Outcome of decompression surgery for cervical spinal cord injury without bone and disc injury in patients with spinal cord compression: a multicenter prospective study

Neurological recovery rate and predictive factors of incomplete AIS grade C spinal cord injury in the older aged population

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C).

SETTINGS

Multi-institutions in Japan.

METHODS

We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis.

RESULTS

Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness).

CONCLUSIONS

Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL.

SPONSORSHIP

No funding was received for this study.

Benefits of Early Surgical Treatment for Patients with Multilevel Cervical Canal Stenosis of Acute Traumatic Central Cord Syndrome

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.

Management of Cervical Spinal Cord Injury without Major Bone Injury in Adults

The incidence of cervical spinal cord injury (CSCI) without major bone injury is increasing, possibly because older people typically have pre-existing cervical spinal canal stenosis. The demographics, neurological injury, treatment, and prognosis of this type of CSCI differ from those of CSCI with bone or central cord injury. Spine surgeons worldwide are debating on the optimal management of CSCI without major bone injury. Therefore, this narrative review aimed to address unresolved clinical questions related to CSCI without major bone injury and discuss treatment strategies based on current findings. The greatest divide among spine surgeons worldwide hinges on whether surgery is necessary for patients with CSCI without major bone injury. Certain studies have recommended early surgery within 24 h after injury; however, evidence regarding its superiority over conservative treatment remains limited. Delayed MRI may be beneficial; nevertheless, reliable factors and imaging findings that predict functional prognosis during the acute phase and ascertain the necessity of surgery should be identified to determine whether surgery/early surgery is better than conservative therapy/delayed surgery. Quality-of-life assessments, including neuropathic pain, spasticity, manual dexterity, and motor function, should be performed to examine the superiority of surgery/early surgery to conservative therapy/delayed surgery.

Efficacy of surgical treatment and conservative treatment for cervical spinal cord injury without fracture and dislocation in adults: A meta-analysis

BACKGROUND

The aim of this study was to investigate the efficacy of surgical treatment and conservative treatment for cervical spinal cord injury without fracture and dislocation (CSCIWFD) in adults by meta-analysis.

METHODS

With a time span from 2010 to 2022, PubMed, Web of Science, Embase, China National Knowledge Infrastructure (CNKI) and Wanfang databases were searched for all clinical randomized controlled trials on the comparison of surgical treatment and conservative treatment for CSCIWFD in adults. The Cochrane quality assessment tool was used as the standard. Stata 16.0 statistical software was used for meta-analysis.

RESULTS

A total of 870 articles were retrieved, and 12 studies were finally included for meta-analysis. Among them, there were 451 patients in the observation group (surgical treatment) and 346 patients in the control group (conservative treatment). The results of meta-analysis showed that the observation group was superior to the control group in the effective rate (OR = 4.737, 95% CI [2.613, 8.586], P < .001), Japanese Orthopedic Association (JOA) score at 3 months after treatment (SMD = 1.038, 95% CI [0.417, 1.659], P = .001), 6 months after treatment (SMD = 3.135, 95% CI [2.120, 4.151], P < .001) and 12 months after treatment (SMD = 2.808, 95% CI [1.880, 3.737], P < .001). In addition, the JOA scores of patients at 12 months after surgical treatment (SMD = 6.397, 95% CI [4.654, 8.14], P < .001) and conservative treatment (SMD = 3.197, 95% CI [2.144, 4.24], P < .001) were significantly higher than those before treatment.

CONCLUSIONS

Surgical treatment can improve the effective rate and JOA score of adult patients with CSCIWFD compared to conservative treatment. This suggests that surgical treatment can significantly improve the patient's spinal cord function.

Posterior Hybrid Technique for the Treatment of Traumatic Cervical Spinal Cord Injury with High Signal Intensity on T2WI

Objective

To evaluate the efficacy of the posterior hybrid technique (PHT) for the treatment of traumatic cervical spinal cord injury without vertebral fracture or dislocation with high signal intensity on T2WI (CSCIH).

Methods

A comparative analysis of clinical efficacy between CSCIH patients who underwent anterior decompression and fusion (ADF) surgery and those who underwent PHT surgery was retrospectively conducted. Demographic characteristics, cervical range of motion (CRM), cross-sectional area of spinal cord (CSASC), spinal canal area residual rate (SCARR), high signal intensity ratio (HSIR), Cervical Japanese Orthopedic Association (CJOA) score, and neck disability index (NDI) were assessed.

Results

Forty-three CSCIH cases with PHT and 46 CSCIH cases with ADF were collected from January 2013 to January 2017. The CRM in patients with PHT was superior to that in patients with ADF at the final follow-up (64.21 ± 18.46° vs. 48.71 ± 19.34°, p = 0.0002). The SCARR also showed greater improvements in the PHT group than in the ADF group (final follow-up: 93.54 ± 11.09% vs. 88.13 ± 10.84%, p = 0.022). Both groups indicated significant improvements in the CSASC and HSIR (p < 0.05); however, no significant differences were observed between the two groups. All patients showed improvements in the CJOA score and the NDI after surgery (p < 0.05). At the 6-month follow-up, the ADF group had better NDI scores than the PHT group (31.17 ± 10.42 vs. 36.78 ± 9.65, p = 0.010), whereas the PHT group exhibited better improvements than the ADF group at the final follow-up (66.86 ± 9.28% vs. 57.67 ± 10.22%, p < 0.0001).

Conclusion

The PHT was as effective as ADF in the treatment of CSCIH, whereas the PHT was superior in the improvement of patients' health-related quality of life and in CRM preservation during the long-term follow-up.

Cervical single open-door laminoplasty with or without local lateral mass screw fixation and fusion to treat cervical spinal cord injuries accompanied by segmental spinal canal stenosis

Study Design

Retrospective.

Objectives

To investigate the efficacy of cervical single open-door laminoplasty with and without local lateral mass screw fixation and fusion as treatments for cervical spinal cord injuries accompanied by multisegmental spinal canal stenosis.

Setting

The Second Affiliated Hospital, School of Medicine, Zhejiang University.

Methods

Of all enrolled patients, 42 formed a stable group who underwent cervical single open-door laminoplasty alone and 14 formed an unstable group who underwent the procedure combined with lateral mass screw fixation and fusion. Neurological function was evaluated before surgery, at discharge, and at final follow-up using the American Spinal Cord Injury Association (ASIA) impairment scale and the Japanese Orthopedic Association (JOA) score.

Results

ASIA scores reflected improved neurological function in 52.5% of the stable group (15 with grade-D and 4 with grade-A injuries did not improve) and 45.5% of the unstable group (3 with grade-D and 3 with grade-A injuries did not improve). Postoperative JOA scores reflected 19.1% ± 21.6% improvement in the stable group and 18.6% ± 18.4% improvement in the unstable group (P > 0.05). Final follow-up JOA scores reflected 49.2% ± 31.7% improvement in the stable group and 47.1% ± 39.2% improvement in the unstable group (P > 0.05).

Conclusions

Laminoplasty combined with local fusion aided the treatment of unstable cervical spinal cord injuries and spinal stenosis. Such stenosis is the main pathological factor causing multiple spinal cord compressions in patients with cervical spinal cord injuries.

Improvement After Surgery in a Patient With Prolonged Tetraplegia Due to Cervical Spinal Cord Injury Without Bone Injury

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.

