Over the past 8 years, advances in the US Military Health System (MHS) have led to extensive changes in the way combat casualty care is provided to deployed service members with a traumatic brain injury (TBI). Changes include the application of cutting-edge Clinical Practice Guidelines, use of pioneering technologies, and advances in evacuation procedures. Compared with previous engagements, current operations occur on a much smaller scale, and more frequently in austere environments, such that effective medical support is increasingly challenging. In this paper, the authors describe key aspects of the current continuum of TBI care in the US military, from the point of injury through rehabilitation, with an emphasis on how emerging technologies and evidence-based Clinical Practice Guidelines assist MHS clinicians with providing the best clinical care possible in the changing battlefield.
Rachel Lazarus, Katherine Helmick, Saafan Malik, Emma Gregory, Yll Agimi, and Donald Marion
Emma M. Sim, Matthew H. Claydon, Rhiannon M. Parker, and Gregory M. Malham
The anterior approach to the lumbar spine may be associated with iliac artery thrombosis. Intraoperative heparin can be administered to prevent thrombosis; however, there is a concern that this will increase the procedural blood loss. The aim of this study was to examine whether intraoperative heparin can be administered without increasing blood loss in anterior lumbar spine surgery.
A prospective study of consecutive anterior approaches for lumbar spine surgery was performed between January 2009 and June 2014 by a single vascular surgeon and a single spine surgeon. Patients underwent an anterior lumbar interbody fusion (ALIF) at L4–5 and/or L5–S1, a total disc replacement (TDR) at L4–5 and/or L5–S1, or a hybrid procedure with a TDR at L4–5 and an ALIF at L5–S1. Heparin was administered intravenously when arterial flow to the lower limbs was interrupted during the procedure. Heparin was usually reversed on removal of the causative retraction.
The cohort consisted of 188 patients with a mean age of 41.7 years; 96 (51.1%) were male. Eighty-four patients (44.7%) had an ALIF, 57 (30.3%) had a TDR, and 47 (25.0%) had a hybrid operation with a TDR at L4–5 and an ALIF at L5–S1. One hundred thirty-four patients (71.3%) underwent a single-level procedure (26.9% L4–5 and 73.1% L5–S1) and 54 (28.7%) underwent a 2-level procedure (L4–5 and L5–S1). Seventy-two patients (38.3%) received heparinization intraoperatively. Heparin was predominantly administered during hybrid operations (68.1%), 2-level procedures (70.4%), and procedures involving the L4–5 level (80.6%).
There were no intraoperative ischemic vascular complications reported in this series. There was 1 postoperative deep venous thrombosis.
The overall mean estimated blood loss (EBL) for the heparin group (389.7 ml) was significantly higher than for the nonheparin group (160.5 ml) (p < 0.0001). However, when all variables were analyzed with multiple linear regression, only the prosthesis used and level treated were found to be significant in blood loss (p < 0.05). The highest blood loss occurred in hybrid procedures (448.1 ml), followed by TDR (302.5 ml) and ALIF (99.7 ml). There were statistically significant differences between the EBL during ALIF compared with TDR and hybrid (p < 0.0001), but not between TDR and hybrid. The L4–5 level was associated with significantly higher blood loss (384.9 ml) compared with L5–S1 (111.4 ml) (p < 0.0001).
During an anterior exposure for lumbar spine surgery, the administration of heparin does not significantly increase blood loss. The prosthesis used and level treated were found to significantly increase blood loss, with TDR and the L4–5 level having greater blood loss compared with ALIF and L5–S1, respectively. Heparin can be administered safely to help prevent thrombotic intraoperative vascular complications without increasing blood loss.
Lennart Riemann, Daphne C. Voormolen, Katrin Rauen, Klaus Zweckberger, Andreas Unterberg, Alexander Younsi, and the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Investigators and Participants
The aim of this paper was to evaluate the prevalence of postconcussive symptoms and their relation to health-related quality of life (HRQOL) in pediatric and adolescent patients with mild traumatic brain injury (mTBI) who received head CT imaging during initial assessment.
Patients aged between 5 and 21 years with mTBI (Glasgow Coma Scale scores 13–15) and available Rivermead Post Concussion Questionnaire (RPQ) at 6 months of follow-up in the multicenter, prospectively collected CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) study were included. The prevalence of postconcussive symptoms was assessed, and the occurrence of postconcussive syndrome (PSC) based on the ICD-10 criteria, was analyzed. HRQOL was compared in patients with and without PCS using the Quality of Life after Brain Injury (QOLIBRI) questionnaire.
A total of 196 adolescent or pediatric mTBI patients requiring head CT imaging were included. High-energy trauma was prevalent in more than half of cases (54%), abnormalities on head CT scans were detected in 41%, and admission to the regular ward or intensive care unit was necessary in 78%. Six months postinjury, 36% of included patients had experienced at least one moderate or severe symptom on the RPQ. PCS was present in 13% of adolescents and children when considering symptoms of at least moderate severity, and those patients had significantly lower QOLIBRI total scores, indicating lower HRQOL, compared with young patients without PCS (57 vs 83 points, p < 0.001).
Adolescent and pediatric mTBI patients requiring head CT imaging show signs of increased trauma severity. Postconcussive symptoms are present in up to one-third of those patients, and PCS can be diagnosed in 13% 6 months after injury. Moreover, PCS is significantly associated with decreased HRQOL.