For those readers not familiar with Dr. Alex Vaccaro, he is the Everrett J. and Marion Gordon Professor of Orthopaedic Surgery and Professor of Neurosurgery at Thomas Jefferson University in Philadelphia, Pennsylvania. He was the recipient of the Leon Wiltse award given for excellence in leadership and clinical research for spine care by the North American Spine Society (NASS) and is the past President of the American Spinal Injury Association and current President of the Association for Collaborative Spine Research. Dr. Vaccaro has over 530 peer reviewed and 195 non-peer reviewed publications. He has published over 300 book chapters and is the editor of over 44 textbooks and co-editor of OKU-Spine I and editor of OKU-8. Dr. Vaccaro is Vice Chairman of the department of Orthopaedic Surgery, Co-Director of the Regional Spinal Cord Injury Center of the Delaware Valley and Co-Director of Spine Surgery and the Spine Fellowship program at Thomas Jefferson University Hospital where he instructs current fellows and residents in the diagnosis and treatment of various spinal problems and disorders.
In light of the increase in spinal trauma during the summer months and the rural nature of many areas in Texas, Dr. Alex Vaccaro offered his insights into the types of injuries that occur, the best practices for improved patient outcomes, and trends in spinal care. The main sources of these injuries are sports, automobile, and water injuries. How patients are stabilized and treated can have a significant impact on cost and the provider’s revenue cycle.
RR: A great deal of spine trauma occurs in the summer, what types of injuries are the most common?
AV: There are more motor vehicles accidents because of travel and the summer holidays. In automobile accidents, the most common area to be fractured is the thoraco-lumbar spine. Thoraco-lumbar compression fractures are the most common, followed by flexion/distration injuries and damage to the cervical spine. Flexion/distraction injuries can take the form of a ligamentous injury and/or a fracture, which is often referred to as a Chance fracture. According to the American Academy of Orthopaedic Surgeons, “[m]en experience fractures of the thoracic or lumbar spine four times more often than women.”
More water related injuries are also seen. Cervical spine axial-compression and axial-dislocation fractures. These often result from diving or boating injuries where people dive into shallow water and hit their head-first. Hence, causing the cervical spine to compress.
I mostly interact with primary care physicians on two occasions: (1) if you have treated them; and (2) if the pc physician has called you for a consult.
RR: Through your research and experience, what are the most effective ways increase better outcomes for spine trauma patients?
AV: There are two key components: stabilization and having surgery within 24-hours of injury. For physicians and other medical professionals who are not at a trauma level facility, they key is stabilization and getting the patient transported to a spine trauma facility as safely and quickly as possible. The most common practice is to utilize a hardboard and collar with side-neck mounts and a forehead strap to prevent head rotation during transportation to a Spinal Cord Center. Traction is not administered at the initial site; however, it is always used in a spinal trauma of the cervical spine once the patient reaches the higher-level care facility. A similar process is used for a thoracic and lumbar spine. Overall, the patient is packaged, stabilized and sent to higher-level center right away.
The next step is to get the patient to the operating room. In the retrospective Surgical Treatment of Acute Spinal Cord Injury Study (“STASCIS”), we discovered that if we operated within 24 hours then patients had a significant increase in neurologic outcome. There were three arms of the study and steroid use was accounted for.
A major area of spinal cord injury treatment is under attack at the present time. Previously, all patients were treated with steroids. Now, the benefit of steroid use has been viewed in a negative light by CNS/AANS. It has been concluded that steroid use poses just as much risk to the patient as the intended benefit to the patient. Outside of steroid-use, there is no other proven medicinal method for the treatment of acute spinal cord injuries. (http://www.medscape.com/viewarticle/781669).
RR: What are some general items you deal with in your daily practice, as well as current trends in spinal cord injury treatment?
AV: As more experience is gained with the spine, it is becoming less invasive. It is similar to what happened with knee surgery. What used to be one large incision is now a series of smaller incisions, which preserves soft tissue.
What we are discussing in terms of informed consent, treatment and expected outcomes are the most frequent bioethics discussions. The main issue is whether we have reasonable assurances that the patients and their families do understand what informed consent means and the nuances of the surgery, even if they say yes.
Written by: Rachel V. Rose, JD, MBA
Written by: Rachel V. Rose, JD, MBA
