1
|
Zheng R, Fan Y, Guan B, Fu R, Yao L, Wang W, Li G, Zhou Y, Chen L, Feng S, Zhou H. A critical appraisal of clinical practice guidelines on surgical treatments for spinal cord injury. Spine J 2023; 23:1739-1749. [PMID: 37339698 DOI: 10.1016/j.spinee.2023.06.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 05/10/2023] [Accepted: 06/14/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND CONTEXT Spinal cord injury (SCI) is a global health problem with a heavy economic burden. Surgery is considered as the cornerstone of SCI treatment. Although various organizations have formulated different guidelines on surgical treatment for SCI, the methodological quality of these guidelines has still not been critically appraised. PURPOSE We aim to systematically review and appraise the current guidelines on surgical treatments of SCI and summarize the related recommendations with the quality evaluation of supporting evidence. STUDY DESIGN Systematic review. METHODS Medline, Cochrane library, Web of Science, Embase, Google Scholar, and online guideline databases were searched from January 2000 to January 2022. The most updated and recent guidelines containing evidence-based or consensus-based recommendations and established by authoritative associations were included. The Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument containing 6 domains (eg, applicability) was used to appraise the included guidelines. An evidence-grading scale (ie, level of evidence, LOE) was utilized to evaluate the quality of supporting evidence. The supporting evidence was categorized as A (the best quality), B, C, and D (the worst quality). RESULTS Ten guidelines from 2008 to 2020 were included, however, all of them acquired the lowest scores in the domain of applicability among all the six domains. Fourteen recommendations (eight evidence-based recommendations and six consensus-based recommendations) were totally involved. The SCI types of the population and timing of surgery were studied. Regarding the SCI types of the population, eight guidelines (8/10, 80%), two guidelines (2/10, 20%), and three guidelines (3/10, 30%) recommended surgical treatment for patients with SCI without further clarification of characteristics, incomplete SCI, and traumatic central cord syndrome (TCCS), respectively. Besides, one guideline (1/10, 10%) recommended against surgery for patients with SCI without radiographic abnormality. Regarding the timing of surgery, there were eight guidelines (8/10, 80%), two guidelines (2/10, 20%), and two guidelines (2/10, 20%) with recommendations for patients with SCI without further clarification of characteristics, incomplete SCI, and TCCS, respectively. For patients with SCI without further clarification of characteristics, all eight guidelines (8/8, 100%) recommended for early surgery and five guidelines (5/8, 62.5%) recommended for the specific timing, which ranged from within 8 hours to within 48 hours. For patients with incomplete SCI, two guidelines (2/2, 100%) recommended for early surgery, without specific time thresholds. For patients with TCCS, one guideline (1/2, 50%) recommended for surgery within 24 hours, and another guideline (1/2, 50%) simply recommended for early surgery. The LOE was B in eight recommendations, C in three recommendations, and D in three recommendations. CONCLUSIONS We remind the reader that even the highest quality guidelines often have significant flaws (eg, poor applicability), and some of the conclusions are based on consensus recommendations which is certainly less than ideal. With these caveats, we found most included guidelines (8/10, 80%) recommended early surgical treatment for patients after SCI, which was consistent between evidence-based recommendations and consensus-based recommendations. Regarding the specific timing of surgery, the recommended time threshold did vary, but it was usually within 8 to 48 hours, where the LOE was B to D.
Collapse
Affiliation(s)
- Ruiyuan Zheng
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Yuxuan Fan
- Department of Orthopaedics, Tianjin Medical University General Hospital, Tianjin Medical University, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin, 300052, P.R. China
| | - Bin Guan
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Runhan Fu
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Wei Wang
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Guoyu Li
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
| | - Yue Zhou
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing, 400000, P.R. China
| | - Lingxiao Chen
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China; Sydney Musculoskeletal Health, The Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Shiqing Feng
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China; Department of Orthopaedics, Tianjin Medical University General Hospital, Tianjin Medical University, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin, 300052, P.R. China
| | - Hengxing Zhou
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China; Department of Orthopaedics, Tianjin Medical University General Hospital, Tianjin Medical University, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin, 300052, P.R. China.
| |
Collapse
|
2
|
Zhou Q, He W, Lv J, Liu H, Yang H, Zhang J, Liu T. Benefits of Early Surgical Treatment for Patients with Multilevel Cervical Canal Stenosis of Acute Traumatic Central Cord Syndrome. Orthop Surg 2023; 15:3092-3100. [PMID: 37771121 PMCID: PMC10694011 DOI: 10.1111/os.13904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/27/2023] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Currently, there exists considerable debate surrounding the optimal treatment approaches for different subtypes of patients with spinal cord injury (SCI). The purpose of this study was to conduct a comparative analysis of the benefits associated with conservative treatment and treatments with different surgical periods for patients diagnosed with acute traumatic central cord syndrome (ATCCS) and multilevel cervical canal stenosis (CCS). METHODS A retrospective cohort study was conducted, and 93 patients who met inclusion and exclusion criteria in our hospital between 2015 and 2020 were followed for a minimum duration of 2 years. Among them, 30 patients (Group A) received conservative treatment, 18 patients (Group B) received early surgery (≤7 days), and 45 patients (Group C) received late surgery (>7 days). The American Spinal Injury Association (ASIA) grade, Japanese Orthopedic Association (JOA) score, and recovery rate (RR) were evaluated. Multivariate linear regression was used to analyze prognostic determinants. Cost-utility analysis was performed based on the EQ-5D scale. RESULTS The ASIA grade, JOA score, and RR of all three groups improved compared with the previous evaluation (P < 0.05). During follow-up, the ASIA grade, JOA score, and RR of Group B were all better than for Group A and Group C (P < 0.05), while there was no significant difference between Group A and C (P > 0.05). The EQ-5D scale in Group B was optimal at the last follow-up. The incremental cost-utility ratio (ICUR) of Group A was the lowest, while that of Group B compared to Group A was less than the threshold of patients' willingness to pay. Age, initial ASIA grade, and treatment types significantly affected the outcomes. CONCLUSIONS Both conservative and surgical treatments yield good results. Compared with patients who received conservative treatment and late surgery, patients who received early surgery had better clinical function and living quality. Despite the higher cost, early surgery is cost-effective when compared to conservative treatment. Younger age, initial better ASIA grade, and earlier surgery were associated with better prognosis.
Collapse
Affiliation(s)
- Quan Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Wei He
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Jiaheng Lv
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Hao Liu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Huilin Yang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Junxin Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Tao Liu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| |
Collapse
|
3
|
Nishida N, Tripathi S, Mumtaz M, Kelkar A, Kumaran Y, Sakai T, Goel VK. The Effect of Anterior-Only, Posterior-Only, and Combined Anterior Posterior Fixation for Cervical Spine Injury with Soft Tissue Injury: A Finite Element Analysis. World Neurosurg 2023; 171:e777-e786. [PMID: 36584897 DOI: 10.1016/j.wneu.2022.12.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/24/2022] [Accepted: 12/25/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This finite element analysis aimed to investigate the effects of surgical procedures for cervical spine injury. METHODS A three-dimensional finite element model of the cervical spine (C2-C7) was created from computed tomography. This model contained vertebrae, intervertebral discs, anterior longitudinal ligament, and posterior ligament complex. To create the cervical spine injury model, posterior ligament complex and anterior longitudinal ligament at C3-C4 were resected and the center of the intervertebral disc was resected. We created posterior-only fixation (PF), anterior-only fixation (AF), and combined anterior-posterior fixation (APF) models. A pure moment with a compressive follower load was applied, and range of motion, annular/nucleus stress, instrument stress, and facet forces were analyzed. RESULTS In all motion except for flexion, range of motion of PF, AF, and APF models decreased by 80%-95%, 85%-93%, and 97%-99% compared with the intact model. C3-C4 annulus stress of PF, AF, and APF models decreased by 28%-72%, 96%-100%, and 99%-100% compared with the intact model. Facet contact forces of PF, AF, and APF models decreased by 77%-79%, 97%-99%, and 77%-86% at C3-C4 compared with the intact model. Screw stress in the PF model was higher than in the APF model, and plate stress in the AF model was lower than in the APF model, but bone graft stress in the AF model was higher than in the APF model. CONCLUSIONS Cervical stabilization was preserved by the APF model. Regarding range of motion, the PF model had an advantage compared with the AF model except for flexion. An understanding of biomechanics provides useful information for the clinician.
