Objectives To develop and user-test a patient decision aid providing evidence-based information for people with chronic low back pain (LBP) and degenerative disc disease considering lumbar fusion. Design Convergent parallel mixed methods study. Setting A prototype patient decision aid was developed, guided by the International Patient Decision Aid Standards (IPDAS) criteria, a multidisciplinary steering committee, and insights from previous studies. Participants were recruited via social media and the authors’ collaborative networks to refine and evaluate the decision aid. Participants Individuals who underwent lumbar fusion for chronic LBP and health professionals who manage these patients were purposively sampled. Primary and secondary outcomes Semi-structured interviews and questionnaires were used to gather feedback and assess the decision aid’s acceptability, usability, and preparedness for decision-making. Framework analysis was used for interview data and descriptive analysis for questionnaires. Results Sixteen clinicians (5 physiotherapists, 2 rheumatologists, 2 surgeons, 7 general practitioners) and seven patients participated, most rating the prototype’s acceptability as ‘excellent’ or ‘good’. Usability (mean [SD], health professionals: 78 [16], patients: 72 [8]) and preparedness for decision-making (health professionals: 73 [14], patients: 72 [10]) also scored highly. However, some viewed the prototype as biased against lumbar fusion, and suggestions to include more personalised information were made. Conclusions This study showed that our prototype patient decision aid is acceptable, useful, and prepares patients to make informed decisions about spinal fusion for chronic LBP and degenerative disc disease. Future studies will assess the clinical impact of our decision aid and its optimal distribution timing.

Background: International guidelines recommend maintenance of mean arterial pressure (MAP) >85 mmHg to defend spinal cord perfusion pressure after acute traumatic spinal cord injury (SCI). Variation in practice has been demonstrated in the emergency department blood pressure management of SCI in New South Wales (NSW). It is unknown whether this variation exists in the phase of intensive care management of acute SCI. Objectives: The objective of this study was to describe and compare current blood pressure management in the intensive care unit (ICU) of patients with acute traumatic SCI in two SCI referral centres in NSW. Methods: Patients with acute traumatic SCI admitted to two SCI referral centres, Unit A and Unit B during 2018-2019 in NSW, were included. Data were summarised using descriptive statistics. Results: Ninety-eight patients were included, with 91 patients having been prescribed a blood pressure target, 81(83%) having required vasopressors, and 18 (18%) of these having been documented to have complications associated with vasopressor use. The average prescribed MAP target was 78 (interquartile range [IQR]: 10) mmHg in Unit A and 76 (IQR: 12) mmHg in Unit B. Median durations of prescribed target were 120 (IQR: 72) hours and 120 (IQR: 120) hours in Unit A and Unit B, respectively. The average MAP over the first 7 d was 88 (standard deviation: 9.5) mmHg in Unit A and 85 (standard deviation: 7.5) mmHg in Unit B. Sixty-three patients (64%) had a documented systolic blood pressure <90 mmHg in the first 24 h. Median ICU length of stay (LOS) was 9.7 (IQR: 11) d in Unit A and 6 (IQR: 6.6) d in Unit B. Median hospital LOS was 27 (IQR: 56.2) d in Unit B and 34.7 (IQR: 32.3) d in Unit B. ICU LOS was longer in patients who had a MAP target than in those who did not. Conclusions: Current blood pressure management in acute SCI in NSW involves ICU admission and blood pressure support with vasopressors; however, prescribed blood pressure targets are not in line with international guidelines. (c) 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

BACKGROUND:Spinal cord injury (SCI) clinical trials typically rely on a single primary endpoint to assess drug efficacy. This strategy fails to adequately capture the full impact of treatment in heterogenous neurological conditions like SCI. A more patient-centric analysis requires assessment of neurological function, functional capacity, and quality of life, incorporating meaningful patient-reported outcomes. The global statistical test (GST) addresses this challenge using a unified statistical conclusion regarding the superiority of a treatment strategy over another by evaluating multiple trial endpoints simultaneously. METHODS:The RISCIS trial (Safety and Efficacy of Riluzole in Acute Spinal Cord Injury Study) data was analysed using a multivariate nonparametric GST, integrating the total American Spinal Injury Association (ASIA) motor score (TOTM), Spinal Cord Independence Measure (SCIM), and SF-36 PCS (Short Form-36 Physical Component Scale) scores. In the RISCIS trial, patients with severe cervical SCI (AIS A, B, and C) were randomised to receive riluzole or placebo within 12 h of injury in a double blinded fashion. We compared six-month outcomes between groups using a modified O'Brien's rank sum test with sample variance adjustment. Higher summed ranks represent better global outcomes. The overall probability of improvement was computed using a summary estimate, the global treatment effect (GTE). FINDINGS:A total of 131 patients (mean age 45.8 years old, 82% males) completed the six-month outcome assessment. Among these, 49.6% were classified as AIS A, 20.6% as AIS B, and 29% as AIS C. Riluzole was administered within 12 h from injury for 14 days in 65 patients, while 66 received a placebo. The unadjusted mean change from baseline to six months showed a favourable response in the riluzole group compared to placebo across TOTM (p = 0.28 by t-test; p = 0.26 by Wilcoxon test), SCIM (p = 0.04 by t-test; p = 0.02 by Wilcoxon test), or SF-36 PCS (p = 0.23 by t-test; p = 0.21 by Wilcoxon test) scores. Using the GST to simultaneously assess these measures, the riluzole group exhibited a higher rank sum compared to placebo [median rank sum = 207 (IQR: 166-246) in riluzole vs 185 (IQR: 146-236) in placebo, p = 0.04]. Subgroup analysis revealed the greatest treatment benefit among patients with AIS A injuries (GTE = 0.16, 95% CI: 0.01-0.31, p = 0.02). At six months, the probability that riluzole treatment resulted in overall better outcomes than placebo across all assessed outcomes was 58%. INTERPRETATION:Riluzole was associated with improved global outcomes in patients with severe traumatic SCI, based on a composite score integrating ASIA total motor scores, SCIM, and SF36 outcomes at six months. Riluzole is a promising therapeutic option in SCI, but further investigation through higher-quality studies incorporating multidimensional assessments is warranted. FUNDING:No funding was received for the present work. The original clinical trial (NCT01597518) was funded by the AO Foundation, United States Department of Defense (DOD), and the Praxis Spinal Cord Institute.

Introduction Surgical and invasive procedures are widely used in adults with degenerative lumbar spinal stenosis when conservative treatments fail. However, little is known about the comparative efficacy and safety of these interventions. To address this, we will perform a network meta-analysis (NMA) and systematic review to compare the efficacy and safety of surgical and invasive procedures for adults with degenerative lumbar spinal stenosis. Methods and analysis We will include randomised controlled trials assessing surgical and invasive treatments for adults with degenerative lumbar spinal stenosis. We will search AMED, CINAHL, EMBASE, the Cochrane Library and MEDLINE. Only English studies will be included and no restriction will be set for publication status. For efficacy, our primary outcome will be physical function. Secondary outcomes will include pain intensity, health-related quality of life, global impression of recovery, work absenteeism and mobility. For safety, our primary outcome will be all-cause mortality. Secondary outcomes will include adverse events (number of events or number of people with an event) and treatment withdrawal due to adverse effect. Two reviewers will independently select studies, extract data and assess the risk of bias (Revised Cochrane risk-of-bias tool for randomized trials) of included studies. The quality of the evidence will be evaluated through the Grading of Recommendations Assessment, Development and Evaluation framework. Random-effects NMA will be performed to combine all the evidence under the frequentist framework and the ranking results will be presented through the surface under the cumulative ranking curve and mean rank. All analyses will be performed in Stata and R. Ethics and dissemination No ethical approval is required. The research will be published in a peer-reviewed journal. PROSPERO registration number CRD42018094180.

