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68 T. F. VanderHeiden, S. E. Smith and P. F. Stahel
Fig. 4. Injury Classification. Modified AO classification of spine fractures. This worksheet
includes determination of the fracture type, assessment of stability, neurological status, and
treatment recommendation. A-type injuries result from mainly axial forces applied to the
spinal column and produce anterior and middle column injuries (“A” = axial). B-type injuries
involve bending forces that can couple both compression and tension depending on the
location of the center-of-rotation (“B” = bending). The posterior ligamentous complex (PLC)
is typically ruptured in these injuries. C-type injuries involve multidirectional forces and
produce highly unstable injuries involving 360° of the spinal column (“C” = circle), including rupture of the PLC. When spine surgeons couple these fracture mechanisms, the
morphology of the injury, along with the neurological status of the patient, it can become
straight-forward to determine stability and incorporate a surgical treatment strategy.
Spine Trauma: Diagnosis, Clearance, and Mobility 69
Table 1. Injury scoring system. The thoracolumbar injury
classification and severity score (TLICSS) can help the spine surgeon determine the need for surgical intervention.
Score
Fracture Morphology
Compression Injury 1
Burst Fracture +1 = 2
Translational/Rotational Injury 3
Distraction Injury 4
Neurological Injury
Intact 0
Nerve-root Injury 2
Complete Injury 2
Incomplete Injury 3
Cauda Equina Injury 3
Posterior Ligamentous Complex
Intact PLC 0
Injury Suspected in PLC 2
Injured PLC 3
Summation Total score
NonOperative Zone
“Grey” Zone
Operative Zone
< 4
= 4
> 4
Review of Current Literature with References
• A meta-analysis of almost 15,000 patients done by Pancyzkowski et al., pub-
lished in the Journal of Neurosurgery, determined that removing the rigid
cervical immobilizer in obtunded patients is reasonable and safe so long as the
CT scan of the cervical spine was negative for acute injury. MRI was deemed
unnecessary in this situation [Panczykowski DM, Tomycz ND, Okonkwo DO,
“Comparative effectiveness of using computed tomography alone to exclude
cervical spine injuries in obtunded or intubated patients: meta-analysis of
14,327 patients with blunt trauma.” J Neurosurg (2011); 115: 541–549].
70 T. F. VanderHeiden, S. E. Smith and P. F. Stahel
• A retrospective cohort study of nearly 400 patients at a single institution
showed that CT scan of the cervical spine identified all unstable spinal injuries. Furthermore, the investigators concluded that clearing the spine does not
require further radiographs once a CT scan is determined to exclude acute
injury. In fact, obtaining upright X-rays delayed spinal clearance in a large
proportion of patients [Harris TJ, Blackmore CC, Mirza SK, Jurkovich GJ,
“Clearing the cervical spine in obtunded patients.” Spine (Phila Pa 1976)
(2008); 15; 33: 1547–1553].
• A retrospective cohort study at a single institution analyzing data from nearly
700 patients showed that MRI scan was not necessary to clear the cervical
spine in patients with normal trauma cervical CT scans using modern imaging
protocols. In reviewing data from patients that had an MRI scan of the cervical spine contemporaneously, 21% of patients had injuries diagnosed by MRI
that were not identified on the CT scan. However, none of those patients had
unstable injuries, none of those patient required surgical treatment, and none
of those patients developed instability [Tomycz ND, Chew BG, Chang YF,
Darby JM, Gunn SR, Nicholas DH, Ochoa JB, Peitzman AB, Schwartz E,
Pape HC, Spiro RM, Okonkwo DO, “MRI is unnecessary to clear the cervical
spine in obtunded/comatose trauma patients: the four-year experience of a
level I trauma center.” J Trauma (2008); 64: 1258–1263].
• A very recent cross-sectional, observational study evaluating the concept of
cervical “spinal clearance” protocols at United States Level 1 Trauma Centers
showed that this idea is still a highly-debated, controversial, and challenging
topic with immense variability. The paper does show the importance of
dividing trauma patients into groups and utilizing a step-wise, algorithmic
approach to spinal clearance. It also addresses the interesting topic of evaluating
patients with ongoing neck pain despite negative imaging [Theologis AA,
Dionisio R, Mackersie R, McClellan RT, Pekmezci M, “Cervical spine clearance protocols in level I trauma centers in the United States.” Spine (Phila Pa
1976) (2013) (Epub ahead of print)].
