurred more frequently in the 20–40 year old age groups. Discussion: Mortality rate in our study was 26%. Mortality rates were highest in patients with cervical spine injuries (37%). The causes of mortality were from suicide attempts, falls and RTA. The mortality rates in these groups were 20%, 22% and 32% respectfully. Our review highlights significantly higher mortality in the over 60-age group. Our population had high numbers of suicide attempts. We highlight suicide attempts as a significant aetiology for SCI. All the deaths in the suicide group were as a result of jumping from high buildings. In patients over 60, c-spine injuries are by far the common level of SCI. Subdural haematomas occurred in almost 10% of patients with c- spine injuries. Any injury to the cervical spine should therefore prompt investigation for intracranial trauma. The GCS should be closely monitored and a low threshold for performing a CT scan is advisable. Thoracic spine injuries are strongly associated with severe chest injuries. Lumbar spine and sacral injuries are strongly associated with severe pelvic and lower limb injuries. Understanding the demographics and etiology is essential to allow effective planning for spinal services. Appreciating the injuries associated with SCI should ensure better care for patients, by recognizing problems earlier and using a multidisciplinary approach to optimize treatment and reduce morbidity and mortality

Objective: To assess the correlation between the Denis classification and clinical outcomes. Subjects and Design: We performed a retrospective study of 87 patients with spinal injuries in the thoracolumbar region. All patients were admitted to the Oswestry Spinal injuries unit between Jan 1990 and December 1998. Following a review of their notes, CT scans and radiographs, we attempted to classify their injuries according to the Denis (3 column) Classification of spinal injuries. Outcome Measures: The patients were assessed both at the time of presentation and on subsequent follow up. Neurological function was assessed using the Frankel classification. Results: The results of the study show that the correlation between Denis classification and clinical outcome is poor. In addition, the relative proportions of the two most common Major Injury types described by Denis were reversed in our study with Burst fractures forming the majority of injuries. This difference in out come was attributed primarily to the increased use of CT scanning in our study. It appears that Denis misdiagnosed a significant number of burst (two column) fractures as compression (anterior column) fractures. Conclusions: Our findings showed no correlation between the degree of instability and the number of columns disrupted. We believe that only 3 column fracture dislocations are fundamentally unstable. In addition, our results support the practise of treating vertebral fractures by conservative means with no apparent correlation between treatment modality and neurological outcome at long term follow up

Spinal injury at more than one level is not uncommon. Awareness of multilevel injury of the spine and associated neurological patterns is important for the proper initial management of the patient. This study presents the incidence, pattern of signs and the neurological consequences of multilevel spinal injury. A review of 935 patients with spinal injuries revealed that lesions occurred in multiple levels in 9.7%; in over half of the cases, neurological lesions were incomplete. Multiple level non-contiguous lesions at more than two levels had the worst prognosis with 70% of patients suffering complete paraplegia

Aim: To analyse the epidemiology of spinal injuries presented in our tertiary referral centre. Materials and Methods: 202 patients who sustained traumatic spinal column injury were admitted in our tertiary referral centre from 1999 to mid 2002. The case notes were looked at for epidemiological details. Results: Of 202 patients, 136 were male and the rest were females. Both in males and females, we found 2 peaks in the age incidence of spinal cord injuries. First peak was noted between the age group of 18–30 years and the second peak was noted above 60 years. We classified the spinal column injuries into upper cervical, lower cervical, thoracic, dorso-lumbar, lumber and sacral. Lower cervical and cervico-dorsal junction fractures constituted 48% of the spectrum of spinal column fractures. Significant soft tissue injury was noted in 12 patients. Multiple level spinal injuries were present in 16 patients (7.9%). Although road traffic accidents were responsible for 32% of the fractures, domestic falls also contributed to 30.6% of the fractures. 50%of these domestic falls occurred in patients above 60 years of age. We classified the falls into two categories; those from a height above 6 feet were classed as severe falls, which occurred in 65.6% of cases. Below this height the falls were classed as low falls. 71% of the patients who sustained low falls were above 60 years. Sporting accidents caused 19.8% of the spinal fractures. 27% of them are due to diving. Significantly self-harm was found to be a cause of spinal fracture in 3 patients. 67.8% (137) of the patients sustained neurological injury. Incomplete spinal cord injury was present in 86 patients and complete injury in 51 patients. Tetraplegia and tetraparesis was noted in 89 patients where as paraplegia and paraparesis was noted in 48 patients. 26 patients required ventilation at the time of admission. 63 patients sustained polytrauma of which chest injury was found in one third of the poly traumatised patients. Conclusion: From our observations, we find that there is an increasing trend of elderly population who are more susceptible for spinal trauma. Traditional high velocity trauma and high falls though still contribute a significant proportion of spinal injuries, equal proportions of spinal fractures are caused by low falls commonly seen in elderly patients. These epidemiological trends will have implications on treatment, rehabilitation and outcome of spinal injuries

