Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach

Under pressure - A historical vignette on surgical timing in traumatic spinal cord injury

Introduction

It was not even a century ago when a spinal cord injury (SCI) would inevitably result in a fatal outcome, particularly for those with complete SCI. Throughout history, there have been extensive endeavours to change the prospects for SCI patients by performing surgery, even though many believed that there was no way to alter the catastrophic course of SCI. To this day, the debate regarding the efficacy of surgery in improving the neurological outcome for SCI patients persists, along with discussions about the timing of surgical intervention.

Research question

How have the historical surgical results shaped our perspective on the surgical treatment of SCI?

Material and methods

Narrative literature review.

Results

Throughout history there have been multiple surgical attempts to alter the course of SCI, with conflicting results. While studies suggest a potential link between timing of surgery and neurological recovery, the exact impact of immediate surgery on individual cases remains ambiguous. It is becoming more evident that, alongside surgical intervention, factors specific to both the patient and their surgical treatment will significantly influence neurological recovery.

Conclusion

Although a growing number of studies indicates a potential correlation of surgical timing and neurological outcome, the precise influence of urgent surgery on an individual basis remains uncertain. It is increasingly apparent that, despite surgery, patient- and treatment-specific factors will also play a role in determining the neurological outcome. Notably, these very factors have influenced the results in previous studies and our views concerning surgical timing.

Navigating Complexity: A Case Report of Concurrent Central Cord Syndrome and Stroke in an Elderly Gentleman

Central cord syndrome (CCS) predominantly manifests in elderly individuals with pre-existing cervical spondylosis resulting from hyperextension mechanisms. However, it is not exclusive to the older population and can occur in younger individuals following traumatic cervical spine injuries or, less frequently, due to nontraumatic causes. The impact of this syndrome is more pronounced in the upper extremities, where motor function experiences greater impairment compared to sensory function. CCS presents itself along a spectrum of severity. At one end, individuals may exhibit weakness confined to the hands and forearms while preserving sensory function. At the other extreme, complete quadriparesis may occur, albeit with sacral sparing being the sole indication of an incomplete spinal cord injury. This spectrum underscores the varied and nuanced clinical presentations within CCS. Moreover, concurrent acute stroke presentations can mimic CCS symptoms, further complicating the diagnostic process. The challenge lies in differentiating these two distinct conditions, particularly in an elderly population with overlapping risk factors. This diagnostic challenge adds a layer of complexity to clinical decision-making and underscores the importance of comprehensive evaluations in patients presenting with neurological symptoms. This case report presents a 73-year-old gentleman with a history of a recent stroke and motor vehicle accidents, highlighting the diagnostic challenges and multidisciplinary management required for concurrent CCS and stroke mimicry. This report is unique, as there are no existing case report publications detailing concurrent CCS and stroke. It emphasizes the necessity for a comprehensive diagnostic approach and coordinated care in managing such intricate cases.

Traumatic Human Spinal Cord Injury: Are Single Treatments Enough to Solve the Problem?

Traumatic spinal cord injury (SCI) results in partial or complete motor deficits, such as paraplegia, tetraplegia, and sphincter control, as well as sensory disturbances and autonomic dysregulation such as arterial hypotension, lack of sweating, and alterations in skin lability. All this has a strong psychological impact on the affected person and his/her family, as well as costs to healthcare institutions with an economic burden in the short, medium, and long terms. Despite at least forty years of experimental animal studies and several clinical trials with different therapeutic strategies, effective therapy is not universally accepted. Most of the published works on acute and chronic injury use a single treatment, such as medication, trophic factor, transplant of a cell type, and so on, to block some secondary injury mechanisms or promote some mechanisms of structural/functional restoration. However, despite significant results in experimental models, the outcome is a moderate improvement in muscle strength, sensation, or eventually in sphincter control, which has been considered non-significant in human clinical trials. Here we present a brief compilation of successful individual treatments that have been applied to secondary mechanisms of action. These studies show limited neuroprotective or neurorestorative approaches in animal models and clinical trials. Thus, the few benefits achieved so far represent a rationale to further explore other strategies that seek better structural and functional restoration of the injured spinal cord.

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.

Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures

BACKGROUND

There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.

MATERIALS AND METHODS

The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment.

RESULTS

Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated.

CONCLUSIONS

This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients.

LEVEL OF EVIDENCE

IV.

TRIAL REGISTRATION

not applicable (consensus paper).

Five-year mortality after traumatic central cord syndrome in Wales

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Methods

Patients aged ≥ 18 years with a traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and data about injury, management, and outcome were collected. Statistical analysis was performed to assess mortality and between-group differences.

Results

A total of 65 patients were identified (66.2% male (n = 43), mean age 63.9 years (SD 15.9)). At a minimum of five years' follow-up, 32.3% of CCS patients (n = 21) had died, of whom six (9.2%) had died within 31 days of their injury. Overall, 69.2% of patients (n = 45) had been managed conservatively. There was no significant difference in age between conservatively and surgically managed patients (p = 0.062). Kaplan-Meier analysis revealed no significant difference in mortality between patients managed conservatively and those managed surgically (p = 0.819). However, there was a significant difference in mortality between the different age groups (< 50 years vs 50 to 70 years vs > 70 years; p = 0.001). At five years' follow-up, 55.6% of the patient group aged > 70 years at time of injury had died (n = 15). Respiratory failure was the most common cause of death (n = 9; 42.9%).

Conclusion

Almost one-third of patients with a traumatic CCS in Wales had died within five years of their injury. The type of management did not significantly affect mortality but their age at the time of injury did. Further work to assess the long-term functional outcomes of surviving patients is needed to generate more reliable prognostic information.

Advance in hyperbaric oxygen therapy in spinal cord injury

Spinal cord injury (SCI) is a severe lesion comporting various motor, sensory and sphincter dysfunctions, abnormal muscle tone and pathological reflex, resulting in a severe and permanent lifetime disability. The primary injury is the immediate effect of trauma and includes compression, contusion, and shear injury to the spinal cord. A secondary and progressive injury usually follows, beginning within minutes and evolving over several hours after the first ones. Because ischemia is one of the most important mechanisms involved in secondary injury, a treatment to increase the oxygen tension of the injured site, such as hyperbaric oxygen therapy, should theoretically help recovery. Although a meta-analysis concluded that hyperbaric oxygen therapy might be helpful for clinical treatment as a safe, promising and effective choice to limit secondary injury when appropriately started, useful and well-defined protocols/guidelines still need to be created, and its application is influenced by local/national practice. The topic is not a secondary issue because a well-designed randomized controlled trial requires a proper sample size to demonstrate the clinical efficacy of a treatment, and the absence of a common practice guideline represents a limit for results generalization. This narrative review aims to reassemble the evidence on hyperbaric oxygen therapy to treat SCI, focusing on adopted protocols in the studies and underlining the critical issues. Furthermore, we tried to elaborate on a protocol with a flowchart for an evidence-based hyperbaric oxygen therapy treatment. In conclusion, a rationale and shared protocol to standardize as much as possible is needed for the population to be studied, the treatment to be adopted, and the outcomes to be evaluated. Further studies, above all, well-designed randomized controlled trials, are needed to clarify the role of hyperbaric oxygen therapy as a strategic tool to prevent/reduce secondary injury in SCI and evaluate its effectiveness based on an evidence-based treatment protocol. We hope that adopting the proposed protocol can reduce the risk of bias and drive future studies.

