Listen to Sarah Gill, Editor-in-Chief Professor Ben Ollivere and Deputy Editor Brett Rocos discuss the August issue of Bone & Joint 360 in the first episode of BJ360 Podcasts. This includes an insight into the August Feature and discussions of four papers highlighted by Brett.
Listen to Sarah Gill, Editor-in-Chief Professor Ben Ollivere and Deputy Editor Brett Rocos discuss the August issue of Bone & Joint 360 in the first episode of BJ360 Podcasts. This includes an insight into the August Feature and discussions of four papers highlighted by Brett.
[00:00:00] Welcome to the BJ360 Podcast. This is the inaugural September 2020 episode. I'm Sarah Gill, Orthopedic Trauma Consultant at the Queen Elizabeth University hospital in Glasgow. And I'm delighted to be hosting this podcast. Our plan is to have a monthly podcast alternating between a journal club discussion of the papers in the recent 360 issue and a round table discussion on topics that affect our day-to-day clinical practice that we really hope will be of interest to our listenership.
Whether you're joining us on your daily commutes or your weekend jog, or just waiting for that quick spinal unblock to cook, we're very grateful that you've seen time to listen. It only seems polite and frankly, sensible to commence the podcast by asking to have the BJ360 editorial team to join me today.
And that is Mr. Brett Rocos and Professor Ben Oliverre. Brett is currently the senior neuro-orthopedic spine fellow in Toronto Western hospital. He previously completed a [00:01:00] spine and trauma fellowship also in Toronto and finished his training in Bristol in 2019. He's involved in the XR Medics Group, providing medical support to many varied extreme sports races.
And I'm told that it's in fact where he first met our second panel member who barely needs an introduction. Professor Ben Oliverre is a professor in Trauma & Orthopedics at Queens Medical Centre in Nottingham. He's the editor-in-chief for 360 and a full-time trauma surgeon with a specific interest in trauma frames and nonunions. And as well as having contributed a huge amount to large multicentre studies of last few years, he has certainly contributed a lot to the emerging rib fracture fixation practice in the UK.
In the first half of the September episode, we're going to ask Mr. Brett Rocos for three papers of highlights from the August edition of the BJ360, and then we're going to discuss in detail the people he selected, which addresses the question of trauma of [00:02:00] complete traumatic spinal cord injury. I'd like to start off today's podcast just by drawing attention to the Feature from the August 2020 BJ360.
And this really looked at the somewhat unpopular topic, I'm sure, of litigation and claims. The way this has been looked at by John Mason, who's the clinical lead for litigation as part of the golf programme. Is that programme's contribution to how claims have changed over the years in relation to Trauma & Orthopedics.
And the good news is that there's been a drop in the number of claims and costs associated with those claims over the last four years in T&O, which is not what we've seen in other surgical disciplines. And I think that's very encouraging, but one of the key things I actually took away from this piece is that only a third of claims relate to a previously lodged complaint or critical incident. And that really made me think about how we use our M&Ms and how we collect M & M data. I think it's a very sensitive subject, obviously claims made against clinicians are made against [00:03:00] departments, but the key message here is that unless that information is being shared as part of M & M and lessons are being learned, then we might be really robbing ourselves of what is really useful information going forward and improving our practice in relation to patients.
So this was a very positive piece. It really looks like Godphers puts us ahead of the curve in orthopedics and articulates what we already know, which is that learning from claims and incidents is really important in improving patient care. And it really relies on robust, local systematic practices. And that manager engagement in that dialogue is essential. So it really made me think about going back to the department. I'm looking at how we manage our M & M data.
I think that's all right, Sarah. I think it's one of those kind of dark secrets. Isn't it? The people try and hide in the corner, the number of claims that are going on and that sort of stuff. And it is really difficult when one comes in, you know, personally I've had a couple over the years and they've kept protected from it as a trainee. And then you start as a consultant and you find some, there's all these complaints, you sort of try [00:04:00] and deal with them and, you know, often they're unfair and so on, but actually the truth is that the complaint leads to the claim. And if you recognize the complaint, it's not necessarily accepting guilt, but there's patterns of behavior that result in complaints and actually minimizing those seems a sensible thing to do. And I think that's a really good message from the paper. And I agree with you, you know, complaints are very rarely discussed M & M you know, who wants to go through their dirty laundry, so to speak?
Yeah. I mean, in spines, we're certainly acutely aware of the risks that we're undertaking and complaints will be passed out. And if you look at the business literature, we know that for every one complaint we receive, there's eight to ten that are considered by somebody that aren't submitted.
So people are aware that these mistakes and problems are occurring. They're just not getting around to submitting complaints. The other thing is to come back to Ben's point there about, you know, as a trainee we don't have a concept of how complaints and, and claims and so on moves through the system and how to not just prevent them, but how to [00:05:00] address them as an inevitable part of practice and incorporating that into the M & M process.
