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Wang Y, Yi H, Wang J, Song Y. Early Surgery (Within 24 Hours) Benefits Patients Suffering from Acute Thoracolumbar Spinal Cord Injury: A Meta-analysis. Clin Spine Surg 2023; 36:210-216. [PMID: 36070773 DOI: 10.1097/bsd.0000000000001385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A meta-analysis of early surgery for acute thoracolumbar spinal cord injury. OBJECTIVE To evaluate whether early surgery increases the American Spinal Injury Association (ASIA) grade of patients confronted with acute thoracolumbar spinal cord injury. SUMMARY OF BACKGROUND DATA The idea that early surgery aids the recovery of spinal cord function in patients confronted with acute thoracolumbar spinal cord injury is controversial. METHODS All articles were retrieved from the PubMed, Embase, Web of Science and Scopus databases, which were searched from onset until 1 May 2021. All data are presented as odds ratios (ORs) and mean deviations (MDs) with 95% confidential intervals (CIs). RESULTS Ten studies, including 6 prospective studies, 3 retrospective studies, and 1 randomized controlled trial, containing 952 patients, were included in the analysis. The results showed that early surgery significantly reduced the number of patients with ASIA grade A (OR 0.27, 95% CI: 0.13-0.58, P <0.01) and B (OR 0.56, 95% CI: 0.39-0.82, P <0.01) status but greatly increased the number of patients with grade E status (OR 1.44, 95% CI: 1.06-1.96, P <0.01). Generally, the patients receiving early surgery achieved >1 ASIA grade improvement (OR 1.70, 95% CI: 1.31-2.21, P <0.01) or >2 ASIA grade (OR 3.55, 95% CI: 2.20-5.70, P <0.01) improvements. Although early surgery did not reduce the incidence of operative complications (OR 0.72, 95% CI: 0.45-1.16, P <0.01), the duration of hospitalization was greatly shortened (MD-3.48, 95% CI: -0.45 to-2.91, P <0.01). CONCLUSIONS The spinal cord function of acute thoracolumbar spinal cord injury patients can benefit from early decompression. This conclusion should be further verified with randomized controlled trials.
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Affiliation(s)
- Yang Wang
- Department of Orthopedics, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong Pharmaceutical University; Guangzhou, Guangdong Province, China
| | - Hanxiao Yi
- Department of Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian Wang
- Department of Orthopedics, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong Pharmaceutical University; Guangzhou, Guangdong Province, China
| | - Yancheng Song
- Department of Orthopedics, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangdong Pharmaceutical University; Guangzhou, Guangdong Province, China
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ter Wengel PV, De Haan Y, Feller RE, Oner FC, Vandertop WP. Complete Traumatic Spinal Cord Injury: Current Insights Regarding Timing of Surgery and Level of Injury. Global Spine J 2020; 10:324-331. [PMID: 32313798 PMCID: PMC7160809 DOI: 10.1177/2192568219844990] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
STUDY DESIGN A narrative literature review. OBJECTIVES To review the neurological recovery patterns in traumatic spinal cord injury (tSCI) patients with a complete lack of motor and sensory function below the level of injury (ie, ASIA A [American Spinal Injury Association scale]), as well as the impact of level of injury and timing of surgical intervention. RESULTS Spontaneous neurological recovery in patients with complete tSCI differs per level of injury: patients with cervical and thoracolumbar tSCI recover ≥1 ASIA grade in 17.3% to 34.0% 1 year after injury, compared with 10.7% to 18.6% in thoracic tSCI. Surgical decompression within 24 hours has a beneficial effect on neurological recovery in patients with complete cervical tSCI, whereas this effect is less clear for thoracic and thoracolumbar tSCI. A 1- or 2-grade improvement in the ASIA scale does not necessarily result in functional recovery. CONCLUSION In complete tSCI, the level of injury as well as surgical timing affect neurological recovery. There appears to be a beneficial effect of early surgical decompression in patients with complete cervical tSCI, more so than for thoracic and thoracolumbar tSCI. Frequently, the effect of surgical intervention is evaluated by an improvement in ASIA grade, but it is unclear whether this scale is sensitive enough to evaluate meaningful effectiveness of the intervention and desired outcome for patients with tSCI.
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Affiliation(s)
- Paula Valerie ter Wengel
- VU University Medical Center, Amsterdam, Netherlands,Leiden University Medical Center, Leiden, Netherlands,Paula Valerie ter Wengel, De Boelelaan 1117,
Amsterdam 1081 HV, Netherlands.
| | | | | | | | - William Peter Vandertop
- VU University Medical Center, Amsterdam, Netherlands,Academic Medical Center, Amsterdam, Netherlands
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ter Wengel PV, Martin E, De Witt Hamer PC, Feller RE, van Oortmerssen JAE, van der Gaag NA, Oner FC, Vandertop WP. Impact of Early (<24 h) Surgical Decompression on Neurological Recovery in Thoracic Spinal Cord Injury: A Meta-Analysis. J Neurotrauma 2019; 36:2609-2617. [DOI: 10.1089/neu.2018.6277] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Paula Valerie ter Wengel
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, VUmc, Amsterdam, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Martin
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, VUmc, Amsterdam, The Netherlands
| | | | - Ricardo E. Feller
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, VUmc, Amsterdam, The Netherlands
| | | | - Niels A. van der Gaag
- Department of Neurosurgery, HagaZiekenhuis, the Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - F. Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - William Peter Vandertop
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, VUmc, Amsterdam, The Netherlands
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, AMC, Amsterdam, The Netherlands
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Khorasanizadeh M, Yousefifard M, Eskian M, Lu Y, Chalangari M, Harrop JS, Jazayeri SB, Seyedpour S, Khodaei B, Hosseini M, Rahimi-Movaghar V. Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis. J Neurosurg Spine 2019; 30:683-699. [PMID: 30771786 DOI: 10.3171/2018.10.spine18802] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/11/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance. METHODS A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis. RESULTS A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups. CONCLUSIONS The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.