Early Predictors and Outcomes of American Spinal Injury Association Conversion at Discharge in Surgical and Nonsurgical Management of Sports-Related Spinal Cord Injury

OBJECTIVE

This study aims to evaluate the rate of improvement in neurologic recovery of patients with sports-related spinal cord injury (SRSCI) who had surgical intervention (SS) and those who did not (NSS). We aimed to 1) evaluate the rate of American Spinal Injury Association (ASIA) conversion in patients with and without surgery, and 2) assess predictors of conversion in ASIA grade.

METHODS

The National Spinal Cord Injury Model Systems Database (SCIMS) was used from 1973 to 2016. Patients with SRSCI were included. The primary outcome was rate of conversion in ASIA grade. Multivariate logistic regression was performed with separate subgroup analysis on patients with cervical injury (represented by odds ratio [OR]; 95% confidence interval [CI]).

RESULTS

A total of 1647 patients had SRSCI with 1502 (91%) SSs. Most patients (88%) were male, white (87%), and between the ages of 15 and 29 years (63%). Patients undergoing SS had significantly longer inpatient rehabilitation length of stay (LOS) (P < 0.001) and a more patients undergoing SS had complete motor or sensory loss compared with the NSS group. Multivariate logistic regression showed that injury at the thoracic level (OR, 0.41; 95% CI, 0.21-0.78), age 15-29 years (OR, 0.44; 95% CI, 0.20-0.97]), water-based injury (OR, 0.45; 95% CI, 0.21-0.95), and ASIA impairment grades of B, C, and D at admission were significantly associated with ASIA SCORE conversion.

CONCLUSIONS

We found that patients undergoing SS had longer LOS and a higher prevalence of complete injuries. Surgical intervention was not associated with conversion in ASIA grade to an improved status at time of discharge in a large cohort of patients with SRSCI and in a subcohort of patients with cervical SRSCI.

Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case

BACKGROUND

Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue.

OBSERVATIONS

Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery.

LESSONS

Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Neurosurgery in 21st-Century Wars in the Middle East: Narrative Review of Literature

Military neurosurgery has played a crucial role in the development of neurosurgery over time. Much of this progress is due to war-related experiences. Owing to the number and severity of war injuries and the limitations caused by war, surgeons have had to examine different methods and design special protocols for patient management. Given that in recent decades most wars have taken place in the Middle East, many lessons can be learned by reviewing the experiences of neurosurgeons in these wars. Wars in Iraq, Syria, Afghanistan, Lebanon, and Yemen have been the largest and longest conflicts in the Middle East since the beginning of the 21st century, and a number of studies reported the experiences of surgeons in these wars. In this study, we reviewed the experience of military surgeons in managing war neurosurgical injuries in these areas within the last 2 decades.

Role of Invasive Urodynamic Studies in Establishing Cauda Equina Syndrome and Postoperative Recovery

STUDY DESIGN

Retrospective with prospective follow-up.

OBJECTIVE

Confirming the diagnosis of CES based purely on symptoms and signs is unreliable and usually associated with high false positive rate. A missed diagnosis can permanently disable the patient. Present study aims to determine the relationship between clinical symptoms/ signs (bladder dysfunction) with UDS, subsequently aid in surgical decision making and assessing post-operative recovery.

METHODS

A prospective follow-up of patients with disc herniation and bladder symptoms from January 2018 to July 2020 was done. All patients underwent UDS and grouped into acontractile, hypocontractile and normal bladder. Data regarding PAS, VAC, GTP, timing to surgery and onset of radiculopathy and recovery with correlation to UDS was done preoperatively and post operatively.

RESULTS

107 patients were studied (M-63/F-44). Patients with PAS present still had acontractile (61%) or hypocontractile (39%) detrusor and with VAC present, 57% had acontractile and 43% hypocontractile detrusors. 10 patients with both PAS and VAC present had acontractile detrusor. 82% patients with acute radiculopathy (<2 days) improved when operated <24 hrs while only 47% showed improvement with chronic radiculopathy. The detrusor function recovered in 66.1% when operated <12 hours, 40% in <12-24 hours of presentation.

CONCLUSION

Adjuvant information from UDS in combination with clinicoradiological findings help in accurate diagnosis even in patients with no objective motor and sensory deficits. Quantitative findings on UDS are consistent with postoperative recovery of patient's urination power, representing improvement and can be used as a prognostic factor.

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.

The past, present, and future of traumatic spinal cord injury therapies: a review

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Risk Factors for Poor Prognosis of Spinal Cord Injury without Radiographic Abnormality Associated with Cervical Ossification of the Posterior Longitudinal Ligament

Purpose

To investigate the factors associated with the prognosis of spinal cord injury without radiographic abnormality (SCIWORA) accompanied by cervical ossification of the posterior longitudinal ligament (C-OPLL).

Methods

We retrospectively investigated 287 patients with SCIWORA associated with C-OPLL, who were admitted within 30 days after trauma to our facility between August 2014 and August 2018. All patients were divided into the good or poor prognosis group. Patient demographics were analyzed. Besides, occupying ratio on CT and spinal cord high signal changes in MRI T2WI were measured and recorded. Multivariate linear regression was applied to analyze the correlation of prognosis with spinal cord high signal changes in MRI T2WI, cause of injury, and occupying ratio.

Results

Occupying ratio of ossification mass was 43.5 ± 10.7% in the poor prognosis group and 27.3 ± 7.7% in the good prognosis group. The occurrence rate of high signal changes in MRI T2WI was 84.2% in the poor prognosis group and 41.3% in the good prognosis group. Poor prognosis was correlated with high occupying ratio and spinal cord high signal changes in MRI T2WI. In the patient with SCIWORA associated with C-OPLL, ROC curve of occupying ratio showed 30% as a predictor for the poor prognosis. Among the 92 patients with occupying ratio ≤ 30%, poor prognosis was observed in 5 cases (5.4%), whereas in the 72 cases with occupying ratio > 30%, poor prognosis was seen in 33 cases (45.8%). Postoperative AIS grade at final follow-up in occupying ratio > 30% group was significantly worse.