Prevalence of pre-existing factors causing spinal cord compression: Is there a difference between patients suffering from cervical spinal cord injury with and without bone injury?

BACKGROUND

Recently, the prevalence of elderly patients suffering from cervical spinal cord injury (CSCI) without bone injury has been increasing in various countries. Pre-existing factors causing spinal cord compression, such as ossification of the posterior longitudinal ligament (OPLL), can increase the risk of CSCI without bone injury. However, no study has compared the prevalence of pre-existing factors between CSCI with and without bone injury. This study aimed to compare the prevalence of pre-existing factors between CSCI with and without bone injury.

METHODS

In 168 consecutive patients with CSCI, pre-existing factors including OPLL, posterior spur of the vertebral body, developmental stenosis, disc bulge and calcification of yellow ligament (CYL) were evaluated on imaging studies. The prevalence of each type of pre-existing factors was compared between patients with and without bone injury.

RESULTS

The prevalence of pre-existing factors in patients without bone injury (86%) was significantly higher than in those with bone injury (20%) (P < 0.001; odds ratio, 23.9). The most common pre-existing factor was OPLL followed by developmental stenosis, posterior spur, disc bulge and CYL in both groups. OPLL, development stenosis and posterior spur were significantly more common in patients without bone injury compared to those with bone injury (P < 0.01).

CONCLUSIONS

Prevalence of pre-existing factors, such as OPLL, development stenosis and posterior spur was significantly higher in patients without bone injury than in those with bone injury. Thus, these pre-existing factors might be a potential risk of CSCI without bone injury.

Does cervical curvature affect neurological outcome after incomplete spinal cord injury without radiographic abnormality (SCIWORA): 1-year follow-up

Background

At present, surgery is the primary clinical treatment for SCIWORA patients, but conservative treatment still plays an important role in patients with incomplete spinal cord injury. As an important index of cervical spine degeneration, cervical curvature has an impact on the prognosis of spinal cord injury patients. This paper studied the prognosis of conservatively treated patients with SCIWORA and the correlation between cervical curvature and neurological prognosis.

Methods

A retrospective study was conducted in all the patients with SCI admitted to the Third Affiliated Hospital of Hebei Medical University between January 2017 and June 2020. Data were recorded in 106 eligible patients, including sex, age, injury factors, Cobb angle, CCI, CSA, and ASIA motor and sensory scores. The Wilcoxon sign rank sum test was used to analyze the data postinjury and at the 1-year follow-up. Pearson correlation analysis was performed for the Cobb angle, CCI and CSA. Simple linear regression analysis and multiple linear regression analysis were performed for each group of variables.

Results

The Wilcoxon signed rank sum test confirmed that the Cobb angle, the CCI and the CSA of the patients were not significantly different at the 1-year follow-up when compared with the postinjury values, and the ASIA motor and sensory scores were significantly improved. The Pearson correlation analysis showed correlations among the Cobb angle, the CCI and the CSA. Simple linear regression analysis and multiple linear regression analysis showed that the nerve recovery rate was negatively correlated with age and was positively correlated with the Cobb angle.

Conclusion

Conservative treatment of incomplete SCIWORA can achieve a good prognosis. There is a clear correlation between the Cobb angle, CCI and CSA, and the Cobb angle, as an important influencing factor, needs to be considered. For SCIWORA patients undergoing nonsurgical treatment, improving cervical curvature is beneficial to the prognosis of patients. Age negatively affects the neurological prognosis.

Does surgery improve neurological outcomes in older individuals with cervical spinal cord injury without bone injury? A multicenter study

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.

The pathophysiology of cervical spinal cord injury: what are the differences between traumatic injury and degenerative disorder

STUDY DESIGN

Retrospective comparative clinical study.

OBJECTIVE

To establish eligible diagnostic criteria for traumatic cervical spinal cord injury (TCSCI) without major fracture or dislocation and create a definitive clinical protocol by comparing the pathophysiology of CSCI in both traumatic and degenerative disorders.

SETTING

Fukuoka, Japan.

METHODS

A total of 21 TCSCI patients and 16 rapid progressive clinical deterioration of cervical spondylotic myelopathy (rp-CSM: additional cervical spinal cord injury with an existing cervical myelopathy) patients with impairment graded as C or D on the American Spinal Injury Association (ASIA) Impairment Scale were included in the study. Magnetic resonance (MR) images and ASIA motor scores were evaluated for all of the patients at the time of admission and 12 months postoperatively.

RESULTS

The T2-weighted MR images for all patients showed an abnormally high intramedullary signal in the area of the injured segment at the first examination. At 12 months post-surgery, 47.62% of patients with TCSCI and none with rp-CSM had an abnormally low intramedullary signal change on T1-weighted MR images. The neurological improvement with rp-CSM was significantly greater than that with TCSCI at 12 months postoperatively.

CONCLUSIONS

Our results suggest that the pathophysiology of CSCI between traumatic injury and degenerative disorder are similar, but not identical. The most important factor in the early pathophysiological differential diagnosis between these two pathologies is the presence of an existing cervical myelopathy. We believe that early prognosis with eligible diagnosis for CSCI may lead to early preparations for social rehabilitation in each case.

Prognostic Factors for Cervical Spinal Cord Injury without Major Bone Injury in Elderly Patients

In the current aging society, there has been a marked increase in the incidence of cervical spinal cord injury (CSCI) without major bone injury. This multi-center study aimed to identify predictors of neurological improvement in elderly patients with CSCI without major bone injury. The participants were 591 patients aged ≥65 years with CSCI without major bone injury and a minimum follow-up period of three months. Neurologic status was defined using the American Spinal Injury Association (ASIA) impairment scale (AIS). Univariate and multi-variate analyses were performed to identify prognostic factors for walking recovery in AIS A-C cases and full upper extremity motor recovery in AIS D cases. In AIS A-C cases, body mass index (odds ratio (OR): 1.112), magnetic resonance imaging signal change (OR: 0.240), AIS on admission (OR: 3.497), comorbidity of dementia/delirium (OR: 0.365), and post-injury pneumonia (OR: 0.194) were identified as independent prognostic factors for walking recovery. The prevalence of ossification of the posterior longitudinal ligament (OR: 0.494) was also found to be an independent prognostic factor in AIS B and C cases only. In AIS D cases, age (OR: 0.937), upper extremity ASIA motor score on admission (OR: 1.230 [per 5 scores]), and operation (OR: 0.519) were independent prognostic factors for full motor recovery. The severity of AIS at admission was the strongest predictor of functional outcomes. Promoting rehabilitation, however, through measures to reduce cognitive changes, post-injury pneumonia, and unhealthy body weight changes can contribute to greater neurological improvement in AIS A-C cases.

Prognostic Factors for the Postoperative Improvement of Spinal Cord-Related Neuropathic Pain in Patients with Degenerative Cervical Myelopathy

Introduction

The number of patients with degenerative cervical myelopathy (DCM) requiring surgical treatment has markedly increased in today's aging society. Such patients often exhibit impaired activities of daily living because of motor dysfunction as well as neuropathic pain (NeP). Although many studies have demonstrated the safety and efficacy of surgical treatment for DCM, residual postoperative NeP has not been well described. Therefore, this study aimed to identify the predictors of postoperative NeP improvement in patients with DCM.

