This is an uncommon injury. But when encountered it can cause the trauma professional (and the patient) some major headaches. The majority of the vertebral artery injuries you are likely to encounter are caused by blunt trauma. They are generally diagnosed using CT angiography, and the treatment usually consists of low dose anti-platelet agents like aspirin. Occasionally, coiling or stenting using interventional radiology is needed.
But penetrating trauma is a totally different animal. Gunshot is the most common mechanism, because of the small windows available to access the artery within the vertebral canal using a knife. See the course of the artery in the picture below:
Unfortunately, this bony cage also makes it difficult to surgically approach the artery, especially if the field is continually filling with blood.
The techniques for dealing with this injury according to the doctor books are:
Send the patient to interventional radiology. Cutting off flow using coils is the preferred technique. Gelfoam and other products are not used because of the concern for distal embolization (to the brain). Stenting may be a consideration for blunt trauma, but not for penetrating.
Or, obtain proximal control by ligating the vertebral artery as it takes off from the subclavian. Hmm, this requires either a separate incision, or a supraclavicular extension of your neck incision. It takes time and is not as easy as it sounds.
Generally, the trauma surgeon stumbles upon this injury while doing a trauma neck exploration. Bleeding can be pesky, and may serve to obscure the field. My preferred method of control is:
Jam a wad of bone wax into the vertebral canal right where the bleeding is coming from.
Then jam another wad into the canal in the space below it. Proximal control!
Jam one final wad into the space above, if accessible. Distal control!
End of problem. Then do a thorough evaluation for all other injuries and address them. Feel free to share any additional tips that you may have!
I love to hate dogma. And there’s probably nothing in surgery more sacred and more ingrained than how to take care of a wound. Everybody knows that you have to keep surgical or traumatic wounds dry, and that once you can get them wet, showers are good at baths are bad. Right?
And for something as common as wound management, there must be some kind of research, right? Not so! I did quite a bit of digging through the literature since 1966 and managed to find only five papers. Here are the highlights:
A prospective study of 100 patients were randomized to shower or bathe postoperatively. Of note, the wounds were sprayed with a clear plastic dressing before getting in the water. The was no difference in infection rates.
Another prospective study of 100 patients with stapled incisions after spine surgery were allowed to bathe after 2 to 5 days. Compared to historical controls, there were no differences in infection rates even though the study patients had more complex operations than controls.
A prospective randomized study of 121 patients after hernia surgery found no difference in infection between shower and dry groups
A large randomized study of 817 patients similarly showed no difference between shower and dry groups
Another randomized trial of 170 patients showed no difference in infections between shower after 24 hours and control groups
Get the picture? And interestingly, the few wound infections documented in any of the studies tended to occur in the dry groups, although this was not statistically significant.
Bottom line: In general, it is not harmful to get a wound wet after 24 hours. We don’t know exactly why because of the paucity of the literature, but think about it. The water that we shower or bathe in is the same water that we drink. It’s very close to sterile. When we do shower or bathe, the bacteria that come in contact with the wound are our normal skin flora, which are already in and on the wound. Plus, most incisions that have been closed are water-tight within about 24 hours. It’s more likely that using soap and water is good for you because it washes away tons of bacteria, including the pathogens!
Prospective randomised trial of the early postoperative bathing. BMJ 19 in June 1976: 1506-1507, 1976.
Wound care after posterior spinal surgery. Does early grading affect the rate of wound complications? Spine (Phila PA 1976) 21(18):2160-2162, 1996.
Does a shower with postoperative wound healing at risk? Chirurg 68(7): 715-717, 1997.
Modification of postoperative wound healing by showering. Chirurg 71(2):234-236, 2000.
Postoperative wound healing in wound-water contact. Zentralbl Chir 125(2):157-160, 2000.
Delayed or missed diagnoses happen. It’s a reflection on the state of technology and our own diagnostic acumen. Unfortunately, a few cases of delayed diagnosis result in morbidity, potential lawsuits, and rarely, death.
How often does delayed diagnosis occur? A few spot check type articles were published about 15 years ago, but little has been done to slice and dice the data. And as usual, the old data ranged widely in its assessment of the incidence of this problem (1-18% !). However, I managed to find a (somewhat) more recent one that gives a little clearer picture of this issue.
A single pediatric hospital in Indiana reported its experience from 1997 to 2006. This interval included the time that it was verified as a Level II Trauma Center (2000 onwards). They included children 0-14 who had sustained “major trauma.” This was defined as multiple system injuries, high-energy impacts, and gunshots. In this study, delayed diagnosis was defined as one found after a stable patient was admitted to their room. In patients taken directly to OR, it was one found after the patient left the recovery room.
Here are the factoids:
1100 patients met study criteria. 98% were blunt trauma.
Only 44 patients had delayed diagnoses of 47 injuries
Average time to diagnosis was 4 days (range 8 hours to 28 days)
34% of diagnoses were made within 24 hours
3 diagnoses were made at a followup visit, all for upper extremity/should fractures
80% of delayed diagnoses required a change in therapy, most commonly a sling or cast. 15% required surgery.
The long-term delayed diagnosis rate was 4%
Bottom line: Delayed diagnosis remains an issue in patient of all ages. The reported 4% rate subjectively seems about right to me. The most important lesson from this study is the extremely high percentage of delayed diagnoses that required further therapy. This is why it is so important to implement a specific system (the tertiary survey) to seek out these diagnoses.
A tertiary survey is a repeat head-to-toe physical exam and a review of all radiographic imaging performed to date. The trauma center should define the time interval from admission, and I recommend no more than 24-48 hours. We do not count any diagnoses found during this exam as being delayed. However, if a tertiary exam was not performed, or injuries are found after it was completed, we do consider it delayed an run it through our performance improvement process.
A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).
Recent work looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.
Here are the factoids:
249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
Mean injury grade was 2.7, which is fairly high
Mean bedrest was 1.6 days, and mean hospital stay was 2.5
Bedrest was the limiting factor for hospital stay in 62% of cases
There were no delayed complications of the injury
Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We’ve been keeping both adults and children at bedrest only overnight, and our average length of stay for isolated solid organs is about 1.5 days. But really, who says that staying in bed for any period of time avoids complications? There are lots of other evil things that can happen!
The July Trauma MedEd Newsletter will be released to subscribers this weekend. I’ll be continuing to cover that topic no one wants to think about but everyone wants to know more about: Malpractice and trauma professionals. This issue is Part 2.
Does family presence in resuscitation affect malpractice?
Does admitting an error increase malpractice risk?