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Segi N, Nakashima H, Machino M, Ito S, Yokogawa N, Sasagawa T, Funayama T, Eto F, Watanabe K, Nori S, Furuya T, Yunde A, Nakajima H, Hasegawa T, Yamada T, Terashima Y, Hirota R, Suzuki H, Imajo Y, Ikegami S, Uehara M, Tonomura H, Sakata M, Hashimoto K, Onoda Y, Kawaguchi K, Haruta Y, Suzuki N, Kato K, Uei H, Sawada H, Nakanishi K, Misaki K, Terai H, Tamai K, Inoue G, Shirasawa E, Kakutani K, Iizuka Y, Takasawa E, Akeda K, Kiyasu K, Tominaga H, Tokumoto H, Funao H, Oshima Y, Yoshii T, Kaito T, Sakai D, Ohba T, Seki S, Otsuki B, Ishihara M, Miyazaki M, Okada S, Imagama S, Kato S. Epidemiology of Cervical Fracture/Cervical Spinal Cord Injury and Changes in Surgical Treatment Modalities in Elderly Individuals During a 10-year Period: A Nationwide Multicenter Study in Japan. Global Spine J 2024; 14:1583-1594. [PMID: 36638077 PMCID: PMC11394505 DOI: 10.1177/21925682231151643] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES To investigate changes over a 10-years period in the profile of cervical spine and spinal cord injuries among the elderly in Japan. METHODS The current multicenter study was a retrospective analysis of inpatients aged ≥65 years, suffering cervical fracture (CF) and/or cervical spinal cord injury (CSCI). We analyzed 1413 patients' epidemiology (from 2010 to 2019). Moreover, 727 patients who underwent surgical treatment were analyzed in 2 groups: the early (2010-2014) and late period (2015-2019). RESULTS Both the number of patients and number of surgical patients showed a significant increasing trend (P < .001), while the mean age, the distribution of injury levels and paralysis severity, and the proportion of surgical indications remained the same. The number of surgical patients doubled from 228 to 499 from the early to late periods. Posterior surgery was the most common approach (90.4%), instrumentation surgery with screws increased significantly, and the range of fusion was significantly longer in the late period (2.1 vs 2.7 levels, P = .001). Significantly worsening neurological symptoms were recorded in the late period (1.3% vs 5.8%, P = .006), with C5 palsy being the major one. Otherwise, perioperative, major, and other complications, including mortality, did not differ significantly in incidence. CONCLUSIONS Both the number of elderly CF and/or CSCI patients and number of patients undergoing surgery increased dramatically over the decade without any change in profile. Instrumentation surgeries with screws increased, without an increase in systemic complications.
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Affiliation(s)
- Naoki Segi
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Sadayuki Ito
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Noriaki Yokogawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
| | - Takeshi Sasagawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
- Department of Orthopedics Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Fumihiko Eto
- Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsushi Yunde
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences University of Fukui, Fukui, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Tomohiro Yamada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
- Department of Orthopaedic Surgery, Nagoya Kyoritsu Hospital, Aichi, Japan
| | - