So, our next speaker is Dr. Andreas Dimitriadis from United Kingdom, Concomitant Cranial Spinal Trauma, Lessons from a Systematic Review. Dear Chairman and colleagues, thank you for the invitation. The topic arose out of a discussion in our department where we could not provide an accurate figure of the incidence and prevalence of concomitant cranial spinal injuries. So we decided to address this knowledge gap by doing a systematic review, no disclosures. So head and spinal injury is a disproportionate cause of mobility and mortality following trauma. It comes with a high burden of disease due to long-term physical as well as mental disability. The anatomical and biomechanical relationship between the cranial and spinal structures makes such an injury likely and can happen both with a head injury causing spinal injury but also in spinal injury we should be looking for minor head injuries if not obvious. The truth is that the quoted prevalence in the few studies available is very variable and up to this point there's been no systematic analysis of the available data. So to determine this, we addressed it in a few ways. We looked at the patients with spinal injury looking at the coincidence of cranial injury and the reverse. In other words, we looked at patients with cranial injury trying to find the coincidence of spinal injury. The methodology was straightforward. We used the PRISMA system, which is a preferred reporting item for systematic reviews and meta-analysis. The inclusion criteria were studies reporting such prevalence of traumatic brain injury and spinal injury. We also specifically looked at C-spine and we only did this in adults. We excluded studies reporting prevalence of specific head or spinal injuries only or in a rehabilitation population only. We looked at the quality and risk of bias assessment. We used a stroke checklist and the statistical analysis involved Q-tests, I-squared tests, subgroup analysis, and forest plots. At the first glance, we were optimistic. We had 1,600 studies identified, 73 full-text studies assessed for eligibility. Unfortunately, going through the criteria, only 21 were included in the review. And if we look at the study characteristics, all of these were observational, of course. It's not an easy topic for level one or level two studies. Most of them were cross-sectional or retrospective designs. You can see there the origin of most of the publications. Fourteen of these were single-center studies. Seven were multi-center trauma database studies. We included studies defined by, where traumatic brain injury was defined by Glasgow Coma score, the abbreviated injury score. We tabulated symptoms, the diagnostic codes, the radiological findings, and the combinations. And then also the spinal injury studies, including radiology and, again, coding. So let's take them in turn. This is looking at the prevalence of cervical spine injury in a population of brain injury reported people. Eleven studies were found, total sample size just over half a million, high degree of heterogeneity in the quality, but the prevalence was found to be 6.5%. In other words, if you have a head injury, primarily head injury, the chance of concomitant c-spine injury is 6.5%. Subgroup analysis found only four studies looking at c-spine injury in patients that had a head injury through a road traffic accident or a motor vehicle accident. Heterogeneity, even though a smaller group, the heterogeneity was slightly better. And the prevalence of concomitant c-spine injury in this subgroup of head injuries was almost double, 12%. Next one, what is the prevalence of spinal injury in patients with traumatic brain injury? So this is all spinal injury, not just c-spine. Only two studies, total sample population 190,000, meta-analysis inappropriate, prevalence 12.5%, more or less, in both studies. And the next way of looking at this, nine studies looking at the prevalence of concomitant TBI in patients with primarily reported c-spine injury, again, high-degree heterogeneity, prevalence 40%. So if you have a c-spine injury as your primary mode of presentation, the chance that you had a head injury also, 40%, whereas the opposite was only 6 to 12%. The prevalence of TBI in any kind of spinal injury, only five studies, 90,000 patients, again high-degree heterogeneity, 32%. So if you have a spinal injury as your primary mode of presentation, the risk of head injury, concomitant head injury, is 32% anywhere in the spine, and 40% specifically in the c-spine, with c-spine. So let's summarize this again. This is the closing slides. The prevalence of concomitant injury in several patient groups is reported. The prevalence of concomitant cervical spine injury with TBI is 6.5%. And if it was a motor vehicle accident, then it's 11.7%. On the other hand, the prevalence of concomitant spinal injury of any location in those patients with TBI, only studied in two papers, 12.5%. In the reverse, in those with cervical spine injury, the prevalence of TBI is 40%. And in those with any spinal injury, the prevalence of TBI is 32%. So what do we do with this data? The discussion points are pretty much a repeat, but essentially concomitant c-spine injury is less common, but important to consider due to the grave consequence of a missed injury. High heterogeneity was confirmed. This can be due to a wide variety of reasons, such as the country of origin, the date of publication, the protocol used, the data collection system. But there's no doubt that this data is poor. It gives some numbers, but it identifies a knowledge gap that can only be addressed with larger studies, which cannot be small, regional, single, or small number-centered studies. It has to be regional, continental, or intercontinental. And there's an opportunity now with large registries to try and extract this data as well. Thank you for your attention. APPLAUSE

concomitant cranial spinal trauma

systematic review

observational studies

prevalence of concomitant cervical spine injury

traumatic brain injury (TBI)