Efficacy of Ultra-Early (< 12 h), Early (12-24 h), and Late (>24-138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

Time from injury to acute surgery for patients with traumatic cervical spinal cord injury in South-East Norway

Background

The recommended treatment for cervical spinal cord injury (cSCI) is surgical decompression and stabilization within 24 h after injury. The aims of the study were to estimate our institutional compliance with this recommendation and identify potential factors associated with surgical delay.

Methods

Population-based retrospective database study of patients operated for cSCI in 2015-2022 within the South-East Norway Health Region (3.1 million inhabitants). Data extracted were demographics, injury description, management timeline, place of primary triage [local hospital (LH) or neurotrauma center (NTC)]. Main outcome variables were: (1) time from injury to surgery at NTC, (2) time from injury to admission NTC, and (3) time from admission NTC to surgery.

Results

We found 243 cSCI patients having acute neck surgery. Their median age was 63 years (IQR 47-74 years), 77% were male, 48% were ≥65 years old. Primary triage at an LH occurred in 150/243 (62%). The median time from injury to acute surgery was 27.8 h (IQR 15.4-61.9 h), and 47% had surgery within 24 h. The median time from injury to NTC admission was 5.6 h (IQR 1.9-19.4 h), and 67% of the patients were admitted to the NTC within 12 h. Significant factors associated with increased time from injury to NTC admission were transfer via LH, severe preinjury comorbidities, less severe cSCI, time of injury other than night, absence of multiple injuries. The median time from NTC admission to surgery was 16.7 h (IQR 9.5-31.0 h), and 70% had surgery within 24 h. Significant factors associated with increased time from NTC admission to surgery were increasing age and non-translational injury morphology.

Conclusion

Less than half of the patients with cSCI were operated on within the recommended 24 h time frame after injury. To increase the fraction of early surgery, we suggest the following: (1) patients with clinical suspicion of cSCI should be transported directly to the NTC from the scene of the accident, (2) MRI should be performed only at the NTC, (3) at the NTC, surgery should commence on the same calendar day as arrival or as the first operation the following day.

Optimal Timing in Cervical Spinal Cord Injury: A Comprehensive Meta-Analysis of Ultra-Early Surgical Intervention Within Five Hours

The optimal timing of surgery for cervical spinal cord injuries (SCI) and its impact on neurological recovery continue to be subjects of debate. This systematic review and meta-analysis aims to consolidate and assess the existing evidence regarding the efficacy of ultra-early decompression surgery in improving clinical outcomes after cervical SCI. A search was conducted in PubMed, Embase, Cochrane, and CINAHL databases from inception until September 18, 2023, focusing on human studies. The groups were categorized into ultra-early decompression (decompression surgery ≤ 5 hours post-injury) and a control group (decompression surgery between 5-24 hours post-injury). A random effects meta-analysis was performed on all studies using R Studio. Outcomes were reported as effect size (OR, treatment effect, and 95% CI. Of the 140 patients, 63 (45%) underwent decompression ≤ 5 hours, while 77 (55%) underwent decompression > 5 hours post-injury. Analysis using the OR model showed no statistically significant difference in the odds of neurological improvement between the ultra-early group and the early group (OR = 1.33, 95% CI: 0.22-8.18, p = 0.761). This study did not observe significant neurological improvement among cervical SCI patients who underwent decompression within five hours. Due to the scarcity of literature on the ultra-early decompression of cervical SCI, this study underscores the necessity for additional investigation into the potential benefits of earlier interventions for cervical SCI to enhance patient outcomes.

Neurocritical care and neuromonitoring considerations in acute pediatric spinal cord injury

Management of pediatric spinal cord injury (SCI) is an essential skill for all pediatric neurocritical care physicians. In this review, we focus on the evaluation and management of pediatric SCI, highlight a novel framework for the monitoring of such patients in the intensive care unit (ICU), and introduce advancements in critical care techniques in monitoring and management. The initial evaluation and characterization of SCI is crucial for improving outcomes as well as prognostication. While physical examination and imaging are the main stays of the work-up, we propose the use of somatosensory evoked potentials (SSEPs) and transcranial magnetic stimulation (TMS) for challenging clinical scenarios. SSEPs allow for functional evaluation of the dorsal columns consisting of tracts associated with hand function, ambulation, and bladder function. Meanwhile, TMS has the potential for informing prognostication as well as response to rehabilitation. Spine stabilization, and in some cases surgical decompression, along with respiratory and hemodynamic management are essential. Emerging research suggests that targeted spinal cerebral perfusion pressure may provide potential benefits. This review aims to increase the pediatric neurocritical care physician's comfort with SCI while providing a novel algorithm for monitoring spinal cord function in the ICU.

An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery

STUDY DESIGN

Clinical practice guideline development.

OBJECTIVES

Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI).

METHODS

A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence.

CONCLUSIONS

It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

The 2023 AO Spine-Praxis Guidelines in Acute Spinal Cord Injury: What Have We Learned? What Are the Critical Knowledge Gaps and Barriers to Implementation?

STUDY DESIGN

Narrative summary of the 2023 AO Spine-Praxis clinical practice guidelines for management in acute spinal cord injury (SCI).

OBJECTIVES

The objective of this article is to summarize the key findings of the clinical practice guidelines for the optimal management of traumatic and intraoperative SCI (ISCI). This article will also highlight potential knowledge translation opportunities for each recommendation and discuss important knowledge gaps and areas of future research.

METHODS

Systematic reviews were conducted according to accepted methodological standards to evaluate the current body of evidence and inform the guideline development process. The summarized evidence was reviewed by a multidisciplinary guidelines development group that consisted of international multidisciplinary stakeholders. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to rate the certainty of the evidence for each critical outcome and the "evidence to recommendation" framework was used to formulate the final recommendations.

RESULTS

The key recommendations regarding the timing of surgical decompression, hemodynamic management, and the prevention, diagnosis, and management of ISCI are summarized. While a strong recommendation was made for early surgery, further prospective research is required to define what constitutes sufficient surgical decompression, examine the role of ultra-early surgery, and assess the impact of early surgery in different SCI phenotypes, including central cord syndrome. Furthermore, additional investigation is required to evaluate the impact of mean arterial blood pressure targets on neurological recovery and to determine the utility of spinal cord perfusion pressure measurements. Finally, there is a need to examine the role of neuroprotective agents for the treatment of ISCI and to prospectively validate the new AO Spine-Praxis care pathway for the prevention, diagnosis, and management of ISCI. To optimize the translation of these guidelines into practice, important barriers to their implementation, particularly in underserved areas, need to be explored. Ultimately, these recommendations will help to establish more personalized approaches to care for SCI patients.

CONCLUSIONS

The recommendations from the 2023 AO Spine-Praxis guidelines not only highlight the current best practice in the management of SCI, but reveal critical knowledge gaps and barriers to implementation that will help to guide further research efforts in SCI.

Timing of Decompressive Surgery in Patients With Acute Spinal Cord Injury: Systematic Review Update

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Surgical decompression is a cornerstone in the management of patients with traumatic spinal cord injury (SCI); however, the influence of the timing of surgery on neurological recovery after acute SCI remains controversial. This systematic review aims to summarize current evidence on the effectiveness, safety, and cost-effectiveness of early (≤24 hours) or late (>24 hours) surgery in patients with acute traumatic SCI for all levels of the spine. Furthermore, this systematic review aims to evaluate the evidence with respect to the impact of ultra-early surgery (earlier than 24 hours from injury) on these outcomes.

METHODS

A systematic search of the literature was performed using the MEDLINE database (PubMed), Cochrane database, and EMBASE. Two reviewers independently screened the citations from the search to determine whether an article satisfied predefined inclusion and exclusion criteria. For all key questions, we focused on primary studies with the least potential for bias and those that controlled for baseline neurological status and specified time from injury to surgery. Risk of bias of each article was assessed using standardized tools based on study design. Finally, the overall strength of evidence for the primary outcomes was assessed using the GRADE approach. Data were synthesized both qualitatively and quantitively using meta-analyses.

RESULTS

Twenty-one studies met inclusion and exclusion criteria and formed the evidence base for this review update. Seventeen studies compared outcomes between patients treated with early (≤24 hours from injury) compared to late (>24 hours) surgical decompression. An additional 4 studies evaluated even earlier time frames: <4, <5, <8 or <12 hours. Based on moderate evidence, patients were 2 times more likely to recover by ≥ 2 grades on the ASIA Impairment Score (AIS) at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, moderate evidence suggested that patients receiving early decompression had an additional 4.50 (95% CI 1.70 to 7.29) point improvement on the ASIA motor score. With respect to administrative outcomes, there was low evidence that early decompression may decrease acute hospital length of stay. In terms of safety, there was moderate evidence that suggested the rate of major complications does not differ between patients undergoing early compared to late surgery. Furthermore, there was no difference in rates of mortality, surgical device-related complications, sepsis/systemic infection or neurological deterioration based on timing of surgery. Firm conclusions were not possible with respect to the impact of ultra-early surgery on neurological, functional or safety outcomes given the poor-quality studies, imprecision and the overlap in the time frames examined.

CONCLUSIONS

This review provides an evidence base to support the update on clinical practice guidelines related to the timing of surgical decompression in acute SCI. Overall, the strength of evidence was moderate that early surgery (≤24 hours from injury) compared to late (>24 hours) results in clinically meaningful improvements in neurological recovery. Further studies are required to delineate the role of ultra-early surgery in patients with acute SCI.

Early Versus Delayed Surgery for Elderly Traumatic Cervical Spinal Injury: A Nationwide Multicenter Study in Japan

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

The effectiveness of early surgery for cervical spinal injury (CSI) has been demonstrated. However, whether early surgery improves outcomes in the elderly remains unclear. This study investigated whether early surgery for CSI in elderly affects complication rates and neurological outcomes.

METHODS

This retrospective multicenter study included 462 patients. We included patients with traumatic acute cervical spinal cord injury aged ≥65 years who were treated surgically, whereas patients with American Spinal Injury Association (ASIA) Impairment Scale E, those with unknown operative procedures, and those waiting for surgery for >1 month were excluded. The minimum follow-up period was 6 months. Sixty-five patients (early group, 14.1%) underwent surgical treatment within 24 hours, whereas the remaining 397 patients (85.9%) underwent surgery on a standby basis (delayed group). The propensity score-matched cohorts of 63 cases were compared.

RESULTS

Patients in the early group were significantly younger, had significantly more subaxial dislocations (and fractures), tetraplegia, significantly lower ASIA motor scores, and ambulatory abilities 6 months after injury. However, no significant differences in the rate of complications, ambulatory abilities, or ASIA Impairment Scale scores 6 months after injury were observed between the matched cohorts. At 6 months after injury, 61% of the patients in the early group (25% unsupported and 36% supported) and 53% of the patients in the delayed group (34% unsupported and 19% supported) were ambulatory.

CONCLUSIONS

Early surgery is possible for CSI in elderly patients as the matched cohort reveals no significant difference in complication rates and neurological or ambulatory recovery between the early and delayed surgery groups.

Ultra-early (≤8 hours) surgery for thoracolumbar spinal cord injuries: A systematic review and meta-analysis

Background

The impact of the timing of surgery on neurological recovery in thoracolumbar spinal cord injuries (tSCI) is still a subject of discussion. Accumulating evidence is supporting early decompression (<24 hours) following tSCI. However, the potential advantages of earlier decompression remain uncertain. This systematic review and meta-analysis summarize and analyze the current evidence on the effectiveness of ultra-early decompression surgery on clinical outcomes following tSCI.

Methods

A search was conducted in the electronic databases Medline, Embase, Scopus, and Web of Science from their inception until May 2022 for human studies. Groups were stratified into ultra-early (surgery within 8 hours of injury) vs control group operated >8 hours of injury. The authors included the study data from their institutional case series of thoracolumbar spinal cord injury from 2015 to 2018. An arm-based meta-analysis was performed on all studies using the R Studio. For studies that qualified, a contrast-based meta-analysis was also performed with a standardized mean difference (SMD). Outcomes were reported as effect size, treatment effect, and effect difference, all with 95% confidence intervals (CI).

Results

Of the 133 patients, 74.4% patients were male. 76 (57.1%) underwent decompression ≤8 hours, while 57 (42.9%) underwent decompression >8 hours from injury. Quantitative analysis using the SMD model showed a significant difference in mean AIS improvement in the ultra-early group (Effect size 1.15 [0.62-1.67], p<.0001). On arm-based meta-analysis, a statistically significant treatment effect was found for the ultra-early arm (1.25 [0.91-1.67]), while > 8-hour arm did not show significance (0.30 [-0.08-0.71]). There was a statistically significant effect difference between the two arms (0.96 [0.49-1.48]).

Conclusions

This study observed a significant improvement in the mean AIS score in patients undergoing decompression within 8 hours of tSCI. Given the scant literature regarding ultra-early decompression of tSCI, this study solidifies the need to further explore the role of early interventions for tSCIs to improve patient outcomes.

Pathophysiology and surgical decision-making in central cord syndrome and degenerative cervical myelopathy: correcting the somatotopic fallacy

Our understanding of Central Cord Syndrome (CCS), a form of incomplete spinal cord injury characterized by disproportionate upper extremity weakness, is evolving. Recent advances challenge the traditional somatotopic model of corticospinal tract organization within the spinal cord, suggesting that CCS is likely a diffuse injury rather than focal lesion. Diagnostic criteria for CCS lack consensus, and varied definitions impact patient identification and treatment. Evidence has mounted for early surgery for CCS, although significant variability persists in surgical timing preferences among practitioners. A demographic shift toward an aging population has increased the overlap between CCS and Degenerative Cervical Myelopathy (DCM). Understanding this intersection is crucial for comprehensive patient care. Assessment tools, including quantitative measures and objective evaluations, aid in distinguishing CCS from DCM. The treatment landscape for CCS in the context of pre-existing DCM is complex, requiring careful consideration of pre-existing neurologic injury, patient factors, and injury factors. This review synthesizes emerging evidence, outlines current guidelines in diagnosis and management, and emphasizes the need for ongoing research to refine our understanding and treatment strategies for this evolving patient population.

A Review of Strategies Associated with Surgical Decompression in Traumatic Spinal Cord Injury

Traumatic spinal cord injury (TSCI) is frequent. Timely diagnosis and treatment have reduced the mortality, but the long-term recovery of neurologic functions remains ominous. After TSCI, tissue bleeding, edema, and adhesions lead to an increase in the intraspinal pressure, further causing the pathophysiologic processes of ischemia and hypoxia and eventually accelerating the cascade of secondary spinal cord injury. Timely surgery with appropriate decompression strategies can reduce that secondary injury. However, disagreement about the safety and effectiveness of decompression surgery and the timing of surgery still exists. The level and severity of spinal cord injury do have an impact on the timing of surgery; therefore, TSCI subpopulations may benefit from early surgery. Early surgery perhaps has little effect on recovery from complete TSCI but might be of benefit in patients with incomplete injury. Early decompression should be considered in patients with incomplete cervical TSCI. Patient age should not be used as an exclusion criterion for early surgery. The best time point for early surgery is although influenced by the shortest duration to thoroughly examine the patient's condition and stabilize the patient's state. After the patient's condition is fully evaluated, we can perform the surgical modality of emergency myelotomy and decompression. Therefore, a number of conditions should be considered, such as standardized decompression methods, indications and operation timing to ensure the effectiveness and safety of early surgical intervention, and promotion of the functional recovery of residual nerve tissue.

Spontaneous hemorrhage of spinal epidural capillary hemangioma resulting in hyperacute neurologic deficit: A case report

INTRODUCTION

Spinal epidural capillary hemangioma is a very rare variety of tumors, usually with a predilection for the thoracic spine.

CASE PRESENTATION

A 16-year-old female complained of hyperacute neurologic deficit progressed within hour, which presented by acute paraplegia, and loss of all sensations from her lower limbs up to her breasts. Neurologic exam revealed paralysis of lower limbs (0/5 on both legs) with a flaccid tone, absence of reflexes, weakness of the trunk with sensory level T4, bilateral flexion of plantar reflexes, and loss of sphincters' controls. Emergent magnetic resonance imaging showed a dumbbell-shaped epidural mass in the posterior aspect of the spinal canal at the T1-T2 level, measuring approximately 1.1 × 4.5 × 1.5 cm in size. The lesion was isointense on T1-weighted, hyperintense on T2-weighted, and a little enhancement after gadolinium administration. The surgery was obtained nearly 16 hours after paralysis, which eradicated the lesion with good hemostasis. Histological examination showed a well-organized vascular tissue that haphazardly arranged and confirmed the diagnosis of capillary hemangioma. Neurological improvement was quickly observed within days after surgery and further complete recovery was achieved 2 months after discharge.

CONCLUSION

We report an extremely rare case of spinal epidural capillary hemangioma, where acute spontaneous hemorrhage in the lesion resulted in the hyperacute neurologic deficit within an hour. Since these are benign lesions, the immediate surgical intervention results in a very favorable prognosis and is considered the treatment of choice. Also, this case highlighted and rose the question of a better neurologic improvement in younger age patients with spinal cord injury.

Stem Cell Scaffolds for the Treatment of Spinal Cord Injury-A Review

Spinal cord injury (SCI) is a profoundly debilitating yet common central nervous system condition resulting in significant morbidity and mortality rates. Major causes of SCI encompass traumatic incidences such as motor vehicle accidents, falls, and sports injuries. Present treatment strategies for SCI aim to improve and enhance neurologic functionality. The ability for neural stem cells (NSCs) to differentiate into diverse neural and glial cell precursors has stimulated the investigation of stem cell scaffolds as potential therapeutics for SCI. Various scaffolding modalities including composite materials, natural polymers, synthetic polymers, and hydrogels have been explored. However, most trials remain largely in the preclinical stage, emphasizing the need to further develop and refine these treatment strategies before clinical implementation. In this review, we delve into the physiological processes that underpin NSC differentiation, including substrates and signaling pathways required for axonal regrowth post-injury, and provide an overview of current and emerging stem cell scaffolding platforms for SCI.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

Timing of Surgery and Pre-operative Physiological Parameters as Clinical Predictors of Surgical Outcomes in Traumatic Subaxial Cervical Spine Fractures and Dislocations

Objective  To evaluate the risk factors and outcomes in patients surgically treated for subaxial cervical spine injuries with respect of the timing of surgery and preoperative physiological parameters of the patient. Methods  26 patients with sub-axial cervical spine fractures and dislocations were enrolled. Demographic data of patients, appropriate radiological investigation, and physiological parameters like respiratory rate, blood pressure, heart rate, PaO2 and ASIA impairment scale were documented. They were divided pre-operatively into 2 groups. Group U with patients having abnormal physiological parameters and Group S including patients having physiological parameters within normal range. They were further subdivided into early and late groups according to the timing of surgery as U early , U late, S early and S late . All the patients were called for follow-up at 1, 6 and 12 months. Results  56 percent of patients in Group S had neurological improvement by one ASIA grade and a good outcome irrespective of the timing of surgery. Patients in Group U having unstable physiological parameters and undergoing early surgical intervention had poor outcomes. Conclusion  This study concludes that early surgical intervention in physiologically unstable patients had a strong association as a risk factor in the final outcome of the patients in terms of mortality and morbidity. Also, no positive association of improvement in physiologically stable patients with respect to the timing of surgery could be established.

Current insights into the management of spinal cord injury

Background

Traumatic spinal cord injury (SCI) is a serious disorder that results in severe impairment of neurological function as well as disability, ultimately reducing a patient's quality of life. The pathophysiology of SCI involves a primary and secondary phase, which causes neurological injury.

Methods

Narrative review on current clinical management of spinal cord injury and emerging therapies.

Results

This review explores the management of SCI through early decompressive surgery, optimizing mean arterial pressure, steroid therapy and focused rehabilitation. These management strategies reduce secondary injury mechanisms to prevent the propagation of further neurological damage. The literature regarding emerging research is also explored in cell-based, gene, pharmacological and neuromodulation therapies, which aim to repair the spinal cord following the primary injury mechanism.

Conclusions

Outcomes for patients with SCI can be enhanced and improved if primary and secondary phases of SCI can be addressed.

Prognostic MRI parameters in acute traumatic cervical spinal cord injury

PURPOSE

The aim of this study is to estimate the prognostic value of some features documented on preoperative MRI study in patients with acute cervical spinal cord injury.

METHODS

The study was conducted in patients operated for cervical spinal cord injury (cSCI) from April 2014 to October 2020. The quantitative analysis on preoperative MRI scans included: length of the spinal cord intramedullary lesion (IMLL the canal diameter at the level of maximal spinal cord compression (MSCC) and the presence of intramedullary hemorrhage. The canal diameter at the MSCC was measured on the middle sagittal FSE-T2W images at the maximum level of injury. The America Spinal Injury Association (ASIA) motor score was used for neurological assessment at hospital admission. At 12-month follow-up all patients were examined with the SCIM questionnaire.