This is a study to investigate the diagnostic and prognostic value of MRI in spinal cord injury. We performed this prospective study on sixty two patients of acute spinal trauma. We evaluated the epidemiology of spinal trauma & various traumatic findings by MRI. MRI findings were correlated with clinical findings at admission & discharge according to ASIA impairment scale. Four types of MR signal patterns were seen in association with spinal cord injury-cord edema / non haemmorhagic cord contusion (CC), severe cord compression (SCC), cord hemorrhage (CH) and epidural heamatoma (EH). Isolated lesion of cord contusion was found in 40%. All other MR signal patterns were found to be in combination. In cord contusion we further subdivided the group into contusion of size < 3 cm and contusion of size > 3 cm to evaluate any significance of length of cord contusion. In cord heammorhage involving >1cm of the cord, focus was said to be sizable. On bivariate analysis, there was a definitive correlation of cord contusion (CC) involving <3cm & > 3cm of cord with sensory outcome. In >3cm, chances of improvement was 5.75 times lesser than in patients with CC involving <3cm of cord (odds ratio = 5.75 (95% CI: 0.95, 36), Fisher's exact p = 0.0427 (p<.05). In severe cord compression (SCC) the risk of poor outcome was more (odds ratio 4.3 and p=0.149) however was not statistically significant. It was noted that the patients in which epidural hematoma (EH) was present, no improvement was seen, however, by statistical analysis it was not a risk factor and was not related with the outcome (odds ratio – 0.5 and p = 0.22). Presence of cord oedema / non haemorrhagic contusion was not associated with poor outcome (odds ratio 0.25 and p=0.178). On multiple logistic regression / multivariate analysis for estimating prognosis, sizable focus of haemorrhage was most consistently associated with poor outcome (odds ratio −6.73 and p= 0.32) however it was not statistically significant. The risk of retaining a complete cord injury at the time of follow up for patients who initially had significant haemorrhage in cord was more than 6 fold with patients without initial haemorrhage (odds ratio 6.97 and p= .0047). Besides being helpful in diagnosis, MRI findings may serve as a prognostic indicator for clinical, neurological and functional outcome in acute spinal trauma patients

Aims. The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Methods. Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. Results. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Conclusion. Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research. Cite this article: Bone Joint J 2023;105-B(4):400–411