Methods

This retrospective study included 92 outpatients with postoperative chronic NeP (≥3 months) related to DCM. Data were obtained from clinical information, magnetic resonance imaging (MRI) findings, and patient-based questionnaires using the Neuropathic Pain Symptom Inventory (NPSI) and the Brief Scale for Psychiatric Problems in Orthopaedic Patients. Univariate and multivariate analyses were performed for patients with NPSI improvement rates <30% and ≥30% to identify prognostic factors.

Results

Among 92 patients, 61 (66.3%) had residual NeP, with a low improvement rate even after surgery. The independent negative prognostic factors for NeP improvement after surgery were older age at operation (odds ratio (OR): 0.932), longer symptom duration before surgery (OR: 0.589), and higher preoperative NPSI score (OR: 0.932). The cut-off value of symptom duration before surgery for postoperative NeP improvement was 1 year. By contrast, the preoperative Japanese Orthopaedic Association score and MRI findings, including signal intensity change and the degree of spinal cord compression, were not associated with postoperative NeP improvement. Moreover, even in patients with an NPSI improvement rate ≥30%, the NPSI subscores for deep pain and paresthesia/dysesthesia remained high.

Conclusions

Discrepancies between physician- and image-based assessments and patient-based assessments were identified as factors associated with improvement in postoperative NeP. Our findings are important for both spine surgeons and patients to manage patient expectations with respect to recovery during the postoperative course.

Pros and Cons of Early and Very Early Surgery for Traumatic Central Cord Syndrome with Spinal Stenosis: Literature Review and Case Report

BACKGROUND

 The case of a 69-year-old patient with an acute traumatic central cord syndrome (ATCCS) with preexisting spinal stenosis raised a discussion over the question of conservative versus surgical treatment in the acute setting. We provide a literature overview on the management (conservative vs. surgical treatment) of ATCCS with preexisting spinal stenosis.

METHODS

 We reviewed the literature concerning essential concepts for the management of ATCCS with spinal stenosis and cervical spinal cord injury. The data retrieved from these studies were applied to the potential management of an illustrative case report.

RESULTS

 Not rarely has ATCCS an unpredictable neurologic course because of its dynamic character with secondary injury mechanisms within the cervical spinal cord in the early phase, the possibility of functional deterioration, and the appearance of a neuropathic pain syndrome during late follow-up. The result of the literature review favors early surgical treatment in ATCCS patients with preexisting cervical stenosis.

CONCLUSION

 Reluctance toward aggressive and timely surgical treatment of ATCCS should at least be questioned in patients with preexisting spinal stenosis.

Comparison of Early Surgical Treatment With Conservative Treatment of Incomplete Cervical Spinal Cord Injury Without Major Fracture or Dislocation in Patients With Pre-existing Cervical Spinal Stenosis

STUDY DESIGN

This was a retrospective comparative study.

OBJECTIVE

The objective of this study was to evaluate the clinical outcomes of early surgical treatment (<24 h) and conservative treatment of incomplete cervical spinal cord injury (CSCI) without major fracture or dislocation in patients with pre-existing cervical spinal canal stenosis (CSCS).

SUMMARY OF BACKGROUND DATA

The relative benefits of surgery, especially early surgical treatment, and conservative treatment for CSCI without major fracture or dislocation in patients with pre-existing CSCS remain unclear. Animal models of CSCI have demonstrated that early surgical decompression immediately after the initial insult may prevent or reverse secondary injury. However, the clinical outcomes of early surgery for incomplete CSCI in patients with pre-existing CSCS are still unclear.

MATERIALS AND METHODS

The medical records and radiographic data of 54 patients admitted to our facility between 2005 and 2015 with American Spinal Injury Association (ASIA) impairment scale grade B or C and pre-existing CSCS without major fracture or dislocation were retrospectively reviewed. Thirty-three patients (mean age, 57.4±14.0 y) underwent early surgical treatment within 24 hours after initial trauma (S group), and 21 patients (mean age, 56.9±13.6 y) underwent conservative treatment (C group) performed by 2 spinal surgeons in accordance with their policies. The primary outcome was the degree of improvement in ASIA grade after 2 years.

RESULTS

During the 2-year follow-up period, higher percentages of patients in the S group than in the C group showed ≥1 grade (90.9% vs. 57.1%, P=0.0051) and 2 grade (30.3% vs. 9.5%) improvements in ASIA grade. Multivariate analysis showed that treatment type, specifically early surgical treatment, was the only factor significantly associated with ASIA grade improvement after 2 years (P=0.0044).

CONCLUSIONS

Early surgery yielded better neurological outcomes than conservative treatment in patients with incomplete CSCI without major fracture or dislocation and pre-existing CSCS.

LEVEL OF EVIDENCE

Level III.

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

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.

Updated Review: The Steroid Controversy for Management of Spinal Cord Injury

BACKGROUND

Acute spinal cord injury (ASCI) is a devastating event that can have a profound impact on the lives of patients and their families. While no definitive medical treatment exists, the role of methylprednisolone (MP) in the management of ASCI and other spinal cord pathologies has been investigated in depth; however, its use remains contentious. While MP initially showed promise in the efficacy of ASCI treatment, more recent studies have questioned its use citing numerous systemic adverse effects. Pharmacologic treatments in this area are poorly understood due to the scarcity of knowledge surrounding the pathophysiology and heterogeneity of patients presenting with these conditions. Despite these shortcomings and due to the lack of alternative treatment options, MP is still widely used by physicians.

METHODS

We review prior and current literature on the use of MP treatment for ASCI patients with a discussion of novel drug delivery systems that have demonstrated the potential to improve MP's bioavailability at the site of injury while minimizing systemic side effects. In addition, current views on the role of MP and dexamethasone in metastatic spinal cord compression and postoperative infection are reviewed.

RESULTS

While some data support benefits in the use of steroids on spinal cord pathology, extensive research suggests at best limited effects and an unresolvable risk/benefit problem.

CONCLUSIONS

At present, evidence regarding use of dexamethasone for MSCC is contentious, especially regarding dose regiments. Ultimately, further investigation into the use of steroids is required to determine its utility in treating patients with spinal cord pathology.

Postoperative changes in spinal cord signal intensity in patients with spinal cord injury without major bone injury: comparison between preoperative and postoperative magnetic resonance images

OBJECTIVE

Although increased signal intensity (ISI) on MRI is observed in patients with cervical spinal cord injury (SCI) without major bone injury, alterations in ISI have not been evaluated. The association between postoperative ISI and surgical outcomes remains unclear. This study elucidated whether or not the postoperative classification and alterations in MRI-based ISI of the spinal cord reflected the postoperative symptom severity and surgical outcomes in patients with SCI without major bone injury.

METHODS

One hundred consecutive patients with SCI without major bone injury (79 male and 21 female) with a mean age of 55 years (range 20-87 years) were included. All patients were treated with laminoplasty and underwent MRI pre- and postoperatively (mean 12.5 ± 0.8 months). ISI was classified into three groups on the basis of sagittal T2-weighted MRI: grade 0, none; grade 1, light (obscure); and grade 2, intense (bright). The neurological statuses were evaluated according to the Japanese Orthopaedic Association (JOA) scoring system and the American Spinal Injury Association Impairment Scale (AIS).