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Affiliation(s)
| | - Mahmoud Yousefifard
- 2Physiology Research Center and Department of Physiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahsa Eskian
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Yi Lu
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryam Chalangari
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - James S Harrop
- 4Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia
- 5Neurosurgery, Delaware Valley Regional Spinal Cord Injury Center, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | | | - Simin Seyedpour
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Behzad Khodaei
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Mostafa Hosseini
- 6Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Ghajarzadeh M, Saberi H. Transportation mode and timing of spinal cord decompression and stabilization in patients with traumatic spinal cord injury in Iran. Spinal Cord 2018; 57:150-155. [PMID: 30201998 DOI: 10.1038/s41393-018-0189-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 07/05/2018] [Accepted: 07/23/2018] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Cross-sectional retrospective study. OBJECTIVE To describe the transportation mode to hospital and timing of spinal cord decompression and stabilization (D&S), length of hospital stay, frequency of pressure injuries, and sepsis during hospitalization. SETTING Brain and Spinal Injury Research Center, Tehran, Iran. METHODS Eight hundred and thirty patients with traumatic spinal cord injury (TSCI) were enrolled. Mode of transportation and length of time to reach the first hospital, length of hospital stay (LOS), and the time span between hospital arrival and decompression and stabilization (D&S) were recorded. RESULTS Fifty-nine percent of the enrolled individuals were transported to the first hospital by ambulance, while 41% were transferred by vehicles without medical equipment and personnel. Median length of time to reach the first hospital was 1 h for both ambulance and non-equipped car groups, with no statistically significant difference (p = 0.1). Median LOS, frequencies of pressure injuries, and sepsis based on the injury levels were not significantly different between two transportation modalities. One hundred and seventy-seven individuals had early surgery, and 254 had late surgery. Median LOS was 13 days in the early surgery group and 20 days in the late surgery group (p = 0.002). Frequencies of pressure injuries and sepsis were not significantly different between the late and early surgery groups for various injury levels. CONCLUSION About 59% of our patients had been transported to a hospital by non-medical personnel. Those with late surgery had significantly longer LOS. Improving TSCI patients' transportation method and early surgical interventions, if possible, may be considered.
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Affiliation(s)
- Mahsa Ghajarzadeh
- Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hooshang Saberi
- Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran.
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van Middendorp JJ, Hosman AJF, Doi SAR. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013; 30:1781-94. [PMID: 23815524 DOI: 10.1089/neu.2013.2932] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Abstract The debate over the effects of the timing of surgical spinal decompression after traumatic spinal cord injury (tSCI) has remained unresolved for over a century. The aim of the current study was to perform a systematic review and quality-adjusted meta-analysis of studies evaluating the effects of the timing of spinal surgery after tSCI. Studies were searched for through the MEDLINE(®) database (1966 to August 2012) and a 15-item, tailored scoring system was used for assessing the included studies' susceptibility to bias. Random effects and quality effects meta-analyses were performed. Models were tested for robustness using one way and criterion-based sensitivity analysis and funnel plots. Results are presented as weighted mean differences (WMDs) and odds ratios (ORs) with 95% confidence intervals (CIs). A total of 18 studies were analyzed. Heterogeneity was evident among the studies included. Quality effects models showed that - when compared with "late" surgery - "early" spinal surgery was significantly associated with a higher total motor score improvement (WMD: 5.94 points, 95% CI:0.74,11.15) in seven studies, neurological improvement rate (OR: 2.23, 95% CI:1.35,3.67) in six studies, and shorter length of hospital stay (WMD: -9.98 days, 95% CI:-13.10,-6.85) in six studies. However, one way and criterion-based sensitivity analyses demonstrated a profound lack of robustness among pooled estimates. Funnel plots showed significant proof of publication bias. In conclusion, despite the fact that "early" spinal surgery was significantly associated with improved neurological and length of stay outcomes, the evidence supporting "early" spinal surgery after tSCI lacks robustness as a result of different sources of heterogeneity within and between original studies. Where the conduct of a surgical, randomized controlled trial seems to be an unfeasible undertaking in acute tSCI, methodological safeguards require the utmost attention in future cohort studies. (Prospero registration number: PROSPERO CRD42012003182. See also http://www.crd.york.ac.uk/NIHR_PROSPERO/ ).