Conclusions

Patients suffering from SCIWORA with C-OPLL have poor prognosis when they have higher occupying ratio of ossification mass and spinal cord high signal changes in MRI T2WI. The cut-off value of occupying ratio for predicting the poor prognosis was 30% in patients with SCIWORA associated with C-OPLL.

Comparison of Anterior and Posterior Approaches for Acute Traumatic Central Spinal Cord Syndrome with Multilevel Cervical Canal Stenosis without Cervical Fracture or Dislocation

INTRODUCTION

This is a retrospective comparative study that aims to compare the benefits of different surgical approaches for patients with multilevel cervical canal stenosis (CCS) without cervical fracture or dislocation of acute traumatic central cord syndrome (ATCCS).

METHODS

From January 2015 to December 2018, 59 patients were included in the study. Among them, 35 patients (Group A) received anterior surgery and 24 patients (Group B) received posterior surgery. Primary outcome measures were American Spinal Cord Injury Association (Asia) grade, Japanese Orthopaedic Association (JOA) score, and recovery rate (RR). Secondary outcome measures included operation time, intraoperative blood loss, visual analogue scale (VAS) score, cervical sagittal parameters, and complications. Multivariate linear regression was used to analyze prognostic determinants.

RESULTS

Compared with Group B, Group A had longer operation time and more intraoperative blood loss (P < 0.05). However, the VAS score of Group B was higher than that of Group A at discharge (P < 0.05). There was no significant difference in cervical sagittal plane parameters between the two groups (P > 0.05). Postoperative complications were different in the two groups. During follow-up, the Asia grade, the JOA score, and RR of both groups improved (P < 0.05), but there were no significant differences between the two groups (P > 0.05). Younger age, earlier surgery, and better preoperative Asia grade were correlated with better prognosis.

CONCLUSIONS

For patients with multilevel CCS without cervical fracture or dislocation of ATCCS, both surgical approaches had good outcomes. Although no significant differences were found in the primary outcome measures between the two groups, there were different recommendations for the secondary outcome measures. Younger age, earlier surgery, and better preoperative Asia grade were protective factors for better prognosis.

Pursuing More Aggressive Timelines in the Surgical Treatment of Traumatic Spinal Cord Injury (TSCI): A Retrospective Cohort Study with Subgroup Analysis

Background: The optimal timing of surgical therapy for traumatic spinal cord injury (TSCI) remains unclear. The purpose of this study is to evaluate the impact of “ultra-early” (<4 h) versus “early” (4–24 h) time from injury to surgery in terms of the likelihood of neurologic recovery. Methods: The effect of surgery on neurological recovery was investigated by comparing the assessed initial and final values of the American Spinal Injury Association (ASIA) Impairment Scale (AIS). A post hoc analysis was performed to gain insight into different subgroup regeneration behaviors concerning neurological injury levels. Results: Datasets from 69 cases with traumatic spinal cord injury were analyzed. Overall, 19/46 (41.3%) patients of the “ultra-early” cohort saw neurological recovery compared to 5/23 (21.7%) patients from the “early” cohort (p = 0.112). The subgroup analysis revealed differences based on the neurological level of injury (NLI) of a patient. An optimal cutpoint for patients with a cervical lesion was estimated at 234 min. Regarding the prediction of neurological improvement, sensitivity was 90.9% with a specificity of 68.4%, resulting in an AUC (area under the curve) of 84.2%. In thoracically and lumbar injured cases, the estimate was lower, ranging from 284 (thoracic) to 245 min (lumbar) with an AUC of 51.6% and 54.3%. Conclusions: Treatment within 24 h after TSCI is associated with neurological recovery. Our hypothesis that intervention within 4 h is related to an improvement in the neurological outcome was not confirmed in our collective. In a clinical context, this suggests that after TSCI there is a time frame to get the right patient to the right hospital according to advanced trauma life support (ATLS) guidelines.

Complete Lumbar Spine Dislocation With Full Neurological Recovery

The thoracolumbar region is the most vulnerable segment of the spine to traumatic injuries. It represents a region of transition of the relatively fixed and immobile thoracic spine and flexible lumbar spine. Injuries to the thoracolumbar region often result from high-energy trauma. We present the case of a 24-year-old woman who was brought to the emergency department after a fall from a great height. She presented with severe back pain that was associated with the inability to move both of her lower limbs with absent sensation and loss of urinary and bowel continence. Otherwise, she was hemodynamically stable. The patient underwent a computed tomography scan of the abdomen and pelvis. It demonstrated a complete fracture-dislocation of the second lumbar vertebra relative to the first lumbar vertebra causing shortening of the vertebral column. The second lumbar vertebra had a complete lateral dislocation and appeared in the same axial plane as the first lumbar vertebra giving the appearance of a "double vertebrae" sign. The patient was prepared for emergency open reduction internal fixation with a posterior surgical approach. The operation was done under general anesthesia with the use of sensory-evoked potential responses to avoid any neurological injury. Good realignment of the thoracolumbar spine was achieved. Six months after the operation, the patient was asymptomatic and resumed her regular activities. Complete traumatic lateral dislocation of the lumbar spine is very rare. Early diagnosis of such fracture by computed tomography scan is crucial to avoid maneuvers that may cause unintended spinal cord injuries.

Secondary spinal cord changes and spinal deformity following traumatic spinal cord injury

Secondary spinal cord changes can follow spinal cord injuries (SCIs). This retrospective study was to uncover the chronic secondary changes that affect the spinal cord following severe injuries and to evaluate the influence of residual spinal deformity in the development of posttraumatic spinal cord changes. Fifty-eight patients (39 male, 19 female) with complete traumatic SCI and recent Magnetic resonance imaging (MRI) follow-up were reviewed retrospectively. A minimum of 2 years duration between trauma and MRI study was required (mean 2.9 years [2.1-4.7]). Two groups of patients were formed: with spinal deformity (and or spinal canal compromise) and without spinal deformity (and or spinal canal compromise). MRI of the injured spine demonstrated four major types of spinal cord changes; these are spinal cord atrophy, myelomalacia, syrinx, and focal cyst formation. The correlation of these changes to the presence of spinal deformity and or spinal canal compromise was also studied. Twenty-three patients (40%) of the studied population had more than 30° kyphosis and or 50% compromise of the spinal canal. Chronic spinal cord changes occurred in 25 patients (43%), 17 of these changes occurred in patients with spinal deformity and the remaining 8 occurred in patients without spinal deformity or canal compromise (p ≤ .05). The prevalence of spinal cord atrophy and focal cysts was significantly higher in patients with residual deformity and or spinal canal compromise (p ≤ .05). The authors recommend proper spinal cord decompression and fixation for patients with complete SCI to reduce the chance of secondary SCI.