RESULTS

At linear regression analysis, the length of the spinal cord lesion [β coefficient -10.35, 95% confidence interval (CI)-13.71 to-6.99; p < 0.001], the diameter of the canal at the level of the MSCC (β coefficient 6.99, 95% CI 0.65 to 13.33; p = 0.032), and the intramedullary hemorrhage (β coefficient  - 20.76, 95% CI - 38.70 to - 2.82; p = 0.025), were significantly associated with the score at the SCIM questionnaire at one year follow-up: shorter spinal cord lesion, greater diameter of the canal at the level of the MSCC, and absence of intramedullary hemorrhage were predictors of better outcome.

CONCLUSION

According to the findings of our study, the spinal length lesion, canal diameter at the level of spinal cord compression and intramedullary hematoma documented by the preoperative MRI study were associated with the prognosis of patients with cSCI.

Which treatment provides the best neurological outcomes in acute spinal cord injury?

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research.

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.

Early surgical intervention alleviates sensory symptoms following acute traumatic central cord syndrome

PURPOSE

To investigate the impact of early versus delayed surgery on sensory abnormalities in acute traumatic central cord syndrome (ATCCS).

METHODS

Pressure pain threshold (PPT), temporal summation (TS), conditioned pain modulation (CPM) and pain assessments were performed in 72 ATCCS patients (early vs. delayed surgical treatment: 32 vs. 40) and 72 healthy subjects in this ambispective cohort study. These examinations, along with mechanical detection threshold (MDT) and disabilities of arm, shoulder and hand (DASH), were assessed at 2 years postoperatively.

RESULTS

Preoperatively, more delayed surgical patients had neuropathic pain below level compared with early surgical patients (P < 0.05). Both early and delayed surgical patients showed reduced PPT in common painful areas and increased TS, while reduced CPM only existed in the latter (P < 0.05). Reduced PPT in all tested areas, along with abnormalities in TS and CPM, was observed in patients with durations over 3 months. Both incidences and intensities of pain and pain sensitivities in common painful areas were reduced in both treatment groups postoperatively, but only early surgical treatment improved the CPM and TS. Follow-up analysis demonstrated a higher MDT and lower PPT in hand, greater TS, greater DASH, lower pain intensities and higher incidence of dissatisfaction involving sensory symptoms in delayed surgical patients than in early surgical patients (P < 0.05).

CONCLUSIONS

Central hypersensitivity may be involved in the persistence of sensory symptoms in ATCCS, and this augmented central processing may commence in the early stage. Early surgical treatment may reverse dysfunction of endogenous pain modulation, thus reducing the risk of central sensitization and alleviating sensory symptoms.

Surgical Decompression of Traumatic Cervical Spinal Cord Injury: A Pilot Study Comparing Real-Time Intraoperative Ultrasound After Laminectomy With Postoperative MRI and CT Myelography

BACKGROUND

Decompression of the injured spinal cord confers neuroprotection. Compared with timing of surgery, verification of surgical decompression is understudied.

OBJECTIVE

To compare the judgment of cervical spinal cord decompression using real-time intraoperative ultrasound (IOUS) following laminectomy with postoperative MRI and CT myelography.

METHODS

Fifty-one patients were retrospectively reviewed. Completeness of decompression was evaluated by real-time IOUS and compared with postoperative MRI (47 cases) and CT myelography (4 cases).

RESULTS

Five cases (9.8%) underwent additional laminectomy after initial IOUS evaluation to yield a final judgment of adequate decompression using IOUS in all 51 cases (100%). Postoperative MRI/CT myelography showed adequate decompression in 43 cases (84.31%). Six cases had insufficient bony decompression, of which 3 (50%) had cerebrospinal fluid effacement at >1 level. Two cases had severe circumferential intradural swelling despite adequate bony decompression. Between groups with and without adequate decompression on postoperative MRI/CT myelography, there were significant differences for American Spinal Injury Association motor score, American Spinal Injury Association Impairment Scale grade, AO Spine injury morphology, and intramedullary lesion length (IMLL). Multivariate analysis using stepwise variable selection and logistic regression showed that preoperative IMLL was the most significant predictor of inadequate decompression on postoperative imaging (P = .024).

CONCLUSION

Patients with severe clinical injury and large IMLL were more likely to have inadequate decompression on postoperative MRI/CT myelography. IOUS can serve as a supplement to postoperative MRI/CT myelography for the assessment of spinal cord decompression. However, further investigation, additional surgeon experience, and anticipation of prolonged swelling after surgery are required.

Time is spine: What's over the horizon

The overarching theme in the early treatment of acute spinal cord injury (SCI) is to reduce the extent of secondary damage to facilitate early neurological and functional recovery. Although multiple studies have brought us innovative and potential new therapies to treat SCI, ameliorating neural damage remains a formidable challenge. Knowledge translation of clinical and basic research studies has shown that surgical intervention is a valuable treatment modality; however, the role, timing and optimal technique in surgery remains a topic of great controversy. While evidence to support the concept of ultra-early surgery for acute SCI continues to emerge, current protocols and international guidelines that encourage reducing time from trauma to surgery support the concept of "Time is Spine". The present article provides a critical narrative review of the current best practice, with a particular focus on the timing of surgical intervention, which shapes our understanding of how time is of the essence in the management of acute SCI.

Proposal of a Management Algorithm to Predict the Need for Expansion Duraplasty in American Spinal Injury Association Impairment Scale Grades A-C Traumatic Cervical Spinal Cord Injury Patients

Expansion duraplasty to reopen effaced subarachnoid space and improve spinal cord perfusion, autoregulation, and spinal pressure reactivity index (sPRX) has been advocated in patients with traumatic cervical spinal cord injury (tCSCI). We designed this study to identify candidates for expansion duraplasty, based on the absence of cerebrospinal fluid (CSF) interface around the spinal cord on magnetic resonance imaging (MRI), in the setting of otherwise adequate bony decompression. Over a 61-month period, 104 consecutive American Spinal Injury Association Impairment Scale (AIS) grades A-C patients with tCSCI had post-operative MRI to assess the adequacy of surgical decompression. Their mean age was 53.4 years, and 89% were male. Sixty-one patients had falls, 31 motor vehicle collisions, 11 sport injuries, and one an assault. The AIS grade was A in 56, B in 18, and C in 30 patients. Fifty-four patients had fracture dislocations; there was no evidence of skeletal injury in 50 patients. Mean intramedullary lesion length (IMLL) was 46.9 (standard deviation = 19.4) mm. Median time from injury to decompression was 17 h (interquartile range 15.2 h). After surgery, 94 patients had adequate decompression as judged by the presence of CSF anterior and posterior to the spinal cord, whereas 10 patients had effacement of the subarachnoid space at the injury epicenter. In two patients whose decompression was not definitive and post-operative MRI indicated inadequate decompression, expansion duraplasty was performed. Candidates for expansion duraplasty (i.e., those with inadequate decompression) were significantly younger (p < 0.0001), were AIS grade A (p < 0.0016), had either sport injuries (six patients) or motor vehicle collisions (three patients) (p < 0.0001), had fracture dislocation (p = 0.00016), and had longer IMLL (p = 0.0097). In regression models, patients with sport injuries and inadequate decompression were suitable candidates for expansion duraplasty (p = 0.03). Further, 9.6% of patients failed bony decompression alone and either did (2) or would have (8) benefited from expansion duraplasty.