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Affiliation(s)
- Joost J van Middendorp
- 1 Stoke Mandeville Spinal Foundation, National Spinal Injuries Centre , Stoke Mandeville Hospital, Aylesbury, United Kingdom
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Abstract
OBJECTIVE To assess the feasibility of iPhone-based teleradiology as a potential solution for the diagnosis of acute cervico-dorsal spine trauma. MATERIALS AND METHODS We have developed a solution that allows visualization of images on the iPhone. Our system allows rapid, remote, secure, visualization of medical images without storing patient data on the iPhone. This retrospective study is comprised of cervico-dorsal computed tomogram (CT) scan examination of 75 consecutive patients having clinically suspected cervico-dorsal spine fracture. Two radiologists reviewed CT scan images on the iPhone. Computed tomogram spine scans were analyzed for vertebral body fracture and posterior elements fractures, any associated subluxation-dislocation and cord lesion. The total time taken from the launch of viewing application on the iPhone until interpretation was recorded. The results were compared with that of a diagnostic workstation monitor. Inter-rater agreement was assessed. RESULTS The sensitivity and accuracy of detecting vertebral body fractures was 80% and 97% by both readers using the iPhone system with a perfect inter-rater agreement (kappa:1). The sensitivity and accuracy of detecting posterior elements fracture was 75% and 98% for Reader 1 and 50% and 97% for Reader 2 using the iPhone. There was good inter-rater agreement (kappa: 0.66) between both readers. No statistically significant difference was noted between time on the workstation and the iPhone system. CONCLUSION iPhone-based teleradiology system is accurate in the diagnosis of acute cervicodorsal spinal trauma. It allows rapid, remote, secure, visualization of medical images without storing patient data on the iPhone.
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Knop C, Kranabetter T, Reinhold M, Blauth M. Combined posterior-anterior stabilisation of thoracolumbar injuries utilising a vertebral body replacing implant. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:949-63. [PMID: 19357875 PMCID: PMC2899585 DOI: 10.1007/s00586-009-0970-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 01/12/2009] [Accepted: 03/24/2009] [Indexed: 10/20/2022]
Abstract
The authors report on a prospectively followed series of 35 patients with injuries of the thoracolumbar spine from T7 to L3. The radiological course after combined posterior-anterior surgery with anterior column reconstruction with a distractible vertebral body replacing implant demonstrated a stable reconstruction technique with almost no re-kyphosing. In 18/18 patients with CT follow-up intervertebral fusion was observed as bony bridging lateral to the VBR implant. The functional/clinical outcome of the patients was analysed with a set of eight validated outcome scales. After an average follow-up period of 2(1/2) years encouraging results were noticed. The neurological improvement rate (> or =1 Frankel/ASIA grade) was 8/12 patients (67%) with a complete recovery in 6 cases. 17/29 patients returned to former occupation; 20/29 patients returned to former leisure activities; 24/28 patients rated their general outcome as "unlimited and pain free" or "occasionally and/or mild complaints" with a VAS score of >80 (scale 0-100). The psychometric questionnaires revealed good results with strong correlation comparing the different scoring systems statistically: mean McGill Pain Questionnaire 12.5 (0-40); mean Oswestry Disability Index 20% (0-51). 13/29 patients scored <4 in the Roland and Morris Disability Questionnaire. The German back pain questionnaire (Funktionsfragebogen Hannover Rücken) showed a mean "functional capacity" of 75%, corresponding with moderate restriction. We concluded the presented method as highly effective to completely reduce and maintain an anatomic spinal alignment. The outcome tended to be better in comparison with non-operatively treated patients as well as with norm populations with low back pain.
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Affiliation(s)
- Christian Knop
- Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Innsbruck, Austria.
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Jagannathan J, Chankaew E, Urban P, Dumont AS, Sansur CA, Kern J, Peeler B, Elias WJ, Shen F, Shaffrey ME, Whitehill R, Arlet V, Shaffrey CI. Cosmetic and functional outcomes following paramedian and anterolateral retroperitoneal access in anterior lumbar spine surgery. J Neurosurg Spine 2008; 9:454-65. [DOI: 10.3171/spi.2008.9.11.454] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this paper, the authors review the functional and cosmetic outcomes and complications in 300 patients who underwent treatment for lumbar spine disease via either an anterior paramedian or conventional anterolateral retroperitoneal approach.
Methods
Seven surgeons performed anterior lumbar surgeries in 300 patients between August 2004 and December 2006. One hundred and eighty patients were treated with an anterior paramedian approach, and 120 patients with an anterolateral retroperitoneal approach. An access surgeon was used in 220 cases (74%). Postoperative evaluation in all patients consisted of clinic visits, assessment with the modified Scoliosis Research Society–30 instrument, as well as a specific questionnaire relating to wound appearance and patient satisfaction with the wound.
Results
At a mean follow-up of 31 months (range 12–47 months), the mean Scoliosis Research Society–30 score (out of 25) was 21.2 in the patients who had undergone the anterior paramedian approach and 19.4 in those who had undergone the anterolateral retroperitoneal approach (p = 0.005). The largest differences in quality of life measures were observed in the areas of pain control (p = 0.001), self-image (p = 0.004), and functional activity (p = 0.003), with the anterior paramedian group having higher scores in all 3 categories. Abdominal bulging in the vicinity of the surgical site was the most common wound complication observed and was reported by 22 patients in the anterolateral retroperitoneal group (18%), and 2 patients (1.1%) in the anterior paramedian group. Exposures of ≥ 3 levels with the anterolateral approach were associated with abdominal bulging (p = 0.04), while 1- or 2-level exposures were not (p > 0.05). Overall satisfaction with incisional appearance was higher in patients with an anterior paramedian incision (p = 0.001) and with approaches performed by an access surgeon (p = 0.004).