RESULTS

Preoperatively, 8 patients had grade 0 ISI, 49 had grade 1, and 43 had grade 2; and postoperatively, 20 patients had grade 0, 24 had grade 1, and 56 had grade 2. The postoperative JOA scores and recovery rate (RR) decreased significantly with increasing postoperative ISI grade. The postoperative ISI grade tended to increase with the postoperative AIS grade. Postoperative grade 2 ISI was observed in severely paralyzed patients. The postoperative ISI grade improved in 23 patients (23%), worsened in 25 (25%), and remained unchanged in 52 (52%). Patients with an improved ISI grade had a better RR than those with a worsened ISI grade.

CONCLUSIONS

Postoperative ISI reflected postoperative symptom severity and surgical outcomes. Alterations in ISI were seen postoperatively in 48 patients (48%) and were associated with surgical outcomes.

Acute traumatic quadriplegia: Predictors of in-hospital and six-month mortality

Background

Traumatic spinal cord injury is one of the most disastrous and devastating health burdens all over the world with a high mortality rate. The present study aimed to evaluate the predictors of in-hospital and six-month mortality in these patients.

Methods

The electronic medical records of 87 consecutive patients with acute complete traumatic quadriplegia were reviewed to extract clinical, radiological, and laboratory data. Simple and multiple logistic regression models were used to estimate crude and adjusted odds with 95% confidence interval (CI) ratios for the predictors of in-hospital mortality and six-month mortality.

Results

There were 48 males and the mean age was 38.67 ± 12.81; in-hospital and six-month mortality were 21.84% and 11.76%, respectively. Traffic road accidents (67.8%) and falls (12.6%) were the most common causes of injury. The univariate analysis demonstrated advanced age, level of injury, late surgery or no surgical intervention, the lack of methylprednisolone therapy, a higher Charlson comorbidity index, the Injury Severity Score, and the presence of respiratory failure or bradycardia on admission were predictors of in-hospital mortality ( p < 0.05). In the final multiple logistic regression model, the level of injury (OR = 0.02 (0.001,0.35), p = 0.008) and the presence of respiratory failure (OR = 2.37 (0.03,13.88), p = 0.024) were the only predictors of in-hospital mortality. The univariate model showed that the level of injury, respiratory failure on admission, and the Injury Severity Score were the predictors of six-month mortality; however, the level of injury was the only predictor of the six-month mortality (OR = 1.12 (0.99, 1.27), p = 0.028) according to the multiple logistic regression model.

Conclusions

Several factors could affect in-hospital and six-month mortality in patients with traumatic spinal cord injury. Our findings demonstrated the level of injury and respiratory failure on admission as independent predictors of in-hospital mortality in these patients. Furthermore, the level of injury was the only independent predictor of six-month mortality in the present study.

Predictive factors for irreversible motor paralysis following cervical spinal cord injury

STUDY DESIGN

A retrospective observational study.

OBJECTIVES

To elucidate predictive clinical factors associated with irreversible complete motor paralysis following traumatic cervical spinal cord injury (CSCI).

SETTING

Hokkaido Spinal Cord Injury Center, Japan.

METHODS

A consecutive series of 447 traumatic CSCI persons were eligible for this study. Individuals with complete motor paralysis at admission were selected and divided into two groups according to the motor functional outcomes at discharge. Initial findings in magnetic resonance imaging (MRI) and other clinical factors that could affect functional outcomes were compared between two groups of participants: those with and those without motor recovery below the level of injury at the time of discharge.

RESULTS

Of the 73 consecutive participants with total motor paralysis at initial examination, 28 showed some recovery of motor function, whereas 45 remained complete motor paralysis at discharge, respectively. Multivariate logistic regression analysis showed that the presence of intramedullary hemorrhage manifested as a confined low intensity changes in diffuse high-intensity area and more than 50% of cord compression on MRI were significant predictors of irreversible complete motor paralysis (odds ratio [OR]: 8.4; 95% confidence interval [CI]: 1.2-58.2 and OR: 14.4; 95% CI: 2.5-82.8, respectively).

CONCLUSION

The presence of intramedullary hemorrhage and/or severe cord compression on initial MRI were closely associated with irreversible paralysis in persons with motor complete paralysis following CSCI. Conversely, subjects with a negligible potential for recovery could be identified by referring to these negative findings.

Early durotomy with duroplasty for severe adult spinal cord injury without radiographic abnormality: a novel concept and method of surgical decompression

PURPOSE

Treatment options for adult spinal cord injury without radiographic abnormality (ASCIWORA) varied. Compression of ASCIWORA may more likely result from spinal cord lesions such as edema and hemorrhage or contusion. This study aimed to explore the clinical effect of early durotomy with duroplasty decompression in the treatment of severe ASCIWORA.

METHODS

Data of 16 patients with ASCIWORA who underwent early ( < 72 h) posterior laminectomy followed by durotomy with duroplasty decompression from June 2015 to January 2017 were retrospectively analyzed. Patients' prognosis was analyzed by American Spinal Injury Association Impairment Scale (AIS) grades and scores. In 3 patients, intraspinal pressure (ISP) was continuously monitored for 1 week.

RESULTS

Cervical magnetic resonance imaging (MRI) revealed spinal cord edema in 9 patients and suspected hemorrhage or contusion in 7 cases. Pathological manifestations of spinal cord injury found during the operation were consistent with preoperative MRI findings. Of the 16 cases, AIS grade was improved by 1 grade in 3 cases, 2 grades in 11 cases, and 3 grades in 1 case. The AIS scores at the last follow-up were significantly higher than preoperative scores. There was a high level of ISP after laminectomy, whereas ISP continued to decrease steadily after durotomy.

CONCLUSIONS

Durotomy helps thoroughly decompress the spinal cord and improve cerebrospinal fluid circulation in severe ASCIWORA cases. Cervical MRI and pathological investigation of the spinal cord can be used to evaluate and predict the prognosis of ASCIWORA patients. ISP monitoring is an effective method for evaluating intramedullary pressure and decompression. These slides can be retrieved under Electronic Supplementary Material.

Differences in clinical outcomes between traumatic cervical myelopathy and degenerative cervical myelopathy: A comparative study of cervical spinal cord injury without major bone injury and cervical spondylotic myelopathy

A comparative study to examine the surgical outcomes of traumatic cervical myelopathy (TCM) patients was designed. The study aim was to compare the surgical outcomes between TCM and degenerative cervical myelopathy (DCM) and to characterize the preoperative symptoms and postoperative residual symptoms in TCM patients. One hundred consecutive patients with TCM (81 men, 19 women; mean age, 57.7 years; range, 31-79 years) and 100 consecutive patients with DCM (88 men, 12 women; mean age, 58.4 years; range, 36-78 years) were included in this study. All patients were treated by laminoplasty. The pre- and postoperative neurological statuses were evaluated according to the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy. The recovery rate (RR) of each function was compared between the two groups. The mean preoperative JOA scores of motor function of the upper extremity in the TCM and DCM groups were 1.9 and 2.3, respectively (P < 0.01). After surgery, the mean RRs of motor function of the upper extremity in the TDM and DCM groups were 36.4% and 55.7%, respectively (P < 0.01) and in the lower extremity were 32.3% and 46.5%, respectively (P < 0.05). The RR for sensory function of the lower extremity was significantly lower in TCM patients than in DCM patients (39.6 vs 68.2, respectively; P < 0.0001). Motor function impairments of the upper and lower extremities and sensory function impairments of the lower extremities after surgery were more persistent in the TCM group than in the DCM group.