INTRODUCTIONInterventions provided in the early phases after spinal cord injury (SCI) may improve neurological recovery and provide for best possible functional outcomes. Knowing this relies on early and clear documentation of the level and grade of the spinal cord injury. Guidelines advocate for early documentation of neurological status within 72 h of injury to allow early prognostication and to help guide initial management. It is unclear whether this is current practice in New South Wales (NSW).METHODSPatients with acute SCI who were admitted to two SCI referral centers during 2018-2019 in NSW were included. Data relating to documentation of neurological status, timing of imaging, surgery and transfer to spinal cord injury center were collected and summarized using descriptive statistics.RESULTSOnly 18 percent of patients had an acceptable neurological examination according to the International Standards for Classification of Spinal Cord Injury (ISNCSCI) within 72 h of injury (either not done, or unable to determine the neurological level of injury). At the first neurological examination, the neurological level of injury and grade was unable to be determined in 26.8% of patients and 29.9% of patients respectively. At discharge from acute care and transfer to rehabilitation, the neurological level was undetermined in 28.9% of patients and grade undetermined in 26.8%. ISNCSCI examination was most commonly performed by spinal rehabilitation doctors after patients were discharged from the intensive care unit (ICU).CONCLUSIONSDocumentation of neurological level and grade of SCI within 72 h of injury is not being performed in the large majority of this cohort, which may impede evaluation of neurological improvement in response to acute treatment, and hinder prognostication.

Although placebo-controlled trials are considered the gold standard for evaluating the efficacy of healthcare interventions, they can be perceived to be controversial and challenging to conduct for surgical treatments. The SUcceSS trial is the first placebo-controlled trial of lumbar decompression surgery for symptomatic lumbar canal stenosis. The SUcceSS trial has experienced common issues affecting the implementation of randomised placebo-controlled surgery trials, accentuated by the COVID-19 pandemic. Using the SUcceSS trial as an example, we discuss key challenges and mitigation strategies specific to the conduct of a randomised placebo-controlled surgical trial. Overall, the key lessons learned were (i) involving key stakeholders early and throughout the trial design phase may increase clinician and patient willingness to participate in a placebo-controlled trial of surgical interventions, (ii) additional resources (e.g. budget, staff time) are likely required to successfully operationalise trials of this nature, (iii) the level of placebo fidelity, timing of randomisation relative to intervention delivery, and nuances of the surgical procedure under investigation should be considered carefully. Findings are based on one example of a placebo-controlled surgical trial; however, researchers may benefit from employing or building from the strategies described and lessons learned when designing or implementing future trials of this nature.