Conclusions
Patients who undergo an anterior paramedian approach to the lumbar spine have a higher quality of life and better cosmetic outcomes than patients undergoing an anterolateral retroperitoneal approach.
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Affiliation(s)
| | | | | | | | | | - John Kern
- 3Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Benjamin Peeler
- 3Surgery, University of Virginia Health System, Charlottesville, Virginia
| | | | | | | | | | - Vincent Arlet
- 1Departments of Neurosurgery,
- 2Orthopedic Surgery, and
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Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg 2008; 128:959-66. [PMID: 18040702 DOI: 10.1007/s00402-007-0518-1] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Optimal timing of stabilization for spinal injuries is discussed controversially. The goal of this study is to investigate the neurological recovery and its influencing factors in thoracolumbar spine fractures after surgical decompression and stabilization within 8 h of spinal cord injury versus surgery which is performed between 3 and 15 days. METHODS Twenty-seven patients undergoing thoracolumbar stabilization with neurological deficit for an acute thoracolumbar spinal injury at the level of Th8-L2 vertebra at Selcuk University between March 2004 and December 2006 were recorded. Patients with neurological deficit and medically stable for surgery underwent immediate stabilization within 8 h defined as group I (n = 12) and patients underwent operation in 3-15 days after thoracolumbar injury were defined as group II (n = 15). Patients were assessed for neurologic deficit and improvement as defined by the scoring system of American spinal injury association (ASIA). RESULTS In spite of comparable demographic data, patients in group I had a significantly shorter overall hospital and intensive care unit stay and had lesser systemic complications such as pneumonia and also exhibited better neurological improvement than group II (p < 0.05). CONCLUSION Early surgery may improve neurological recovery and decrease hospitalization time and also additional systemic complications in patients with thoracolumbar spinal cord injuries. Thus early stabilization of thoracolumbar spine fractures within 8 h after trauma appears to be favorable.
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Affiliation(s)
- Sahika Liva Cengiz
- Neurosurgery Department, Meram Faculty of Medicine, Selcuk University, A/5 Meram Akyokuş, Konya, Turkey.
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Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med 2008; 31:403-79. [PMID: 18959359 PMCID: PMC2582434 DOI: 10.1043/1079-0268-31.4.408] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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12
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Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976) 2006; 31:S28-35; discussion S36. [PMID: 16685233 DOI: 10.1097/01.brs.0000217973.11402.7f] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Evidence-based literature review. OBJECTIVE To provide updated evidence-based recommendations regarding spinal cord decompression in patients with acute spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA It is controversial whether early decompression following SCI conveys a benefit in neurologic outcome. METHODS MEDLINE search of experimental and clinical studies showing the effect of decompression on neurologic outcome following SCI. We focused on articles published within the last 10 years, with a particular emphasis on research conducted within the past 5 years. RESULTS A total of 66 articles were retrieved. Animal studies consistently show that neurologic recovery is enhanced by early decompression. There was 1 randomized controlled trial that showed no benefit to early (<72 hours) decompression. Several recent prospective series suggest that early decompression (<72 hours) can be performed safely and may improve neurologic outcomes. A recent systematic review showed that early decompression (<24 hours) resulted in statistically better outcomes compared to both delayed decompression and conservative treatment. CONCLUSIONS There are currently no standards regarding the role and timing of decompression in acute SCI. We recommend urgent decompression of bilateral locked facets in a patient with incomplete tetraplegia or in a patient with SCI with neurologic deterioration. Urgent decompression in acute cervical SCI remains a reasonable practice option and can be performed safely. There is emerging evidence that surgery within 24 hours may reduce length of intensive care unit stay and reduce post-injury medical complications.
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Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery and Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
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Fehlings MG, Perrin RG. The role and timing of early decompression for cervical spinal cord injury: update with a review of recent clinical evidence. Injury 2005; 36 Suppl 2:B13-26. [PMID: 15993113 DOI: 10.1016/j.injury.2005.06.011] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
It remains controversial whether early decompression following spinal cord injury conveys a benefit in neurological outcome. The goal of this paper is to provide evidence-based recommendations regarding spinal cord decompression in patients with acute spinal cord injury. We performed a Medline search of experimental and clinical studies reporting on the effect of decompression on neurological outcome following spinal cord injury. Animal studies consistently show that neurological recovery is enhanced by early decompression. One randomized controlled trial showed no benefit to early (<72 h) decompression, however, several recent prospective series suggest that early decompression (<12 h) can be performed safely and may improve neurological outcomes. A recent meta-analysis showed that early decompression (<24 h) resulted in statistically better outcomes compared to both delayed decompression and conservative management. Currently, there are no standards regarding the role and timing of decompression in acute spinal cord injury. We recommend urgent decompression of bilateral locked facets in patients with incomplete tetraplegia or in patients with spinal cord injury experiencing neurological deterioration. Urgent decompression in acute cervical spinal cord injury remains a reasonable practice option and can be performed safely.
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Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.