Prognostic factors and optimal management for patients with cervical spinal cord injury without major bone injury

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.

Pathological changes of distal motor neurons after complete spinal cord injury

Traumatic spinal cord injury (SCI) causes serious disruption of neuronal circuits that leads to motor functional deficits. Regeneration of disrupted circuits back to their original target is necessary for the restoration of function after SCI, but the pathophysiological condition of the caudal spinal cord has not been sufficiently studied. Here we investigated the histological and biological changes in the distal part of the injured spinal cord, using a mice model of complete thoracic SCI in the chronic stage (3 months after injury). Atrophic changes were widely observed in the injured spinal cord both rostral and caudal to the lesion, but the decrease in area was mainly in the white matter in the rostral spinal cord while both the white and gray matter decreased in the caudal spinal cord. The number of the motor neurons was maintained in the chronic phase of injury, but the number of presynaptic boutons decreased in the lumbar motor neurons caudal to the lesion. Using laser microdissection, to investigate gene expressions in motor neurons caudal to the lesion, we observed a decrease in the expressions of neuronal activity markers. However, we found that the synaptogenic potential of postsynapse molecules was maintained in the motor neurons after SCI with the expression of acetylcholine-related molecules actually higher after SCI. Collectively, our results show that the potential of synaptogenesis is maintained in the motor neurons caudal to the lesion, even though presynaptic input is decreased. Although researches into SCI concentrate their effort on the lesion epicenter, our findings suggest that the area caudal to the lesion could be an original therapeutic target for the chronically injured spinal cord.

Establishment and verification of a surgical prognostic model for cervical spinal cord injury without radiological abnormality

Some studies have suggested that early surgical treatment can effectively improve the prognosis of cervical spinal cord injury without radiological abnormality, but no research has focused on the development of a prognostic model of cervical spinal cord injury without radiological abnormality. This retrospective analysis included 43 patients with cervical spinal cord injury without radiological abnormality. Seven potential factors were assessed: age, sex, external force strength causing damage, duration of disease, degree of cervical spinal stenosis, Japanese Orthopaedic Association score, and physiological cervical curvature. A model was established using multiple binary logistic regression analysis. The model was evaluated by concordant profiling and the area under the receiver operating characteristic curve. Bootstrapping was used for internal validation. The prognostic model was as follows: logit(P) = -25.4545 + 21.2576VALUE + 1.2160SCORE - 3.4224TIME, where VALUE refers to the Pavlov ratio indicating the extent of cervical spinal stenosis, SCORE refers to the Japanese Orthopaedic Association score (0-17) after the operation, and TIME refers to the disease duration (from injury to operation). The area under the receiver operating characteristic curve for all patients was 0.8941 (95% confidence interval, 0.7930-0.9952). Three factors assessed in the predictive model were associated with patient outcomes: a great extent of cervical stenosis, a poor preoperative neurological status, and a long disease duration. These three factors could worsen patient outcomes. Moreover, the disease prognosis was considered good when logit(P) ≥ -2.5105. Overall, the model displayed a certain clinical value. This study was approved by the Biomedical Ethics Committee of the Second Affiliated Hospital of Xi'an Jiaotong University, China (approval number: 2018063) on May 8, 2018.

MR T2 image classification in adult patients of cervical spinal cord injury without radiographic abnormality: A predictor of surgical outcome

OBJECTIVES

Although patients with cervical spinal cord injury without radiographic abnormality (SCIWORA) present increased signal intensity (ISI) on magnetic resonance imaging (MRI), its degree has not been examined. This study evaluated the clinical effectiveness of MRI-based ISI in adult patients of SCIWORA. Its predictive value for symptom severity was also evaluated.

PATIENTS AND METHODS

One-hundred consecutive SCIWORA patients who had undergone expansive laminoplasty were enrolled. Among them, 79 were male and 21 were female. The mean age was 55 years (range 20-87). All patients underwent MRI in the acute phase, and ISI was classified into three groups based on sagittal T2-weighted MRI: Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The pre- and postoperative neurological status was evaluated using the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score) and the ASIA impairment scale (AIS).

RESULTS

Preoperative MRI showed Grade 0 in 8 patients, Grade 1 in 49 patients, and Grade 2 in 43 patients. There were no differences in age and gender among three groups. The pre- and postoperative JOA scores decreased significantly with an increasing ISI grade. The recovery rate of JOA score decreased with the ISI grade. The ISI grade tended to increase with the pre- and postoperative AIS grades. ISI Grade 2 on MRI was observed in severely paralyzed cases.

CONCLUSIONS

MRI-based ISI classification is correlated with preoperative symptom severity in adult patients with SCIWORA and can be a predictor of surgical outcome.

Sequential neurological improvements after conservative treatment in patients with complete motor paralysis caused by cervical spinal cord injury without bone and disc injury

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.

Effects of Treatment of Cervical Spinal Cord Injury without Fracture and Dislocation in A Medium-to Long-Term Follow-Up Study

OBJECTIVES

The purpose of this study is to evaluate the clinical effects of cervical spinal cord injury without fracture and dislocation (CSCIWFD) treatment in a medium-to long-term follow-up study. The clinical treatment of CSCIWFD is also discussed.

METHODS

A consecutive series of 42 CSCIWFD patients with complete follow-up data were retrospectively analyzed. Among these patients, 9 received conservative treatment and 33 underwent surgical treatment from June 2009 to March 2013. Neurologic functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) scoring system and the Frankel grade on admission, during hospital discharge, and at final follow-up. The average follow-up time was 49.6 months (range, 36-68 months).

RESULTS

The 33 cases with surgical treatment showed significantly higher JOA scores at the final follow-up than those with conservative treatment. In addition, statistically significant differences were found in all of the follow-up visits between patients whose operations were performed within 7 days after injury and those performed after 7 days (P < 0.05). Early surgery promoted spinal cord recovery. However, JOA scores at 49.6 months postsurgery were not significantly different between patients treated via the anterior approach and those treated via the posterior approach (P > 0.05). On the basis of Frankel functional classification, differences were also significant between surgical treatment and conservative treatment at all of the follow-up visits.

CONCLUSIONS

Early surgical treatment for CSCIWFD can directly relieve spinal cord compression. The medium-to long-term follow-up revealed that surgery clearly promotes decompression.

Sensitivity and specificity of the 'knee-up test' for estimation of the American Spinal Injury Association Impairment Scale in patients with acute motor incomplete cervical spinal cord injury

STUDY DESIGN

A retrospective study.

OBJECTIVE

Precise classification of the neurological state of patients with acute cervical spinal cord injury (CSCI) can be challenging. This study proposed a useful and simple clinical method to help classify patients with incomplete CSCI.

SETTING

Spinal Injuries Centre, Japan.

METHODS

The sensitivity and specificity of the 'knee-up test' were evaluated in patients with acute CSCI classified as American Spinal Injury Association Impairment Scale (AIS) C or D. The result is positive if the patient can lift the knee in one or both legs to an upright position, whereas the result is negative if the patient is unable to lift the knee in either leg to an upright position. The AIS of these patients was classified according to a strict computerised algorithm designed by Walden et al., and the knee-up test was tested by non-expert examiners.