Collapse
Affiliation(s)
- Norihiro Nishida
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan.
| | - Sudharshan Tripathi
- Engineering Center for Orthopaedic Research Excellence, Departments of Bioengineering and Orthopaedics, University of Toledo, Toledo, Ohio, USA
| | - Muzammil Mumtaz
- Engineering Center for Orthopaedic Research Excellence, Departments of Bioengineering and Orthopaedics, University of Toledo, Toledo, Ohio, USA
| | - Amey Kelkar
- Engineering Center for Orthopaedic Research Excellence, Departments of Bioengineering and Orthopaedics, University of Toledo, Toledo, Ohio, USA
| | - Yogesh Kumaran
- Engineering Center for Orthopaedic Research Excellence, Departments of Bioengineering and Orthopaedics, University of Toledo, Toledo, Ohio, USA
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Vijay K Goel
- Engineering Center for Orthopaedic Research Excellence, Departments of Bioengineering and Orthopaedics, University of Toledo, Toledo, Ohio, USA
| |
Collapse
|
4
|
Muacevic A, Adler JR, Nakagawa H, Takahashi A, Matsumine A. Improvement After Surgery in a Patient With Prolonged Tetraplegia Due to Cervical Spinal Cord Injury Without Bone Injury. Cureus 2023; 15:e33420. [PMID: 36751226 PMCID: PMC9899152 DOI: 10.7759/cureus.33420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/07/2023] Open
Abstract
Treatment strategies for patients with cervical spinal cord injury (CSCI) without major bone injury in the acute phase are under debate. For CSCI without major bone injury, conservative treatment is often the first choice owing to the absence of fractures and spinal column instability. However, treatment of CSCI without major bone injury by either surgery or conservative measures remains controversial. We described a case of a 48-year-old man with cervical American Spinal Cord Injury Association Impairment Scale (AIS) grade C tetraplegia as a result of a fall. Computed tomography scan and magnetic resonance imaging revealed no fractures and widespread T2-hyperintense signal changes in the cord centered on C3-4. The paralyzed condition of his lower extremities remained unchanged with conservative treatment for eight months after the injury. Therefore, he underwent decompression surgery eight months after the injury. At two weeks postoperatively, he could transfer and walk using a walker. After discharge, he underwent regular home-visit rehabilitation and gradually improved his physical functions, including gait ability one year postoperatively. We encountered a case in which surgery and intensive rehabilitation eight months after the injury improved motor function. The combination of surgery in the chronic phase and postoperative rehabilitation can therefore improve the outcomes. The message in this paper is by no means a recommendation for "late surgery." However, we suggested that surgical treatment might be an option if the functional improvement is poor, as even quite late surgery can provide functional improvement.
Collapse
|
5
|
Nori S, Watanabe K, Takeda K, Yamane J, Kono H, Yokogawa N, Sasagawa T, Ando K, Nakashima H, Segi N, Funayama T, Eto F, Yamaji A, Furuya T, Yunde A, Nakajima H, Yamada T, Hasegawa T, Terashima Y, Hirota R, Suzuki H, Imajo Y, Ikegami S, Uehara M, Tonomura H, Sakata M, Hashimoto K, Onoda Y, Kawaguchi K, Haruta Y, Suzuki N, Kato K, Uei H, Sawada H, Nakanishi K, Misaki K, Terai H, Tamai K, Shirasawa E, Inoue G, Kiyasu K, Iizuka Y, Takasawa E, Funao H, Kaito T, Yoshii T, Ishihara M, Okada S, Imagama S, Kato S. Does surgery improve neurological outcomes in older individuals with cervical spinal cord injury without bone injury? A multicenter study. Spinal Cord 2022; 60:895-902. [PMID: 35690640 DOI: 10.1038/s41393-022-00818-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES To investigate the neurological outcomes of older individuals treated with surgery versus conservative treatment for cervical spinal cord injury (CSCI) without bone injury. SETTING Thirty-three medical institutions in Japan. METHODS This study included 317 consecutive persons aged ≥65 years with CSCI without bone injury in participating institutes between 2010 and 2020. The participants were followed up for at least 6 months after the injury. Individuals were divided into surgery (n = 114) and conservative treatment (n = 203) groups. To compare neurological outcomes and complications between the groups, propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed. RESULTS After propensity score matching, the surgery and conservative treatment groups comprised 89 individuals each. Surgery was performed at a median of 9.0 (3-17) days after CSCI. Baseline factors were comparable between groups, and the standardized difference in the covariates in the matched cohort was <10%. The American Spinal Injury Association (ASIA) impairment scale grade and ASIA motor score (AMS) 6 months after injury and changes in the AMS from baseline to 6 months after injury were not significantly different between groups (P = 0.63, P = 0.24, and P = 0.75, respectively). Few participants who underwent surgery demonstrated perioperative complications such as dural tear (1.1%), surgical site infection (2.2%), and C5 palsy (5.6%). CONCLUSION Conservative treatment is suggested to be a more favorable option for older individuals with CSCI without bone injuries, but this finding requires further validation.
Collapse
Affiliation(s)
- Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Kazuki Takeda
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Orthopaedic Surgery, Japanese Red Cross Shizuoka Hospital, 8-2 Otemachi, Aoi-ku, Shizuoka, 420-0853, Japan
| | - Junichi Yamane
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Orthopaedic Surgery, National Hospital Organization Murayama Medical Center, 2-37-1 Gakuen, Musashimurayama-shi, Tokyo, 208-0011, Japan
| | - Hitoshi Kono
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Keiyu Orthopedic Hospital, 2267 Akodacho, Tatebayashi-shi, Gunma, 374-0013, Japan
| | - Noriaki Yokogawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Takeshi Sasagawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.,Department of Orthopedics Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishinagae, Toyama, Toyama, 930-8550, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Fumihiko Eto
- Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akihiro Yamaji
- Department of Orthopaedic Surgery, Ibaraki Seinan Medical Center Hospital, 2190, Sakaimachi, Sashima, Ibaraki, 306-0433, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate school of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Atsushi Yunde
- Department of Orthopaedic Surgery, Graduate school of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Tomohiro Yamada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan.,Department of Orthopaedic Surgery, Nagoya Kyoritsu Hospital, 1-172 Hokke, Nakagawa-ku, Nagoya-shi, Aichi, 454-0933, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yoshinori Terashima
- Department of Orthopaedic Surgery, Sapporo Medical University, South 1-West 16-291, Chuo-ku, Sapporo, 060-8543, Japan.,Department of Orthopaedic Surgery, Matsuda Orthopedic Memorial Hospital, North 18-East 4-1 Kita-ku, Sapporo, 001-0018, Japan
| | - Ryosuke Hirota
- Department of Orthopaedic Surgery, Sapporo Medical University, South 1-West 16-291, Chuo-ku, Sapporo, 060-8543, Japan
| | - Hidenori Suzuki
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-kogushi, Ube city, Yamaguchi, 755-8505, Japan
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-kogushi, Ube city, Yamaguchi, 755-8505, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Munehiro Sakata
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.,Department of Orthopaedics, Saiseikai Shiga Hospital, 2-4-1 Ohashi Ritto, Shiga, 520-3046, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Yoshito Onoda
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yohei Haruta
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Kenji Kato
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8393, Japan.,Department of Orthopaedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hirokatsu Sawada
- Department of Orthopaedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, 577, Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Kosuke Misaki
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, 577, Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka-city, Osaka, 545-8585, Japan
| | - Koji Tamai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka-city, Osaka, 545-8585, Japan
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, 783-8505, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University, Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University, Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852 Hatakeda, Narita, Chiba, 286-0124, Japan.,Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba, 286-0124, Japan.,Department of Orthopaedic Surgery and Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaokal, Suita, Osaka, 565-0871, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University Hospital, 2-3-1 Shinmachi, Hirakata, Osaka, 573-1191, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaokal, Suita, Osaka, 565-0871, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| |
Collapse
|
6
|
Nishida N, Tripathi S, Mumtaz M, Kelkar A, Kumaran Y, Sakai T, Goel VK. Soft Tissue Injury in Cervical Spine Is a Risk Factor for Intersegmental Instability: A Finite Element Analysis. World Neurosurg 2022; 164:e358-e366. [PMID: 35513283 DOI: 10.1016/j.wneu.2022.04.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Soft tissue cervical spine injury (CSI) has the possibility of causing cervical segmental instability, which can lead to spinal cord injury. There is a lack of certainty in assessing whether soft tissue CSI is unstable or not. This biomechanical study aimed to investigate the risk factors of soft tissue CSI. METHODS A 3-dimensional finite element model of the ligamentous cervical spine (C2-C7) was created from medical images. Three soft tissue injury models were simulated at C4-C5: 1) posterior ligament complex (PLC) injury, 2) intervertebral disk (ID) with anterior longitudinal ligament injury (IDI), and 3) anterior longitudinal ligament, PLC, and ID injury (API) model. Pure moment with compressive follower load was applied, and the range of motion, annular stress, nucleus stress, and facet forces were analyzed. RESULTS For the IDI and API models, the range of motion increased at the injury level in extension (by 101%) and left/right axial rotations (>30%) compared with the intact model. The IDI and API models showed an increase of >50% in annular and nucleus stresses at the injury level in extension and left/right rotations compared with the intact model. The PLC injury showed similar stresses as the intact model except for flexion. The facet contact forces of IDI and API models increased more than 100% compared with other models in all motions. CONCLUSIONS In CSI, all soft tissues have a key role in stabilizing cervical spine, but ID is the most important component of all.
