Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient’s cervical spine?

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Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient’s cervical spine?

J Surg Res. 2013 Oct 10;

Authors: Satahoo SS, Davis JS, Garcia GD, Alsafran S, Pandya RK, Richie CD, Habib F, Rivas L, Namias N, Schulman CI

Abstract
BACKGROUND: Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient.
METHODS: Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed.
RESULTS: A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries.
CONCLUSIONS: In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date.

PMID: 24157265 [PubMed – as supplied by publisher]

Activation of p38 mitogen-activated protein kinase in the dorsal root ganglion contributes to pain hypersensitivity after plantar incision.

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Activation of p38 mitogen-activated protein kinase in the dorsal root ganglion contributes to pain hypersensitivity after plantar incision.

Neuroscience. 2013 Mar 27;234:77-87

Authors: Mizukoshi K, Sasaki M, Izumi Y, Miura M, Watanabe M, Amaya F

Abstract
BACKGROUND: The phosphorylation of p38 mitogen-activated protein kinase (MAPK) in the dorsal root ganglion (DRG) promotes primary afferent sensitization. The role of p38MAPK signaling in the DRG in the pathogenesis of plantar incision hyperalgesia has not been investigated.
RESULTS: Levels of phosphorylated p38MAPK (p-p38MAPK) obviously increased in the DRG after plantar incision. Unmyelinated and myelinated DRG neurons that express p-p38MAPK contained small to medium cell bodies, suggesting that p-p38MAPK expression is induced in neurons with C- and Aδ-fibers. The p-p38MAPK inhibitors FR167653 or SB203580 inhibited incision-induced mechanical hypersensitivity and spontaneous pain behavior. The systemic administration of tumor necrosis factor-α (TNF-α) inhibitor prevented subsequent incision-induced activation of p38MAPK in the DRG and alleviated mechanical hypersensitivity after the incision.
CONCLUSIONS: p38MAPK signaling in the DRG plays a crucial role in the development of primary afferent sensitization and pain behavior caused by plantar incision.

PMID: 23298852 [PubMed – indexed for MEDLINE]

Compressive Preload Reduces Segmental Flexion Instability After Progressive Destabilization of the Lumbar Spine.

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Compressive Preload Reduces Segmental Flexion Instability After Progressive Destabilization of the Lumbar Spine.

Spine (Phila Pa 1976). 2013 Oct 22;

Authors: Fry RW, Alamin TF, Voronov LI, Fielding L, Ghanayem AJ, Parikh A, Carandang G, McIntosh BW, Havey RM, Patwardhan AG

Abstract
Study Design. Biomechanical human cadaveric study.Objective. We hypothesized that increasing compressive preload will reduce the segmental instability after nucleotomy, posterior ligament resection and decompressive surgery.Summary of Background Data. The human spine experiences significant compressive preloads in vivo due to spinal musculature and gravity. While the effect of destabilization procedures on spinal motion has been studied, the effect of compressive preload on the motion response of destabilized, multi-segment lumbar spines has not been reported.Methods. Eight human cadaveric spines (L1-Sacrum, 51.4±14.1yrs) were tested intact, after L4-L5 nucleotomy, after interspinous and supraspinous ligaments transection, and after midline decompression (bilateral laminotomy, partial medial facetectomy and foraminotomy). Specimens were loaded in flexion (8Nm) and extension (6Nm) under 0N, 200N, and 400N compressive follower preload. L4-L5 range of motion (ROM) and flexion stiffness in the high flexibility zone (HFZ) were analyzed using repeated-measures analysis of variance and multiple comparisons with Bonferroni correction.Results. With a fixed set of loading conditions, a progressive increase in segmental ROM along with expansion of the HFZ (decrease of flexion stiffness) was noted with serial destabilizations. Application of increasing compressive preload did not substantially change segmental ROM, but did significantly increase the segmental stiffness in the HFZ. In the most destabilized condition 400N preload did not return the segmental stiffness to intact levels.Conclusion. Anatomical alterations representing degenerative and iatrogenic instabilities are associated with significant increases in segmental ROM and decreased segmental stiffness. While application of compressive preload, mimicking the effect of increased axial muscular activity, significantly increased the segmental stiffness, it was not restored to intact levels; thereby suggesting that core strengthening alone may not compensate for the loss of structural stability associated with midline surgical decompression. This suggests that there may be a role for surgical implants or interventions that specifically increase flexion stiffness and limit flexion ROM to counteract the iatrogenic instability resulting from surgical decompression.

PMID: 24153162 [PubMed – as supplied by publisher]