Effect of the Timing of Surgery on Neurological Recovery for Patients with Incomplete Paraplegia Caused by Metastatic Spinal Cord Compression

Objective

This study aimed to investigate the effect of timing of surgery on neurological recovery for patients with metastatic spinal cord compression (MSCC).

Methods

According to the timing of surgery, 75 patients with incomplete paraplegia caused by MSCC were assigned to 3 groups: within 3 days (group A), between 4 days and 7 days (group B), and after 7 days (group C). T-test, one-way ANOVA, Mann–Whitney U-test, and Chi-square test were used to evaluate the difference in the improvement of American Spinal Injury Association Impairment Scale (AIS) and ambulatory status, the incidence of perioperative complications, surgical site infection, and the length of hospital stay between 3 groups.

Results

Patients with incomplete paraplegia treated in our department had an average of 17.4±1.8 days delayed and most occurred before hospitalization (4.0±0.4 vs 13.2±1.8, P<0.001). There was no significant difference in the AIS improvement between patients with different pre-op AIS. The timing of surgery was significantly correlated with AIS improvement (correlation coefficient=−0.257, P=0.019). Sub-analysis showed that patients who underwent surgery within 7 days (group A and group B) had significantly better AIS improvement compared with group C (improved at least 1 grade, P=0.043; improved more than 1 grade, P=0.039) and the surgery timing was more important for patients with AIS B and C. The timing of surgery was significantly correlated with the length of hospital stay (correlation coefficient=0.335, P=0.003). Patients of group C had the longest length of hospital stay (P=0.002). The incidence of perioperative complications and surgical site infection did not differ significantly between the 3 groups.

Conclusion

Delay surgery was common in incomplete paraplegia patients with MSCC. Patients with AIS B and C who underwent surgery within 7 days had better AIS improvement.

The Histopathology of Severe Graded Compression in Lower Thoracic Spinal Cord Segment of Rat, Evaluated at Late Post-injury Phase

Spontaneous recovery of lost motor functions is relative fast in rodent models after inducing a very mild/moderate spinal cord injury (SCI), and this may complicate a reliable evaluation of the effectiveness of potential therapy. Therefore, a severe graded (30 g, 40 g and 50 g) weight-compression SCI at the Th9 spinal segment, involving an acute mechanical impact followed by 15 min of persistent compression, was studied in adult female Wistar rats. Functional parameters, such as spontaneous recovery of motor hind limb and bladder emptying function, and the presence of hematuria were evaluated within 28 days of the post-traumatic period. The disruption of the blood-spinal cord barrier, measured by extravasated Evans Blue dye, was examined 24 h after the SCI, when maximum permeability occurs. At the end of the survival period, the degradation of gray and white matter associated with the formation of cystic cavities, and quantitative changes of glial structural proteins, such as GFAP, and integral components of axonal architecture, such as neurofilaments and myelin basic protein, were evaluated in the lesioned area of the spinal cord. Based on these functional and histological parameters, and taking the animal’s welfare into account, the 40 g weight can be considered as an upper limit for severe traumatic injury in this compression model.

Better late than never: Clinical outcomes of delayed fixation in thoracolumbar spinal trauma

PURPOSE

To analyse factors influencing functional outcome and neurological recovery in patients undergoing delayed surgery for traumatic spinal cord injury (SCI) involving thoracolumbar spine.

METHODS

Retrospective analysis of 33 patients with thoracolumbar SCI who underwent delayed surgery (≥ 72hrs post-trauma) with a minimum follow-up of 1 year (average:32.55 months) was done. The parameters studied included age, sex, co-morbidities, mode of trauma, associated trauma, level and number of vertebrae involved, fracture morphology, thoracolumbar injury classification and severity score (TLICS), maximal spinal cord compression (MSCC), signal changes in the cord, neurological deficit as per the American Spinal Injury Association (ASIA) scale, lower extremity motor score (LEMS), bowel bladder involvement, time interval between trauma and surgery.

RESULTS

Mean time interval from injury to spine surgery was 24.45 days. At the end of 1-year follow-up, 17(51.5%), 12(36.36%), and 3(9.1%) patients had ≥ 1, ≥ 2, and ≥ 3-grade ASIA improvement, respectively. The mean LEMS rose to 33.86 from 17.09 (P < 0.001). 8 out of 20 patients with bladder involvement showed improvement. 4 patients succumbed, 22 were ambulatory, and 7 remained non-ambulatory. On comparing various parameters, pre-operative LEMS score (P-value: < 0.001), cord signal changes (P-value:0.002), and presence of cord transection (P-value:0.007) differed significantly in the above-mentioned three groups, while age (P-value:0.442), average TLICS (P-value:0.872), time from injury to surgery (P-value:0.386) did not differ significantly.

CONCLUSION

This study highlights that there is still a significant scope for neurological improvement even after delayed surgery in patients with thoracolumbar SCI. The lower the LEMS score at the time of presentation, signal changes in the cord and presence of cord transection have a significant influence on unfavourable clinical outcomes at the end of 1-year post-surgery.

Current updates on various treatment approaches in the early management of acute spinal cord injury

Spinal cord injury (SCI) is a debilitating condition which often leads to a severe disability and ultimately impact patient's physical, psychological, and social well-being. The management of acute SCI has evolved over the couple of decades due to improved understanding of injury mechanisms and increasing knowledge of disease. Currently, the early management of acute SCI patient includes pharmacological agents, surgical intervention and newly experimental neuroprotective strategies. However, many controversial areas are still surrounding in the current treatment strategies for acute SCI, including the optimal timing of surgical intervention, early versus delayed decompression outcome benefits, the use of methylprednisolone. Due to the lack of consensus, the optimal standard of care has been varied across treatment centres. The authors have shed a light on the current updates on early treatment approaches and neuroprotective strategies in the initial management of acute SCI in order to protect the early neurologic injury and reduce the future disability.

Surgical outcome and risk factors for cervical spinal cord injury patients in chronic stage: a 2-year follow-up study

PURPOSE

This study aims to assess the nerve function deficient recovery in surgically treated patients with cervical trauma with spinal cord injury (SCI) in chronic stage and figure out prognostic predictors of improvement in impairment and function.

METHODS

We reviewed the clinical and radiological data of 143 cervical SCI patients in chronic stage and divided into non-operative group (n = 61) and operative group (n = 82). The severity of neurological involvement was assessed using the ASIA motor score (AMS) and Functional Independence Measure Motor Score (FIM MS). The health-related quality of life was measured using the SF-36 questionnaire. Correspondence between the clinical and radiological findings and the neurological outcome was investigated.

