https://www.srcv.ro/en/ghiduri/Preventia%20trombembolismului%20la%20pacientii%20nonortopedici%20-%20Ghidurile%20ACCP%202012.pdf

Prevention of VTE in Nonorthopedic Surgical Patients : Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Study design Systematic review of the literature and analysis of pooled data. Objectives To better understand the incidence of thromboembolic disease in postoperative spinal patients, and to establish a starting point for defining appropriate postoperative prophylaxis protocols. Summary of background data The risk of thromboembolic disease is well studied for some orthopedic procedures. However, the incidence of postoperative thromboembolic disease is less well-defined in patients who have had spinal surgery. Methods The MEDLINE database was queried using the search terms deep venous thrombosis or DVT, pulmonary embolus, thromboembolic disease, and spinal or spine surgery. Abstracts of all identified articles were reviewed. Detailed information from eligible articles was extracted. Data were compiled and analyzed by simple summation methods when possible to stratify rates of DVT and/or pulmonary embolus for a given prophylaxis protocol, screening method, and type of spinal surgery. Results Twenty-five articles were eligible for full review. DVT risk ranged from 0.3% to 31%, varying between patient populations and methods of surveillance. Pooling data from the 25 studies, the overall rate of DVT was 2.1%. DVT rate was influenced by prophylaxis method: no prophylaxis, 2.7%; compression stockings (CS), 2.7%; pneumatic sequential compression device (PSCD), 4.6%; PSCD and CS, 1.3%; chemical anticoagulants, 0.6%; and inferior vena cava filters with/without another method of prophylaxis, 22%. DVT rate was also influenced by the method of diagnosis, ranging from 1% to 12.3%. Conclusion As risk of DVT after routine elective spinal surgery is fairly low, it seems reasonable to use CS with PSCD as a primary method of prophylaxis. There is insufficient evidence to support or refute the use of chemical anticoagulants in routine elective spinal surgery. In addition, there is insufficient evidence to suggest that screening patients undergoing elective spinal surgery with ultrasound or venogram is routinely warranted.

Thromboembolic disease in spinal surgery: a systematic review.

Die Versorgung schwerstverletzter Patienten im Schockraum bedeutet fur das multidisziplinare Behandlungsteam einen strukturierten Evaluationsprozess in einen zielgerichteten Behandlungsprozess zu uberfuhren. Neben dem Faktor Zeit und dem Erkennen vital bedrohlicher Verletzungen, die haufig unter dem Begriff „deadly six“ zusammengefasst werden, sollten aber auch sog. „Bagatellverletzungen“ nicht ubersehen werden, da sie die Lebensqualitat nach Trauma mitunter entscheidend beeinflussen konnen. Die S3-Leitlinie Polytrauma erhebt nicht den Anspruch auf Vollstandigkeit. Wichtige Inhalte, wie z. B. die Versorgung von Kindern sind bisher noch nicht in die Leitlinie eingeflossen, werden aber fur die Uberarbeitung fest eingeplant.

S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung

Traumatic injuries of the spine and spinal cord are common and potentially devastating lesions. We present a comprehensive overview of the classification of vertebral fractures, based on morphology (e.g., wedge, (bi)concave, or crush fractures) or on the mechanism of injury (flexion-compression, axial compression, flexion-distraction, or rotational fracture-dislocation lesions). The merits and limitations of different imaging techniques are discussed, including plain X-ray films, multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI) for the detection. There is growing evidence that state-of-the-art imaging techniques provide answers to some of the key questions in the management of patients with spine and spinal cord trauma: is the fracture stable or unstable? Is the fracture recent or old? Is the fracture benign or malignant? In summary, we show that high-quality radiological investigations are essential in the diagnosis and management of patients with spinal trauma.