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Rath SA, Kahamba JF, Kretschmer T, Neff U, Richter HP, Antoniadis G. Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization. Neurosurg Rev 2004; 28:44-52. [PMID: 15480889 DOI: 10.1007/s10143-004-0356-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2003] [Accepted: 08/24/2004] [Indexed: 10/26/2022]
Abstract
Surgical decompression and internal fixation of the injured spine have become standard procedures in the management of thoracic and lumbar spine fractures, but their effectiveness on neurological recovery remains controversial. We report on 169 consecutive patients with thoracic and lumbar spine fractures who were treated by reduction, fusion, and internal fixation using transpedicular screw-rod systems. Open decompression was carried out in 67 (39.6%) of them, including all 42 patients (25%) who presented with initial neurological deficits. At least 8 months following surgery, 30 (71%) had neurologically improved by one to three grades on the Frankel scale. Thirteen (59%) out of 22 patients whose initial deficits had been classified as "motor useless" (Frankel grades A to C) could walk, at least with support. Thirteen out of 20 patients with posttraumatic deficit Frankel D ("motor useful") improved to full recovery (Frankel E). In six (3.6%) patients (all from the group of the 127 patients without initial neurological deficits), permanent slight postoperative neurological impairment of one Frankel grade (E to D) was seen, among them two (1.2%) with new minor motor deficit. Neurological outcome was significantly better (p<0.01) in patients operated upon within the first 24 h after injury than in those who underwent surgery later. Severity of injury also had a negative influence (p<0.001) on neurological recovery. Analysis suggests that there may be significant neurological improvement in patients treated surgically very early.
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Affiliation(s)
- Stefan Arthur Rath
- Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Ludwig-Heilmeyer-Strasse 2, 89312, Gunzburg, Germany.
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La Rosa G, Conti A, Cardali S, Cacciola F, Tomasello F. Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach. Spinal Cord 2004; 42:503-12. [PMID: 15237284 DOI: 10.1038/sj.sc.3101627] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
STUDY DESIGN Definitive and unequivocal evidence to support the practice of early or late surgery is still lacking in clinical studies. Accordingly, meta-analysis is one of the few methods that offer a rational, statistical approach to management decision. A review of the clinical literature on spinal cord injury with emphasis on the role of early surgical decompression and a meta-analysis of results was performed. OBJECTIVES To determine whether neurological outcome is improved in traumatic spinal cord-injured patients who had surgery within 24 h as compared with those who had late surgery or conservative treatment. METHODS A Medline search covering the period 1966-2000, supplemented with manual search, was used to locate studies containing information on indication, rationale and timing of surgical decompression after spinal cord injuries. The analysis included a total of 1687 eligible patients. RESULTS Statistically, early decompression resulted in better outcome compared with both conservative (P<0.001) and late management (P<0.001). Nevertheless, analysis of homogeneity showed that only data regarding patients with incomplete neurological deficits who had early surgery were reliable. CONCLUSIONS Although statistically the percentage of patients with incomplete neurological deficits improving after early decompression appear 89.7% (95% confidence interval: 83.9, 95.5%), to be better than with the other modes of treatment when taking into consideration the material available for analysis and the various other factors including clinical limitations; early surgical decompression can only be considered as practice option for all groups of patients.
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Affiliation(s)
- G La Rosa
- Neurosurgical Clinic, University of Messina School of Medicine, Messina, Italy
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Ramani PS. Evaluation of surgical intervention in acute spinal cord injured patients — A review. INDIAN JOURNAL OF NEUROTRAUMA 2004. [DOI: 10.1016/s0973-0508(04)80020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Fehlings MG, Sekhon LH, Tator C. The role and timing of decompression in acute spinal cord injury: what do we know? What should we do? Spine (Phila Pa 1976) 2001; 26:S101-10. [PMID: 11805616 DOI: 10.1097/00007632-200112151-00017] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The management of acute spinal cord injury has traditionally concentrated on preventative measures as well as, for the better part of the previous century, conservative care. Pharmacologic interventions, in particular intravenous methylprednisolone therapy, have shown modest improvements in clinical trials and are still undergoing evaluation. More recent interest has focused on the role of surgical reduction and decompression, particularly "early" surgery. A review of the current evidence available in the literature suggests that there is no standard of care regarding the role and timing of surgical decompression. There are insufficient data to support overall treatment standards or guidelines for this topic. There are, however, Class II data indicating that early surgery (<24 hours) may be done safely after acute SCI. Furthermore, there are Class III data to suggest a role for urgent decompression in the setting of 1) bilateral facet dislocation and 2) incomplete spinal cord injury with a neurologically deteriorating patient. Whereas there is biologic evidence from experimental studies in animals that early decompression may improve neurologic recovery after SCI, the relevant time frame in humans remains unclear. To date, the role of decompression in patients with SCI is only supported by Class III and limited Class II evidence and accordingly can be considered only a practice option. Accordingly, there is a strong rationale to undertake prospective, controlled trials to evaluate the role and timing of decompression in acute SCI.
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Affiliation(s)
- M G Fehlings
- Department of Neurosurgery, Royal North Shore and Dalcross Private Hospital, Sydney, New South Wales, Australia.