Surgical Considerations to Improve Recovery in Acute Spinal Cord Injury

Acute traumatic spinal cord injury (SCI) can be a devastating and costly event for individuals, their families, and the health system as a whole. Prognosis is heavily dependent on the physical extent of the injury and the severity of neurological dysfunction. If not treated urgently, individuals can suffer exacerbated secondary injury cascades that may increase tissue injury and limit recovery. Initial recognition and rapid treatment of acute SCI are vital to limiting secondary injury, reducing morbidity, and providing the best chance of functional recovery. This article aims to review the pathophysiology of SCI and the most up-to-date management of the acute traumatic SCI, specifically examining the modern approaches to surgical treatments along with the ethical limitations of research in this field.

Early decompression promotes motor recovery after cervical spinal cord injury in rats with chronic cervical spinal cord compression

The number of elderly patients with spinal cord injury without radiographic abnormalities (SCIWORA) has been increasing in recent years and common of most cervical spinal cord injuries. Basic research has shown the effectiveness of early decompression after spinal cord injury on the spinal cord without stenosis; no studies have reported the efficacy of decompression in models with spinal cord compressive lesions. The purpose of this study was to evaluate the effects of decompression surgery after acute spinal cord injury in rats with chronic spinal cord compressive lesions, mimicking SCIWORA. A water-absorbent polymer sheet (Aquaprene DX, Sanyo Chemical Industries) was inserted dorsally into the 4–5th cervical sublaminar space in 8-week-old Sprague Dawley rats to create a rat model with a chronic spinal compressive lesion. At the age of 16 weeks, 30 mildly myelopathic or asymptomatic rats with a Basso, Beattie, and Bresnahan score (BBB score) of 19 or higher were subjected to spinal cord compression injuries. The rats were divided into three groups: an immediate decompression group (decompress immediately after injury), a sub-acute decompression group (decompress 1 week after injury), and a non-decompression group. Behavioral and histological evaluations were performed 4 weeks after the injury. At 20 weeks of age, the BBB score and FLS (Forelimb Locomotor Scale) of both the immediate and the sub-acute decompression groups were significantly higher than those of the non-decompression group. There was no significant difference between the immediate decompression group and the sub-acute decompression group. TUNEL (transferase-mediated dUTP nick end labeling) staining showed significantly fewer positive cells in both decompression groups compared to the non-decompression group. LFB (Luxol fast blue) staining showed significantly more demyelination, and GAP-43 (growth associated protein-43) staining tended to show fewer positive cells in the non-decompression group. Decompression surgery in the acute or sub-acute phase of injury is effective after mild spinal cord injury in rats with chronic compressive lesions. There was no significant difference between the immediate decompression and sub-acute decompression groups.

Systematic Nursing Interventions Combined with Continuity of Care in Patients with a Spinal Fracture Complicated with a Spinal Cord Injury and Its Effect on Recovery and Satisfaction

Objective. The aim of this study is to examine the application value of systematic nursing interventions combined with continuity of care in cases with a spinal fracture complicated with a spinal cord injury and its effect on recovery and satisfaction. Methods. We identified ninety cases with a spinal fracture complicated with a spinal cord injury who were admitted to local hospital from May 2019 to May 2021 as research subjects and assigned them into an experimental group (systematic nursing combined with continuity of care, n = 45) and a control group (conventional nursing, n = 45) according to their admission order. The level of life of all groups between intervention was evaluated with reference to the Generic Quality of Life Inventory-74 (GQOLI-74) Rating Scale. The Hospital Anxiety and Depression (HAD) scale was used to assess the emotional status of patients before and after intervention. The complication rates, nursing outcomes, nursing satisfaction, and rehabilitation outcomes of all cases were calculated. Results. The GQOLI-74 score of the experimental group was higher than that of another group ( $P<0.05$ ). Lower HAD scores of experimental group were observed than that of another group ( $P<0.05$ ). The experimental group obtained remarkably higher nursing effective rates and higher nursing satisfaction than another group ( $P<0.05$ ). Rehabilitation outcome of the experimental group outperformed that another group ( $P<0.05$ ). Conclusion. The use of systematic nursing intervention combined with continuity of care for cases with spinal fracture complicated with a spinal cord injury can enhance the nursing effect, effectively relieve cases’ psychological pressure, improve patients’ level of life and nursing satisfaction, and contribute to the maintenance of a good nurse-patient relationship, which merits clinical promotion.

Diagnostic Value of Magnetic Resonance Imaging Scan, Multislice Spiral Computed Tomography Three-Dimensional Reconstruction Combined with Plain Film X-Ray in Spinal Injuries

Objective

The main objective is to explore the diagnostic value of magnetic resonance imaging (MRI) scan, multislice spiral computed tomography (MSCT) three-dimensional reconstruction combined with plain film X-ray in spiral injuries.

Methods

By means of retrospective study, the data of 100 patients with spiral injury treated in our hospital from January 2020 to December 2021 were retrospectively analyzed, and all patients received MRI scan, MSCT three-dimensional reconstruction, and plain film X-ray examination, and by taking the operation results as the reference, the diagnostic results of different diagnostic modalities were analyzed, and the accordance rates (diagnostic result/surgical result × 100%) of the three diagnostic modalities and their combination were calculated, respectively.

Results

Among the 100 patients, 52 cases (52%) had a fracture at the anterior column of the spine, 28 cases (28%) had a fracture at the middle column of the spine, and 20 cases (20%) had a fracture at the posterior column of spine; 24 cases (24%) had simple flexion compression fracture, 60 cases (60%) had burst fracture, 6 cases (6%) had seat belt fracture, and 10 cases (10%) had fracture dislocation. The accordance rate of combined diagnosis for fracture site was 100%, and that for fracture type was 98.0%; MRI could visualize bone marrow injuries, ligamentous injuries, soft tissue injuries, and nerve root injuries that could not be visualized on X-ray plain films, and 3D reconstruction with MSCT could clearly demonstrate the 3D relationship of spinal fracture displacement, fracture line orientation, and spinal injury.

Conclusion

Plain film X-ray is the basic method for diagnosing spinal injuries, while MRI and MSCT have their unique advantages in this regard, and patients with a negative result of X-ray plain film can be examined by MRI and MSCT to observe the spinal injury comprehensively.

Predicting the Role of Preoperative Intramedullary Lesion Length and Early Decompressive Surgery in ASIA Impairment Scale Grade Improvement Following Subaxial Traumatic Cervical Spinal Cord Injury

BACKGROUND

 Traumatic cervical spinal cord injury (TCSCI) is a disabling condition with uncertain neurologic recovery. Clinical and preclinical studies have suggested early surgical decompression and other measures of neuroprotection improve neurologic outcome. We investigated the role of intramedullary lesion length (IMLL) on preoperative magnetic resonance imaging (MRI) and the effect of early cervical decompressive surgery on ASIA impairment scale (AIS) grade improvement following TCSCI.