We're invariably that the trainees are involved, I think is key. And it will be a key part of the proclaiming for consultant practice shift. We're seeing in the syllabus for trainees.
Yeah, I think they're really interesting highlights, particularly as you say, the bridge between sort of trainee and then yeah. We're moving into consultantship and I think it very much does feel like the dirty laundry and that's where I think maybe management facilitation of those discussions, it's very easy to say nonjudgmental way, et cetera, but I think it's actually violent, you know, vital rather for the integrity of the process.
And I think it's something that, you know, certainly I think we could all look at probably most departments is how we deal with that.
Right. So if we come to you next, your papers to highlights.
Yeah, absolutely. So I'm always impressed when we go through the papers that we choose, that those, as you say, that have a direct impact on practice and always catches my eye, the negative [00:06:00] results, because I think too many too often that papers are published.
So the three I've chosen they're two spine predictably and one actually from the oncology lit.
Sure.
The first I've looked at is a study out of Taipei, Taiwan, that compares incubation with nasal tracheal intubation. When you're doing tear cervical decompressions and fusions.
We know that things like hoarse voice and dysphagia things following surgery are really common. And what this paper has done is compared two groups with 55 and each patient with orotracheal intubation. And nasal tracheal intubation. A really simple method of technology, everything else, all being equal, cuff pressures in place to the same pressure and so on.
But what they've shown is that the nasal tracheal tubes actually gives you a lower impact of a low incidence of dysphagia and hoarseness of voice. And from my own experience, I know that this is something that patients were alarmed with the moment they wake up. And so anything that reduces the instance of that complication, I think is really useful.
It's not something we typically consider, but it's something we can [00:07:00] direct our anesthetic colleagues towards and say, Hey, you know, have you thought of this? It's a really practical tip and there's some decent evidence to support it. And it's pretty robust paper. So I'd certainly recommend anybody who's involved in that sort of practice looking at it.
The second paper that drew my attention is actually quite a short paper and again, very practical. It's again spine, and it talks about how, if we start cases later in the day, how those cases cost more money, take longer and have a higher rate of complication. And this is a retrospective analysis and they looked at over three and a half thousand patients who were elective patients who had ACD and posterior cervical decompression and fusion over eight years. And they divided them into those cases that started before or after 2:00 PM.
And what they found was that when they conducted sub analysis, the patients under oing the surgery in the later group were more likely to be discharged at somewhere other than their own home. Or were more likely to return to the operating theater during their initial stay for a complication, wound complication or hematoma or something like that. And were more [00:08:00] likely to return to the emergency department within three months following surgery.
They've concluded that actually better scheduling is a way to decrease utilization and costs. I suspect that it's slightly more complicated than that of just saying, well, you know, before or after lunch, but it starts to really lend evidence to recognize that actually we are human. We do get tired starting later in the day. You know, its not always a great idea for these more complicated patients. And maybe it's something, again, we need to draw, draw attention of our theater, scheduling staff and, and so on towards just being a bit more cognizant of, of what cases we're doing when.
And lastly, and somewhat perhaps atypically I've taken something from the oncology literature. And this just appealed to me because I thought this is a, it's a great study that's going to influence care. And what this group out of Columbus in the USA have done, they have looked at neoadjuvant radiation and improving the negative margin resection and sarcoma in the extremity. And what they've done is they've taken 1400 patients from the US cancer database and they've conducted a sub analysis, looking at those who went underwent neoadjuvant, [00:09:00] adjuvant, and no radiotherapy prior to extremity sarcoma, and actually found that neoadjuvant therapy led to a great high frequency of negative margins, but didn't influence survival at all in this group.
They showed that radiation at any point during the treatment reduces local recurrences, which I suppose stands to reason that goes alongside the existing literature. But I thought that, you know, actually this is a group that stood up on their pedestal and said, actually, neoadjuvant, radiotherapy goes with all the others, but actually doesn't really improve survival compared to normal treatment. Maybe it compromises a postoperative wound care. But actually they, they pinned that hat on the wall and said improves resection, but not the survival. So perhaps it's something to think about. But as I say, you know, a negative result is still a useful results. And I think it's going to influence the treatment of these patients with extremity sarcoma.
Yeah, fantastic. Yeah, really succinct. Some are very complex papers, so thank you. Thanks very much for that Brett.
Right. We're going to move on to the sort of the [00:10:00] main course as it were. So Brett, you have chosen a spinal paper that talks about essentially complete traumatic spinal cord injuries. And I found this paper really fascinating as someone who has no spinal practice, but is, you know, obviously involved in patients around the peripheries in terms of the multiply injured patient, et cetera. So I was really interested by this paper and really interested to get your take on it.