RESULTS

At 2-year follow-up, surgery resulted in greater improvement in AMS and FIM MS than non-operative group. Regression analysis revealed that lower initial AMS (P = 0.000), longer duration after injury (P = 0.022) and injury above C4 level (P = 0.022) were factors predictive of lower final AMS. Longer duration (P = 0.020) and injury above C4 level (P = 0.010) were associated with a lower FIM MS. SF-36 scores were significantly lower in higher age (P = 0.015), female patients (P = 0.009) and patients with longer duration (P = 0.001).

CONCLUSION

It is reasonable to consider surgical decompression in patients with cervical SCI in chronic stage and persistent spinal cord compression and/or gross cervical instability. Initial AMS, longer duration, injury above C4 level, higher age and female patients are the five major relevant factors of functional recovery.

Effects of durotomy versus myelotomy in the repair of spinal cord injury

Current management for spinal cord injury aims to reduce secondary damage and recover sensation and movement. Acute spinal cord injury is often accompanied by spinal cord compartment syndrome. Decompression by durotomy and/or myelotomy attempts to relieve secondary damage by completelyrelieving the compression of the spinal cord, removing the necrotic tissue, decreasing edema, reducing hemorrhage, and improving blood circulation in the spinal cord. However, it is controversial whether durotomy and/or myelotomy after spinal cord injury are beneficial to neurological recovery. This review compares the clinical effects of durotomy with those of myelotomy in the treatment of spinal cord injury. We found that durotomy has been performed more than myelotomy in the clinic, and that durotomy may be safer and more effective than myelotomy. Durotomy performed in humans had positive effects on neurological function in 92.3% of studies in this review, while durotomy in animals had positive effects on neurological function in 83.3% of studies. Myelotomy procedures were effective in 80% of animal studies, but only one clinical study of myelotomy has reported positive results, of motor and sensory improvement, in humans. However, a number of new animal studies have reported that durotomy and myelotomy are ineffective for spinal cord injury. More clinical data, in the form of a randomized controlled study, are needed to understand the effectiveness of durotomy and myelotomy.

Thoracolumbar Junction Fracture: Principle of Management

The thoracolumbar junction (TLJ) is the most common site of traumatic spinal injury. Its management is a highly controversial area. There are no specific guidelines for management of these injuries. The primary goal of treatment of TLJ fractures involves protecting the spinal cord from further neural damage, obtaining the stability by reconstructing anatomical alignment of spinal column, and returning patients to workplace through early mobilization and rehabilitation. There is a great variation in evaluation of stability of these fractures, which is one of the crucial factors in deciding the treatment. Controversy also exists regarding conservative versus operative treatment, timing of intervention, anterior versus posterior approach, short versus long segment fixation, and bracing versus no bracing. This article had reviewed the conflicting results and recommendations for management of TLJ fractures of previously published reports in PubMed, PubMed Central, and Medline databases. We analyzed these related articles which addresses issues regarding evaluation of stability, indications for operative and conservative treatment, timing of surgery, surgical approach, and fusion length.

A Randomized Controlled Trial of Early versus Late Surgical Decompression for Thoracic and Thoracolumbar Spinal Cord Injury in 73 Patients

Convincing clinical evidence exists to support early surgical decompression in the setting of cervical spinal cord injury (SCI). However, clinical evidence on the effect of early surgery in patients with thoracic and thoracolumbar (from T1 to L1 [T1–L1]) SCI is lacking and a critical knowledge gap remains. This randomized controlled trial (RCT) sought to evaluate the safety and efficacy of early (<24 h) compared with late (24–72 h) decompressive surgery after T1–L1 SCI. From 2010 to 2018, patients (≥16 years of age) with acute T1–L1 SCI presenting to a single trauma center were randomized to receive either early (<24 h) or late (24–72 h) surgical decompression. The primary outcome was an ordinal change in American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at 12-month follow-up. Secondary outcomes included complications and change in ASIA motor score (AMS) at 12 months. Outcome assessors were blinded to treatment assignment.

Of 73 individuals whose treatment followed the study protocol, 37 received early surgery and 36 underwent late surgery. The mean age was 29.74 ± 11.4 years. In the early group 45.9% of patients and in the late group 33.3% of patients had a ≥1-grade improvement in AIS (odds ratio [OR] 1.70, 95% confidence interval [CI]: 0.66-4.39, p = 0.271); significantly more patients in the early (24.3%) than late (5.6%) surgery group had a ≥2-grade improvement in AIS (OR 5.46, 95% CI: 1.09-27.38, p = 0.025). There was no statistically significant difference in the secondary outcome measures. Surgical decompression within 24 h of acute traumatic T1–L1 SCI is safe and is associated with improved neurological outcome, defined as at least a 2-grade improvement in AIS at 12 months.

Preliminary Findings After Nonoperative Management of Traumatic Cervical Spinal Cord Injury on a Background of Degenerative Disc Disease: Providing Optimum Patient Care and Costs Saving in a Nigerian Setting

OBJECTIVE

We assessed the hypothesis that nonoperative management would be a viable treatment option for patients with underlying degenerative disease who have traumatic cervical spinal cord injury (TCSI) without neurological deterioration and/or spinal instability during hospitalization.

METHODS

Data were collected prospectively from 2011 to 2016. All the patients had been treated nonoperatively with hard cervical collar immobilization. The clinical parameters assessed included the Frankel grade at presentation and discharge, the occurrence of deep vein thrombosis, urinary tract infection, sphincter dysfunction, and pressure sores. The radiographic data collected included magnetic resonance imaging signal cord changes. P ≤ 0.05 represented a significant association between the Frankel grade at presentation and the outcome parameters.

RESULTS

A total of 28 patients were included in the present study. Of the patients who had presented with Frankel grade B, 85.71% had improved to a higher grade, 90.91% of the patients with Frankel grade C had improved to a higher grade, and 14.29% of the patients with Frankel grade D had improved to Frankel grade E. All the patients had satisfactory spinal stability, as evidenced by dynamic radiographs, after treatment.

CONCLUSION

The findings from the present study have shown that nonoperative management can result in improved neurological outcomes for patients with underlying degenerative disease who have experienced TCSI without evidence of neurological deterioration and spinal instability. The Frankel grade at presentation was significantly associated with outcome parameters such as the neurological outcome on discharge and the occurrence of urinary tract infection. The results from the present study could be helpful to neurological surgeons in rural and other low-resource settings because the cost savings realized by nonoperative treatment will not sacrifice the provision of adequate care to their patients.

Nonoperative treatment of traumatic spinal injuries in Tanzania: who is not undergoing surgery and why?

STUDY DESIGN

Retrospective, cohort study of a prospectively collected database.

OBJECTIVES

In a cohort of patients with traumatic spine injury (TSI) in Tanzania who did not undergo surgery, we sought to: (1) describe this nonoperative population, (2) compare outcomes to operative patients, and (3) determine predictors of nonoperative treatment.