Collapse
Affiliation(s)
- Norihiro Nishida
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Yamaguchi Prefecture, Japan.
| | - Sudharshan Tripathi
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedics, The University of Toledo, Toledo, Ohio, USA
| | - Muzammil Mumtaz
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedics, The University of Toledo, Toledo, Ohio, USA
| | - Amey Kelkar
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedics, The University of Toledo, Toledo, Ohio, USA
| | - Yogesh Kumaran
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedics, The University of Toledo, Toledo, Ohio, USA
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Yamaguchi Prefecture, Japan
| | - Vijay K Goel
- Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedics, The University of Toledo, Toledo, Ohio, USA
| |
Collapse
|
7
|
Zhang C, Lee VKH, Yu JML, Cheung JPY, Koljonen PA, Shea GKH. Length of Cervical Stenosis, Admission ASIA Motor Scores, and BASIC Scores Are Predictors of Recovery Rate Following Central Cord Syndrome. Spine (Phila Pa 1976) 2022; 47:212-219. [PMID: 34310538 DOI: 10.1097/brs.0000000000004178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE This study aims to determine whether quantitative magnetic resonance imaging (MRI) parameters and radiological scoring systems could be used as a reliable assessment tool for predicting neurological recovery trajectory following acute traumatic central cord injury syndrome (CCS). SUMMARY OF BACKGROUND DATA Controversy remains in whether CCS should be managed conservatively or by early surgical decompression. It is essential to understand how clinical and radiological parameters correlate with neurological deficits and how they predict recovery trajectories. METHODS We identified patients with CCS admitted between 2011 and 2018 with a minimum of 1-year follow-up. Cervical MRIs were analyzed for cord/canal dimensions, Brain and Spinal Injury Center (BASIC) scores and sagittal grading as ordinal scales of intraparenchymal cord injury. Japanese Orthopaedic Association (JOA) recovery rates (≥50% as good, < 50% as poor) were analyzed against these variables by logistic regression and receiver operator characteristic (ROC) curves. Additionally, we evaluated American Spinal Injury Association motor scale (AMS) scores/recovery rates. RESULTS Sixty patients were included, of which 30 were managed conservatively and 30 via surgical decompression. The average follow-up duration for the entire cohort was (51.1 ± 25.7) months. Upon admission, sagittal grading correlated with AMS and JOA scores (P < 0.01, β = 0.48). Volume of the C2 to C7 canal and axial cord area over the site of maximal compression correlated with AMS and JOA scores respectively (P = 0.04, β = 0.26; P = 0.01, β = 0.28). We determined admission AMS more than 61 to be a clinical cutoff for good recovery (area under the receiver operating curve [AUC] = 0.74, 95% confidence interval [CI]: 0.61-0.85, sensitivity 80.9%, specificity 69.2%, P < 0.01). Radiological cutoffs to identify patients with poor recovery rates were length of cervical spinal stenosis more than 3.9 cm (AUC = 0.76, 95% CI: 0.63-0.87, specificity 91.7%, sensitivity 52.2%, P < 0.01), BASIC score of more than 1 (AUC = 0.69, 95% CI: 0.56-0.81, specificity 80.5%, sensitivity 51.1%, P = 0.02). Surgical decompression performed as a salvage procedure upon plateau of recovery did not improve neurological outcomes. CONCLUSION Clinical and radiological parameters upon presentation were prognosticative of neurological recovery rates in CCS. Surgery performed beyond the acute post-injury period failed to improve outcomes.Level of Evidence: 3.
Collapse
Affiliation(s)
- Changmeng Zhang
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | | | | | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Paul Aarne Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Graham Ka Hon Shea
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| |
Collapse
|
8
|
Tanishima S, Mihara T, Ogawa S, Takeda C, Fujiwara S, Nagashima H. Bilateral facet effusion is a risk factor for segmental instability with cervical injury without vertebral fracture. Sci Rep 2021; 11:12531. [PMID: 34131235 PMCID: PMC8206338 DOI: 10.1038/s41598-021-91981-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 06/01/2021] [Indexed: 11/26/2022] Open
Abstract
Magnetic resonance imaging (MRI) is effective in identifying cervical spine injury after trauma. However, cervical instability without major bone injury or dislocation is challenging to assess. Hence, the current study aimed to investigate and compare the MRI and radiography findings of segmental instability in patients with cervical spine injury. We investigated 34 participants with cervical spine injury without vertebral fracture. Based on the radiography findings, the participants were categorized into two: group A with segmental instability (n = 11) and group B without segmental instability (n = 23). Both groups were compared in terms of the presence of segmental instability on radiography and MRI. Anterior longitudinal ligament (ALL) injury, disc injury, and bilateral facet effusion were observed in 6/11, 5/11, and 7/11 patients in group A and in 5/23, 2/23 and 7/23 patients in group B, respectively. The results showed significant differences (p < 0.05). Moreover, 2 and 10 of 11 patients in group A and 16 and 7 of 23 patients in group B presented with hemi lateral facet effusion and paravertebral muscle injury, respectively. However, the results did not significantly differ. According to a logistic regression analysis, bilateral facet effusion after trauma was associated with cervical segmental instability (odd ratio: 10.6, 95% confidence interval: 1.31–84.7). Facet joint effusion might be caused by capsule injury during trauma. Most participants with segmental instability had ALL, disc, and flavum injury and bilateral facet effusion. Therefore, we need to consider bilateral facet effusion with other soft tissue damage of the cervical spine as an association factor to show the instability.
Collapse
Affiliation(s)
- Shinji Tanishima
- Division of Orthopedic Surgery, Department of Sensory of Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago, Tottori, 683-8504, Japan.
| | - Tokumitsu Mihara
- Division of Orthopedic Surgery, Department of Sensory of Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago, Tottori, 683-8504, Japan
| | - Shinya Ogawa
- Department of Orthopedic Surgery, Japanese Red Cross Masuda Hospital, Masuda, Shimane, 698-8501, Japan
| | - Chikako Takeda
- Division of Orthopedic Surgery, Department of Sensory of Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago, Tottori, 683-8504, Japan
| | - Satoshi Fujiwara
- Department of Orthopedic Surgery, Sanin Rosai Hospital, Yonago, Tottori, 683-0002, Japan
| | - Hideki Nagashima
- Division of Orthopedic Surgery, Department of Sensory of Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago, Tottori, 683-8504, Japan
| |
Collapse
|
9
|
Abstract
This article reviews the historical origins of central cord syndrome (CCS), the mechanism of injury, pathophysiology, and clinical implications. CCS is the most common form of incomplete spinal cord injury. CCS involves a spectrum of neurologic deficits preferentially affecting the hands and arms. Evidence suggests that in the twenty-first century CCS has become the most common form of spinal cord injury overall. In an era of big data and the need to standardize this particular diagnosis to unite outcome data, we propose redefining CCS as any adult cervical spinal cord injury in the absence of fracture/dislocation.
