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BACKGROUND The severity of rib fractures has been previously evaluated by combining categorical data, but these methods have only low predictive capability for respiratory complications and mortality. This study aimed to establish a more accurate method for predicting the development of pneumonia, a frequent complication in chest injuries, using anatomical relationships. METHODS We analyzed three-dimensional reconstructed images of 644 consecutive trauma patients who underwent whole-body computed tomography (CT) in our institution within a 36-month study period from April 2017. The anatomical relationship between the right and left thoracic volumes of non-rib fracture patients was used to estimate thoracic volume changes on the injured side in unilateral rib fracture patients. The predictive capability of changes in thoracic volume for the development of pneumonia was evaluated according to the area under the receiver operating characteristic curve and compared with that of previous chest wall severity evaluation methods. RESULTS Of the 644 patients, 133 and 478 patients had unilateral rib fractures and non-rib fractures, respectively. The amount of change in thoracic volume due to unilateral rib fractures was significantly greater in pneumonia patients (400 mL vs. 160 mL, p < 0.01). The area under the receiver operating characteristic curve for the development of pneumonia was 0.83, which tended to be higher than that of the previous severity scoring methods. CONCLUSION The amount of change in chest volume, which can be estimated using CT images, has better predictive capability for pneumonia than previous severity assessment methods based on categorical data. The amount of change in chest volume measured using whole-body CT can be used to rapidly determine the optimal treatment for severe chest wall injuries. LEVEL OF EVIDENCE Prognostic study, level IV.

Cranioplasty complications after decompressive craniectomy (DC) in infants are not fully recognized. We aimed to devise and assess the efficacy of a hinge and floating DC (HFDC) technique for treating infantile acute subdural hematoma. Five infants, aged 2-20 months, were included. Intracranial pressure was controlled below 20 mmHg, no additional surgery was required, and there was no incidence of surgical site infection or bone graft resorption.

Background: Although early surgery is known to be effective for the treatment of traumatic cervical spinal cord injury (CSCI), whether it is equally effective in severe CSCI cases remains undetermined. This study aimed to determine whether surgery within 24 h improves the neurological prognosis and reduces the complications associated with surgery for traumatic severe CSCI.Methods: The data of 42 patients with traumatic severe CSCI with American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades A–B who underwent surgery between December 2007 and May 2018 were retrospectively reviewed. The participants were classified into early surgery (24 h) groups. Using the inverse probability of treatment weighting (IPTW) with propensity score adjustment for confounding factors, the AIS grades before and 1 month following surgical treatment, which were considered the primary outcomes, were compared. The secondary outcomes were the intensive care unit length of stay (ICU-LOS) and occurrence of respiratory complications and cardiac arrest.Results: In the early surgery group (n = 32, 76%), the average time to surgery was 10.25 h (4–23 h). The IPTW analysis indicated significant differences in the neurological improvement according to the AIS grade at 1 month following surgery (odds ratio [OR]: 17.1, 95% confidence interval [Cl]: 1.9–156.7, p = 0.012), the ICU-LOS >7 days (OR: 0.14, 95% Cl: 0.02–0.90, p = 0.04), and the occurrence of respiratory complications (OR: 0.08, 95% Cl: 0.01–0.73, p = 0.03) and cardiac arrest (OR: 0.13, 95% Cl: 0.02–0.85, p = 0.03).Conclusions: Early surgery (within 24 h) for traumatic severe CSCI may improve the neurological prognosis and prevent a long ICU-LOS and postoperative complications.

Background: It is unclear whether early surgery for traumatic severe cervical spinal cord injury (CSCI) improves neurological outcomes and reduces complications. This study aimed to determine whether surgery within 24 h improves the neurological prognosis of and reduces the complications associated with surgery for traumatic severe CSCI.Methods: The data of 42 patients with traumatic severe CSCI with American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades of A–B who underwent surgery between December 2007 and May 2018 were retrospectively reviewed. The participants were divided into early surgery (< 24 h) and late surgery (> 24 h) groups. With inverse probability of treatment weighting (IPTW) using a propensity score adjusted for confounding factors, we compared the AIS grade before and 1 month after surgical treatment as the primary outcome. The secondary outcome was the intensive care unit length of stay (ICU-LOS) and occurrence of respiratory complications and cardiac arrest.Results: In the early surgery group (n = 32, 76%), the average time to surgery was 10.25 h (4–23 h). The IPTW analysis indicated significant differences in neurological improvement according to the AIS grade at 1 month after surgery (odds ratio [OR]: 17.1 95% confidence interval [Cl]: 1.9–156.7, p = 0.012), ICU-LOS > 7 days (OR: 0.14 95% Cl: 0.02–0.90, p = 0.04), respiratory complications (OR: 0.08 95% Cl: 0.01–0.73, p = 0.03), and cardiac arrest (OR: 0.13 95% Cl: 0.02–0.85, p = 0.03).Conclusion: Early surgery (within 24 h) for traumatic severe CSCI may be effective in improving the neurological prognosis and preventing a long ICU-LOS and postoperative complications.