SETTING

Tertiary referral hospital.

METHODS

All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, fracture morphology, neurologic exam, indication for surgery, length of hospitalization, and mortality. Regression analyses were used to report outcomes and predictors of nonoperative treatment.

RESULTS

270 patients met inclusion criteria, of which 145 were managed nonoperatively. Demographics between groups were similar. The nonoperative group was young (mean = 35.5 years) and primarily male (n = 125, 86%). Nonoperative patients had 7.39 times the odds of death (p = 0.003). Patients with AO type A0/1/2/3 fractures (p < 0.001), ASIA E exams (p = 0.016), cervical spine injuries (p = 0.005), and central cord syndrome (p = 0.016) were more commonly managed nonoperatively. One hundred and twenty-four patients (86%) had indications for but did not undergo surgery. After multivariate analysis, the only predictor of nonoperative management was sustaining a cervical injury (p < 0.001).

CONCLUSIONS

Eighty-six percent of nonoperative TSI patients had an indication for surgery. Nonoperative management was associated with an increased risk of mortality. Cervical injury was the single independent risk factor for not undergoing surgery. The principle reason for nonoperative management was cost of implants. While a causal relationship between nonoperative management and inferior outcomes cannot be made, efforts should be made to provide surgery when indicated, regardless of a patient's ability to pay.

Traumatic cervical spine injury: Short-and medium-term prognostic factors in 102 patients

Background:

Traumatic cervical spine injuries (CSIs) can be defined as osteodiscoligamentous lesions and are frequent in the young and active population. These lesions are often associated with significant devastating neurological deficits. Here, we sought to establish short-and medium-term prognostic factors that could help predict future outcomes.

Methods:

We retrospectively reviewed 102 adults admitted for traumatic CSI over an 11-year period (January 2004–December 2014). Patients were graded using Frankel scale as exhibiting good or poor outcomes.

Results:

Two risk factors that significantly predicted results for CSI included original poor Frankel grades (e.g., A and B) and initial neurovegetative disorders (e.g., respectively, P = 0.019 and P = 0.001). However, we did not anticipate that two other risk factors, operative delay and mechanism of trauma, would not significantly adversely impact outcomes.

Conclusion:

Here, we identified two significant risk factors for predicting poor outcomes following CSI; poor initial Frankel Grades A and B and neurovegetative disorders at the time of original presentation.

Surgical treatment of traumatic thoracolumbar fractures: a retrospective review of 101 cases

PURPOSE

To evaluate the outcomes of vertebral stabilisation after acute traumatic thoracolumbar fractures, correlating the outcome with patient clinical data, type and location of fracture, presence of neurological damage, timing of surgical intervention and number of instrumented levels. The results have been evaluated also through the AO classification and AOSIS score.

METHODS

Retrospective analysis of 101 patients with traumatic thoracolumbar injuries from T3 to L5 operated 2011-2016 by posterior or antero-posterior fixation. The demographic data, trauma dynamics, number and type of fractures, associated lesions, timing of surgery, hospital stay, AOSIS score, RKA, SF-36 and ODI scores, pre- and post-operative neurological condition (ASIA grade), possible complications and re-interventions were evaluated for each patient.

RESULTS

Fractures mainly involved the region between T11 and L2. The probability of medullary involvement increases with the increase in severity of the main fracture type with no relation with the vertebral region. Type B and C fractures were common in the thoracic region and rare in the thoracolumbar junction. ODI and SF-36 scores were significantly better in patients with a lower AOSIS score, specifically in lesions classified as type A, amyelic and with no comorbidity. No difference was found in the clinical scores between thoracic, thoracolumbar and lumbar fractures, nor between male and female patients. None of the 10 patients with ASIA A lesion at presentation achieved any degree of recovery: 50% of them had a thoracic lesion. Re-intervention rate was 15%. Hospital stay was significantly higher in patients with type C fractures, and complication rate was on average 14% (7% in type A fractures, 16% in B and 25% in C).

CONCLUSIONS

This study confirmed the validity of the posterior approach in the surgical treatment of thoracolumbar fractures. Outcomes and complication risks are related to fracture severity. Surgical treatment can be recommended even with an AOSIS score of two or three. The combined antero-posterior approach could be useful in cases with LSC > 8, especially in the thoracolumbar region. The degree of neurological recovery depends on fracture type, location, ASIA score and presence of comorbidities. Early intervention in myelic patients allows for a better prognosis. Level of evidence III retrospective case series.

Neurological function following early versus delayed decompression surgery for drop foot caused by lumbar degenerative diseases

The purpose of this study was to investigate the effectiveness of early (<72 h) versus late (≥72 h) decompression surgery after the onset of drop foot caused by root disorder in lumbar degenerative diseases (LDDs). Data were included from 60 patients who underwent decompression surgery for drop foot caused by LDDs, including lumbar disk herniation or lumbar spinal stenosis. The primary outcome was ordinal change in the manual muscle test (MMT) at 2 years follow-up. Secondary outcomes included changes in the Japanese Orthopedic Association's (JOA) score. The early- and late-stage surgery groups included 20 and 40 patients with mean durations from the onset of drop foot to operation of 0.8 days (range, 0-3 days) and 117.1 days (range, 10-891 days), respectively. There was no significant difference (p = 0.33) between the early- and late-stage surgery groups in the improvement of MMT scores to >4 (90% versus 80%, respectively). However, more patients in the early-stage group achieved an MMT score >5 compared with those in the late-stage surgery group (80% versus 45%; p = 0.03). Furthermore, the recovery rate of JOA scores was significantly higher in the early-stage (89.1%) compared with the late-stage surgery group (68.6%; p < 0.001). Early decompression surgery produced better neurological recovery; however, an improvement of >4 in the MMT score was achieved in 80% of cases with late decompression.

Early surgical intervention among patients with acute central cord syndrome is not associated with higher mortality and morbidity

Background

Conflicting reports exist regarding mortality and morbidity of early surgical decompression in the setting of acute central cord syndrome (ACS) in multisystem trauma despite evidence of improved neurological outcomes. Consequently, optimal decompression timing in ACS in multisystem trauma patients remains controversial. This study aims to determine the association between early surgery for acute traumatic central cord and all-cause mortality among multisystem trauma patients in the National Trauma Data Bank (NTDB) using propensity score matching.

Methods

We used the NTDB (years 2011-2014) to perform a retrospective cohort study, which included patients >18 years, with ACS (identified using ICD-9 coding). Collected patient data included demographics, surgery timing (≤24 hours, >24 hours), injury mechanism, Charlson comorbidity index (CCI), injury severity score (ISS), serious adverse events (SAE). Logistic regression and propensity matching were used to investigate the relationship between surgery timing and subsequent inpatient mortality.

