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Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, “baby’s butt,” “Mickey Mouse ears,” absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal.

BackgroundAccurate medication reconciliation in trauma patients is essential but difficult. Currently there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS) based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.MethodsPlasma samples were collected from 356 patients who provided informed consent including-10 healthy controls, 19 known positive or negative controls and 327 trauma patients over 65 years of age who were evaluated at our large, urban Level 1 Trauma Center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage was compared with LCMS results to determine overall accuracy, sensitivity, specificity and positive and negative predictive values (PPV, NPV) of the assay.ResultsOf 356 patients, 39 were on DOACs (10.96%): 21 were on Apixaban, 14 on rivaroxaban and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.06%, (PPV 92.50% and NPV 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.11% (PPV 86.36% and NPV 99.40%). There were three false positive results and two false negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.ConclusionsThis LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.Study type: diagnostic testBasic Science paper: therefore does not require a level of evidence.

Study design Retrospective analysis of a prospective cohort. Objective Change in cervical angular alignment may be associated with dysphagia. Summary of background data Bony deformities of the cervical spine may be associated with secondary contractures of soft tissues in the neck. Acute surgical deformity correction causes in changes in soft tissue tension in the anterior neck, resulting in dysphagia. Methods The study population included patients undergoing 1 and 2 level elective anterior cervical discectomy and fusion for cervical myelopathy or radiculopathy. Preoperative and postoperative radiographs at 2 weeks were measured by a blinded observer for C2-C7 endplate angle, C2-C7 posterior vertebral body length, and occipital condyle plumb line distance on upright lateral radiographs at 2, 6, and 12 weeks postoperatively. Patients were prospectively queried about dysphagia incidence and severity using a numeric rating scale. Multiple linear regression analysis was used to determine the effect of change in radiographic parameters controlling for demographic characteristics. Results The study population included 25 patients with complete radiographs. The mean change in C2-C7 angle was -0.6 degrees (SD 9), the mean change in C2-C7 length was 1.7 mm (SD 26), the mean change in occipital condyle plumb line distance was 2.3 mm (SD 20).Multiple linear regression analysis was performed including operative time, age, sex, number of levels, and change in radiographic parameters as independent variables and using dysphagia score as the dependent variable. The change in C2-C7 angle and operative time were the only statistically significant predictors of change in dysphagia at 2 and 6 weeks postoperatively. Conclusions These results indicate that lordotic change in spinal alignment and longer operative times are associated with increased postoperative dysphagia. Surgeons should counsel patients in whom a large angular correction is expected about the possibility for postoperative dysphagia. Furthermore, future studies on dysphagia incidence should include radiographic alignment as an independent predictor of dysphagia.

Dysphagia is common in the early postoperative period after anterior cervical discectomy and fusion (ACDF). Several mechanisms, including soft-tissue swelling, have been implicated as a cause of postoperative dysphagia.To determine whether anterior soft-tissue swelling is greater in patients with postoperative dysphagia.Prospective cohort study.Forty-three patients.Validated dysphagia questionnaire, lateral cervical spine radiographs.Patients undergoing one- or two-level ACDF using allograft bone and anterior instrumentation were enrolled. Baseline patient demographic characteristics and history were recorded. A dysphagia questionnaire, including a dysphagia numeric rating scale (DNRS; range, 0-10), was administered preoperatively and 2 and 6 weeks postoperatively. Lateral cervical radiographs were obtained preoperatively and 2 and 6 weeks postoperatively. The anterior cervical soft-tissue shadow width was measured at each level. Patients were divided into groups based on the 2-week dysphagia questionnaire: Group 1 (no symptoms/mild dysphagia) and Group 2 (moderate/severe dysphagia). Anterior soft-tissue shadow width at each level was compared between groups. Correlation was used to assess the relationship between DNRS and anterior soft-tissue swelling.Forty-three patients (24 females; average age, 47.9) were enrolled. Fifteen patients had one-level and 28 patients had two-level ACDF. The anterior soft-tissue shadow width increased significantly from preoperative values at all levels except C1 at 2 and 6 weeks and C2 at 6 weeks. At 2 weeks, 18 patients had no symptoms/mild dysphagia (Group 1) and 25 patients had moderate/severe dysphagia (Group 2). The average DNRS was 1.1 for Group 1 and 5.3 for Group 2 (p.001). This difference decreased by 6 weeks but remained significant. There were no significant differences in the soft-tissue measurements between groups at any level. There was no significant correlation between the DNRS and anterior soft-tissue swelling at any time point.There is a significant increase in anterior cervical soft-tissue swelling after ACDF. The width of prevertebral soft-tissue does not correlate with postoperative dysphagia.