Yeah. Yeah. So it's, you know, spinal cord injury, you know, across the UK, it's really centralized in regional centers as well, but I think, yes. I mean, I would certainly expect they're real trainee and if not a consultant involved in trauma care to be aware of. You know, going back over the last decade or so, there's been a lot of interest and some really good quality studies looking at traumatic spinal cord injury.
And this paper out of Amsterdam really has sought to bring all those together in almost a narrative review type format. And what they've done is looked at the outcomes of traumatic spinal cord injury with a complete asia A injury [00:11:00] in the cervical the thoracic and especially the cauda equina and they've taken each of those in subsections and looked at how useful early decompression is when tackling each of those.
Now of course the cervical spine, we all know is the most vulnerable to complete spinal cord injury. And that's probably the most well-trodden roots, looking back to something fairly landmark, like the Stacy's trial back in 2012, which almost comprehensively proved that early decompression was the way to go to improve the spinal cord recovery by one to two levels, which can be the difference between being institutionalized and, you know, independent at home. If you look at something from a four to a six and so on.
What really caught my eye with this paper was actually that they looked at the evidence for the thoracic cord and the lumber and conus. And the reason that's interesting is there's a lot less evidence for this. So they looked at the thoracic cord and found that, you know, up to 34% of people with cervical spine had total cord injury but within the thoracic spine that's much less well [00:12:00] defined and yeah, but somewhere between 16 and 73%, so quite a wide range, and *inaudible* up to 70% of polytrauma patients have a degree of thoracic spine injury. So it's something we all need to know about.
At one year, those patients with a thoracic Asia A, 89.3 they've quoted. So now 90% of patients with a thoracic total cord injury will stay with an ASIA A. Then they're not going to improve really a great deal. Though they've said the mean recovery is between 0.1 to 4.5 points at one year after injury. And that's referring to the ASIA score. You know, again, it's a wide range and the vast majority will not make an improvement, regardless of whether you decompress early or late.
When it comes to the conus and the cauda equinas, this is where it gets really interesting because picking those two conflicting diagnoses apart is in practice very difficult to do and notoriously the conus medullaris syndrome is it has an enormously variable presentation. And some centres will treat that as a cauda [00:13:00] equina urgent decompression, and others will leave it to recover on its own.
If you have an injury to the conus or the cauda equina, this paper quotes 21% of patients will present with a complete lack of motor and sensory function. That's probably less than my experience. I would say it's probably slightly lower than that, but. You know, you can't argue with the numbers here.
And they're saying that actually the recovery with a conus or cauda equina injury is better than with a thoracic with up between three and five motor score points improvement compared to 0.1 to four in the thoracic cord. You know this paper, the conclusion really is that surgical decompression of the cord within 24 hours, regardless of where in the cord is injured. Its largely difficult to disprove and it needs to be recommended throughout. And the meta-analysis with regards to cervical cord shows that you get this 2 Asia grade improvement in about 25% of patients who have decompression within a day, 24 hours, rather than 10% in over 24 hours. So the evidence in the cervical cord is pretty clear.
And the [00:14:00] thoracic quarters, as I say, I think the evidence is much less clear. There's a lot less data out there. There's a much more variation in the presentation of a thoracic cord injury. And similarly in the lumbar spine and cauda equina again the data really isn't there to support it.
There is some studies looking at comparing your classic cauda equina syndrome that we're familiar with, with the disc prolapse, numbness and so on comparing that to an injury and suggest, well, maybe we should treat them the same. Maybe we should decompress within eight hours. Maybe that leads to a better outcome, but the data is so vague that it's impossible to really draw a robust conclusion there.
Well that's really one of the things that I was thinking of that came to my mind when I was reading this cause this is a very comprehensive literature of sort of trying to bring together the current evidence base. And one of the things I had written down is looking at the numbers in the studies, you know, barring the meta-analysis, which looked really at the question of timing of decompression. The numbers in all of the studies are relatively small and certainly very small in [00:15:00] orthopedic terms. So my view would be, have we got enough data to answer these questions yet, or is it, this is the best we're going to get because studies of these nature are very difficult?
Yeah. So I think the honest answer is no. If you look at it completely dispassionately, we don't have the numbers to sit here and say, there is a right or wrong answer here. You know, the most robust evidence comes from cervical spine. I think there's very little doubt now that early decompression, the C spine is useful. Outside of that I think we're looking at a best practice type picture rather than definitive evidence.
Do I think the numbers are ever going to be there? I think over time they might be. A lot of this data comes from North America where there's a much tighter focus on timing of surgery because of the culture of practice over here, but I think meta-analysis is the only way we're ever going to increase numbers.
The other problem with starting to come against, of course, with these studies is the ethics of doing them. There's now increasingly, you know, [00:16:00] less and less appetite for doing studies where you're purposefully delaying surgery at all. So these are all observational studies where for some other reason, a patient's surgery is delayed. And one of the weaknesses of this that the authors actually mentioned, is actually in polytrauma patients that are unstable or have other life threatening injuries. Those are the patients that are in the longer than 24 hours surgery group and those other injuries could be directly related to their cord injury in their lack of recovery, following it, hypotension, hacerse type response.