RESULTS

Among the 200 patients, 95 and 105 were classified as AIS C and AIS D, respectively. Overall, 126 and 74 patients demonstrated positive and negative results, respectively, when evaluated using the knee-up test. A total of 104 patients with positive results and 73 patients with negative results were classified as AIS D and AIS C, respectively. The sensitivity, specificity, positive predictive and negative predictive values of this test for all patients were 99.1, 76.8, 82.5 and 98.7, respectively.

CONCLUSIONS

The knee-up test may allow easy and highly accurate estimation, without the need for special skills, of AIS classification for patients with incomplete CSCI.

Clinical outcomes of late decompression surgery following cervical spinal cord injury with pre-existing cord compression

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The purpose of the current study was to examine the effectiveness of late decompression surgery for traumatic cervical spinal cord injury (CSCI) with pre-existing cord compression.

SETTING

Murayama Medical Center, National Hospital Organization, Tokyo, Japan.

METHODS

In total 78 patients with traumatic CSCI without bone injury hospitalized in 2012-2015 in our institute for rehabilitation after initial emergency care were divided into four groups according to the compression rate (CR) of the injured level and whether or not decompression surgery was performed. Neurological status was evaluated by American Spinal Injury Association impairment scale (AIS), Barthel index, and Spinal Cord Independence Measure (SCIM).

RESULTS

In the severe compression group (CR ≥ 40%), >2 grade improvement in the AIS was observed in 30% of patients with surgical treatment, although it was not observed in any patient without surgery. The SCIM improvement rate at discharge was 60% in the surgical treatment group and 20% in the non-surgical treatment group. In the minor compression group (CR < 40%), >2 grade improvement in the AIS was observed in 18% of patients with surgical treatment and in 11% without surgery. The SCIM improvement rate at discharge was 52% in the surgical treatment group and 43% in the non-surgical treatment group.

CONCLUSIONS

These results indicate that surgical treatment has an advantage for patients following traumatic CSCI with severe cord compression. In contrast, surgical efficacy is not proved for CSCI patients without severe cord compression.

Role of surgery in spinal cord injury

This article deals with the main issues of surgical management of acute spinal cord injury patients – discussing the importance of timing of surgery with physiologic stability of the cord, and indications for surgery – absolute and relative. The importance of the type of injury to the spinal column, besides the cord injury, is also discussed. A brief review of relevant literature has been performed to try and answer the question whether early or late surgical treatment for acute spinal cord injury is better than conservative management, reflecting the ethos of treatment for these problems in RJ&AH Orthopaedic Hospital in Oswestry.

Spinal cord injury-The role of surgical treatment for neurological improvement

Acute spinal cord injury (ASCI) is common and no consensuses have been reached regarding timing of surgical decompression. This article highlights the main issues regarding surgical management of ASCI patients. The importance of timing of surgery along with physiological stability of the cord, and indications for surgery has been discussed to facilitate better understanding of the condition. The importance of the type of injury to the spinal column, besides the cord injury, is also discussed. A brief review of relevant literature has been done to try and answer the question whether early or late surgical treatment for ASCI is better than conservative management, reflecting the ethos of treatment for these problems in Robert Jones And Agnes Hunt Orthopaedic Hospital in Oswestry.

Morphology of the injured posterior wall causing spinal canal encroachment in osteoporotic vertebral fractures

BACKGROUND CONTEXT

The relationship between fractured posterior vertebral wall patterns and the protrusion of bony fragments into the spinal canal is not clear.

PURPOSE

We sought to elucidate the effects of fracture patterns of the injured posterior wall on posterior wall instability and spinal canal encroachment using computed tomography myelography (CTM) in two different positions.

STUDY DESIGN/SETTING

This is a prospective analysis of CTM in both supine and semi-sitting positions.

PATIENT SAMPLE

The sample includes 36 consecutive elderly patients with delayed neurologic disorders due to insufficient bone union at the posterior vertebral wall after vertebral fracture.

OUTCOME MEASURES

Radiological parameters, including the rates of dural compression and of occupation by bony fragments (OBFr) and the posterior vertebral body height ratio (PVBHr), were used.

METHODS

All patients were examined using CTM in both supine and semi-sitting positions. According to fracture patterns of the posterior vertebral wall, we classified injured posterior walls with one fragment as the simple type and those with two or more fragments as the comminuted type.

RESULTS

The simple type was found in 19 of 36 cases, whereas the comminuted type was found in 17 of 36 cases. A significant correlation was identified between changes in OBFr and PVBHr in both the simple and comminuted types. The mean change of PVBHr between the two positions in the comminuted type was significantly larger (9.2%) than that in the simple type (4.8%). Likewise, the mean change in OBFr in the comminuted type (14.0%) was significantly larger than that in the simple type (8.2%), indicating that the injured posterior vertebral wall with the comminuted type would be more likely to collapse and protrude into the spinal canal.

CONCLUSIONS

Both simple and comminuted fracture types could cause protrusion of vertebral fragments into the spinal canal because of a collapsing non-united posterior vertebral wall; however, the comminuted type showed more severe spinal canal encroachment, with axial loading. The morphology of the injured posterior wall is thus important for estimating instability.

Outcome of laminoplasty in cervical spinal cord injury with stable spine

Background and Objective:

Cervical spinal cord injury (CSCI) with a stable spine has been increasing as the elderly population is dramatically increasing all over the world. In this study, we evaluated the neurological outcome of decompression surgery (laminoplasty) for these patients.

Materials and Methods:

Forty-one patients with CSCI with stable spine who underwent decompression surgery (laminoplasty) were retrospectively studied. Inclusion criteria were as follows: CSCI without instability, spinal cord contusion in magnetic resonance image (MRI), spinal cord compression rate more than 20%, neurologic deficit American Spinal Cord Injury Association ([ASIA] scale from A to D), and follow-up of at least 12 months. Preoperative neurological state, clinical outcome, and neurological function were measured using the ASIA impairment scale, Japanese Orthopaedic Association (JOA) grading scale, and Hirabayashi recovering rate, respectively.

Results:

Thirty-three (80.4%) patients showed improvement in ASIA grade at 12-month follow-up. Four (9.7%) patients in ASIA Grade A and 4 (9.7%) patients in ASIA Grade D remain unchanged. The mean JOA score improved from 8.4 ± 6.1 points preoperatively to 11.2 ± 5.4 points at 12 months postoperatively. Improvement in JOA was statistically significant (P < 0.05). The mean Hirabayashi recovery rate was 37.4 ± 25.3%.

Conclusion:

Surgical decompression (laminoplasty) is helpful in relieving cord compromise and neurological deficit in CSCI with stable spine.

Clinical Influence of Cervical Spinal Canal Stenosis on Neurological Outcome after Traumatic Cervical Spinal Cord Injury without Major Fracture or Dislocation

Study Design

Retrospective case series.

Purpose

To clarify the influence of cervical spinal canal stenosis (CSCS) on neurological functional recovery after traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation.

Overview of Literature

The biomechanical etiology of traumatic CSCI remains under discussion and its relationship with CSCS is one of the most controversial issues in the clinical management of traumatic CSCI.

Methods

To obtain a relatively uniform background, patients non-surgically treated for an acute C3–4 level CSCI without major fracture or dislocation were selected. We analyzed 58 subjects with traumatic CSCI using T2-weighted mid-sagittal magnetic resonance imaging. The sagittal diameter of the cerebrospinal fluid (CSF) column, degree of canal stenosis, and neurologic outcomes in motor function, including improvement rate, were assessed.