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18
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Tator CH, Fehlings MG. Chapter 6 Clinical Trials in Spinal Cord Injury. CLINICAL TRIALS IN NEUROLOGIC PRACTICE 2001. [DOI: 10.1016/s1877-3419(09)70013-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Fehlings MG, Tator CH. An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies. J Neurosurg 1999; 91:1-11. [PMID: 10419353 DOI: 10.3171/spi.1999.91.1.0001] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors conducted an evidence-based review of the literature to evaluate critically the rationale and indications for and the timing of decompressive surgery for the treatment of acute, nonpenetrating spinal cord injury (SCI). METHODS The experimental and clinical literature concerning the role of, and the biological rationale for, surgical decompression for acute SCI was reviewed. Clinical studies of nonoperative management of SCI were also examined for comparative purposes. Evidence from clinical trials was categorized as Class I (well-conducted randomized prospective trials), Class II (well-designed comparative clinical studies), or Class II (retrospective studies). Examination of studies in which animal models of SCI were used consistently demonstrated a beneficial effect of early decompressive surgery, although it is difficult to apply these data directly to the clinical setting. The clinical studies provided suggestive (Class III and limited Class II) evidence that decompressive procedures improve neurological recovery after SCI. However, no clear consensus can be inferred from the literature as to the optimum timing for decompressive surgery. Many authors have advocated delayed treatment to avoid medical complications, although good evidence from recent Class II trials indicates that early decompressive surgery can be performed safely without causing added morbidity or mortality. CONCLUSIONS There is biological evidence from experimental studies in animals that early decompressive surgery may improve neurological recovery after SCI, although the relevant interventional timing in humans remains unclear. To date, the role of surgical decompression in patients with SCI is only supported by Class III and limited Class II evidence. Accordingly, decompressive surgery for SCI can only be considered a practice option. Furthermore, analysis of the literature does not allow definite conclusions to be drawn regarding appropriate timing of intervention. Hence, there is a need to conduct well-designed experimental and clinical studies of the timing and neurological results of decompressive surgery for the treatment of acute SCI.
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Affiliation(s)
- M G Fehlings
- Division of Neurosurgery and Spinal Program, Toronto Hospital and University of Toronto, Ontario, Canada.
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20
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Tator CH, Fehlings MG, Thorpe K, Taylor W. Current use and timing of spinal surgery for management of acute spinal surgery for management of acute spinal cord injury in North America: results of a retrospective multicenter study. J Neurosurg 1999; 91:12-8. [PMID: 10419357 DOI: 10.3171/spi.1999.91.1.0012] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECT A multicenter retrospective study was performed in 36 North American centers to examine the use and timing of surgery in patients who have sustained acute spinal cord injury (SCI). The study was performed to obtain information required for the planning of a randomized controlled trial in which early and late decompressive surgery are compared. METHODS The records of all patients aged 16 to 75 years with acute SCI admitted to 36 centers within 24 hours of injury over a 9-month period in 1994 and 1995 were examined to obtain data on admission variables, methods of diagnosis, use of traction, and surgical variables including type and timing of surgery. A total of 585 patients with acute SCI or cauda equina injury were admitted to participating centers, although approximately half were ultimately excluded because they did not meet inclusion criteria. Common causes for exclusion were late admission, age, gunshot wound, and absence of signs of compression on imaging studies. Thus, only approximately 50% of patients with acute SCI would be eligible for inclusion in a study of acute decompressive surgery. Although all patients underwent computerized tomography (CT) scanning, only 54% underwent magnetic resonance imaging, and CT myelography was performed in only 6%. Complete neurological injuries (American Spinal Injury Association Grade A) were present in 57.8%. Traction was applied in only 47% of patients who sustained cervical injury, in whom decompressive traction was successful in only 42% of cases. Neurological deterioration occurred in 8.1% of cases after traction. Surgery was performed in 65.4% of patients. The timing of surgery varied widely: less than 24 hours postinjury in 23.5%, between 25 and 48 hours postinjury in 15.8%, between 48 and 96 hours in 19%, and more than 5 days postinjury in 41.7% of patients. CONCLUSIONS These data indicate that although surgery is commonly performed in patients with acute SCI, one third of cases are managed nonoperatively, and there is very little agreement on the optimum timing of surgical treatment. The results of this study confirm the need for a randomized controlled trial to assess the optimum timing of decompressive surgery in SCI.
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Affiliation(s)
- C H Tator
- Division of Neurosurgery and Spinal Program, Toronto Western Hospital and University of Toronto, Ontario, Canada.
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21
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Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 1997; 87:239-46. [PMID: 9254087 DOI: 10.3171/jns.1997.87.2.0239] [Citation(s) in RCA: 245] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The optimal management of acute spinal cord injuries remains to be defined. The authors prospectively applied resuscitation principles of volume expansion and blood pressure maintenance to 77 patients who presented with acute neurological deficits as a result of spinal cord injuries occurring from C-1 through T-12 in an effort to maintain spinal cord blood flow and prevent secondary injury. According to the Intensive Care Unit protocol, all patients were managed by using Swan-Ganz and arterial blood pressure catheters and were treated with immobilization and fracture reduction as indicated. Intravenous fluids, colloid, and vasopressors were administered as necessary to maintain mean arterial blood pressure above 85 mm Hg. Surgery was performed for decompression and stabilization, and fusion in selected cases. Sixty-four patients have been followed at least 12 months postinjury by means of detailed neurological assessments and functional ability evaluations. Sixty percent of patients with complete cervical spinal cord injuries improved at least one Frankel or American Spinal Injury Association (ASIA) grade at the last follow-up review. Thirty percent regained the ability to walk and 20% had return of bladder function 1 year postinjury. Thirty-three percent of the patients with complete thoracic spinal cord injuries improved at least one Frankel or ASIA grade. Approximately 10% of the patients regained the ability to walk and had return of bladder function. As of the 12-month follow-up review, 92% of patients demonstrated clinical improvement after sustaining incomplete cervical spinal cord injuries compared to their initial neurological status. Ninety-two percent regained the ability to walk and 88% regained bladder function. Eighty-eight percent of patients with incomplete thoracic spinal cord injuries demonstrated significant improvements in neurological function 1 year postinjury. Eighty-eight percent were able to walk and 63% had return of bladder function. The authors conclude that the enhanced neurological outcome that was observed in patients after spinal cord injury in this study was in addition to, and/or distinct from, any potential benefit provided by surgery. Early and aggressive medical management (volume resuscitation and blood pressure augmentation) of patients with acute spinal cord injuries optimizes the potential for neurological recovery after sustaining trauma.