There is an unmet clinical need for a spinal fusion implant material that recapitulates the biological and mechanical performance of natural bone. We have developed a bioceramic, Sr-HT-Gahnite, which has been identified as a potential fusion device material. This material has the capacity to transform the fu -ture of the global interbody devices market, with follow on social, economic, and environmental benefits, rooted in its remarkable combination of mechanical properties and bioactivity. In this study, and in line with FDA requirements, the in vivo preclinical systemic biological safety of a Sr-HT-Gahnite interbody fu-sion device is assessed over 26 weeks in sheep under good laboratory practice (GLP). Following the in-life phase, animals are assessed for systemic biological effects via blood haematology and clinical biochem-istry, strontium dosage analysis in the blood and wool, and histopathology examination of the distant organs including adrenals, brain, heart, kidneys, liver, lungs and bronchi, skeletal muscle, spinal nerves close to the implanted sites, ovaries, and draining lymph nodes. Our results show that no major changes in blood haematology or biochemistry parameters are observed, no systemic distribution of strontium to the blood and wool, and no macroscopic or histopathological abnormalities in the distant organs when Sr-HT-Gahnite was implanted, compared to baseline and control values. Together, these results indicate the systemic safety of the Sr-HT-Gahnite interbody fusion device. The results of this study extend to the systemic safety of other Sr-HT-Gahnite implanted medical devices in contact with bone or tissue, of sim-ilar size and manufactured using the described processes.Statement of significanceThis paper is considered original and innovative as it is the first that thoroughly reports the systemic biological safety of previously undescribed bioceramic material, Sr-HT-Gahnite. The study has been per-formed under good laboratory practice, in line with FDA requirements for assessment of a new interbody fusion device, making the results broadly applicable to the translation of sheep models to the human cer-vical spine; and also the translation of Sr-HT-Gahnite as a biomaterial for use in additional applications. We expect this study to be of broad interest to the readership of Acta Biomaterilia. Its findings are directly applicable to researchers and clinicians working in bone repair and the development of synthetic biomaterials.(c) 2022 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Riluzole is a sodium-glutamate antagonist that attenuates neurodegeneration in amyotrophic lateral sclerosis (ALS). It has shown favorable results in promoting recovery in pre-clinical models of traumatic spinal cord injury (tSCI) and in early phase clinical trials. This study aimed to evaluate the efficacy and safety of riluzole in acute cervical tSCI. An international, multi-center, prospective, randomized, double-blinded, placebo-controlled, adaptive, Phase III trial (NCT01597518) was undertaken. Patients with American Spinal Injury Association Impairment Scale (AIS) A-C, cervical (C4-C8) tSCI, and <12 h from injury were randomized to receive either riluzole, at an oral dose of 100 mg twice per day (BID) for the first 24 h followed by 50 mg BID for the following 13 days, or placebo. The primary efficacy end-point was change in Upper Extremity Motor (UEM) scores at 180 days. The primary efficacy analyses were conducted on an intention to treat (ITT) and completed cases (CC) basis. The study was powered at a planned enrolment of 351 patients. The trial began in October 2013 and was halted by the sponsor on May 2020 (and terminated in April 2021) in the face of the global COVID-19 pandemic. One hundred ninety-three patients (54.9% of the pre-planned enrolment) were randomized with a follow-up rate of 82.7% at 180 days. At 180 days, in the CC population the riluzole-treated patients compared with placebo had a mean gain of 1.76 UEM scores (95% confidence interval: -2.54-6.06) and 2.86 total motor scores (CI: -6.79-12.52). No drug-related serious adverse events were associated with the use of riluzole. Additional pre-planned sensitivity analyses revealed that in the AIS C population, riluzole was associated with significant improvement in total motor scores (estimate: standard error [SE] 8.0; CI 1.5-14.4) and upper extremity motor scores (SE 13.8; CI 3.1-24.5) at 6 months. AIS B patients had higher reported independence, measured by the Spinal Cord Independence Measure score (45.3 vs. 27.3; d: 18.0 CI: -1.7-38.0) and change in mental health scores, measured by the Short Form 36 mental health domain (2.01 vs. -11.58; d: 13.2 CI: 1.2-24.8) at 180 days. AIS A patients who received riluzole had a higher average gain in neurological levels at 6 months compared with placebo (mean 0.50 levels gained vs. 0.12 in placebo; d: 0.38, CI: -0.2-0.9). The primary analysis did not achieve the predetermined end-point of efficacy for riluzole, likely related to insufficient power. However, on pre-planned secondary analyses, all subgroups of cervical SCI subjects (AIS grades A, B and C) treated with riluzole showed significant gains in functional recovery. The results of this trial may warrant further investigation to extend these findings. Moreover, guideline development groups may wish to assess the possible clinical relevance of the secondary outcome analyses, in light of the fact that SCI is an uncommon orphan disorder without an accepted neuroprotective treatment.

Abstract Background Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. Methods This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013–2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. Results Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others. Conclusions Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.

The study aimed to determine how much change in neurogenic claudication spinal surgeons expect in patients following lumbar decompression for lumbar spine stenosis (LSS), and radicular leg pain following microdiscectomy. Secondary aims were to identify surgeons' preferences regarding surgical techniques for lumbar decompression, and their rating of the quality of current evidence for lumbar decompression. All Australian spine surgeons were invited, of whom 71 completed the survey (31% response rate). Only registered spinal surgeons were included. The online survey, administered using REDCap, included 4 sections: demographics and background; expected change in symptoms on a +/100% scale (-100% worst, 0% no change and 100% best possible); surgical preference; and rating of current evidence for lumbar decompression compared with other treatments. There were 71 complete responses, 76% were neurosurgeons (N = 54), predominantly male (96%; N = 68). On average, surgeons expected an 86% (median: 87%, inter-quartile range (IQR): 80%, 91%) improvement in neurogenic claudication following lumbar decompression for LSS and 89% (median: 91%, IQR: 85%, 95%) improvement in radicular pain following microdiscectomy. A multiple linear regression found no surgeon characteristics were associated with expected change following surgery. The preferred surgical technique for LSS was full laminectomy (58%; N = 41). Thirty-five percent of surgeons accurately rated the evidence supporting the superiority of lumbar decompression compared with non-surgical care for LSS as low quality. Spine surgeons expect large symptom improvements following lumbar decompression and microdiscectomy. Understanding of the current evidence was higher for lumbar decompression with fusion, than for decompression alone for LSS. (c) 2021 Elsevier Ltd. All rights reserved.