• Early spinal fixation and stabilization is the rule for managing unstable
spinal trauma in critically injured patients. The DHMC spine team recommends surgery within 24-hours of injury (“ Spine-Damage-Control”) to
enable the best results for avoiding complications in these highly injured
patients. A prospective cohort study shows that this treatment approach
significantly decreases length of hospitalization, ventilator dependent days,
and other complications [Stahel PF, VanderHeiden TF, Flierl MA, Matava B,
Gerhardt DC, Bolles G, Beauchamp K, Burlew CC, Johnson JL, Moore EE,
“The impact of a standardized ‘spine-damage-control’ protocol for unstable
Spine Trauma: Diagnosis, Clearance, and Mobility 71
thoracic and lumbar spine fractures in severely injured patients: a prospective cohort study.” J Trauma Acute Care Surg (2013); 74: 590–596].
• Accurate diagnosis and classification of spinal injuries helps to guide treat-
ment of critically injured patients. As such, the impact of utilizing classification
systems is widely appreciated amongst spinal surgeons. The Thoracolumbar
Injury Classification and Severity Scale (TLICSS Score) has proven to be a
valid instrument with which to help guide treatment. A retrospective cohort
study confirmed the efficacy and validity of this tool as it helped provide
successful treatment decisions for spinal trauma patients as well as diminished the need to convert to surgical management in patients initially treated
non-operatively [Joaquim AF, Lawrence B, Daubs M, Brodke D, Tedeschi H,
Vaccaro AR, Patel AA, “Measuring the impact of the Thoracolumbar Injury
Classification and Severity Score among 458 consecutively treated patients.”
J Spinal Cord Med (2014); 37: 101–106].
• The use of steroid protocols after acute spinal cord injury was long considered
the standard of care in view that there was a perceived benefit from methylprednisolone on neurological recovery. However, more recent data suggest
that there is in fact no significant benefit in neurological recovery for patients
suffering acute spinal cord injury that receive steroids [Ito Y, Sugimoto Y,
Tomioka M, Kai N, Tanaka M, “Does high-dose methylprednisolone sodium
succinate really improve neurological status in patient with acute cervical
cord injury?: A prospective study about neurological recovery and early complications.” Spine (Phila Pa 1976) (2009); 34: 2121–2124]. Furthermore, it
appears that patients receiving steroid infusions after acute spinal cord injury
suffer from more complications. These include infections, gastrointestinal
complications, and most significantly, pulmonary compromise [Matsumoto T,
Tamaki T, Kawakami M, Yoshida M, Ando M, Yamada H, “Early complications of high-dose methylprednisolone sodium succinate treatment in the
follow-up of acute cervical spinal cord injury.” Spine (Phila Pa 1976) (2001);
26: 426–430]. As such, DHMC Critical Care providers and Spinal Surgeons
avoid the use of steroid administration protocols for acute spinal cord injury.
In place of these protocols, early surgical intervention is employed.
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Chapter 4-(iv)
Surgical Critical Care
and Behavioral Health
Thomas M. Dunn, PhD* and Abraham M. Nussbaum, MD
†
* Greeley Clinical Instructor of Psychiatry, University of Colorado School of Medicine
†
Assistant Professor of Psychiatry, University of Colorado School of Medicine
Take Home Points
• Mental illness and psychological distress commonly occur in surgical
patients.
{ With high base rates of mental illness in the general population, it is
inevitable that such patients will develop a co-occurring condition requiring surgical intervention.
{ Patients who have harmed themselves as a result of a mental illness often
have surgical needs.
Contact information: Denver Health, 777 Bannock Street, MC 0490, Denver, CO 80204;
Email: Thomas.Dunn@dhha.org; Abraham.Nussbaum@dhha.org
73
74 T. M. Dunn and A. M. Nussbaum
• Often, the need for surgery is precipitated by a traumatic event, leaving surgical
patients particularly vulnerable to stress responses and mood disruption.
{ Both mental illness and psychological stress are treatable in the critical
surgical patient.
• The most commonly occurring acute psychiatric presentation in surgical
patients is delirium.
{ Delirium is a life-threatening condition associated with prolonged
hospital stays and poorer outcomes.
{ It is commonly overlooked due to its waxing and waning nature.
• While the surgical team can manage many preexisting psychiatric conditions,
in some instances a formal psychiatric consult may be indicated.
{ If a patient with a serious mental illness is not currently receiving ade-
quate treatment.
{ If a patient requires surgical intervention because of behavior related to
his or her mental illness.
Suicide attempts
Self-mutilation
Lack of self-care leading to surgical emergency
{ Those patients, or their families, spouses or partners, who request consul-
tation from a psychiatrist or psychologist.
{ Patients currently enrolled in a methadone treatment program for opioid
addiction.
Background
• Mental illness is quite prevalent in the U.S.; the National Institute of Mental
Health estimates that in a given year, 1 in 4 adults suffers from symptoms
meeting criteria for a mental disorder.
{ There are often co-occurring mental disorders; nearly half of all persons
with mental illness cope with two or more conditions.
{ Severity of these conditions is often directly related to the degree of stress
the patient is experiencing.
Severe medical problems can worsen some mental disorders.