Results

We identified 2,379 traumatic ACS patients. This group was 79.3% male with an average age of 56.3±15.2. They had an average ISS of 19.5±9.0 and mortality rate of 3.0% (n=72). A total of 731 (30.7%) patients underwent surgery for ACS within 24 hours. Univariate analysis did not show a significantly higher mortality rate in the early versus late surgery groups (3.8% vs. 2.7%, P=0.127). In unadjusted models, early surgery was not predictive of death or SAE + death in full (P=0.129, P=0.140) or matched samples (P=0.137, P=0.280). In models adjusted for age, ISS, and CCI, early surgery was predictive of death and SAE + death using the full sample (P=0.013, P=0.027), but not when using the propensity matched sample (P=0.107, P=0.255).

Conclusions

Early surgical intervention does not appear to be associated with increased mortality among ACS patients unlike previously suggested. We theorize that survival noted within the NTDB is confounded by factors including existing comorbidities and multisystem trauma, rather than surgical timing. Delaying definitive surgical care may predispose patients to worsened greater neurological morbidity.

Acute spinal cord injuries before and after the New Zealand Spinal Cord Impairment Action Plan

BACKGROUND

Early medical and surgical intervention in acute spinal cord injuries can improve long-term functional outcomes. This study aims to observe the effects of the New Zealand (NZ) Spinal Cord Impairment Action Plan on timing to acute decompression and comparing this to the period prior to the policy change.

METHOD

Data were collected in the form a retrospective audit from medical records of 12 patients admitted to Middlemore Hospital from 2010 to 2013 prior to the NZ Spinal Cord Impairment Action Plan, and 11 patients from 2014 to 2015 following the policy change. Time of decompression is defined as either closed reduction or open reduction plus decompression. Patients were transferred from an initial regional hospital to Middlemore Hospital or directly to Middlemore Hospital following injury. Important time points were compared before and after the NZ Spinal Cord Impairment Action Plan.

RESULTS

Cox regression modelling was used to compare statistical data. Following the regional policy change, patients had a shorter time of transfer between hospitals, pre-surgical work up, and hence shorter time to decompression. The mean time of injury to decompression before the policy change is 57.8 and 24.9 h after.

CONCLUSION

Since implementing the NZ Spinal Cord Impairment Action Plan, time to decompression has been significantly reduced compared with the same group prior.

A limited unilateral transpedicular approach for anterior decompression of the thoracolumbar spinal cord in elderly and high-risk patients

Background:

Surgical treatment for elderly patients with thoracolumbar (TL) kyphosis and spinal cord (SC) compression presents significant challenges due to compression location, the amount of deformity, and patient's medical status might not permit full correction of the deformity. In this series, we present a surgical approach that provides adequate decompression without the risks associated with a pedicle subtraction osteotomy/posterior vertebral column resection or an anterior corpectomy.

Methods:

Three patients presented with TL kyphosis and progressive neurologic symptoms. All had acute weakness; none were ambulatory. SC was compressed over the apex of kyphosis, and for some, there was spinal stenosis at the proximal junction of the TL spine. The surgical technique involved unilateral resection of the pars, pedicles, the posterior one-third of the lateral wall of the vertebral body, decancellation of the impinging kyphus, and finally resection of the posterior vertebral body wall compressing the SC followed by instrumentation and fusion two levels above and below the fused segments.

Results:

All patients survived the procedure and left the hospital after 10–22 days. Estimated blood loss was 653 ml. No deep infections occurred. One patient developed acute tubular necrosis but recovered fully. The other two showed improvement of one Frankel grade and were independent in the final follow-up. One patient developed acute tubular necrosis but recovered fully yet his neurologic status was unchaged. The other two showed improvement of one Frankel grade and were independent in the final follow-up.

Conclusion:

The procedure described presents a compromise that fits the more elderly patient that might not be able to tolerate major deformity correction and at the same time provides similar results in the short and medium term to more extensive procedures.

Management of Acute Traumatic Central Cord Syndrome: A Narrative Review

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.

Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis

OBJECTIVE

Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance.

METHODS

A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis.

RESULTS

A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups.

CONCLUSIONS

The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.

Extent of Spinal Cord Decompression in Motor Complete (American Spinal Injury Association Impairment Scale Grades A and B) Traumatic Spinal Cord Injury Patients: Post-Operative Magnetic Resonance Imaging Analysis of Standard Operative Approaches

Although decompressive surgery following traumatic spinal cord injury (TSCI) is recommended, adequate surgical decompression is rarely verified via imaging. We utilized magnetic resonance imaging (MRI) to analyze the rate of spinal cord decompression after surgery. Pre-operative (within 8 h of injury) and post-operative (within 48 h of injury) MRI images of 184 motor complete patients (American Spinal Injury Association Impairment Scale [AIS] grade A = 119, AIS grade B = 65) were reviewed to verify spinal cord decompression. Decompression was defined as the presence of a patent subarachnoid space around a swollen spinal cord. Of the 184 patients, 100 (54.3%) underwent anterior cervical discectomy and fusion (ACDF), and 53 of them also underwent laminectomy. Of the 184 patients, 55 (29.9%) underwent anterior cervical corpectomy and fusion (ACCF), with (26 patients) or without (29 patients) laminectomy. Twenty-nine patients (16%) underwent stand-alone laminectomy. Decompression was verified in 121 patients (66%). The rates of decompression in patients who underwent ACDF and ACCF without laminectomy were 46.8% and 58.6%, respectively. Among these patients, performing a laminectomy increased the rate of decompression (72% and 73.1% of patients, respectively). Twenty-five of 29 (86.2%) patients who underwent a stand-alone laminectomy were found to be successfully decompressed. The rates of decompression among patients who underwent laminectomy at one, two, three, four, or five levels were 58.3%, 68%, 78%, 80%, and 100%, respectively (p < 0.001). In multi-variate logistic regression analysis, only laminectomy was significantly associated with successful decompression (odds ratio 4.85; 95% confidence interval 2.2-10.6; p < 0.001). In motor complete TSCI patients, performing a laminectomy significantly increased the rate of successful spinal cord decompression, independent of whether anterior surgery was performed.

Immediate anterior open reduction and plate fixation in the management of lower cervical dislocation with facet interlocking

Lower cervical dislocation with facet interlocking is one of the most drastic injuries to the cervical spine. The early reduction is thought critical in preventing progressive secondary spinal cord injury. The authors report a new surgical procedure in the management of lower cervical dislocation with facet interlocking. A total of twenty-one cases received immediate single-staged anterior open reduction, realignment and plate fixation under general anesthesia. After the procedures, most cases exhibited improved neurological function. All patients showed stable fusion at 1-year follow-up. Loss of spinal alignment or kyphotic deformity was not found in any case. Hardware failure including screw loosening or penetrating was not observed. In conclusion, the immediate anterior open reduction and plate fixation is a safe and effective procedure in the management of lower cervical dislocation with facet interlocking.