Introduction: Somatosensory evoked potentials are monitored during the surgical treatment of spinal disorders to reduce the risk of cord injury. Whilst studies have examined its role in patients undergoing correction of idiopathic and neuromuscular scoliotic curves, its effectiveness in patients undergoing operative treatment for spinal injury is less certain. Methods and Results: We reviewed the medical records of patients who underwent surgery for spinal trauma. between 1995 and 2000. There were 82 patients with adequate data for analysis who underwent 83 spinal reconstructive procedures. We recorded the age at injury, diagnosis, time of operation, levels instrumented, systolic and diastolic blood pressures and surgical approach. The intraoperative somatosensory evoked potential (SSEP) traces were examined. The SSEP at insertion of electrode was taken as the control level. The highest and lowest intraoperative somatosensory evoked potentials and SSEP at closure were noted and expressed as a percentage of the control value. Forty patients (48%) had a pre-operative neurological deficit. Neurological deterioration occurred postoperatively in three patients. Eighty-three traces from 82 patients were available for analysis. Fifty-seven patients had a fall in trace amplitude by more than 25% of the control, 25 by more than 50% and eight by more than 75%. With an SSEP amplitude loss of 60%, both sensitivity and specificity for the prediction of post-operative neurological injury were optimised at 67 and 81% respectively, with one false negative result. SSEP rise at completion of spinal reconstruction and highest intraoperative SSEP rise was compared with neurological outcome in the 40 patients with abnormal pre-operative neurology. Neurology improved in all patients in this group who had a trace amplitude more than 60% above the control value at end of operation. None had neurological deterioration. There was no correlation between intraoperative SSEP rise and neurological outcome. Conclusion: Loss of trace amplitude more than 50% is common during spinal reconstructive surgery after trauma, however a 60% threshold for SSEP fall improves specificity by reducing the rate of false positive results. A trace amplitude 60% above the control value at completion of operation is specific but not sensitive for postoperative neurological improvement

Patients admitted with spinal injuries following trauma require careful serial examinations to detect any neurological deficit that may develop. Thorough documentation of the findings is of paramount importance. Enforced working practice within the NHS means that these patients are often assessed by different members of staff with varying levels of experience, thus inconsistent documentation can be a cause for concern. The project aim was to design a human computer interface to standardise the performance and documentation of serial neurological examinations in patients with spinal injury, allowing the user to accurately detect any neurological deterioration. A prototype system was developed for ward based PC’s incorporating the essential requirements of the neurological examination. Usability testing was performed on the prototype by recruiting fifteen users who would be expected to routinely perform the neurological examination on spinal injury patients. Usability was defined by a number of well defined goals (impression, efficiency, learnability, memorability, safety and effectiveness) and methods used in the evaluation included direct observation during completion of tasks, a questionnaire and unstructured interview. Both quantitative and qualitative data was collected. This data was subsequently analysed using descriptive and inferential methods. The results of the analysis showed that the users responded favourably to the prototype in respects to the all usability goals except efficiency. This lack of efficiency was expected due to the rigid nature of computer based systems compared to paper based methods of recording data but this disadvantage was more than compensated for by the increased patient safety that the system would provide. It can be concluded from the usability testing that the prototype achieves the aims of the project but further work is required in developing the prototype into a final interface design before beta testing in a clinical environment can be considered

Background. High velocity vertical aircraft ejection seat systems are credited with aircrew survival of 80-95% in modern times. Use of these systems is associated with exposure of the aircrew to vertical acceleration forces in the order of 15-25G. The rate of application of these forces may be up to 250G per sceond. Up to 85% of crew ejecting suffer skeletal injury and vertebral fracture is relatively common (20-30%) when diagnosed by plain radiograph. The incidence of subtle spinal injury may not be as apparent. Aim. A prospective study to evaluate spinal injury following high velocity aircraft ejection. Methods. A prospective case series from 1996 to 2006 was evaluated. During this interval 26 ejectees from 20 aircraft were admitted to the spinal studies unit for comprehensive examination, evaluation and management. The investigations included radiographs of the whole spine and Magnetic Resonance Imaging (incorporating T1, T2 weighted and STIR sagittal sequences). All ejections occurred within the ejection envelope and occurred at an altitude under 2000 feet (mean 460 feet) and at an airspeed less than 500 knots (mean 275 knots). Results. in this series 6 ejectees (24%) had clinical and radiographic evidence of vetebral compression fractures. These injuries were located in the thoracic and thoracolumbar spine. 4 cases required surgery (indicated for angular kyphosis greater than 30 degrees, significant spinal canal compromise, greater than 50% or neurological injury. 1 patient had significant neurological compromise, following an AO A3.3 injury involving the L2 vertebra. 11 ejectees (45 %) had MRI evidence of a combined total of 22 occult thoracic and lumbar fractures. The majority of these ejectees with occult injury had multilevel injuries. Conclusion. This study confirms a high incidence of spinal fracture and particularly occult spinal injury