Study Design. Record linkage study using healthcare utilization and costs data. Objective. To identify predictors of higher acute-care treatment costs and length of stay for patients with traumatic spinal cord injury (TSCI). Summary of Background Data. There are few current or population-based estimates of acute hospitalization costs, length of stay, and other outcomes for people with TSCI, on which to base future planning for specialist SCI health care services. Methods. Record linkage study using healthcare utilization and costs data; all patients aged more than or equal to 16 years with incident TSCI in the Australian state of New South Wales (June 2013–June 2016). Generalized Linear Model regression to identify predictors of higher acute care treatment costs for patients with TSCI. Scenario analysis quantified the proportionate cost impacts of patient pathway modification. Results. Five hundred thirty-four incident cases of TSCI (74% male). Total cost of all acute index episodes approximately AUD$40.5 (95% confidence interval [CI] ±4.5) million; median cost per patient was AUD$45,473 (Interquartile Range: $15,535–$94,612). Patient pathways varied; acute care was less costly for patients admitted directly to a specialist spinal cord injury unit (SCIU) compared with indirect transfer within 24 hours. Over half (53%) of all patients experienced at least one complication during acute admission; their care was less costly if they had been admitted directly to SCIU. Scenario analysis demonstrated that a reduction of indirect transfers to SCIU by 10% yielded overall cost savings of AUD$3.1 million; an average per patient saving of AUD$5,861. Conclusion. Direct transfer to SCIU for patients with acute TSCI resulted in lower treatment costs, shorter length of stay, and less costly complications. Modeling showed that optimizing patient-care pathways can result in significant acute-care cost savings. Reducing potentially preventable complications would further reduce costs and improve longer-term patient outcomes. Level of Evidence: 3

AimCementless prosthesis is one of the major bone-implant interface fixation methods in total joint replacement. Grit blasted surface, hydroxyapatite coated surface and plasma sprayed metallic porous coating have been popularly used. The latter has demonstrated higher bone implant mechanical stability in previous laboratory study in early and middle stages. However, question remains what the mechanism is to make it performing better and how to improve them further. This study is designed to examine the mode of failure in bone-implant interface in a sheep model.MethodPlasma sprayed porous coated (TiPL); hydroxyapatite (HA) coated and and grit blasted (TiGB) titanium implants were examined in the study. Each type has 36 specimens. Implants were inserted into cortical bones in a press-fit fashion in a total of 22 sheep bilateral hind limbs. Specimens were retrieved at 4 weeks and 12 weeks. Push- out testing was performed to just reach ultimate failure. Failed bone-implant interface were investigated by histo...

To describe pre-hospital, emergency department and acute care assessment and management practices of senior clinicians for patients with acute traumatic spinal cord injury (TSCI) across Australia; and to describe clinical practice variation.

This study was performed to compare the mechanism of bone-implant integration and mechanical stability among three popularly used cementless implant surfaces. Plasma sprayed porous surface (TiPL), ...

Lumbar spine fusion is a common procedure associated with a high cost burden and risk of serious complications. We aimed to summarise systematic reviews on the effectiveness of lumbar spine fusion for most diagnoses. We found no high-quality systematic reviews and the risk of bias of the randomised controlled trials in the reviews was generally high. The available evidence does not support a benefit from spine fusion compared to non-operative alternatives for back pain associated with degeneration. The available evidence does not support a clinical benefit from spine fusion compared to non-operative treatment or stabilisation without fusion for thoracolumbar burst fractures. Benefits of spine fusion compared to non-operative treatment for isthmic spondylolisthesis are unclear (one trial at high risk of bias). Surgical intervention for metastatic carcinoma of the spine associated with spinal cord compromise improves mobility and neurological outcome (based on a single trial). Better evidence is required to determine more accurately the effectiveness of spine fusion surgery for all indications. Patients contemplating spinal fusion should be fully informed about the evidence base for their particular problem, including the relative potential benefits and harms of fusion compared with non-operative treatments.