Results

There were no significant relationships between sagittal diameter of the CSF column at the C3–4 segment and their American Spinal Injury Association motor scores at both admission and discharge. Moreover, no significant relationships were observed between the sagittal diameter of the CSF column at the C3–4 segment and their neurological recovery during the following period.

Conclusions

No relationships between pre-existing CSCS and neurological outcomes were evident after traumatic CSCI. These results suggest that decompression surgery might not be recommended for traumatic CSCI without major fracture or dislocation despite pre-existing CSCS.

Subacute T1-low intensity area reflects neurological prognosis for patients with cervical spinal cord injury without major bone injury

STUDY DESIGN

A retrospective imaging and clinical study.

OBJECTIVES

To evaluate the relationship between magnetic resonance imaging (MRI) features and neurological prognosis in patients with traumatic cervical spinal cord injury (CSCI) without major bone injury.

METHODS

A total of 72 patients with CSCI without major bone injury were treated conservatively in our hospital. MRI was performed for all patients at admission and 1 month following injury. We measured the antero-posterior and cranio-caudal diameter of intramedullary intensity changed area with T1-weighted images at the injured segment. Neurological evaluations were performed using the American Spinal Injury Association (ASIA) motor score and the modified Frankel grade at the time of admission and discharge.

RESULTS

There was a significant relationship between the antero-posterior diameter ratio of the T1-weighted low-intensity area on MRI at the subacute stage and the ASIA motor score. The optimal threshold of the T1-weighted low-intensity diameter ratio for predicting the patient's ability to walk with or without assistance at discharge was determined to be 46%. Moreover, 96.8% of the patients with <50% T1-weighted low-intensity area recovered to walk with or without a cane at discharge.

CONCLUSION

The T1-low intensity area may be an important predictive factor for the neurological recovery of CSCI without major bone injury.

Influence of spinal cord compression and traumatic force on the severity of cervical spinal cord injury associated with ossification of the posterior longitudinal ligament

STUDY DESIGN

Retrospective review.

OBJECTIVE

To evaluate the influence of static compression factors and dynamic factors based on the various degrees of traumatic force on the cervical spinal cord injury (SCI) in patients with ossification of the posterior longitudinal ligament.

SUMMARY OF BACKGROUND DATA

Spinal cord disorder occurs as a result of various factors, including static factors and traumatic force. Discussions about the severity of paralysis resulting from SCI must therefore focus on dynamic factors based on the traumatic force as well as on static compression factors. However, the past reports did not describe the influence of traumatic force in detail.

METHODS

Fifty patients presenting with cervical SCI associated with ossification of the posterior longitudinal ligament were included in this study. The American Spinal Injury Association motor score 3 days after injury, the degree of the traumatic force, and the spinal cord compression rate were investigated, and the relationships among these factors were investigated.

RESULTS

Paralysis at the time of injury was not determined by static factors alone or by traumatic force alone. The severity of paralysis at the time of injury was determined on the basis of a combination of both the static factors and the degree of traumatic force.

CONCLUSION

Both the degree of spinal cord compression and the degree of traumatic force were found to be important factors associated with the severity of cervical SCI in patients with ossification of the posterior longitudinal ligament.

LEVEL OF EVIDENCE

4.

Does laminoplasty really improve neurological status in patients with cervical spinal cord injury without bone and disc injury? A prospective study about neurological recovery and early complications

PURPOSE

Cervical spinal cord injury without bone and disc injury in patients with spinal cord compression is a fairly common problem in Japan. Because elderly Japanese population tend to have cervical spinal canal stenosis. However, there has been no consensus in the treatment of these patients. We conducted a prospective study to evaluate treatment outcomes and complications of these patients.

METHODS

Twenty-five patients had been enrolled in this study. Patients who had paralysis of ASIA impairment scale (AIS) A, B or C were included. With each new patient, we alternated whether he/she received surgical treatment (group S) or conservative treatment (group C). Eleven patients were assigned to each group. We compared the two groups' courses of treatment and complications by evaluating their neurological symptoms using the AIS and ASIA motor score (MS) documenting them at the time of injury and 3 months later.

RESULTS

The majority of clinical paralysis was found at the C3/4 level for both the groups. According to complications, there were seven urinary tract infections and four pneumonias in group S and one urinary tract infection and three pneumonias in group C. Both groups had an average MS of 42 at the time of injury. Three months later, the average MSs were 59 points in group S and 65 points in group C.

CONCLUSIONS

In the present study, we found no significant difference in paralysis improvement between surgical and conservative treatment, although we observed a higher frequency of complications with surgery.

Neurologic Outcome of Laminoplasty for Acute Traumatic Spinal Cord Injury without Instability

Objective

The purpose of this study is to evaluate the efficacy of laminoplasty in the treatment of spinal cord injury (SCI) without instability.

Methods

79 patients with SCI without instability who underwent surgical treatment in our institute between January 2005 and September 2012 were retrospectively reviewed. Twenty nine patients fulfilled the inclusion criteria as follows: SCI without instability, spinal cord contusion in MRI, cervical stenosis more than 20%, follow up at least 6 months. Preoperative neurological state, clinical outcome and neurological function was measured using the American Spinal Injury Association (ASIA) impairment scale, modified Japanese Orthopedic Association (mJOA) grading scale and Hirabayashi recovering rate.

Results

Seventeen patients showed improvement in ASIA grade and twenty six patients showed improvement in mJOA scale at 6 month follow up. However, all patients with ASIA grade B and C have shown improvement of one or more ASIA grade. Mean Hirabayashi recovery rate was 47.4±23.7%. There was better neurologic recovery in those who had cervical spondylosis without ossification of posterior longitudinal ligament (OPLL) (p<0.05, χ² test).

Conclusions

It is different in B, C, D with ASIA A that there are debates going on about the application of surgical treatment in ASIA A, and surgical treatment is helpful in B, C, D since it contributes to neurologic improvement. We concluded that laminoplasty provided good neurologic recovery in SCI without instability that cervical canal stenosis, especially spondylosis without OPLL and neurologic deterioration in ASIA B, C and D.

Optimal treatment for spinal cord injury associated with cervical canal stenosis (OSCIS): a study protocol for a randomized controlled trial comparing early versus delayed surgery

Background

The optimal management of acute cervical spinal cord injury (SCI) associated with preexisting canal stenosis remains to be established. The objective of this study is to examine whether early surgical decompression (within 24 hours after admission) would result in greater improvement in motor function compared with delayed surgery (later than two weeks) in cervical SCI patients presenting with canal stenosis, but without bony injury.

Methods/design

OSCIS is a randomized, controlled, parallel-group, assessor-blinded, multicenter trial. We will recruit 100 cervical SCI patients who are admitted within 48 hours of injury (aged 20 to 79 years; without fractures or dislocations; American Spinal Injury Association (ASIA) grade C; preexisting spinal canal stenosis). Patients will be enrolled from 36 participating hospitals across Japan and randomly allocated in a 1:1 ratio to either early surgical decompression (within 24 hours after admission) or delayed surgery following at least two weeks of conservative treatment. The primary outcomes include: 1) the change from baseline to one year in the ASIA motor score; 2) the total score of the Spinal Cord Independence Measure and 3) the proportion of patients who are able to walk without human assistance. The secondary outcomes are: 1) the health-related quality of life as measured by the Medical Outcomes Study Short Form 36 and the EuroQol 5 Dimension; 2) the Neuropathic Pain Symptom Inventory and 3) the walking status as evaluated with the Walking Index for Spinal Cord Injury II. The analysis will be on an intention-to-treat basis. The primary analysis will be a comparison of the primary and secondary outcomes one year after the injury.