Collapse
Affiliation(s)
- Mauricio J Avila
- Department of Neurosurgery, University of Arizona, Banner University Medical Center, PO Box 245070, 1501 North Campbell Avenue, Room 4303, Tucson, AZ 85724-5070, USA
| | - R John Hurlbert
- Department of Neurosurgery, University of Arizona, Banner University Medical Center, PO Box 245070, 1501 North Campbell Avenue, Room 4303, Tucson, AZ 85724-5070, USA.
| |
Collapse
|
10
|
Adult Spinal Cord Injury without Major Bone Injury: Effects of Surgical Decompression and Predictors of Neurological Outcomes in American Spinal Injury Association Impairment Scale A, B, or C. J Clin Med 2021; 10:jcm10051106. [PMID: 33800882 PMCID: PMC7961959 DOI: 10.3390/jcm10051106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 11/17/2022] Open
Abstract
The cervical spine can be injured even in the absence of radiographic abnormality, and the best surgical treatment for adult spinal cord injury without bone injury is debated. The aim of this study was to retrospectively investigate the effect of surgical decompression for severe adult spinal cord injury without major bone injury and to establish predictors of good neurological outcome. We analyzed 11 patients who underwent surgical decompression in severe adult spinal cord injury without major bone injury patients classified as American Spinal Injury Association Impairment Scale (AIS) grade A, B, or C. Neurological assessments were performed using AIS at preoperative and postoperative 1-year follow-up. Radiological evaluations were performed using cervical magnetic resonance imaging (MRI) at preoperative. Seven cases were classified as AIS grade A; two cases as AIS grade B; and two cases as AIS grade C. Five of 11 (45.5%) patients showed improved neurological grade 1-year postoperatively. Intramedullary lesion length (IMLL) (p = 0.047) and compression rate (p = 0.045) had the most powerful effect on AIS grade conversion. This study shows that the fate of the injured spinal cord is determined at the time of the injury, but adequate decompression may have limited contribution to the recovery of neurological function. Compression rate and IMLL on MRI can be used as a predictor of neurological recovery.
Collapse
|
11
|
Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society—Spine Trauma Study Group position statement. 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 2019; 28:2390-2407. [DOI: 10.1007/s00586-019-06085-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 07/06/2019] [Accepted: 07/19/2019] [Indexed: 01/15/2023]
|
12
|
Divi SN, Schroeder GD, Mangan JJ, Tadley M, Ramey WL, Badhiwala JH, Fehlings MG, Oner FC, Kandziora F, Benneker LM, Vialle EN, Rajasekaran S, Chapman JR, Vaccaro AR. Management of Acute Traumatic Central Cord Syndrome: A Narrative Review. Global Spine J 2019; 9:89S-97S. [PMID: 31157150 PMCID: PMC6512200 DOI: 10.1177/2192568219830943] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES To provide an updated overview of the management of acute traumatic central cord syndrome (ATCCS). METHODS A comprehensive narrative review of the literature was done to identify evidence-based treatment strategies for patients diagnosed with ATCCS. RESULTS ATCCS is the most commonly encountered subtype of incomplete spinal cord injury and is characterized by worse sensory and motor function in the upper extremities compared with the lower extremities. It is most commonly seen in the setting of trauma such as motor vehicles or falls in elderly patients. The operative management of this injury has been historically variable as it can be seen in the setting of mechanical instability or preexisting cervical stenosis alone. While each patient should be evaluated on an individual basis, based on the current literature, the authors' preferred treatment is to perform early decompression and stabilization in patients that have any instability or significant neurologic deficit. Surgical intervention, in the appropriate patient, is associated with an earlier improvement in neurologic status, shorter hospital stay, and shorter intensive care unit stay. CONCLUSIONS While there is limited evidence regarding management of ATCCS, in the presence of mechanical instability or ongoing cord compression, surgical management is the treatment of choice. Further research needs to be conducted regarding treatment strategies and patient outcomes.
Collapse
Affiliation(s)
- Srikanth N Divi
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - John J Mangan
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Madeline Tadley
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Wyatt L Ramey
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | | | | | | | | | | | | | | | - Jens R Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Alexander R Vaccaro
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| |
Collapse
|
13
|
Nakajima H, Takahashi A, Kitade I, Watanabe S, Honjoh K, Matsumine A. Prognostic factors and optimal management for patients with cervical spinal cord injury without major bone injury. J Orthop Sci 2019; 24:230-236. [PMID: 30361169 DOI: 10.1016/j.jos.2018.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/05/2018] [Accepted: 10/01/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Even though the number of patients with cervical spinal cord injury (CSCI) without major bone injury is increased, the treatment with either surgery or conservative measures remains controversial. The aim of this study was to assess its prognostic value in the prediction of useful motor recovery and to clarify whether the patients should be treated surgically are present. METHODS We reviewed 63 patients (conservative, n = 36; surgery, n = 27) with CSCI without major bone injury (Frankel A-C). Neurological examination using modified Frankel grade at admission and 6 months after injury and International Stoke Mandeville Games (ISMG) classification at subacute phase after injury, MRI findings including rate of spinal cord compression, extent of cord damage and type of signal intensity change were assessed. RESULTS Thirty-five of 63 patients were improved to walk at 6 months after injury. In multivariate analysis, rate of spinal cord compression, extent of cord damage and improvement of ISMG grade were associated with useful motor recovery. There was no difference in the neurological improvement between conservative and surgical groups. However, patients with spinal cord compression of ≥33.2% showed better motor recovery at 6 months post-injury after surgery than those treated conservatively. There was a positive correlation between the improvement of ISMG grade at subacute phase and Frankel grade at 6 months post-injury. It is difficult to obtain satisfactory surgical outcome for patients with Frankel A or B1 on admission and/or extensive spinal cord damage on T2-weighted image. CONCLUSIONS Conservative treatment is recommended for patients with CSCI without major bone injury. However, we also recommend surgical treatment to acquire walking ability for patients with spinal cord compression of ≥33.2% and low ISMG grade at subacute phase. Among such patients, careful consideration should be given to patients with Frankel A or B1 and/or extensive spinal cord damage on MRI.
Collapse
Affiliation(s)
- Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.
| | - Ai Takahashi
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Ippei Kitade
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Shuji Watanabe
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Kazuya Honjoh
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Akihiko Matsumine
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| |
Collapse
|
14
|
Segal DN, Grabel ZJ, Heller JG, Rhee JM, Michael KW, Yoon ST, Jain A. Epidemiology and treatment of central cord syndrome in the United States. JOURNAL OF SPINE SURGERY 2018; 4:712-716. [PMID: 30714002 DOI: 10.21037/jss.2018.11.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The objective of this study is to demonstrate the epidemiology and trends in management of patients with central cord syndrome (CCS) who present to the emergency department. Recent literature has reported that surgical treatment for CCS have increased over the previous decades. Methods The National Emergency Department Sample (NEDS) was queried from 2009 through 2012 to generate national estimates of patients who presented to the emergency department in the United States and were diagnosed with CCS. Results From 2009 through 2012, there were 11,975 emergency room visits for CCS (mean age 60 years). The two most common injury mechanisms were: fall (55%) and motor vehicle accident (15%). Concomitant cervical fractures were found in 10% patients. Ninety-three percent of patients were admitted to the hospital directly or after transfer to another facility, and 7% were discharged home. Fifty-five percent of patients were treated non-operatively, 39% were treated with cervical fusion surgery and 6% were treated with laminoplasty. Of patients who underwent cervical fusion, 62% received anterior decompression and fusion, 32% received posterior decompression and fusion, and 6% received combined anterior-posterior decompression and fusion. The incidence of in-hospital mortality was 2.6%. Mortality was associated with older patient age (OR 1.06, P<0.001) and greater comorbidities (OR 1.72, P<0.001). Conclusions Majority of patients who presented to the emergency room for CCS in the United States were treated non-operatively. Advanced age and greater comorbidities were the factors that were most associated with increased risk of in-hospital mortality in patients with CCS.