Introduction and Aims: To determine the increased complications of spinal surgery done in non-specialised units for acute spinal injury patients. Method: Retrospective analysis of all admissions to NSIC from February 1999 to August 2000. Results: To hundred and forty-three patients admitted to NSIC over 18 months. Fifty-five patients underwent surgical interventions. Majority of patients were male, average age 36 years. Commonest cause of injury is RTA (45%). A complete injury (ASIA A) occurred in (54.5%) of patients. Primary interventions were done in NSIC, with no major complication, for 36 patients. Nineteen patients operated on in the referring hospital (non-specialised units) before transfer to our centre. Early corrective surgery required for 10 of the total 19 patients due to spinal instability in five patients, non-union in two patients, CSF leak, infection in two patients and wrong level in one patient. A comparison between primary and corrective surgery performed in NSIC by the same surgical team showed that the average length of corrective surgery was 240 minutes, with 150 minutes for primary procedure. Blood loss: 1750 mls on average for corrective surgery, compared to 600 mls for primary intervention. Post-op mobilisation started on average five days after primary surgery and 20 days after corrective surgery. Period of rehabilitation – 16 weeks on average after primary surgery in NSIC, compared to 40 weeks after corrective surgery. Conclusion: Our results showed that early transfer to spinal injury unit and early spinal decompression and stabilisation performed by an experienced spinal surgeon, in a spinal injury centre would prevent complications and delays in rehabilitation

Introduction. Catastrophic neck injury is rare in rugby, however the consequences are invariably devastating. Schoolboys have previously been identified as a group at risk. This study came about as a result of a recent increase in admissions of schoolboy rugby players to the National spinal injuries unit in Glasgow. Aim. To audit schoolboy rugby admissions to spinal injury units throughout the United Kingdom and Ireland, in doing so to appraise the current state of data collection. To obtain estimates of playing numbers from the Home unions. Method. Retrospective review of all 12 spinal injury units for records of cases subsequent to 1996. Representatives of each of the four home unions were contacted to confirm cases and establish playing numbers. Results. Records were available from 1996 in Scotland and Ireland and from 2000 in England and Wales. Two units collect prospective data, two had easily retrievable data. In the absence of any register data retrieval was challenging elsewhere. Of the 36 cases 24 would be classified as catastrophic 12 as near misses. The median age for injury was 17. 51% of injuries occurred in the tackle, 35% in the scrum. 92% of scrum injuries involved neurological damage, 61% with complete neurological loss at presentation, 8% with no neurological injury. Tackle injuries were associated with neurological damage in 42%, 26% with complete lesions and no neurological injury in 57%. Estimates for playing numbers (U18 inclusive) approximate to Scotland 19,000, Wales 30,000, Ireland 40,000 and England 1,200,00. Conclusion. •. A persistent number of schoolboys were injured through the study period. •. Recording of serious neck injuries is inconsistent through the United Kingdom and Ireland. •. The numbers injured in Scotland were disproportionate in view of the relative playing populations. •. Whilst less frequent, scrum injuries were more often associated with spinal cord injury

Aims. The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years. Methods. A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up. Results. The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher’s exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model. Conclusion. For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103–111