BACKGROUND: En bloc resection of Ewing sarcoma in the cervical spine according to Enneking's principles is technically challenging owing to the proximity of important neurovascular structures, the complex local anatomy, and the biomechanical instability of radical resection. The rarity of Ewing sarcoma and variability of its presentation justifies ongoing exploration and compilation of the surgical nuances and subtleties of en bloc resection in the cervical spine.CASE DESCRIPTION: We present a 34-year-old male with Ewing sarcoma of the neck who underwent successful en bloc resection using a novel technique of splitting the laminae and osteomizing the lateral masses under imaging guidance.CONCLUSIONS: This novel and successful approach of en bloc resection in the cervical spine can add to the spinal surgeon's repertoire when dealing with complex cervical tumor masses.

BACKGROUND CONTEXT: Traumatic spinal injuries are often associated with both long-term disability, higher frequency of hospital readmissions. and high medical costs for individuals of all ages. Age differences in terms of injury profile and health outcomes among those who sustain a spinal cord injury have been identified. however, factors that may influence health outcomes among those with a spinal injury have not been extensively examined at a population level. PURPOSE: The present study alms to describe the characteristics of traumatic spinal injury, identify factors predictive of mortality, and estimate the cost of hospital treatment for younger and older people. STUDY DESIGN/SETTING: This is a population-based retrospective epidemiological study using linked hospilalization and mortality records during January 1, 2010 to June 30, 2014 in New South Wales, Australia. PATIENT SAMPLE: The present study included 13,429 hospilalizations. OUTCOME MEASURES: Mortality within 30 and 90 days of hospitalization, hospital length of stay (LOS), and hospitalization costs were determined. METHODS: Hospitalizations with a principal diagnosis of spinal cord injury or spinal fractures were used to identify traumatic spinal injuries. Age-standardized incidence rates were calculated and negative binomial regression was used to examine statistical significant changes over time. Cox proportional hazard regression was used to examine the effect of risk factors on survival at 90 days. RESULTS: There were 13,429 hospitalizations, with 52.4% of individuals aged >= 65 years. The hospitalization rates for individuals aged <= 64 and >= 65 years were both estimated to significantly increase per year by 3.3% (95% confidence interval [CI] 0.97-5.79, p<.006) and 3.3% (95% CI 1.02-5.71, p =.005), respectively. For individuals aged >= 65 years, there were a higher proportion of women injured. comorbid conditions, injuries after a fall in the home or aged care facility, a longer hospital LOS, unplanned hospital admissions, and deaths than individual aged <= 64 years. The average cost per index hospitalization was AUD$23,808 for individuals aged <= 64 years and AUD$31,187 for individuals aged >= 65 years with a total estimated cost of AUD$371 million. Mortality risk at 90 days was increased for individuals who had one or more comorbidities, a higher injury severity score, and if their injury occurred in the home or an aged care facility. CONCLUSIONS: Spinal injury represents a substantial cost and results in debilitating injuries, particularly for older individuals. Spinal injury prevention efforts for older people should focus on the implementation of fall injury prevention, whereas for younger individuals, prevention measures should target road safely. (C) 2017 Elsevier Inc. All rights reserved.