Collapse
Affiliation(s)
- Dale N Segal
- Department of Orthopedics, Emory University, Atlanta, GA, USA
| | | | - John G Heller
- Department of Orthopedics, Emory University, Atlanta, GA, USA
| | - John M Rhee
- Department of Orthopedics, Emory University, Atlanta, GA, USA
| | - Keith W Michael
- Department of Orthopedics, Emory University, Atlanta, GA, USA
| | - S Tim Yoon
- Department of Orthopedics, Emory University, Atlanta, GA, USA
| | - Amit Jain
- Department of Orthopedics, Johns Hopkins University, MD, USA
| |
Collapse
|
15
|
Combined Laminoplasty and Posterior Fusion for Cervical Spondylotic Myelopathy Treatment: A Literature Review. Asian Spine J 2018; 12:446-458. [PMID: 29879772 PMCID: PMC6002171 DOI: 10.4184/asj.2018.12.3.446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 09/08/2017] [Accepted: 10/02/2017] [Indexed: 12/11/2022] Open
Abstract
Study Design A literature review. Purpose To explore the utility of laminoplasty in combination with instrumented fusion, with a focus on neurological outcomes and changes in kyphotic deformity. Overview of Literature Management of cervical spondylotic myelopathy (CSM) to reduce morbidity within the neurosurgical population. Methods A US National Library of Medicine PubMed search was conducted for manuscripts pertaining to cervical laminoplasty and fusion for the management of CSM. Several relevant studies were shortlisted for review, and the bibliographies of the articles were searched for additional references. The search was limited to human studies, English-language literature, and reports on more than one patient. Results Combined laminoplasty and fusion was found to provide at least comparable, if not superior, neurological outcomes in specific patient populations with CSM. The Japanese Orthopedic Association scores, local kyphosis, and C2–C7 angle have been reviewed in several manuscripts, and improvement in each of these categories was found with laminoplasty and fusion. Conclusions The treatment of CSM necessitates an individualized approach based on the pathoanatomical variation. Laminoplasty and fusion can be appropriately used for patients with CSM in a setting of local kyphotic deformity, ossification of the posterior longitudinal ligament, associated segmental instability, and the need for strong stabilization.
Collapse
|
16
|
Mori E, Ueta T, Maeda T, Ideta R, Yugué I, Kawano O, Shiba K. Sequential neurological improvements after conservative treatment in patients with complete motor paralysis caused by cervical spinal cord injury without bone and disc injury. J Neurosurg Spine 2018; 29:1-9. [PMID: 29676669 DOI: 10.3171/2017.10.spine17844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study investigated neurological improvements after conservative treatment in patients with complete motor paralysis caused by acute cervical spinal cord injury (SCI) without bone and disc injury. METHODS This study was retrospective. The authors evaluated neurological outcomes after conservative treatment of 62 patients with complete motor paralysis caused by cervical SCI without bone and disc injury within 72 hours after trauma. The sequential changes in their American Spinal Injury Association Impairment Scale (AIS) grades were reviewed at follow-up 24-72 hours, 1 week, and 1, 3, and 6 months after treatment. RESULTS Of the 31 patients with a baseline AIS grade of A, 2 (6.5%) patients improved to grade B, 5 (16.1%) improved to grade C, and 2 (6.5%) improved to grade D by the 6-month follow-up. The 22 (71.0%) patients who remained at AIS grade A 1 month after injury showed no neurological improvement at the 6-month follow-up. Of the 31 patients with a baseline AIS grade of B, 12 (38.7%) patients showed at least a 1-grade improvement at the 1-month follow-up; 11 (35.5%) patients improved to grade C and 16 (51.6%) patients improved to grade D at the 6-month follow-up. CONCLUSIONS Even in patients with complete motor paralysis caused by cervical SCI without bone and disc injury within 72 hours after trauma, approximately 30% of the patients with an AIS grade of A and 85% of the patients with an AIS grade B improved neurologically after conservative treatment. It is very important to recognize the extent of neurological improvement possible with conservative treatment, even for severe complete motor paralysis.
Collapse
Affiliation(s)
- Eiji Mori
- Departments of1Orthopaedic Surgery and
| | | | | | - Ryousuke Ideta
- 2Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Igisu, Iizuka, Fukuoka, Japan
| | | | | | | |
Collapse
|
17
|
Paquet J, Rivers CS, Kurban D, Finkelstein J, Tee JW, Noonan VK, Kwon BK, Hurlbert RJ, Christie S, Tsai EC, Ahn H, Drew B, Bailey CS, Fourney DR, Attabib N, Johnson MG, Fehlings MG, Parent S, Dvorak MF. The impact of spine stability on cervical spinal cord injury with respect to demographics, management, and outcome: a prospective cohort from a national spinal cord injury registry. Spine J 2018; 18:88-98. [PMID: 28673827 DOI: 10.1016/j.spinee.2017.06.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/13/2017] [Accepted: 06/26/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients. PURPOSE The study aimed to test the authors' hypothesis that spine stability can identify a unique group of patients with regard to demographics, management, and outcomes, which classic CCS definitions do not. STUDY DESIGN/SETTING This is a prospective observational study. PATIENT SAMPLE The sample included participants with cervical SCI included in a prospective Canadian registry. OUTCOME MEASURES The outcome measures were initial hospitalization length of stay, change in total motor score from admission to discharge, and in-hospital mortality. METHODS Patients with cervical SCI from a prospective Canadian SCI registry were grouped into stable and unstable spine cohorts. Bivariate analyses were used to identify differences in demographic, injury, management, and outcomes. Multivariate analysis was used to better understand the impact of spine stability on motor score improvement. No conflicts of interest were identified. RESULTS Compared with those with an unstable spine, patients with cervical SCI and a stable spine were older (58.8 vs. 44.1 years, p<.0001), more likely male (86.4% vs. 76.1%, p=.0059), and have more medical comorbidities. Patients with stable spine cervical SCI were more likely to have sustained their injury by a fall (67.4% vs. 34.9%, p<.0001), and have high cervical (C1-C4; 58.5% vs. 43.3%, p=.0009) and less severe neurologic injuries (ASIA Impairment Scale C or D; 81.3% vs. 47.5%, p<.0001). Those with stable spine injuries were less likely to have surgery (67.6% vs. 92.6%, p<.0001), had shorter in-hospital lengths of stay (median 84.0 vs. 100.5 days, p=.0062), and higher total motor score change (20.7 vs. 19.4 points, p=.0014). Multivariate modeling revealed that neurologic severity of injury and spine stability were significantly related to motor score improvement; patients with stable spine injuries had more motor score improvement. CONCLUSIONS We propose that classification of stable cervical SCI is more clinically relevant than classic CCS classification as this group was found to be unique with regard to demographics, neurologic injury, management, and outcome, whereas classic CCS classifications do not . This classification can be used to assess optimal management in patients where it is less clear if and when surgery should be performed.
Collapse
Affiliation(s)
- Jérôme Paquet
- Laval University, 1401, 18e Rue, Sciences Neurologiques, Québec, QC G1J 1Z4, Canada.