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Affiliation(s)
- F L Vale
- Department of Rehabilitative Medicine, University of Alabama at Birmingham, 35294, USA
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22
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Devilee R, Sanders R, de Lange S. Treatment of fractures and dislocations of the thoracic and lumbar spine by fusion and Harrington instrumentation. Arch Orthop Trauma Surg 1995; 114:100-2. [PMID: 7734229 DOI: 10.1007/bf00422835] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Thirty-three patients with fractures of the thoracolumbar spine were treated by fusion and Harrington instrumentation after early reduction and stabilisation by postural reduction or halo-bifemoral traction. The rod-long-fuse-short technique was used. Postoperatively, all patients were mobilised with an external support. The mean follow-up was 6 years (range 1-13 years). Twenty-eight patients were pain-free, three patients needed sporadic pain medication. One patient was not working due to pain in his leg. One patient had constant pain. Twenty-three patients returned to work. The mean kyphosis increased from 8 degrees postoperatively to 13 degrees at follow-up.
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Affiliation(s)
- R Devilee
- Department of Orthopaedics and Traumatology, Westeinde Hospital, The Hague, The Netherlands
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23
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Weyns F, Rommens PM, Van Calenbergh F, Goffin J, Broos P, Plets C. Neurological outcome after surgery for thoracolumbar fractures. A retrospective study of 93 consecutive cases, treated with dorsal instrumentation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 1994; 3:276-81. [PMID: 7866851 DOI: 10.1007/bf02226579] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Surgical reconstruction and fusion form the treatment of choice for unstable thoracolumbar fractures. It remains difficult, however, to prove that surgical treatment provides an increased potential for neurological recovery. Also, the role of a decompressive laminectomy is still unclear. To address these issues, 93 consecutive cases of thoracolumbar fractures treated with dorsal instrumentation were reviewed. The neurological status at the time of admission and at a mean of 26 months postinjury was graded according to a modified Frankel scale. By using preoperative radiographs and computed tomography scans, we differentiated between fracture-dislocation lesions, dislocation lesions, flexion-distraction lesions, complete and incomplete burst fractures. Spinal stenosis was classified from grade 0 (no stenosis) to grade 3 (> 66% stenosis). All thoracolumbar fractures were treated with posterior instrumentation, using Dick's fixateur interne and Steffee's VSP plates and screws. During this procedure, laminectomy was performed in 33 patients (35%). In 17 cases (52% of the laminectomies), a surgically treatable lesion (dural tear, trapped nerve root, etc.) was found, especially in patients with a combination of a neurological deficit and a dislocation lesion, a fracture-dislocation lesion or a complete burst fracture with spinal stenosis grade 2 or 3. The neurological and functional outcome was excellent: none of the patients deteriorated, 68% made a complete neurological recovery, and 61% regained their previous level of activity.
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Affiliation(s)
- F Weyns
- Department of Neurosurgery, University Hospital Gasthuisberg, Leuven, Belgium
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24
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Duh MS, Shepard MJ, Wilberger JE, Bracken MB. The effectiveness of surgery on the treatment of acute spinal cord injury and its relation to pharmacological treatment. Neurosurgery 1994; 35:240-8; discussion 248-9. [PMID: 7969831 DOI: 10.1227/00006123-199408000-00009] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Using data from the Second National Acute Spinal Cord Injury Study (NASCIS II), the authors sought to characterize the role of surgery in the management of traumatic spinal cord injury and to examine the interaction between pharmacological treatment and surgery. Patients who did not undergo surgery had more severe spinal cord injuries initially than those who had surgery. However, no differences in neurological improvement at 1-year follow-up were found between those who underwent surgery and those who did not. The results suggest that either early surgery (< or = 25 hours after injury) or late surgery (> 200 hours) may be associated with increased neurological recovery, particularly motor function, but these results are equivocal. Surgery was not shown to interact with pharmacological treatments, indicating that the effect of drug treatment in NASCIS II, reported elsewhere, is not influenced by surgery. Other independent variables that best predicted improvement in motor score were age of 25 years or younger, incomplete injury, and lower baseline emergency department neurological scores. This study does not provide clinically relevant evidence concerning the efficacy of timing or the value of surgery in treating patients with spinal cord injuries. A randomized study on the timing and efficacy of spinal cord surgery is needed to obtain valid comparisons of the efficacy of surgical treatments.