Does the Coexistence of Multiple Segmental Rib Fractures in Polytrauma Patients Presenting With "Major" Vertebral Fracture Affect Care and Acute Outcomes?

OBJECTIVE

To determine whether operating on "major" vertebral fractures leads to premature abortion of surgery and/or other acute cardiopulmonary complications.

DESIGN

Retrospective review.

CLINICAL SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS AND INTERVENTION

We retrospectively queried our institutional Trauma Rregistry for all cases presenting with concomitant rib fractures and surgically managed vertebral fractures.

MAIN OUTCOME MEASUREMENTS

The main outcomes included the surgical outcome (aborted vs. successfully performed), total and Intensive Care Unit length of stay (LOS), adverse discharge, mortality, and functional outcomes.

RESULTS

We found 57 cases with concomitant segmental rib fractures and surgically managed vertebral fractures. Seven patients (12%) received a rib fixation, of which 1 received before vertebral fixation and 6 after. Importantly, 4 vertebral fixation cases (7.02%) had to be aborted intraoperatively because of the inability to tolerate prone positioning for surgery. For case-control analysis, we performed propensity score matching to obtain matched controls, that is, cases of vertebral fixation but no rib fractures. On matched case-control analysis, patients with concomitant segmental rib fractures and vertebral fractures were found to have higher Intensive Care Unit LOS [median = 3 days (Inter-Quartile Range = 0-9) versus. 8.4 days, P = 0.003], whereas total LOS, frequency of complete, incomplete or functional spinal cord injury, discharge to rehab, and discharge to nursing home were found to be similar between the 2 groups.

CONCLUSION

Our findings demonstrate that segmental rib fractures with concomitant vertebral fractures undergoing surgical treatment represent a subset of patients that may be at increased risk of intraoperative cardio-pulmonary complications and rib fixation before prone spine surgery for cases in which the neurological status is stable is reasonable.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

A theoretical study and implementation of spinal traction system with real-time biosignal feedback system

A large number of people suffer from spinal diseases, or so called back pain. Although numerous medical devices and therapies have been developed for treatment, back illnesses remain a problematic issue. Recently, the spinal traction has been reported to have a positive effect on spinal diseases, and an intelligent machine which stimulates the spine has been developed. This paper presents a theoretical study of how appropriate force can be applied from the spinal traction system to the spine. The system is designed to stimulate the spine, and the scale of force is controlled by the patient's biological status, such as blood pressure or heart rate. The theoretical force is compared to experimental results, and shows that the force is highly correlated to the theoretical derivation. The proposed approach can be utilized to customize the force on the spine based on the patients' weight and the angle of the spinal traction machine.

The impact of urgent intervention on the neurologic recovery in patients with thoracolumbar fractures

Background

We carried out an observational longitudinal retrospective study between 2000 and 2009 in 28 patients who underwent surgery for unstable vertebral fractures with neurologic deficits.

Methods

For the statistical analysis, we used the Chi²-test to compare proportions in independent groups and the exact Fisher test and the Wilcoxon test for repeated measures, and we compared the mean values using the Mann-Whitney U test at a significance level of P<0.05. Timing to surgical intervention (urgent ≤8 vs. >8 h), and neurologic status using the American Spinal Injury Association (ASIA) Impairment Scale at baseline and at the end of follow-up were assessed. We tested the ASIA score improvement at the end of follow-up using multiple regression analysis, adjusted by variables such as ISS, timing of intervention, location, approach and type of fracture.

Results

Twenty-eight patients were included in the analysis. Of the total, 11 (39.2%) underwent surgery urgently (≤8 h) and 17 (60.8%) in >8 h. The mean difference in the neurologic improvement in all patients was 0.97 (95% CI, 0.51-1.42) and was statistically significant (P=0.001). The mean difference in the neurologic improvement in patients with incomplete lesions was 1.59 (95% CI, 1.01-2.17, P=0.001). In these patients, the mean improvement for those intervened in less than 8 h was 1.73 compared to those operated on after more than 8 h (mean improve 0.47) with a difference statistically significant (P=0.007).

Conclusions

Urgent surgery was associated with neurologic improvement in patients with spinal cord injury (SCI). This improvement was mainly observed in patients with an incomplete lesion.

Case series of posterior instrumentation for repair of burst lumbar vertebral body fractures with entrapped neural elements

Background

Burst fractures of the lumbar vertebrae and laminar fractures associated with dural tears and entrapment of neural elements have been reported in the past as a relatively rare occurrence. To the best of our knowledge, there is no consensus on the approach to repairing these types of fractures. The objective of this study is to describe a method of repair for traumatic burst fractures of the lumbar spine and vertical laminar fractures associated with entrapped neural elements.

Methods

Seventeen patients with lumbar burst fractures were treated from June 2015 through April 2017. Dural tear was detected in all cases included in this study (confirmed intra-operatively). All other burst fractures were excluded. In all cases, unilateral posterior fixation was performed with no distraction initially. The spinal canal was then decompressed; and the entrapped neural elements released. Formal distraction was performed after canal decompression to allow for ligamentotaxis, followed by reduction of the retropulsed fractured segments back into the vertebral body.

Results

Using this method we achieved satisfactory results in that none of the patients had further deterioration of neurological deficit and the fixation allowed for early mobilization. Continued improvement was seen at the time of follow up for each of the studied patients with improved neurology, pain and no CSF leak.

Conclusions

Our institution has demonstrated successful use of a posterior instrumentation, spinal canal decompression, release of entrapped nerve roots, and reduction of the retropulsed segment, in patients with traumatic burst fracture of the lumbar vertebrae complicated by entrapped neural elements.

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.

The case for surgery of the injured spine in the management of traumatic cord injuries

Spinal cord injury can be a life-altering trauma for patients and can be costly to patients and society alike. Generally recognized as biphasic, these injuries have both primary and secondary drivers. Although the primary insult is largely unavoidable, prevention of secondary injury mechanisms-and the resultant cascade-has been a target of substantial research. Continued spinal cord compression has been recognized as one of several deleterious secondary mechanisms, and decompressive and stabilization surgery has been routinely used for neuroprotection in this setting. Numerous biomechanical and animal studies have confirmed its potential utility. More recently, several high-quality randomized trials have concluded that early surgery for spinal cord injury improves rates of recovery when compared with delayed or nonoperative management. Herein, we argue that early surgery for spinal cord injury with continued cord compression offers significant benefit and should be undertaken when not contraindicated.