Introduction Around 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year; a relatively low incidence injury with extremely high long-term associated costs. Care standards are inconsistent nationally, lacking in consensus across important components of care such as prehospital spinal immobilisation, timing of surgery and timeliness of transfer to specialist services. This study aims to develop ‘expertly defined’ and agreed standards of care across the majority of disciplines involved for these patients. Methods and analysis A modified e-Delphi process will be used to gain consensus for best practice across specific clinical early care areas for the patient with TSCI; invited participants will include clinicians across Australia with relevant and significant expertise. A rapid literature review will identify available evidence, including any current guidelines from 2005 to 2015. Level and strength of evidence identified, including areas of contention, will be used to formulate the first round survey questions and statements. Participants will undertake 2–3 online survey rounds, responding anonymously to questionnaires regarding care practices and indicating their agreement or otherwise with practice standard statements. Relevant key stakeholders, including patients, will also be interviewed face to face. Ethics and dissemination Ethics approval for this study was obtained by the NSW Population & Health Services Research Ethics Committee on 14 January 2016 (HREC/12/CIPHS/74). Seeking comprehensive understanding of how the variation in early care pathways and treatment can be addressed to achieve optimal patient outcomes and economic costs; the overall aim is the agreement to a consistent approach to the triage, treatment, transport and definitive care of acute TSCI victims. The agreed practice standards of care will inform the development of a Clinical Pathway with practice change strategies for implementation. These standards will offer a benchmark for state-wide and potentially national policy.

Prospective cohort study. For acute traumatic spinal cord injury (ATSCI), this study aimed to determine differences in outcomes between patient groups stratified by admission time (⩽24 vs >24 h) to the Spinal Injury Unit (SIU) and by the nature of the admission (direct admission to the SIU vs indirect admission via another hospital). We also aimed to measure the effect on time to admission of a ‘non-refusal’ policy that triggered immediate acceptance of ATSCI cases to the SIU. New South Wales, Australia. Study population was all adult SCI patients admitted to the Prince of Wales SIU from 1 January 2001 to 31 December 2012. Patients admitted with chronic-stage SCI or with incomplete data for the duration of their stay were excluded. Comparison of outcomes was made between groups according to the setting of admission. Time to admission before and after initiation (2009) of the ‘non-refusal’ policy was compared. The prevalence of complications, lengths of stay (LOSs) and time to admission were compared by Mann–Whitney non-parametric methods. Count modelling was used to control for confounders of age and gender. A total of 460 cases were identified and 76 were excluded. The early group had fewer pressure areas (41.8% vs 63.2%; P<0.001) and shorter LOS (136 vs 172 days; P<0.001) than the late group. The direct group had fewer pressure areas (35.2% vs 54.9%, P<0.001), deep vein thrombosis (9.9% vs 24.6%, P=0.003) and shorter LOS (124 vs 158 days, P=0.007) than those admitted indirectly. Time to admission was reduced after introduction of the ‘non-refusal’ policy (1.53 vs 0.63 days; P=0.001). Early and direct admission to SIU reduced complication rates and LOS. A non-refusal policy reduced time to admission.

Background: No Australian population-based studies have examined temporal trends in the incidence of fracture of the first or second cervical vertebra (C1 or C2 fractures), their aetiology, treatment and outcome for younger (15-64 years) compared to older (65+ years) individuals. The aim of this research is to examine the circumstances, treatment and outcomes including mortality for C1 or C2 fractures without associated spinal cord injury by age group in New South Wales (NSW), Australia.Method: A retrospective review of C1 or C2 vertebra fractures in individuals aged 15 years and over in the NSW Admitted Patient Data Collection from 1 July 1998 to 30 June 2010. Direct age standardised admission rates were calculated by cervical fracture type and by age group. Negative binomial regression was used to examine the statistical significance of changes in trend over time of hospitalised cervical fractures by age group.Results: The annual rate of hospitalised C1 and C2 fractures without associated spinal cord injury for individuals aged 15 years and over in NSW was 2.3 per 100,000 population, with the rate estimated to increase by 5.3% each year. Those aged 85+ years had the highest rates of hospitalisation. For those aged 15-64 years, road trauma was the most common mechanism of injury, while for those aged 65+ years, a fall was the dominant mechanism of injury. The in-hospital mortality for individuals aged 65+ years was 11.8% compared to 0.7% for those aged 15-64 years.Conclusions: This study identified an estimated increasing trend in C1 and C2 fractures over time, particularly for older individuals. While younger individuals are commonly injured in road traffic accidents, older individuals are predominantly injured following a fall. Injury prevention strategies should be targeted to the different age groups and injury mechanisms. Implementation of effective falls prevention strategies is likely to reduce these injuries in older people whilst road and vehicle safety including vehicle rollover protection standards may improve rates in younger people. (C) 2013 Elsevier Ltd. All rights reserved.