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Affiliation(s)
- M S Duh
- Department of Epidemiology and Public Health, Yale University Medical School, New Haven, Connecticut
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25
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The Effectiveness of Surgery on the Treatment of Acute Spinal Cord Injury and Its Relation to Pharmacological Treatment. Neurosurgery 1994. [DOI: 10.1097/00006123-199408000-00009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Viale GL, Silvestro C, Francaviglia N, Carta F, Bragazzi R, Bernucci C, Maiello M. Transpedicular decompression and stabilization of burst fractures of the lumbar spine. SURGICAL NEUROLOGY 1993; 40:104-11. [PMID: 8362346 DOI: 10.1016/0090-3019(93)90119-l] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Twenty-seven consecutive patients with neurological impairment due to burst fractures of the lumbar spine were operated upon, via the postero-lateral route, over a 38-month-period. Transpedicular fixation devices [posterior segmental fixator (PSF) or variable screw placement system (VSP)] were applied in all cases, in order to achieve short-segment fusion of the fractured spinal segment. Return to useful motor power or neurological normality (median follow-up: 18.7 months) occurred in 22 cases (81% of the whole series), with this outcome resulting in all but one of the cases with preoperative incomplete neurological deficit. Postoperative encroachment of the spinal canal, degree of kyphotic deformity, and reduction of the vertebral height showed statistically significant differences compared with the corresponding preoperative values.
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Affiliation(s)
- G L Viale
- Department of Neurosurgery, University of Genoa Medical School, Italy
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Silvestro C, Francaviglia N, Bragazzi R, Viale GL. Near-anatomical reduction and stabilization of burst fractures of the lower thoracic or lumbar spine. Acta Neurochir (Wien) 1992; 116:53-9. [PMID: 1615770 DOI: 10.1007/bf01541254] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Thirty-one consecutive symptomatic patients with burst fractures of the lower thoracic or lumbar spine (T 11-L4) were treated by early surgery in a 36-month period, with near-anatomical reduction being achieved via the postero-lateral route. Fusion and reconstruction of the vertebral body was done by using autologous or processed bovine bone. Correction of the kyphotic deformity was obtained by using distraction rods or transpedicular devices. The post-operative mean degree of kyphosis, percent vertebral height, and percent canal stenosis showed statistically significant differences, compared with the corresponding pre-operative mean values. All but one of the 25 patients with incomplete paraplegia exhibited neurological improvement, with complete recovery occurring in 20 cases (median follow-up: 16 months) irrespective of the location of the lesion at the thoraco-lumbar junction (T 11-L1) or the lower lumbar segment (L2-L4). Out of the 6 patients with pre-operative complete paraplegia, useful motor power returned in one case with a lesion below L1. The results confirm the suitability of the postero-lateral route and are consistent with the assumption that early near-anatomical reduction and stabilization favours maximum neurological recovery in symptomatic patients.
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Affiliation(s)
- C Silvestro
- Department of Neurosurgery, University of Genoa Medical School, Italy
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Nidecker A, Kocher M, Maeder M, Gratzl O, Zäch GA, Benz UF, Burckhardt B. MR-imaging of chronic spinal cord injury. Association with neurologic function. Neurosurg Rev 1991; 14:169-79. [PMID: 1944931 DOI: 10.1007/bf00310652] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Twenty-two para- and tetraplegic patients with chronic spinal cord injuries were examined with magnetic resonance imaging (MRI). The clinical course in the entire rehabilitation period was recorded and an attempt was made to associate the functional status of the patients with the morphologic findings on MRI. Small and large spinal cord cysts and syringomyelia, cord atrophy, and spinal stenosis were found. Additionally, in a number of patients regions of increased signal intensity within the cord, interpreted as myelomalacia, and obliteration of the intradural extramedullary space, interpreted as arachnopathy, were noted. The large number (13/22) of cystic lesions in our patients was unexpected. It was in contrast to the rate reported in autopsy studies of paraplegics which note only few cysts. Whereas a direct association of morphologic findings with neurologic symptoms and the clinical course was difficult, it was found that patients with large cysts and spinal cord atrophy generally showed no tendency to improve in spite of the measures taken during the rehabilitation period. It is difficult to decide whether the initial trauma with cord hemorrhage is limiting the chance of neurological improvement or if a sequence of events leading from hemorrhage to gliosis and cystic necrosis is the determining factor.
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Affiliation(s)
- A Nidecker
- Institute for MR Imaging Rebgasse, University of Basel, Cantonal Hospital, Switzerland
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A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. N Engl J Med 1990; 323:1207-9. [PMID: 2278580 DOI: 10.1056/nejm199010253231712] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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30
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Lozes G, Fawaz A, Mescola P, Marnay T, Herlant M, Devos P, Cama A, Sertl GO, Brambillas Bas M, Leclercq X, Duhamel P, Skondia V, Jomin M. Percutaneous interbody osteosynthesis in the treatment of thoracolumbar traumatic or tumoural lesions. A review of 51 cases. Acta Neurochir (Wien) 1990; 102:42-53. [PMID: 2407052 DOI: 10.1007/bf01402185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The authors describe a technique of percutaneous interbody osteosynthesis applicable to the dorsal and lumbar spine. 51 patients were so treated for different aetiologies: traumatic conditions (35 cases) and tumoural lesions (16 cases). The material used consisted of special instruments that are positioned in double obliquity by a percutaneous posterolateral approach. A posterior approach limited to the pathological focus was used jointly whenever a graft or a decompression was necessary (19 cases). Several types of anaesthesia were used (local, local-regional, general, neuroleptanalgesia). The patients benefited by the advantages that usually accompany percutaneous techniques. The advantages and limitations of the method are discussed.
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Affiliation(s)
- G Lozes
- Department of Neurosurgery B, University Hospital, Lille, France
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