Discussion

The results of this study will provide evidence of the potential benefit of early surgical decompression compared to the current ‘watch and wait’ strategy.

Trial registration

UMIN000006780; NCT01485458

Clinical relationship between cervical spinal canal stenosis and traumatic cervical spinal cord injury without major fracture or dislocation

PURPOSE

The purpose of the study was to evaluate the clinical relationship between cervical spinal canal stenosis (CSCS) and incidence of traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation, and to discuss the clinical management of traumatic CSCI.

METHODS

Forty-seven patients with traumatic CSCI without major fracture or dislocation (30 out of 47 subjects; 63.83 %, had an injury at the C3-4 segment) and 607 healthy volunteers were measured the sagittal cerebrospinal fluid (CSF) column diameter at five pedicle and five intervertebral disc levels using T2-weighted midsagittal magnetic resonance imaging. We defined the sagittal CSF column diameter of less than 8 mm as CSCS based on the previous paper. We evaluated the relative and absolute risks for the incidence of traumatic CSCI related with CSCS.

RESULTS

Using data from the Spinal Injury Network of Fukuoka, Japan, the relative risk for the incidence of traumatic CSCI at the C3-4 segment with CSCS was calculated as 124.5:1. Moreover, the absolute risk for the incidence of traumatic CSCI at the C3-4 segment with CSCS was calculated as 0.00017.

CONCLUSIONS

In our results, the relative risk for the incidence of traumatic CSCI with CSCS was 124.5 times higher than that for the incidence without CSCS. However, only 0.017 % of subjects with CSCS may be able to avoid developing traumatic CSCI if they undergo decompression surgery before trauma. Our results suggest that prophylactic surgical management for CSCS might not significantly affect the incidence of traumatic CSCI.

Use of Fidji cervical cage in the treatment of cervical spinal cord injury without radiographic abnormality

Spinal cord injury without radiographic abnormality (SCIWORA) is a rare condition seen in adults. Many interbody fusion cages have been developed for its treatment, but clinical studies of Fidji cervical cage are still scarce. A total number of five patients (four male and one female) were reviewed. The ages of the patients ranged from 40 to 60 years. All the patients underwent neurological and radiological examinations. Neurological and functional outcomes were assessed on the basis of Frankel's grade. Three of the patients were Frankel B, and the rest two were Frankel C. Magnetic resonance imaging was also performed for the evaluation of spinal cord and intervertebral disc injury. Anterior cervical discectomy and Fidji cervical cage fusion were performed for all. The fusion status was evaluated on the basis of X-rays. After surgical intervention, the clinical symptoms improved for all the patients. The disc interspaces in all the patients achieved solid union at final follow-up. Fidji cervical cage is very efficient in achieving cervical fusion in patients with SCIWORA. There are few complications associated with the use of this cage, and the functional and neurological outcomes are satisfactory.

Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury

STUDY DESIGN

A retrospective imaging and clinical study.

OBJECTIVE

To evaluate the extraneural soft-tissue damage and its clinical relevance in patients with traumatic cervical spinal cord injury (SCI) without major bone injury.

SUMMARY OF BACKGROUND DATA

To date, various kinds of cervical discoligamentous injuries have been demonstrated on magnetic resonance images in patients with SCI without bony injury. However, it has not been clear whether these magnetic resonance imaging abnormalities are actually related to spinal segmental instability and the patients' neurological status.

METHODS

Eighty-eight adult patients with acute traumatic cervical SCI without major bone injury were examined by flexion-extension lateral radiographs and magnetic resonance images within 2 days after trauma. We excluded patients with flexion recoil injury; therefore, most of the patients included were considered to have sustained a hyperextension injury. Instability of the injured cervical segment was defined when there was more than 3.5-mm posterior translation and/or more than a 11° difference in the intervertebral angle between the site of interest and adjacent segments. The neurological status was evaluated according to the American Spinal Injury Association motor score.

RESULTS

On magnetic resonance images, the damage to the anterior longitudinal ligament and intervertebral disc were apparent in 44 and 37 patients, respectively. Various degrees of prevertebral fluid collection (prevertebral hyperintensity) were demonstrated in 76 patients. These magnetic resonance imaging abnormalities were significantly associated with initial cervical segmental instability as judged by flexion-extension radiographs. Interestingly, the American Spinal Injury Association motor score had a significant association with either magnetic resonance imaging abnormalities or segmental instability but not with the cervical canal diameter.

CONCLUSION

A considerable proportion of the patients with traumatic cervical SCI without major bone injury were shown to have various types of soft-tissue damage associated with cervical segmental instability at the early stages of the injury. The severity of paralysis greatly depended on these discoligamentous injuries.

Comparison of the amounts of canal encroachment between semisitting and supine position of computed tomography-myelography for vertebral fractures of the elderly involving the posterior vertebral wall

STUDY DESIGN

A prospective radiographical trial.

OBJECTIVE

To elucidate effects of loading associated with spinal canal encroachment (SCE) in patients with insufficient bone union after vertebral fractures in the elderly, using computed tomography-myelography in 2 different positions.

SUMMARY OF BACKGROUND DATA

In elderly patients with vertebral fractures, influence of loading would be involved in SCE, but the details are not well understood.

METHODS

Seventeen patients (mean age, 77.4 ± 8 yr; range, 62-91 yr) with various degrees of neurological deficit due to insufficient bone union at both vertebral body and posterior vertebral wall were included in this study. Computed tomography-myelography was performed in both semisitting and supine positions. Kyphotic angle, rate of dural compression, ratio of occupation by bony fragments, and posterior vertebral body height ratio were measured and compared between positions.

RESULTS

Mean ratio of occupation by bony fragments was significantly higher in the semisitting position (47.9 ± 9.2%) than in the supine position (33.9 ± 10.0%, P, 0.001). Similarly, mean posterior vertebral body height ratio was significantly lower in the semisitting position (67.8 ± 10.8%) than in the supine position (76.3 ± 13.3%), indicating a significant loss of vertebral height in the semisitting position (P, 0.001). Mean rate of dural compression was likewise significantly higher in the semisitting position (48.6 ± 13.3%) than in the supine position (33.3 ± 16.5%; P, 0.001). Mean change in ratio of occupation by bony fragments, change in posterior vertebral body height ratio, and angular instability between positions were 13.9 ± 8.6%, 8.5 ± 6.7%, and 13° ± 5.7°, respectively. A significant correlation was identified between change in ratio of occupation by bony fragments and change in posterior vertebral body height ratio (P = 0.001).

CONCLUSION

Our study demonstrated that collapse of the nonunited posterior vertebral wall and intracanal protrusion of vertebral fragments would occur simultaneously with axial loading, causing SCE. Computed tomographic scan obtained in semisitting position seems quite useful to evaluate the amount of SCE by an unstable posterior wall.