| | - Carly S Rivers
- Rick Hansen Institute, 6400-818 West 10th Ave, Vancouver, BC V5Z 1M9, Canada
| | - Dilnur Kurban
- Rick Hansen Institute, 6400-818 West 10th Ave, Vancouver, BC V5Z 1M9, Canada
| | - Joel Finkelstein
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room MG 361, Toronto, ON M4N 3M5, Canada
| | - Jin W Tee
- Department of Neurosurgery, National Trauma Research Institute (NTRI), The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Vanessa K Noonan
- Rick Hansen Institute, 6400-818 West 10th Ave, Vancouver, BC V5Z 1M9, Canada
| | - Brian K Kwon
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, International Collaboration on Repair Discoveries (ICORD), UBC, 818 West 10th Ave, Vancouver, BC V5Z 1M9, Canada
| | - R John Hurlbert
- Department of Clinical Neurosciences, University of Calgary, 12th Floor Foothills Hospital, 1403 29 St NW, Calgary, AB T2N 2T9, Canada
| | - Sean Christie
- Research Division of Neurosurgery, Dalhousie University, 1796 Summer St, Rm 3814, Halifax, NS B3H 3A7, Canada
| | - Eve C Tsai
- Department of Surgery, Division of Surgery, University of Ottawa, C2-1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
| | - Henry Ahn
- University of Toronto Spine Program, 55 Queen St East, Suite 1008, Toronto, ON M5C1R6 Canada
| | - Brian Drew
- Department of Orthopaedic Surgery, McMaster University, 237 Barton St West, Hamilton, ON L8L 2X2, Canada
| | - Christopher S Bailey
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, Room E4, 800 Commissioners Rd East, London, ON N6A 5W9, Canada
| | - Daryl R Fourney
- Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8, Canada
| | - Najmedden Attabib
- Dalhousie University, Horizon Health Network, Division of Neurosurgery Saint John Regional Hospital, P.O. Box 2100, Saint John, NB E2L4L2, Canada
| | - Michael G Johnson
- University of Manitoba, Department of Surgery, Orthopaedics and Neurosurgery, AD4-820 Sherbrook St, Winnipeg, MB, R3A 1R9, Canada
| | - Michael G Fehlings
- Department of Surgery, University of Toronto, 399 Bathurst St, Suite 4ww-449, Toronto, ON M5T 2S8, Canada
| | - Stefan Parent
- Professeur-Agrégé Département de Chirurgie Chaire Académique sur les Déformations de la Colonne, 5400 boul. Western Gouin, Montréal, QC H4L 1C5, Canada
| | - Marcel F Dvorak
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, 818 West 10th Ave, Vancouver, BC V5Z 1M9, Canada
| | | |
Collapse
|
18
|
Inoue T, Suzuki S, Endo T, Uenohara H, Tominaga T. Efficacy of Early Surgery for Neurological Improvement in Spinal Cord Injury without Radiographic Evidence of Trauma in the Elderly. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
19
|
|
20
|
Epstein NE, Hollingsworth R. Diagnosis and management of traumatic cervical central spinal cord injury: A review. Surg Neurol Int 2015; 6:S140-53. [PMID: 26005576 PMCID: PMC4431046 DOI: 10.4103/2152-7806.156552] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 12/30/2014] [Indexed: 12/02/2022] Open
Abstract
Background: The classical clinical presentation, neuroradiographic features, and conservative vs. surgical management of traumatic cervical central spinal cord (CSS) injury remain controversial. Methods: CSS injuries, occurring in approximately 9.2% of all cord injuries, are usually attributed to significant hyperextension trauma combined with congenital/acquired cervical stenosis/spondylosis. Patients typically present with greater motor deficits in the upper vs. lower extremities accompanied by patchy sensory loss. T2-weighted magnetic resonance (MR) scans usually show hyperintense T2 intramedullary signals reflecting acute edema along with ligamentous injury, while noncontrast computed tomography (CT) studies typically show no attendant bony pathology (e.g. no fracture, dislocation). Results: CSS constitute only a small percentage of all traumatic spinal cord injuries. Aarabi et al. found CSS patients averaged 58.3 years of age, 83% were male and 52.4% involved accidents/falls in patients with narrowed spinal canals (average 5.6 mm); their average American Spinal Injury Association (ASIA) motor score was 63.8, and most pathology was at the C3-C4 and C4-C5 levels (71%). Surgery was performed within 24 h (9 patients), 24–48 h (10 patients), or after 48 h (23 patients). In the Brodell et al. study of 16,134 patients with CSS, 39.7% had surgery. In the Gu et al. series, those with CSS and stenosis/ossification of the posterior longitudinal ligament (OPLL) exhibited better outcomes following laminoplasty. Conclusions: Recognizing the unique features of CSS is critical, as the clinical, neuroradiological, and management strategies (e.g. conservative vs. surgical management: early vs. late) differ from those utilized for other spinal cord trauma. Increased T2-weighted MR images best document CSS, while CT studies confirm the absence of fracture/dislocation.
Collapse
Affiliation(s)
- Nancy E Epstein
- Department of NeuroScience, Winthrop University Hospital, Mineola, NY 11501, USA
| | - Renee Hollingsworth
- Department of NeuroScience, Winthrop University Hospital, Mineola, NY 11501, USA
| |
Collapse
|
21
|
Park MS, Moon SH, Lee HM, Kim TH, Oh JK, Suh BK, Lee SJ, Riew KD. Delayed surgical intervention in central cord syndrome with cervical stenosis. Global Spine J 2015; 5:69-72. [PMID: 25649889 PMCID: PMC4303475 DOI: 10.1055/s-0034-1395785] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 10/12/2014] [Indexed: 12/03/2022] Open
Abstract
Study Design Review of the literature. Objective It is generally accepted that surgical treatment is necessary for central cord syndrome (CCS) with an underlying cervical stenosis. However, the surgical timing for decompression is controversial in spondylotic cervical CCS. The purpose of this study is to review the results of early and delayed surgery in patients with spondylotic cervical CCS. Methods MEDLINE was searched for English-language articles on CCS. There were 1,653 articles from 1940 to 2012 regarding CCS, 5 of which dealt with the timing of surgery for spondylotic cervical CCS. Results All five reports regarding the surgical timing of spondylotic cervical CCS were retrospective. Motor improvement, functional independence measures, and walking ability showed similar improvement in early and late surgery groups in the studies with follow-up longer than 1 year. However, greater improvement was seen in the early surgery group in the studies with follow-up shorter than 1 year. The complication rates did not show a difference between the early and late surgery groups. However, there are controversies regarding the length of intensive care unit stay or hospital stay for the two groups. Conclusions There was no difference in motor improvement, functional independence, walking ability, and complication rates between early and late surgery for spondylotic cervical CCS.
Collapse
Affiliation(s)
- Moon Soo Park
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea,Address for correspondence Dr. Moon Soo Park, MD, PhD 896, Pyeongchon-dong, Dongan-gu, Anyang-siGyeonggi-do, 431-070Republic of Korea
| | - Seong-Hwan Moon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hwan-Mo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hwan Kim
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Jae Keun Oh
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Bo-Kyung Suh
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Seung Jin Lee
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - K. Daniel Riew
- Department of Orthopedic Surgery, BJC Institute of Health at Washington University School of Medicine, St. Louis, Missouri, United States
| |
Collapse
|
22
|
Zhang Z, Wang H, Liu C. Acute Traumatic Cervical Cord Injury in Pediatric Patients with os Odontoideum: A Series of 6 Patients. World Neurosurg 2014; 83:1180.e1-6. [PMID: 25535071 DOI: 10.1016/j.wneu.2014.12.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 12/15/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Os odontoideum can lead to instability of the atlantoaxial joint and places the spinal cord at significant risk for acute traumatic catastrophic events or chronic neurologic change. The purpose of this study was to retrospectively review acute cervical cord injury after minor trauma in 6 pediatric patients with os odontoideum. METHODS Between 2012 and 2013, 6 pediatric patients with os odontoideum who suffered acute traumatic cervical cord injury were reviewed retrospectively. Their clinical history, neurologic symptoms, radiological investigations, follow-up period, American Spinal Injury Association (ASIA) impairment classification, and motor score were reviewed. RESULTS There were 2 male and 4 female subjects ranging in age from 4 to 18 years (mean 11.8 years). Before the traumatic injury, 2 cases were asymptomatic and 4 complained of myelopathic feature with unsteadiness on feet. Falls were the most common injury (n = 5), followed by a minor motor vehicle accident (n = 1). Atlantoaxial instability and cord compression were presented in all cases with dynamic cervical lateral radiographs and magnetic resonance imaging. Most patients presented with spinal cord thinning and hyperintensity on T2-weighted sequences in magnetic resonance imaging. Spinal cord compression was anterior in 2 cases and both anterior and posterior in 4. Two patients was classified as ASIA B, 1 as ASIA C, and 3 as ASIA D category on admission. Two patients presented with respiratory failure with mechanical ventilation for over 2 weeks in perioperative period. Postoperatively, all patients improved neurologically and clinically after underwent posterior atlantoaxial fixation and fusion. CONCLUSIONS Pediatric patients with asymptomatic or myelopathic atlantoaxial instability secondary to os odontoideum are at risk for acute spinal cord injury even after minor traumatic injury. Sufficient fixation and fusion should be undertaken as prophylactic treatment of developing myelopathy and to improve neurologic symptoms with acute traumatic cervical cord injury in pediatric patients with os odontoideum.