/pdf/trauma-of-the-spine-and-spinal-cord-imaging-strategies-2p11w8pq7v.pdf

Trauma of the spine and spinal cord: imaging strategies

Study design Surgeon survey. Objective To characterize the incidence of epidural hematoma in postoperative spinal patients; to assess the effect of chemical thromboprophylaxis on the risk of epidural hematoma. Summary of background data The precise indications and/or timing of anticoagulation for thromboembolic prophylaxis following spinal surgery are not clear. Patients who endure periods of extended recumbency and limited mobility after major operative spinal interventions may be at increased risk of thromboembolic disease. Among other factors, spine surgeons must weigh the risk of a symptomatic postoperative epidural hematoma against the benefit of DVT/PE prevention when deciding to initiate chemoprophylaxis. However, the incidence of postoperative epidural hematoma is not well-known, leading to uncertainty regarding the real versus perceived risk of this complication. Methods The MEDLINE database was queried using the search terms epidural hematoma and spinal or spine surgery. Abstracts of all identified articles were reviewed. Studies were deemed eligible if they specifically documented the incidence of clinically significant epidural hematoma in a series of patients who underwent spinal surgery. Detailed information from eligible articles was extracted. Data were compiled and analyzed to examine incidences of clinically relevant postoperative epidural hematoma (i.e., resulted in new, associated neurologic deficit). Results Of 493 abstracts that were identified in the search, a total of sixteen articles were eligible for full review. From this review, the range of reported incidences of epidural hematoma in the literature ranges from 0% to 0.7% in studies where patients received chemical anticoagulation and 0% and 1% in all of the included studies. In no study was the incidence of clinically relevant epidural hematoma greater than 1%. Conclusion The catastrophic morbidity of a symptomatic postoperative epidural hematoma remains a substantial disincentive to start chemoprophylaxis after spinal surgery. The rarity of this complication makes study of its risk factors difficult. Although many surgeons perceive the risk to be higher, the reported incidences of clinically relevant postoperative epidural hematoma are lower, ranging from 0% to 1%. Despite this finding, there is insufficient published data available to precisely define the safety of postoperative chemoprophylaxis. Though not pertaining to prophylaxis, the available evidence does suggest that use of therapeutic doses of heparin in postoperative spinal patients who sustain a PE may have a higher incidence of bleeding complications.

Postoperative spinal epidural hematoma: a systematic review.

Clearing the cervical spine in polytrauma patients still presents a challenge to the trauma team. The risk of an overlooked cervical spine injury is substantial since these patients show painful and life-threatening injuries to one or more organ systems so that clinical examination is usually not reliable. A generally approved guideline to assess the cervical spine in polytrauma patients might significantly reduce delays in diagnosis, but a consistent protocol for evaluating the cervical spine has not been uniformly accepted or followed by clinicians. One purpose of this study was to analyse the common methods for cervical spine evaluation in critically injured patients and its safety and efficacy at this trauma centre. The second purpose was to present a comprehensive diagnostic C-spine protocol, based on the authors' experiences with documented cases. From a prospectively gathered polytrauma database, we retrospectively analysed the clinical records of all polytrauma patients, with skeletal and/or non-skeletal cervical spine injuries, who were admitted to this level I trauma centre between 1980 and 2004. All patients were assessed following the trauma algorithm of our unit (modified by Nast-Kolb). Standard radiological evaluation of the cervical spine consisted of either a single lateral view or a three-view cervical spine series (anteroposterior, lateral, odontoid). Further radiological examinations (functional flexion/extension views, oblique views, CT scan, MRI) were carried out for clinical suspicion of an injury or when indicated by the standard radiographs. Sixteen patients (14%) had a single cross-table lateral view for radiological assessment of the cervical spine during initial trauma evaluation, Twenty-nine patients had a three-view cervical spine series (anteroposterior, lateral, odontoid) and 81 patients underwent extended radiological examinations by cervical CT scan (n=52), functional flexion/extension views (n=26) or MRI (n=3). Correct diagnosis was made in 107 patients (91%) during primary trauma evaluation, whereas in 11 patients (9%) our approach to clear the cervical spine failed to detect significant cervical spine injuries. In six patients skeletal injuries were missed by a single lateral view and in two patients by a three-view standard series because inadequate radiographs with poor technical quality or incomplete visualization of the cervical spine did not show the extent of the injury. In three cases ligamentous injuries were missed despite complete sets of standard radiographs and cervical CT scan, but without functional radiography. Common methods for cervical spine evaluation in critically injured patients were plain radiographs, cervical CT scan and functional flexion/extension views. Cervical CT scan was the most efficient imaging tool in detecting skeletal injuries, showing a sensitivity of 100%. A single cross-table lateral view appeared to be insufficient, as we found a sensitivity of only 63%. Functional radiography or MRI was also necessary, as plain radiographs and CT scan failed to detect significant ligamentous injuries in 6% of the patients. For more comprehensive assessment of the C-spine, we presented a new C-spine protocol based on the authors' experiences, with the aim to avoid unnecessary delays in diagnosis.

Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis.

Background Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomat...

Thromboembolic complications after spinal surgery in trauma patients

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Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis.

Thromboembolic complications after spinal surgery in trauma patients