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Pediatric spinal injury in the US: epidemiology and disparities

Joseph H. Piatt Jr.

OBJECT

In the US, race and economic status have pervasive associations with mechanisms of injury, severity of injury, management, and outcomes of trauma. The goal of the current study was to examine these relationships on a large scale in the setting of pediatric spinal injury.

METHODS

Admissions for spinal fracture without or with spinal cord injury (SCI), spinal dislocation, and SCI without radiographic abnormality were identified in the Kids’ Inpatient Database (KID) and the National Trauma Data Bank (NTDB) registry for 2009. Patients ranged in age from birth up to 21 years. Data from the KID were used to estimate nationwide annual incidences. Data from the NTDB were used to describe patterns of injury in relation to age, race, and payor, with corroboration from the KID. Multiple logistic regression was used to model rates of mortality and spinal fusion.

RESULTS

In 2009, the estimated incidence of hospital admission for spinal injury in the US was 170 per 1 million in the population under 21 years of age. The incidence of SCI was 24 per 1 million. Incidences varied regionally. Adolescents predominated. Patterns of injury varied by age, race, and payor. Black patients were more severely injured than patients of other races as measured by Injury Severity Scale scores. Among black patients with spinal injury in the NTDB, 23.9% suffered firearm injuries; only 1% of white patients suffered firearm injuries. The overall mortality rate in the NTDB was 3.9%. In a multivariate analysis that included a large panel of clinical and nonclinical factors, black race retained significance as a predictor of mortality (p = 0.006; adjusted OR 1.571 [1.141–2.163]). Rates of spinal fusion were associated with race and payor in the NTDB data and with payor in the KID: patients with better insurance underwent spinal fusion at higher rates.

CONCLUSIONS

The epidemiology of pediatric spinal injury in the US cannot be understood apart from considerations of race and economic status.

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Adults with myelomeningocele and other forms of spinal dysraphism: hospital care in the United States since the turn of the millennium

Joseph H. Piatt Jr.

OBJECTIVE

The natural history and management of myelomeningocele (MM) in children is fairly well understood. There is a deficiency of knowledge regarding the care of adults, however, even though there are now more adults than children living with MM. The purpose of this study was to characterize the hospital care of adults with MM and hydrocephalus on a nationwide population base. Adults with other forms of spina bifida (SB) were studied for contrast.

METHODS

The Nationwide Inpatient Sample for the years 2001, 2004, 2007, and 2010 was queried for admissions with diagnostic ICD-9-CM codes for MM with hydrocephalus and for other forms of SB.

RESULTS

There were 4657 admissions of patients with MM and 12,369 admissions of patients with SB in the sample. Nationwide rates of admission increased steadily for both MM and SB patients throughout the study period. Hospital charges increased faster than the health care component of the Consumer Price Index. Patients with MM were younger than patients with SB, but annual admissions of MM patients older than 40 years increased significantly during the study period. With respect to hospital death and discharge home, outcomes of surgery for hydrocephalus were superior at high-volume hospitals. Patients with MM and SB were admitted to the hospital more frequently than the general population for surgery to treat degenerative spine disease.

CONCLUSIONS

Patients with MM and SB continue to require neurosurgical attention in adulthood, and the demand for services for older patients with MM is increasing. Management of hydrocephalus at high-volume centers is advantageous for this population. Patients with MM or SB may experience high rates of degenerative spine disease.

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Ultrasound Guidance

Joseph H. Piatt Jr.

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The Section on Neurological Surgery of the American Academy of Pediatrics: Annual Report 2005 to 2006

Joseph H. Piatt Jr.

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Syringomyelia complicating myelomeningocele: review of the evidence

Joseph H. Piatt Jr.

Syringomyelia is frequently found in association with myelomeningocele. Although often asymptomatic, it can, in exceptional cases, cause severe morbidity. The author performed a structured literature review to address the following aspects of this clinical problem.

What is the natural history? There are data concerning the imaging prevalence, the autopsy prevalence, and the prevalence of clinically active syringomyelia among patients with myelomeningocele, but literature provides no description of the course of this condition over time.

What is the clinical significance? That correlations among symptoms, signs, treatments, and imaging findings are poorly described is no surprise in view of the large fraction of patients with syringomyelia who are asymptomatic. There is, however, an impressive mass of anecdotal evidence associating progressive syringomyelia with untreated (or inadequately treated) hydrocephalus.

How to make the diagnosis? There is no disagreement that magnetic resonance imaging is the diagnostic modality of choice, but the literature provides very little guidance about who should undergo this investigation. There is no analysis of the costs and benefits of screening or periodic surveillance.

What is the best treatment? Many surgical procedures have been reported to be useful as components of complex algorithms relating clinical factors and imaging data to treatment recommendations. There have been no controlled studies. There have been no prospective studies. There have been no multiinstitutional studies. No studies in which outcomes have been evaluated using objective, validated instruments. No studies in which the robustness of treatment effects over time have been documented.