Collapse
Affiliation(s)
- Zhengfeng Zhang
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing, China.
| | - Honggang Wang
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Chao Liu
- Department of Orthopedics, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| |
Collapse
|
23
|
Thompson C, Gonsalves JF, Welsh D. Hyperextension injury of the cervical spine with central cord syndrome. 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 2014; 24:195-202. [PMID: 25077941 DOI: 10.1007/s00586-014-3432-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/21/2014] [Accepted: 06/21/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Traumatic central cord syndrome (TCCS) is the most commonly encountered type of incomplete spinal cord injury. TCCS typically occurs in patients over the age of 50 with a narrow spinal canal and follows an acute hyperextension injury of the cervical spine. Here, we report on the demographics of TCCS patients, their clinical course and outcomes, and the factors that may have influenced these outcomes. METHODS We conducted a retrospective folder review of patients who presented to our facility between January 2004 and December 2008 following hyperextension injury of the cervical spine and with the clinical manifestations of a central cord syndrome. Patient details were obtained from the acute spinal cord injury register at Groote Schuur Hospital and the patient folders, radiographs and magnetic resonance imaging films were reviewed. Predetermined data points were identified, tabulated and analysed, with only information from the injury-related admission being included. RESULTS An ASIA motor score of ≥60 on admission or discharge correlated with an 80 % chance of being able to walk at discharge from hospital. An ASIA motor score of ≤50 on admission correlated with an 80 % chance of not walking at discharge. An ASIA motor score of ≤50 at discharge meant a patient was not only unable to walk, but required placement in a spinal injury rehabilitation centre. Further, if a patient had a cervical spinal canal diameter of ≥8 mm they had a 50 % chance of clinical improvement and nearly 80 % chance of a functional outcome. CONCLUSION The Groote Schuur Hospital patient population differs from the international norm, particularly with respect to age and mechanism of injury. The ASIA motor score and cervical spine canal diameter proved to be useful predictors of outcome. Within our patient group, timing of surgery did not appear to influence the outcome.
Collapse
Affiliation(s)
- Crispin Thompson
- Division of Neurosurgery, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, H53 Old Main Building, Main Road, Observatory, Cape Town, 7295, South Africa,
| | | | | |
Collapse
|
24
|
Trends in the treatment for traumatic central cord syndrome without bone injury in the United States from 2000 to 2009. J Trauma Acute Care Surg 2013; 75:453-8. [DOI: 10.1097/ta.0b013e31829cfd7f] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
25
|
Aarabi B, Hadley MN, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Theodore N, Walters BC. Management of Acute Traumatic Central Cord Syndrome (ATCCS). Neurosurgery 2013; 72 Suppl 2:195-204. [DOI: 10.1227/neu.0b013e318276f64b] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, and University of Maryland, Baltimore, Maryland
| | - Mark N. Hadley
- Division of Neurological Surgery, and Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sanjay S. Dhall
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Daniel E. Gelb
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - R. John Hurlbert
- Department of Clinical Neurosciences, University of Calgary Spine Program, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Curtis J. Rozzelle
- Division of Neurological Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timothy C. Ryken
- Iowa Spine & Brain Institute, University of Iowa, Waterloo/Iowa City, Iowa
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Beverly C. Walters
- Division of Neurological Surgery, and Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Neurosciences, Inova Health System, Falls Church, Virginia
| |
Collapse
|
26
|
Aarabi B, Alexander M, Mirvis SE, Shanmuganathan K, Chesler D, Maulucci C, Iguchi M, Aresco C, Blacklock T. Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis. J Neurosurg Spine 2011; 14:122-30. [DOI: 10.3171/2010.9.spine09922] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The objective of this study was to elucidate the relationship between admission demographic data, validated injury severity measures on imaging studies, and clinical indicators on the American Spinal Injury Association (ASIA) motor score, Functional Independence Measure (FIM), manual dexterity, and dysesthetic pain at least 12 months after surgery for acute traumatic central cord syndrome (ATCCS) due to spinal stenosis.
Methods
Over a 100-month period (January 2000 to April 2008), of 211 patients treated for ATCCS, 59 cases were due to spinal stenosis, and these patients underwent surgical decompression. Five of these patients died, 2 were lost to follow-up, 10 were not eligible for the study, and the remaining 42 were followed for at least 12 months.
Results
In the cohort of 42 patients, mean age was 58.3 years, 83% of the patients were men, and 52.4% of the accidents were due to falls. Mean admission ASIA motor score was 63.8 (upper extremities score, 25.8 and lower extremities score, 39.8), the spinal cord was most frequently compressed at skeletal segments C3–4 and C4–5 (71%), mean midsagittal diameter at the point of maximum compression was 5.6 mm, maximum canal compromise (MCC) was 50.5%, maximum spinal cord compression was 16.5%, and length of parenchymal damage on T2-weighted MR imaging was 29.4 mm. Time after injury until surgery was within 24 hours in 9 patients, 24–48 hours in 10 patients, and more than 48 hours in 23 patients. At the 1-year follow-up, the mean ASIA motor score was 94.1 (upper extremities score, 45.7 and lower extremities score, 47.6), FIM was 111.1, manual dexterity was 64.4% of baseline, and pain level was 3.5. Stepwise regression analysis of 10 independent variables indicated significant relationships between ASIA motor score at follow-up and admission ASIA motor score (p = 0.003), MCC (p = 0.02), and midsagittal diameter (p = 0.02); FIM and admission ASIA motor score (p = 0.03), MCC (p = 0.02), and age (p = 0.02); manual dexterity and admission ASIA motor score (p = 0.0002) and length of parenchymal damage on T2-weighted MR imaging (p = 0.002); and pain level and age (p = 0.02) and length of parenchymal lesion on T2-weighted MR imaging (p = 0.04).
Conclusions
The main indicators of long-term ASIA motor score, FIM, manual dexterity, and dysesthetic pain were admission ASIA motor score, midsagittal diameter, MCC, length of parenchymal damage on T2-weighted MR imaging, and age, but different domains of outcome were determined by different predictors.
Collapse
|
27
|
Chang Y, Jung TD, Yoo DS, Hyun JK. Diffusion Tensor Imaging and Fiber Tractography of Patients with Cervical Spinal Cord Injury. J Neurotrauma 2010; 27:2033-40. [DOI: 10.1089/neu.2009.1265] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yongmin Chang
- Department of Molecular Medicine and Radiology, Kyungpook National University College of Medicine, Daegu, Korea
| | - Tae-Du Jung
- Department of Rehabilitation Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Dong Soo Yoo
- Department of Radiology, Dankook University College of Medicine, Cheonan, Korea
| | - Jung Keun Hyun
- Department of Rehabilitation Medicine, Dankook University College of Medicine, Cheonan, Korea
- Department of Nanobiomedical Science and WCU Research Center of Nanobiomedical Science, Dankook University, Cheonan, Korea
- Institute of Tissue Regeneration Engineering (ITREN), Dankook University, Cheonan, Korea
| |
Collapse
|
28
|
The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability. Spine (Phila Pa 1976) 2010; 35:S180-6. [PMID: 20881460 DOI: 10.1097/brs.0b013e3181f32a44] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review, ambispective analysis of observational data. OBJECTIVE To make recommendations as to whether or not urgent surgical decompression is ever indicated as the optimal treatment for enhancing neurologic recovery in a patient with acute central cord injury without fracture or instability. SUMMARY OF BACKGROUND DATA There are currently no standards regarding the role and timing of decompression in acute traumatic central cord syndrome. In the setting of TCCS without spinal column instability, much controversy exists. METHODS We have performed a thorough literature search based on the following question: "Is there a role for urgent (within 24 hours from injury to surgery) surgical decompression in acute central cord syndrome without fracture or instability specifically to enhance neurologic recovery?" Data including patient demographics, mechanism of injury, comorbidities, neurologic status, and surgical treatment was analyzed from a multicenter STSG observational database. Outcome measured included ASIA Motor Score, ASIA Grade, Functional Independence Measure (FIM) Score, SF-36, Sphincter Disturbance, and Ambulatory status. Measures were recorded on admission, discharge, 6 months and 1 year. RESULTS At 12-month follow-up, early surgery resulted in a 6.31 point greater improvement in total motor score than did the late surgery group, with a P = 0.0358. At 6-month follow-up, early surgery result in higher chance of improvement in ASIA Grade than late surgery, with an odds ratio = 3.39, while at 12-month follow-up early surgery resulted in a higher chance of improvement in ASIA Grade, with an odds ratio of 2.81. Patients who were operated on within 24 hours had 7.79 U more improvement in FIM Total Score than late surgery at 6 month follow-up, with P = 0.0474. CONCLUSION The consensus of experts following review of relevant and examination of observational dataset concluded that it is reasonable and safe to consider early surgical decompression in patients with profound neurologic deficit (ASIA = C) and persistent spinal cord compression due to developmental cervical spinal canal stenosis without fracture or instability. Those with less severe deficit (ASIA = D) can be treated with initial observation with surgery potentially at a later date depending on the extent and temporal profile of the patients neurologic recovery.