METHODS

 In this retrospective study, we investigated 34 TCSCI patients who were admitted over a 12-year period, from January 1, 2008 to January 31, 2020. We studied the patient demographics, mode of injury, IMLL and timing of surgical decompression. The IMLL is defined as the total length of edema and contusion/hemorrhage within the cord. Short tau inversion recovery (STIR) sequences or T2-weighted MR imaging with fat saturation increases the clarity of edema and depicts abnormalities in the spinal cord. All patients included had confirmed adequate spinal cord decompression with cervical fixation and a follow-up of at least 6 months.

RESULTS

 Of the 34 patients, 16 patients were operated on within 24 hours (early surgery group) and 18 patients were operated on more than 24 hours after trauma (delayed surgery group). In the early surgery group, 13 (81.3%) patients had improvement of at least one AIS grade, whereas in the delayed surgery group, AIS grade improvement was seen in only in 8 (44.5%) patients (early vs. late surgery; odds ratio [OR] = 1.828; 95% confidence interval [CI]: 1.036-3.225). In multivariate regression analysis coefficients, the timing of surgery and intramedullary edema length on MRI were the most significant factors in improving the AIS grade following cervical SCI. Timing of surgery as a unique variance predicted AIS grade improvement significantly (p < 0.001). The mean IMLL was 41.47 mm (standard deviation [SD]: 18.35; range: 20-87 mm). IMLL was a predictor of AIS grade improvement on long-term outcome in bivariate analysis (p < 0.001). This study suggests that patients who had IMLL of less than 30 mm had a better chance of grade conversion irrespective of the timing of surgery. Patients with an IMLL of 31 to 60 mm had chances of better grade conversion after early surgery. A longer IMLL predicts lack of improvement (p < 0.05). If the IMLL is greater than 61 mm, the probability of nonconversion of AIS grade is higher, even if the patient is operated on within 24 hours of trauma.

CONCLUSION

 Surgical decompression within 24 hours of trauma and shorter preoperative IMLL are significantly associated with improved neurologic outcome, reflected by better AIS grade improvement at 6 months' follow-up. The IMLL on preoperative MRI can reliably predict outcome after 6 months. The present study suggests that patients have lesser chances of AIS grade improvement when the IMLL is ≥61 mm.

Acute hyperextension myelopathy in children: Radiographic predictors of clinical improvement

STUDY DESIGN

Retrospective case series SETTING: Three hospitals in China.

OBJECTIVE

Previous research indicates that only neurological status on admission determines prognosis of acute hyperextension myelopathy (AHM). The object of this study is to analyze other unfavorable predictors of AHM in children.

METHODS

The clinical data of children with AHM were retrospectively analyzed. The ASIA impairment scale (AIS) grade was recorded upon admission and at last follow-up. Intramedullary lesion length (IMLL) was measured in the sagittal T2-weighted imaging (T2WI) within two weeks after onset; gadolinium enhancement in the cord was recorded for each patient. Relationships among AIS grade, IMLL, gadolinium enhancement in the cord, and clinical improvement were assessed.

RESULTS

A total of 33 patients were included in this retrospective study. IMLL between complete and incomplete injury was significantly different (p < 0.01) in the subacute stage, and no difference was observed in the acute stage. Correlation analysis revealed that AIS grade on admission (r = 0.906, p < 0.001) was significantly positively correlated with clinical improvement. IMLL (r = -0.608, p < 0.001) and abnormal gadolinium enhancement (r = -0.816, p < 0.001) in the cord in the subacute stage were significantly negatively correlated with clinical improvement. There were no associations between IMLL in the acute stage and clinical improvement (r = -0.248, p = 0.242). The statistically significant predictors of clinical improvement were AIS grade on admission, IMLL in the subacute stage, and abnormal gadolinium enhancement.

CONCLUSION

IMLL in the subacute stage and abnormal gadolinium enhancement in the cord are two other prognostic predictors of AHM in children.

Ultra-early Spinal Decompression Surgery Can Improve Neurological Outcome of Complete Cervical Spinal Cord Injury; a Systematic Review and Meta-analysis

Introduction

Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in current guidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysis aims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12 hours after SCI) in improving patients' neurological status.

Methods

A search was performed in Medline, Embase, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinical trials were included in the present study. Exclusion criteria were absence of an early or late surgery group, failure to report neurological status based on the American spinal injury association impairment scale (AIS) grade, failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Two independent reviewers performed data collection, and risk of bias and certainty of evidence assessments. The outcome was reported as odds ratio (OR) and 95% confidence interval (CI).

Results

Data from 16 articles, which studied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompression surgery significantly improves patients' neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However, ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. Moreover, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86 folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improvement compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83; 95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17).

Conclusion

Current guidelines emphasize that spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and location. However, results of the present study demonstrated that certain considerations may be taken into account when performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should be performed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12 hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than in patients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients with AIS B to D does not significantly affect the neurological outcome.

N-Acetylcysteine alleviates spinal cord injury in rats after early decompression surgery by regulating inflammation and apoptosis

OBJECTIVE

Decompression surgery in patients with spinal cord injury (SCI) has a neuroprotective effect by alleviating secondary injury and improving neurological outcomes. N-Acetylcysteine (NAC), a drug approved by the United States Food and Drug Administration, has been shown to play neuroprotective roles via attenuation of apoptosis and inflammation. The purpose of the present study was to investigate the effects of early or late decompression surgery in combination with NAC administration on acute SCI, as well as investigate the underlying mechanisms of its actions.

METHODS

In this study, an acute SCI model was established in rats. The rats were treated with decompression surgery 24/48 h post-SCI in combination with or without NAC.

RESULTS

The results showed that decompression surgery in combination with NAC lead to a better outcome than decompression alone, as demonstrated by the higher Basso, Beattie, and Bresnahan scores. Histopathological examination demonstrated that early decompression surgery in combination with NAC exerted the best therapeutic effect on spinal cord recovery, which was further confirmed by the extent of inflammation and apoptosis. Additionally, we found that NAC might compensate for a lack of late surgery.

CONCLUSIONS

Collectively, early decompression surgery and NAC could be a promising combination for the treatment of acute SCI, and its therapeutic effects may be associated with the regulation of inflammation and apoptosis.

EFFECT OF TIME UNTIL DECOMPRESSION ON NEUROLOGIC RECOVERY AFTER SPINAL CORD INJURY

ABSTRACT Spinal cord injuries can have serious consequences for the individual, such as loss of motor function, sensory impairment, and alteration of physiological systems functions. Treatments for spinal cord injuries involve the use of drugs and surgical approaches. In the surgical field, there is a question about the ideal time after the trauma to perform the surgical procedure. The studies divide the time until surgery after the injury into two categories: “early” and “late”. To review the scientific literature on this topic, and to assess the relative effectiveness of early versus late decompressive surgery, we considered early intervention up to 24 hours and late intervention from 24 hours after the injury. For this, we performed a literature review and selected retrospective, prospective observational studies, clinical studies, and reviews with meta-analysis that compared the recovery time of patients with spinal cord injury after surgeries performed within 24 hours (early) and after 24 hours (late). The results showed potential for neurological improvement with early or even ultra-early surgical decompression (up to 12 hours) in patients with traumatic cervical spinal cord injury. On the other hand, reports about the advantage of early decompression when there is a thoracic injury are scarce. In addition to the time to decompression, the concomitant use of some drugs seems to play an important role in patients’ recovery. Level of Evidence II; Literature review.