The complexity of treatment selection in contemporary practice makes syringomyelia unsuitable for randomized controlled trials of different therapies. Prospective cohort studies are feasible, however, and hold the potential to address many important questions about natural history and patient outcomes.

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The Section on Neurological Surgery of the American Academy of Pediatrics: Annual Report 2006 to 2007

Joseph H. Piatt Jr.

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Progressive syringomyelia controlled by treatment of associated hydrocephalus in an infant with birth injury

Case report

Joseph H. Piatt Jr.

✓The author's aim in reporting this case is to extend awareness of the importance of management of associated hydrocephalus among patients with syringomyelia to the posttraumatic state. A full-term infant was delivered by cesarean section because of transverse lie. In the 2nd week of life, hypotonia affecting the lower limbs and the left upper limb was recognized. On MR imaging, posterior fossa subdural hemorrhage and spinal cord injury at the T-1 and T-2 levels were evident. Sequential imaging studies demonstrated progressive myelomalacic changes in the cervical spinal cord and eventual development of syrinx cavities as far cephalad as C-3. Hydrocephalus developed simultaneously as well. A ventriculoperitoneal cerebrospinal fluid shunt was inserted at 22 months of age. Six months after shunt insertion, MR imaging demonstrated regression of the posttraumatic syringomyelia. The patient was stable from an imaging standpoint at 16 months after shunt insertion, and she has continued to make developmental progress. The importance of treatment of associated hydrocephalus is widely recognized in the management of syringomyelia associated with the Chiari malformations. It should be considered in the management of posttraumatic syringomyelia as well.

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Detected and overlooked cervical spine injury among comatose trauma patients: from the Pennsylvania trauma outcomes study

Joseph H. Piatt Jr.

Object

A rule for identifying patients with traumatic brain injury (TBI) who are at exceptionally low risk of cervical spine injury might be clinically useful. The goal in this study was to research case records to determine whether such a rule would be practicable.

Methods

The Pennsylvania Trauma Outcomes Study database was used to find patients with TBI in whom Glasgow Coma Scale (GCS) scores at admission were 8 or less. Cases of cervical spine injury were identified from diagnostic codes. Associations between these injuries and a variety of clinical variables were tested using chi-square analysis. The probability of a cervical spine injury in these patients was modeled by logistic regression. Decision tree models were constructed and statistical determinants of overlooked cervical spine injury were examined.

The prevalence of cervical spine injury among 41,142 cases of TBI was 8%. The mechanism of injury, presence of thoracolumbosacral (TLS) spinal, limb and/or facial fracture, patient age, GCS score at admission, and the presence of hypotension were all factors associated with cervical spine injury. These were incorporated into the following logistic regression model: probability of cervical spine injury = 1/(1 + exp[4.030 − 0.417*mechanism − 0.264*age − 0.678*TLS − 0.299*limb + 0.218*GCS score − 0.231*hypotension − 0.157*facial]).

This model yielded a rule for clearance of 28% of cases, with a negative predictive value (NPV) of 97%. Decision tree analysis yielded an easily stated rule for clearance of 24% of cases, with an NPV of 98.2%. The prevalence of overlooked cervical spine injury among all patients with severe TBI was 0.3%; the prevalence of overlooked cervical spine injury among patients in whom it was later diagnosed was 3.9%. Overlooked cervical spine injury was less common among patients with associated TLS fractures (odds ratio 0.453, 95% confidence interval 0.245–0.837).

Conclusions

No acceptable rule for relaxation of vigilance in the search for cervical spine injury among patients with severe TBI has been identified. Levels of provider vigilance and consequent rates of overlooked cervical spine injury can be affected by environmental cues and presumably by other behavioral and organizational factors.

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Peritoneal cerebrospinal fluid shunt insertion: a technique for protection of the abdominal catheter

Technical note

Joseph H. Piatt Jr.

✓ A minor modification of the technique of peritoneal cerebrospinal fluid shunt insertion allows more anatomical closure of the abdominal wound and may protect the shunt from contamination by superficial abdominal wound infection.

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A pitfall in the diagnosis of child abuse: external hydrocephalus, subdural hematoma, and retinal hemorrhages

Joseph H. Piatt Jr

External hydrocephalus has been associated with subdural hematomas in infancy, and the hematomas have been noted to be secondary to minor trauma or have even been described as spontaneous. The author reports the case of an infant with external hydrocephalus who developed retinal as well as subdural hemorrhages after sustaining a minor head injury. Although retinal hemorrhage in infancy has been considered virtually pathognomonic of child abuse, in the setting of external hydrocephalus a more cautious interpretation may be appropriate.