Objective-Study Design: Recognizing the value of intraoperative SEP monitoring in scoliosis and other spinal surgery, we applied prospectively continuous SEP recording during reconstructive procedures in 82 patients who sustained 20 cervical, 8 thoracic, 6 thoraco-lumbar, and 48 lumbar vertebral fractures or fractures-dislocations to investigate its efficacy in spinal trauma. Material: Seventy-one patients underwent single anterior or posterior operations, and 11 combined anterior-posterior procedures. Forty patients had incomplete injuries, and 42 had no preoperative neurological deficit. SEP trace amplitude at insertion of electrode was considered as the baseline value, and was compared to the lowest intraoperative signal amplitude and the amplitude at completion of operation. Results: Fifty-nine patients had a depression in wave amplitude of more than 25% during surgery; in 25 patients the trace fell by more than 50%, and in 7 cases a more than 75% diminution was recorded. A loss of 50% in SEP signal amplitude showed 67% sensitivity, and 71% specificity in predicting neurologic outcome. Patients with a fall in SEP amplitude of more than 50% that did not recover at completion of the surgical procedure demonstrated an increased risk of neurological compromise (p< .01). Increasing trace deterioration threshold from 50 to 60% improved specificity to 81% without compromising sensitivity. There was also 100% correlation between the side of the amplitude drop and the side of neurological loss in the trunk or limb (p< .001). A total number of 22 patients had improved SEP recordings before skin closure; 19 of these patients demonstrated an improved neurologic function after the operative procedure. In these 19 patients a positive statistical association could be documented between the signal changes and the neurological outcome (p< .05). Nevertheless, 2 of the patients with up to 20% improvement in the trace amplitude compared to the original control measurement presented deterioration in their neurological picture in the postoperative period. In 17 patients the SEP waveform amplitude was unchanged at conclusion of the operation; in those cases the neurological functional level post-surgery was equally unaltered. No significant difference was obtained when comparing the systolic blood pressures or the core temperatures at skin closure between the different outcome groups (p> .05). A loss of more than 50% in SEP amplitude occurred with significantly increased incidence during the anterior compared to the posterior spinal procedures (p< .001). More than 20% recovery in signal amplitude at conclusion of the procedure in patients with incomplete injuries was correlated with favorable neurological function. Conclusions: Persistent intraoperative decrement in SEP amplitude and poor restitution at completion of surgery increase the risk for postoperative neurologic compromise. In this series, continuous intraoperative SEP monitoring appeared to be adequately reproducible, sufficiently reliable, and therefore a practical tool in monitoring operative procedures for spinal trauma. Even though compared to deformity surgery the method is less sensitive and specific, it may help reduce the incidence of devastating neurologic injury during the operation on an already compromised neural cord, and can provide good prediction in terms of postoperative neurological outcome. Thus, it could be considered a useful surgical adjunct in the management of patients with spinal trauma

High velocity vertical aircraft ejection seat systems are credited with aircrew survival of 80–95% in modern times. Use of these systems is associated with exposure of the aircrew to vertical acceleeration forces in the order of 15–25G. The rate of application of these forces maybe upto 250G per sceond. Upto 85% of crew ejecting suffer skeletal injury and vertebral fracture is relatively common (20–30%) when diagnosed by plain radiograph. The incidence of subtle spinal injury may not be as apparent. A prospective case series, admitted to QMC Nottingham, from 1996 to 2006 was evaluated. During this interval 26 ejectees from 20 aircraft were admitted to the spinal studies unit for comprehensive examination, evaluation and management. The investigations included radiographs of the whole spine and magnetic resonance Imaging (incorporating T1, T2 weighted and STIR saggital sequences). All ejections occurred within the ejection envelope and occurred at an altitude under 2000 feet (mean 460 feet) and at an airspeed less than 500 knots (mean 275 knots). In this series 6 ejectees (24%) had clinical and radiographic evidence of vetebral compression fractures. These injuries were located in the thoracic and thoracolumbar spine. 4 cases required surgery ( indicated for angular kyphosis greater than 30 degrees, significant spinal canal compromise, greater than 50% or neurological injury. 1 patient had significant neurological compromise, following an AO A3.3 injury involving the L2 vertebra. 11 ejectees (45 %) had MRI evidence of a combined total of 22 occult thoracic and lumbar fractures. The majority of these ejectees with occult injury had multilevel injuries. This study confirms a high incidence if spinal fracture and particularly occult spinal injury. Evidently vertical emergency aircraft ejection imposes major insults on the spinal column. Once, appropriately prioritised, life preservation measures have been undertaken, an early MRI of the spne is mandatory as part of comprehensive patient evaluation. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon