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.

Spinal cord pathology revealed by MRI in traumatic spinal cord injury

PURPOSE OF REVIEW

This review covers recent advances in identifying conventional and quantitative neuroimaging spinal cord biomarkers of lesion severity and remote spinal cord pathology following traumatic spinal cord injury (SCI). It discusses the potential of the most sensitive neuroimaging spinal cord biomarkers to complement clinical workup and improve prediction of recovery.

RECENT FINDINGS

At the injury site, preserved midsagittal tissue bridges - based on conventional sagittal T2-weighted scans - can be identified in the majority of SCI patients; its width being predictive of recovery. Remote from the injury, diffusion indices, and myelin/iron-sensitive neuroimaging-based changes are sensitive to secondary disease processes; its magnitude of change being associated with neurological outcome.

SUMMARY

Neuroimaging biomarkers reveal focal and remote cord pathology. These biomarkers show sensitivity to the underlying disease processes and are clinically eloquent. Thus, they improve injury characterization, enable spatiotemporal tracking of cord pathology, and predict recovery of function following traumatic SCI. Neuroimaging biomarkers, therefore, hold potential to complement the clinical diagnostic workup, improve patient stratification, and can serve as potential endpoints in clinical trials.

Early versus Late Surgical Decompression for Traumatic Spinal Cord Injury on Neurological Recovery: A Systematic Review and Meta-Analysis

This study aimed to investigate whether early surgical decompression was associated with favorable neurological recovery in patients with traumatic spinal cord injury (tSCI). We searched PubMed and Embase from the database inception through December 2020 and selected studies comparing the impact of early versus late surgical decompression on neurological recovery as assessed by American Spinal Injury Association Impairment Scale (AIS) for adult patients sustaining tSCI. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Subgroup analysis and meta-regression analysis was conducted to identify significant outcome moderator. We included 26 studies involving 3574 patients in the meta-analysis. The pooled results demonstrated significant association between early surgical decompression and an improvement of at least one AIS grade (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.41-2.41; I2, 48.06%). The benefits of early surgical decompression were consistently observed across different subgroups, including patients with cervical or thoracolumbar injury and patients with complete or incomplete injury. The meta-regression analysis indicated that cut-off timing defining early versus late decompression was a significant effect moderator, with early decompression performed before post-tSCI 8 or 12 h associated with greatest benefits (OR, 3.37; 95% CI, 1.74-6.50; I2, 53.52%). No obvious publication bias was detected by the funnel plot. In conclusion, early surgical decompression was associated with favorable neurological recovery for tSCI patients. However, there was a lack of high-quality evidence and the results need further examination.

Spinal Cord Injury With Tetraplegia in Young Persons After Diving Into Shallow Water: What Has Changed in the Past 10 to 15 Years?

STUDY DESIGN

Retrospective, monocentric, observational study in a tertiary health care center.

OBJECTIVES

To analyze prehospital and clinical findings, complications, neurological improvement and follow-up in a young person cohort with spinal cord injury (SCI) and tetraplegia according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) A to D after diving into shallow water.

METHODS

Included were all persons younger than 50 years with SCI after head-first diving into shallow water between June 2001 and June 2019. All persons with SCI were divided into complete tetraplegia (AIS A) and incomplete tetraplegia (AIS B, C, and D) to test differences.

RESULTS

A total of 59 males (98.7%) and 1 female with a mean age of 27.7 years suffered an SCI. Alcohol use was documented in 25 cases (41.7%). At the time of admission, 33 people (55%) showed a complete tetraplegia (AIS A) and 27 showed an incomplete tetraplegia with 8 AIS B (13.3%), 15 AIS C (25%), and 4 AIS D (6.7%). At the time of discharge, people with initially complete tetraplegia showed a significant improvement from admission to discharge (P ≤ .004). Persons with incomplete tetraplegia were more likely to improve their neurological status compared with complete tetraplegia patients (P ≤ .001). Especially persons with complete tetraplegia suffered from typical SCI-related problems and complications.

CONCLUSIONS

People with SCI and tetraplegia at the time admission show neurological improvement in 50% of the cases with an overall better outcome in persons with incomplete tetraplegia. The surgical treatment of SCI within 24 hours seems to be associated with a better neurological outcome and a lower level of tetraplegia. The incidence of SCI caused by diving into shallow water remains stable without a significant change, especially in high-risk groups. More education and prevention programs are necessary to avoid these injuries.

Emergency surgery for traumatic spinal cord injury in a secondary hospital: A case report

Background:

Cervical spinal cord injury (SCI) is a life-threatening condition. Prompt surgical intervention is needed to avoid hemodynamic and respiratory catastrophe. In Indonesia, however, spine surgery is more common in tertiary hospitals and thus might prolong the time gap to surgery due to referral waiting time.

Case Description:

We performed an emergency surgery for a patient with complete SCI due to unstable cervical fracture. The patient was in spinal shock and experienced respiratory arrest after radiological workup. Stability was achieved in the ICU and patient was directly sent to operating theater. Anterior-posterior approach was chosen to decompress and stabilize the cervical spine. The patient was discharged on postoperative day 17 and was seen well at 1-month follow-up.

Conclusion:

The capability to perform spine procedures should not be exclusive to tertiary hospitals in Indonesia. Satisfying results can be achieved with the presence of capable neurosurgeons or orthopedic surgeons and anesthesiologists in lower-level hospitals.

Characterizing Natural Recovery after Traumatic Spinal Cord Injury

The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6-9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.

Efficacy of Early (≤ 24 Hours), Late (25-72 Hours), and Delayed (>72 Hours) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades C and D Acute Traumatic Central Cord Syndrome Caused by Spinal Stenosis

The therapeutic significance of timing of decompression in acute traumatic central cord syndrome (ATCCS) caused by spinal stenosis remains unsettled. We retrospectively examined a homogenous cohort of patients with ATCCS and magnetic resonance imaging (MRI) evidence of post-treatment spinal cord decompression to determine whether timing of decompression played a significant role in American Spinal Injury Association (ASIA) motor score (AMS) 6 months following trauma. We used the t test, analysis of variance, Pearson correlation coefficient, and multiple regression for statistical analysis. During a 19-year period, 101 patients with ATCCS, admission ASIA Impairment Scale (AIS) grades C and D, and an admission AMS of ≤95 were surgically decompressed. Twenty-four of 101 patients had an AIS grade C injury. Eighty-two patients were males, the mean age of patients was 57.9 years, and 69 patients had had a fall. AMS at admission was 68.3 (standard deviation [SD] 23.4); upper extremities (UE) 28.6 (SD 14.7), and lower extremities (LE) 41.0 (SD 12.7). AMS at the latest follow-up was 93.1 (SD 12.8), UE 45.4 (SD 7.6), and LE 47.9 (SD 6.6). Mean number of stenotic segments was 2.8, mean canal compromise was 38.6% (SD 8.7%), and mean intramedullary lesion length (IMLL) was 23 mm (SD 11). Thirty-six of 101 patients had decompression within 24 h, 38 patients had decompression between 25 and 72 h, and 27 patients had decompression >72 h after injury. Demographics, etiology, AMS, AIS grade, morphometry, lesion length, surgical technique, steroid protocol, and follow-up AMS were not statistically different between groups treated at different times. We analyzed the effect size of timing of decompression categorically and in a continuous fashion. There was no significant effect of the timing of decompression on follow-up AMS. Only AMS at admission determined AMS at follow-up (coefficient = 0.31; 95% confidence interval [CI]:0.21; p = 0.001). We conclude that timing of decompression in ATCCS caused by spinal stenosis has little bearing on ultimate AMS at follow-up.

