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Joseph Piatt

OBJECTIVE

Penetrating injury of the spine in childhood commonly causes profound and life-long disability, but it has been the object of very little study. The goal of the current report is to document temporal trends in the nationwide incidence of this condition and to highlight the differences between penetrating injuries and closed injuries.

METHODS

The Kids’ Inpatient Database was queried for spinal injuries in 1997, 2000, 2003, 2006, 2009, and 2012. Penetrating mechanism was determined by diagnostic coding for open injuries and by mechanistic codes for projectiles and knives. Nationwide annual incidences were calculated using weights provided for this purpose. Unweighted data were used as a cross-sectional sample to compare closed and penetrating injuries with respect to demographic and clinical factors. The effect of penetrating mechanism was analyzed in statistical models of death, adverse discharge, and length of stay (LOS).

RESULTS

The nationwide incidence of penetrating spinal injury in patients less than 18 years of age trended downward over the study period. Patients with penetrating injury were older and much more predominantly male than patients with closed injuries. They resided predominantly in zip codes with lower median household incomes, and they were much more likely to have public health insurance or none at all. They were predominantly black or Hispanic. The risk of hospital death was no different, but penetrating injuries were associated with much higher rates of adverse discharge after LOS, averaging twice as long as closed injuries. Brain, visceral, and vascular injuries were powerful predictors of hospital death, as was upper cervical level of injury. The most powerful predictor of adverse discharge and LOS was spinal cord injury, followed by brain, visceral, and vascular injury and penetrating mechanism.

CONCLUSIONS

Because its pathophysiology requires no elucidation, because the consequences for quality of life are dire, and because the population at risk is well defined, penetrating spinal injury in childhood ought to be an attractive target for public health interventions.

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Joseph Piatt

OBJECTIVE

An implicit expectation of the pioneers of trauma system design was that high clinical volume at select centers could lead to superior outcomes. There has been little study of the regionalization of pediatric craniospinal trauma care, and whether it continues to trend in the direction of regionalization is unknown. The motivating hypothesis for this study was that trauma system design in the United States is proceeding on a rational basis, producing hospital caseloads that are increasing over time and, because of geographic siting appropriate to the needs of catchment areas, in an increasingly uniform manner.

METHODS

Data were obtained from the Kids’ Inpatient Database (KID) for 1997, 2000, 2003, 2006, 2009, and 2012. Cases of traumatic spinal injury (TSI) and severe traumatic brain injury (sTBI) were identified by ICD-9 diagnostic and procedural codes. Records of patients 18 years of age and older were excluded. Hospital caseloads and descriptive statistics were calculated for each year of the study, and trends were examined. The distributions of hospital caseloads were compared year with year and with simulations of idealized systems.

RESULTS

Caseloads of TSI trended upward and caseloads of sTBI were stable, despite a declining nationwide incidence of these conditions during the study period, so the pool of hospitals providing services for pediatric craniospinal trauma contracted to a degree. The distributions of hospital caseloads did not change, and in every year of the study large numbers of hospitals reported small numbers of discharges. In the last year of the study, a quarter of all children with TSI were discharged from hospitals that treated approximately 1 case or fewer every other month and a quarter of all children with sTBI were discharged from hospitals that treated 1 case or fewer every 3 months.

CONCLUSIONS

There has been no previous study of nationwide trends in pediatric craniospinal trauma caseloads. Analysis of hospital caseloads from 1997 through 2012 supports inference of a persisting geographical mismatch between population needs and the availability of services. These observations falsify the study hypothesis. A notable fraction of pediatric craniospinal trauma care continues to be rendered at low-caseload institutions. Novel quality assurance methods tailored to the needs of low-caseload institutions deserve development and study.

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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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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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Joseph H. Piatt Jr.

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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.

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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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Joseph H. Piatt Jr.

In this paper, the author presents 2 cases of sagittal synostosis with scaphocephaly that featured ossified scalp hematomas straddling the sagittal suture in the midparietal region. These ossified lesions were originally cephalohematomas. Collection of blood under the pericranium across the midline was possible in these cases because sagittal synostosis had obliterated the sagittal suture and its dense attachment to overlying periosteum. Scaphocephaly very likely exacerbated the difficulty of the deliveries and contributed to the causation of the scalp hemorrhages.

The alternative hypothesis, that ossification of a scalp hematoma immobilized the suture and caused synostosis, is not tenable for reasons that are reviewed. Sagittal synostosis in these 2 instances was not a complication of birth trauma.