Background Unstable sacral fractures are high-energy injuries and comprise polytrauma. Internal fixation to enable withstanding vertical loads is required to get up early from the bed after an unstable sacral fracture. We developed a new minimally invasive surgical (MIS) procedure for unstable pelvic ring fractures and reported it in Japanese in 2010. We presented our minimally invasive surgical technique of crab-shaped fixation for the treatment of unstable pelvic ring fractures and report on its short-term outcomes. Methods Sixteen patients with unstable pelvic ring fractures (AO types C1, 2, and 3) were treated using crab-shaped fixation. All procedures were performed with the patient in the prone position through 5-cm skin incisions created bilaterally at the level of the posterior superior iliac spine. Four iliac screws were inserted and connected with two rods under the fascia. Percutaneous pedicle screws were inserted at L5 or L4 and connected to the iliac rod using offset connectors. Fracture reduction was then performed. Results The average surgical time was 158 min (range, 117–230 min), with an intraoperative bleeding volume of 299 ml (range, 80–480 ml). Thirty-three pedicle screws and 64 iliac screws were implanted with no instance of malpositioning or perforation. A surgical site infection developed in 2 of the 16 cases. Both were deep methicillin-resistant Staphylococcus aureus infections, with the removal of the distal implants required in only one of these cases. Bony union was achieved in all patients, and all vertical displacements reduced by 7.0 mm, on average (range, 5.4–9.0 mm), to

Lesions in the corpus callosum typically represent malignant tumors such as glioblastoma or lymphoma, because of its compact structure comprising tightly packed white-matter tracts. Brain abscess is rarely seen in the corpus callosum. To the best of our knowledge, solitary bacterial abscess confined to the splenium of the corpus callosum has not been reported previously. We report the case of a 72-year-old woman with rapidly progressing disturbance of consciousness following 1 week of antibiotic treatment for bacterial meningitis. Magnetic resonance imaging demonstrated a ring-enhancing round mass located in the splenium of the corpus callosum on gadolinium-enhanced T1-weighted imaging, also showing a bright signal on diffusion-weighted imaging. The patient underwent occipital craniotomy and direct drainage of the lesion in the splenium through the interhemispheric fissure and achieved complete recovery. Brain abscess should be considered among the differential diagnoses for lesions in the splenium of the corpus callosum. An occipital interhemispheric approach to the splenium might be an important option in cases of brain abscess.

Objective Despite recent advances in medicine, no significant improvement has been achieved in therapeutic outcomes for severe traumatic brain injury (TBI). In the treatment of severe multiple traumas, accurate judgment and prompt action corresponding to rapid pathophysiological changes are required. Therefore, we developed the "All-in-One" therapeutic strategy for severe TBI. In this report, we present the therapeutic concept and discuss its efficacy and limitations. Methods From April 2007 to December 2015, 439 patients diagnosed as having traumatic intracranial injuries were treated at our institution. Among them, 158 patients were treated surgically. The "All-in-One" therapeutic strategy was adopted to enforce all selectable treatments for these patients at the initial stages. The outline of this strategy is as follows: first, prompt trepanation surgery in the emergency room (ER); second, extensive decompression craniotomy (DC) in the operating room (OR); and finally, combined mild hypothermia and moderate barbiturate (H-B) therapy for 3 to 5 days. We performed these approaches on a regular basis rather than stepwise rule. If necessary, internal ecompression surgery and external ventricular drainage were performed in cases in which intracranial pressure could not be controlled. Results Trepanation surgery in the ER was performed in 97 cases; among these cases, 46 had hematoma removal surgery and also underwent DC in the OR. Craniotomy was not enforced unless the consciousness level and pupil findings did not improve after previous treatments. H-B therapy was administered in 56 cases. Internal decompression surgery, including evacuation of traumatic intracerebral hematoma, was additionally performed in 12 cases. Three months after injury, the Glasgow Outcome Scale (GOS) score yielded the following results: good recovery in 25 cases (16%), mild disability in 28 (18%), severe disability in 33 (21%), persistent vegetative state in 9 (6%), and death in 63 (40%). Furthermore, 27 (36%) of the 76 most severe patients who had an abnormal response of bilateral eye pupils were life-saving. Because many cases of a GOS score of ≤5 are included in this study, this result must be satisfactory. Conclusion This therapeutic strategy without any lose in the appropriate treatment timing can improve the outcomes of the most severe TBI cases. We think that the breakthrough in the treatment of severe TBI will depend on the shift in the treatment policy.