Improvised Explosive Device (IED) attacks on vehicles have been a significant feature of recent conflicts. The Dynamic Response Index (DRI), developed for predicting spinal injury in aircraft ejection, has been adopted for testing vehicles in underbelly blast. Recent papers suggest that DRI is not accurate in blast conditions. We suggest that the distribution of blast and ejection injuries is different. A literature review identified the distribution of spinal fractures in aircraft ejection incidents. A Joint Theatre Trauma Registry search identified victims of mounted IED blast with spinal fractures. The distribution of injuries in the two groups was compared using the Kruskall Wallis test. 329 fractures were identified in ejector seat incidents; 1% cervical, 84% thoracic and 16% lumbar. 245 fractures were identified in victims of mounted blast; 16% cervical, 34% thoracic and 50% lumbar. There was no significant similarity between the two (p=1). There was no statistically significant difference between the distribution of fractures in blast survivors versus fatalities. The difference between blast and ejection injury patterns suggests that injury prediction models for ejection should not be extrapolated to blast mechanisms and that new models need to be developed

Purpose of the study: Cases of serious trauma to the cervical spine requiring surgical management in older subjects goes in hand with the general trend towards a more active elderly population. We analyzed retrospectively our experience with 28 patients cared for in our unit from 1990 to 1999. Patients and methods: Mean age of these 11 women and 17 men was 73 years (range 65–93). High-energy trauma was the cause of the cervical injury in 12 patients (42%). The others were victims of falls in their homes. This later cause explains the long delay to care (21 days on the average with a range from zero days to six months). The six patients who had injuries to the upper cervical spine had fractures of the odontoid process secondary to a fall. The mobile segment of the spine was involved in most of the injuries involving the lower cervical spine (eleven severe sprains and six dislocations) resulting from high-energy trauma in half of the cases. These injuries occurred above an osteoarthritic block. Half of the patients had neurological complications: eleven immediate, three late. The Franckel classification was: A=2, C=4, D=7. The same repair technique was used for the upper an lower cervical spine. Five of the six fractures of the odontoid process were fixed with a Bölher screw, and one with posterior fusion. An anterior graft with plate fixation was used 18 times for the lower spine. Roy Camille posterior fixation was used four times because of the irreducible nature of the fracture or because of the need for posterior fusion. Results: Morbidity was high. Seven patients (25%) had serious cardiorespiratory complications leading to death in five patients. All these patients had neurological sequelae (Franckel A and C). For the other patients, the postoperative period was uneventful and similar to that observed in younger patients (immobilization, neurological recovery, consolidation). Discussion: The high frequency of upper cervical spine trauma observed in our series is also reported in the literature. It increases with age. The frequency of neurological involvement was identical to that observed by Roth and Spivak. Prognosis was poor in case of neurological involvement. The appropriateness of surgery in Franckel A patients may be questionable. Surgery cannot avoid the risk of mortality in these patients but it can enable mobilisation and nursing care, avoiding the need for a halo jacket. Conclusion: Spinal trauma in the elderly can be managed similarly to that in young adults, at least in cases without major neurological involvement

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

Cite this article: Bone Joint J 2015;97-B:527–31.

This study assessed the frequency of acute injury to the spinal cord in Irish Rugby over a period of ten years, between 1995 and 2004. There were 12 such injuries; 11 were cervical and one was thoracic. Ten occurred in adults and two in schoolboys. All were males playing Rugby Union and the mean age at injury was 21.6 years (16 to 36). The most common mechanism of injury was hyperflexion of the cervical spine and the players injured most frequently were playing at full back, hooker or on the wing. Most injuries were sustained during the tackle phase of play. Six players felt their injury was preventable. Eight are permanently disabled as a result of their injury.