Collapse
|
29
|
Stevens EA, Marsh R, Wilson JA, Sweasey TA, Branch CL, Powers AK. A review of surgical intervention in the setting of traumatic central cord syndrome. Spine J 2010; 10:874-80. [PMID: 20869001 DOI: 10.1016/j.spinee.2010.07.388] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 06/14/2010] [Accepted: 07/26/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical treatment in the setting of central cord syndrome (CCS) has become safer since Schneider's original description. It is generally accepted that a decompressive surgical intervention is a valid treatment option in a patient with CCS and radiographic evidence of spinal cord compression. The optimal timing of surgical intervention for CCS remains controversial. PURPOSE To review a single institution's experience managing CCS, with particular emphasis on surgical versus medical management, timing of surgery, neurologic outcomes, hospital length of stay, and complications. STUDY DESIGN Retrospective review. PATIENT SAMPLE One hundred twenty-six patients diagnosed with CCS were treated at Wake Forest University Baptist Medical Center between June 1985 and September 2006. OUTCOME MEASURES Neurological outcomes were measured using the Frankel grading scale. Other outcome measures included hospital and intensive care unit (ICU) length of stay and complication profiles. METHODS A retrospective chart review was performed on patients admitted to Wake Forest University Baptist Medical Center with the diagnosis of traumatic central cord injury from June 1985 to September 2006 with institutional review board approval. Neurologic status was recorded on presentation and at maximum follow-up using the Frankel classification. The surgical cohort was stratified into three subgroups with regard to the timing of surgical intervention after injury: surgery less than 24 hours after injury, surgery greater than 24 hours after injury but during the initial admission, and delayed operative intervention on a second hospital admission. Other variables collected included ICU and hospital length of stay and complication profiles. Data analyses were performed using SPSS (SPSS, Chicago, IL, USA) and Excel 2002 (Microsoft, Seattle, WA, USA). RESULTS A total of 126 patients treated for CCS were reviewed. Sixty-seven patients received surgery compared with 59 patients managed nonoperatively. Of those managed operatively, 16 patients received surgery within 24 hours of the time of injury. There were 34 patients who received surgery greater than 24 hours after the time of injury but during their initial admission with a mean time to surgery of 6.4 days (5-52 days). There were 17 patients who received their operation on a second hospital admission with a mean time interval of 137 days between injury and surgery (3-209). Mean follow-up was 32 months (1-210 months). An improvement in Frankel grade was seen in the overall operative cohort compared with those patients who received medical management alone. No statistically significant difference in neurologic outcome using Frankel grades was identified between the surgical subgroups with regard to timing of surgery. A trend toward decreased length of stay was seen in the surgical subgroup that received surgery during their initial admission. No statistically significant difference was identified between complication rates for the operative and nonoperative groups; however, a trend toward fewer complications and deaths was seen in those who received surgery in the first 24 hours or during the initial hospitalization. CONCLUSIONS Surgical treatment in the setting of CCS has become safer since Schneider's original description. Acknowledging its numerous limitations, this retrospective study supports surgical intervention in the setting of CCS as a safe effective management option. Improved Frankel grades were identified in those patients managed surgically compared with those receiving medical management alone. The data further shed light on the safety and potential benefits of early operative intervention for acute CCS compared with delayed surgical treatment. A prospective randomized controlled trial is needed to definitively compare surgical versus medical management and/or early versus delayed surgical treatment in the setting of traumatic CCS.
Collapse
|
30
|
Zhang Z, Zhou Y, Wang J, Chu T, Li C, Ren X, Wang W. Acute traumatic cervical cord injury in patients with os odontoideum. J Clin Neurosci 2010; 17:1289-93. [DOI: 10.1016/j.jocn.2010.01.051] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 01/05/2010] [Accepted: 01/17/2010] [Indexed: 11/27/2022]
|
31
|
Outcome of decompression surgery for cervical spinal cord injury without bone and disc injury in patients with spinal cord compression: a multicenter prospective study. Spinal Cord 2010; 48:548-53. [DOI: 10.1038/sc.2009.179] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
32
|
Diagnostic criteria of traumatic central cord syndrome. Part 1: A systematic review of clinical descriptors and scores. Spinal Cord 2010; 48:652-6. [DOI: 10.1038/sc.2009.155] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
33
|
Yadla S, Klimo Jr P, Harrop J. Traumatic Central Cord Syndrome: Etiology, Management, and Outcomes. Top Spinal Cord Inj Rehabil 2010. [DOI: 10.1310/sci1503-73] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
34
|
|
35
|
Cervical cord injury in patients with ankylosed spines: progressive paraplegia in two patients after posterior fusion without decompression. Spine (Phila Pa 1976) 2009; 34:E861-3. [PMID: 19927093 DOI: 10.1097/brs.0b013e3181bb89fc] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report and clinical discussion. OBJECTIVE To describe technical pitfall to treat 2 cervical cord injuries, including dislocations in patients with ankylosed spine due to diffuse idiopathic skeletal hyperostosis (DISH) or ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA DISH and OPLL are disease processes similar in pathology, which can lead to unexpected fractures due to low-energy trauma. In reported cases of fracture of the ankylosed spine in patients with DISH or OPLL, increasing lever arm and a grossly unstable fracture occurred. However, the actual surgical intervention for these fractures and spinal cord injuries was not discussed. METHODS We report 2 cervical cord injuries, including dislocations in patients with ankylosed spine due to DISH or OPLL. RESULTS Two patients underwent posterior fusion without decompression; however, postoperative progressive paraplegia still occurred. There were 3 points in common: these patients had ankylosed spines due to DISH or OPLL; they were elderly and had spinal canal stenosis; and after undergoing posterior fusion without decompression, their bilateral, lower extremity palsies worsened after surgery. Cervical alignment was slightly different after posterior fusion, and this change concentrated in one segment because adjacent vertebral bodies were ankylosed, and thus, immoveable. Additionally, this stress caused infolding of the ligamentum flavum with resultant spinal cord compression. CONCLUSION In these cases, we recommend posterior fusion and decompression such as laminoplasty to avoid worsening palsy.
Collapse
|
36
|
Aarabi B, Koltz M, Ibrahimi D. Hyperextension cervical spine injuries and traumatic central cord syndrome. Neurosurg Focus 2009; 25:E9. [PMID: 18980483 DOI: 10.3171/foc.2008.25.11.e9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Traumatic central cord syndrome (TCCS), regardless of its biomechanics, is the most frequently encountered incomplete spinal cord injury. Patients with TCCS present with disproportionate weakness of the upper extremities, and variable sensory loss and bladder dysfunction. Fractures and/or subluxations, forced hyperextension, and herniated nucleus pulposus are the main pathogenetic mechanisms of TCCS. Nearly 50% of patients with TCCS suffer from congenital or degenerative spinal stenosis and sustained their injuries during hyperextension as originally described by Schneider in 1954. Immunohistochemical and imaging studies indicate mild to moderate insult to axons and their ensheathing myelin in the lateral funiculi culminating in cytoskeletal injury and impaired conduction. More than one-half of these patients enjoy spontaneous recovery of motor weakness; however, as time goes on, lack of manual dexterity, neuropathic pain, spasticity, bladder dysfunction, and imbalance of gait render their activities of daily living nearly impossible. Based on the current level of evidence, there is no clear indication of the timing of decompression for relief of sustained spinal cord compression in hyperextension injuries. Future research, taking advantage of validated digital imaging data such as maximum canal compromise, maximum spinal cord compression, and lesion length on the CT and MR images, as well as more sensitive measures of bladder and hand function, spasticity, and neuropathic pain may help tailor surgery for a specific group of these patients.
Collapse
Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
| | | | | |
Collapse
|
37
|
Subaxial injury classification system to determine the surgical approach for subaxial cervical spine injuries. CURRENT ORTHOPAEDIC PRACTICE 2008. [DOI: 10.1097/bco.0b013e3282fa74b8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
38
|
|