Trends in Demographics and Markers of Injury Severity in Traumatic Cervical Spinal Cord Injury

Over the past four decades, there have been progressive changes in the epidemiology of traumatic spinal cord injury (tSCI). We assessed trends in demographic and injury-related variables in traumatic cervical spinal cord injury (tCSCI) patients over an 18-year period at a single Level I trauma center. We included all magnetic resonance imaging-confirmed tCSCI patients ≥15 years of age for years 2001-2018. Among 1420 patients, 78.3% were male with a mean age 51.5 years. Etiology included falls (46.9%), motor vehicle collisions (MVCs; 34.2%), and sports injuries (10.9%). Median American Spinal Injury Association (ASIA) Motor Score (AMS) was 44, complete tCSCI was noted in 29.6% of patients, fracture dislocations were noted in 44.7%, and median intramedullary lesion length (IMLL) was 30.8 mm (complete injuries 56.3 mm and incomplete injuries 27.4 mm). Over the study period, mean age and proportion of falls increased (p < 0.001) whereas proportion attributable to MVCs and sports injuries decreased (p < 0.001). Incomplete injuries, AMS, and the proportion of patients with no fracture dislocations increased whereas complete injuries decreased significantly. IMLL declined (p = 0.17) and proportion with hematomyelia did not change significantly. In adjusted regression models, increase in age and decreases in prevalence of MVC mechanism and complete injuries over time remained statistically significant. Changes in demographic and injury-related characteristics of tCSCI patients over time may help explain the observed improvement in outcomes. Further, improved clinical outcomes and drop in IMLL may reflect improvements in initial risk assessment and pre-hospital management, advances in healthcare delivery, and preventive measures including public education.

Injury volume extracted from MRI predicts neurologic outcome in acute spinal cord injury: A prospective TRACK-SCI pilot study

Conventional MRI measures of traumatic spinal cord injury severity largely rely on 2-dimensional injury characteristics such as intramedullary lesion length and cord compression. Recent advances in spinal cord (SC) analysis have led to the development of a robust anatomic atlas incorporated into an open-source platform called the Spinal Cord Toolbox (SCT) that allows for quantitative volumetric injury analysis. In the current study, we evaluate the prognostic value of volumetric measures of spinal cord injury on MRI following registration of T2-weighted (T2w) images and segmented lesions from acute SCI patients with a standardized atlas. This IRB-approved prospective cohort study involved the image analysis of 60 blunt cervical SCI patients enrolled in the TRACK-SCI clinical research protocol. Axial T2w MRI data obtained within 24 h of injury were processed using the SCT. Briefly, SC MRIs were automatically segmented using the sct_deepseg_sc tool in the SCT and segmentations were manually corrected by a neuro-radiologist. Lesion volume data were used as predictor variables for correlation with lower extremity motor scores at discharge. Volumetric MRI measures of T2w signal abnormality comprising the SCI lesion accurately predict lower extremity motor scores at time of patient discharge. Similarly, MRI measures of injury volume significantly correlated with motor scores to a greater degree than conventional 2-D metrics of lesion size. The volume of total injury and of injured spinal cord motor regions on T2w MRI is significantly and independently associated with neurologic outcome at discharge after injury.

Trends in Rates of ASIA Impairment Scale Conversion in Traumatic Complete Spinal Cord Injury

Recent studies of persons with spinal cord injury (SCI) report higher conversion rates of the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades, especially for complete injuries. We examined the rate of conversion over time after complete SCI, accounting for demographic and injury characteristics. Subjects were 16 years of age and older with a complete SCI injury between 1995 and 2015, enrolled in the National SCI Database as day-1 admissions. We grouped subjects into 3-year intervals and assessed trends in conversion for the total sample and by tetraplegia (Tetra), high paraplegia (levels T1–9, HPara), and low paraplegia (levels T10–12, LPara).We used logistic regression to identify factors related to conversion such as age, sex, etiology, and level of injury. Of 2036 subjects, 1876 subjects had a follow-up examination between 30 and 730 days post-injury. Average age at injury was 34.2 ± 14.6 years; 79.8% were male, 44.6% Tetra, 35.3% HPara, and 20.1% LPara. There was a strong trend toward increased rates of conversion over time (p < 0.01 for all groups), especially for Tetra (to incomplete from 17.6% in 1995–1997 to 50% in 2013–2015, and to motor incomplete from 9.4% to 28.1%). Conversion rates for Para were less dramatic. There were increased odds of converting to incomplete for year of injury, level of injury (Tetra >LPara >HPara), non-violent etiology, and age (older is better). We found similar factors for conversion to motor incomplete, except sex was significant and etiology was not. Conversion rates from complete to incomplete and motor incomplete injury have been increasing, particularly for persons with tetraplegia. This has implications for acute clinical trials and for prognostication early after SCI.

Motor unit number index detects the effectiveness of surgical treatment in improving distal motor neuron loss in patients with incomplete cervical spinal cord injury

BACKGROUND

Recovery of motor dysfunction is important for patients with incomplete cervical spinal cord injury (SCI). To enhance the recovery of muscle strength, both research and treatments mainly focus on injury of upper motor neurons at the direct injury site. However, accumulating evidences have suggested that SCI has a downstream effect on the peripheral nervous system, which may contribute to the poor improvement of the muscle strength after operation. The aim of this study is to investigate the impact of early vs. delayed surgical intervention on the lower motor neurons (LMNs) distal to the injury site in patients with incomplete cervical SCI.

METHODS

Motor unit number index (MUNIX) was performed on the tibialis anterior (TA), extensor digitorum brevis (EDB) and abductor hallucis (AH) in 47 patients with incomplete cervical SCI (early vs. delayed surgical-treatment: 17 vs. 30) and 34 healthy subjects approximately 12 months after operation. All patients were further assessed by American spinal injury association (ASIA) motor scales and Medical Research Council (MRC) scales.

RESULTS

There are no difference of both ASIA motor scores and MRC scales between the patients who accepted early and delayed surgical treatment (P > 0.05). In contrast, the patients undergoing early surgical treatment showed lower MUSIX values in both bilateral EDB and bilateral TA, along with greater MUNIX values in both right-side EDB and right-side TA, compared to the patients who accepted delayed surgical treatment (P < 0.05).

CONCLUSIONS

Cervical SCI has a negative effect on the LMNs distal to the injury site. Early surgical intervention in Cervical SCI patients may improve the dysfunction of LMNs distal to the injury site, reducing secondary motor neuron loss, and eventually improving clinical prognosis.