Exacerbation of preexisting mental illness, particularly depression,
can impair a patient’s ability to follow a postoperative regimen.
Surgical Critical Care and Behavioral Health 75
{ Rarely, however, does mental illness present for the first time during a
surgical admission. The surgeon should be wary of the patient who
acutely develops severe symptoms of mental illness after surgery.
Sudden psychosis and agitation is likely delirium or the effect of a
psychoactive substance. Delirium is often secondary to post-surgical
complication, such as infection. Organic causes should be ruled out
before attributing psychosis to a primary psychiatric condition.
Depression symptoms may be an acute stress response.
Nightmares and anxiety may suggest acute stress.
• Substance use disorders are also quite common and likely to be minimized by
the patient.
{ Withdrawal from alcohol can be quite severe and seriously complicate a
surgical course.
{ Some patients may continue to use drugs of abuse while admitted.
{ The latest (5
th
) edition of the Diagnostic and Statistical Manual of the
American Psychiatric Association, the DSM, no longer distinguishes
between substance abuse and substance dependence.
Collectively known as “substance use disorders.”
• While self-harm behavior makes up only a small percentage of overall psy-
chiatric patients, they are over-represented in surgical settings.
{ Nearly a third of individuals attempting suicide will do so using an injuri-
ous mechanism, most often cutting or stabbing, firearms, hanging, or
jumps from heights.
{ Individuals suffering from self-inflicted trauma are believed to be incapa-
ble of refusing surgical care.
{ All states have specific laws addressing the involuntary psychiatric treat-
ment of suicidal patients.
Many of these laws specify a very short period of time (in many states,
72 hours) that an individual can be hospitalized involuntarily.
Main Body
• Delirium
{ May occur in up to 80% of intensive care unit patients, with postoperative
patients particularly susceptible.
{ The most common acute psychiatric condition in the surgical setting.
76 T. M. Dunn and A. M. Nussbaum
Associated with increased mortality and length of stay.
Significant burden on nursing staff.
Less than half of those who become delirious will return to their base-
line cognitive functioning and the one-year mortality rate is
approximately 35%.
Delirium is often misidentified early in its course.
Although typically lasting a few days, some cases may take up to eight
weeks to resolve.
Early identification and intervention is critical.
{ Defining features
Abrupt disturbance in attention and awareness developing in hours to
days.
An accompanying cognitive deficit (often in language, memory or
perception, sleep/wake functioning).
A waxing and waning presentation.
{ Classically, delirium will present in one of three states:
Hyperactive: Agitation, restlessness, over-activity.
Hypoactive: Lethargy, somnolence, under-activity.
Mixed State: Features of both.
{ Hyperactive delirium may present with combativeness, hallucinations,
restlessness, pressured speech/shouting, singing, anger/irritability, wandering, distractibility, etc.
Often confused with psychosis, or being irritable at baseline.
{ Hypoactive delirium may present as poverty of speech, staring for long
periods of time, decreased activity, and significant apathy.
Often confused with depression or negativity.
{ The pathophysiology of delirium is very complicated, but likely due to a
poverty of acetylcholine and/or an excess of dopamine.
Usually secondary to multiple etiologies (including disease states and
neural insults).
{ Identifying delirium
There are commercially available screening instruments; the richmond
agitation sedation scale (RASS) and the confusion assessment
method intensive care unit (CAM-ICU) are commonly in use.
Surgical Critical Care and Behavioral Health 77
Because of its sudden onset, as well as its tendency to wax and wane,
the surgeon is unlikely to be the first to become aware that the patient
is having trouble.
Ö Typically nursing or family members are the first to notice.
{ Risk factors for delirium (acronym is I WATCH DEATH)
Infection
Withdrawal from alcohol and benzodiazepines
Acute metabolic abnormalities
Trauma — particularly brain injury, factures and burns
CNS pathology, including seizures, intracranial bleeding, space occu-
pying lesions
Hypoxia
Deficiencies, particularly thiamine
Endocrinopathies
Acute vascular disturbances, such as hypertensive encephalopathy
Toxins/drugs, including drugs of abuse, opioids, benzodiazepines, and
drugs with anticholinergic properties
Heavy metals, such as lead poisoning
{ Additional risk factors for delirium
Multiple indwelling catheters
Immobility
Age ≥ 65
Sensory impairment (e.g. blindness or deafness)
Premorbid neural insults, including severe mental illness, develop-
mental delay, severe substance use, traumatic brain injury.
Severity of illness: Those with APACHE II scores of 18 and higher
often transition to delirium.
{ Treatment of delirium tends to be broken down into nonpharmacological
and pharmacological approaches.
{ Nonpharmacological treatment of delirium:
Be vigilant for delirium, SICU nurses should be specifically trained to
be aware of this condition.
Ö There are several screening instruments available to identify and
rate severity of delirium, including CAM and CAM-ICU.