We know that the cord through secondary mechanisms, you know, failings that are showed that, you know, a number of years ago now. So I think it's going to be a very complicated process and I can see it being incremental rather than a single leap forward. For me what it's taught me is well, you know, Brett is it's going to be hard to justify delaying decompression of according to you, wherever you are in the spine, in the absence of a very clear clinical reason, not to. Of course, that needs to be balanced with the logistics of [00:17:00] where you work in particular. And we can't forget it in the UK with our shift in practice that operating at 2:00 AM in a unit that doesn't do this sort of work almost on a routine basis.
Exactly. That was something else that you've already touched on, on another big thing. So if you read this paper in broad brush strokes, it would say, okay, well the most common, complete traumatic spinal cord injuries is cervicle. That's where we've got the most data to say, actually, these patients do best if A theyre surgically decompressed and if B theyre surgically decompressed early. Thinking about that early I.E within 24 hours of injury. Um, two questions around that - one- would that represent if we just said, okay, broad brush strokes, we're going to accept that now as best practice and we're going to Institute that, would that represent a significant change in practice in the UK and B how doable is that? What would we need to put in place to allow that to happen?
Yeah. So I don't think it would be a [00:18:00] radical change in practice, but I do think it would perhaps leave the theater management profession, if you like, to just rethink their balance of skills and so on out of hours, because it is we're in that difficult bridge between neurosurgery and orthopedic surgery, where there's a lot of pooling of resources and crossing of nursing staff.
So you bring a team familiar with the spine. They may not be familiar with the bilateral or the two plating of the distal femur, which is far more likely to need some attention after that, or even something simpler like an ex fix. I think it is achievable and I can see a time where it just is what has to be done in the same way that I think cauda equinas need to be tackled really aggressively. But I do think it will need a shift in practice.
Alongside that speaking, you know, on the soap boxes as someone who's recently finished their training, you know, trainees will need to become familiar with identifying this as A a priority and B being able to get the ball rolling with these cases, you know, [00:19:00] out of hours. It's not something typically tackled by trainees or more junior nursing staff and so on.
And so, as the tides shift, you know, we following the consultant need to know what we're doing with this sort of thing.
I think certainly, you know, I was thinking about the last time that I was considering these questions in a big way, it was probably in all honesty a few years ago preparing for the FRCS finals, when you're going to be asked to defend your practice regarding certain things. And certainly at that time, it was I think, accepted that, you know, the non- complete traumatic spinal cord injuries were a much greater clinical priorities to the complete, and the tide has already changed on that, especially with the survivals.
Yeah, you're right. Yeah, absolutely. You know, traditionally we were told there's something to lose with those who are incomplete, so we should work quickly. And those who are complete it's kind of game over. We now know that's not the case. We now know the urgent decompression prevents that secondary injury [00:20:00] that we're seeing with the free radical formation and some of the drug trials coming in now that are seeking to control that secondary injury rely on that decompression.
So I think those waters have shifted.
Interesting update for me. And other small thing I took away from this was just about who should be doing the initial documentation and assessment. You know, I thought it was really interesting to be acknowledged in this big literature review that actually, you know, the seniority of the person doing that and recording that is really vital. Cause even there, you know, they were finding in pretty, what were otherwise as robust a papers as possible, there were significant discrepancies and therefore, you know, someone with experience needs to be documenting the neurological exam.
Yeah, absolutely. You know, it's something that we do, you know, every day when you're on a neurological or a spine based practice and don't think too much about it, but it is something that a non-spine oriented trainee might do very infrequently. And as you say, particularly around the exam, but aside from that, and we know that in a polytrauma setting, you know, that [00:21:00] there's a thousand things going on at once. And quite often the neurological exam is not cursory, but it has to be done briefly. We will see in the ASIA sheet, which is a very comprehensive documentation of how things on, and you can have another debate about how practical that is.
But, you know, I think it needs to be born in mind and you just have to do the best you can do. But ultimately the earlier the decompression is done, I think this is moving the direction of saying that the better the recovery will be for that patient.
Yeah, really fascinating and a great sort of, you know, I think it's a people with quite a clear message in terms of, as you say, I'd sort of, you know, turning the sea shifting. I think that's a very sort of thing with this paper and it kind of lends a lot of credence to some refocus on that as a political topic.
Brett, thanks for picking such interesting papers and your really interesting insight into the area of surgery. I hope everyone's enjoyed listening to that as much as we've enjoyed [00:22:00] taking part in it.
And please do join us for the second part of the September podcast, where myself and Ben Oliverre will also contribute our picks from the journal.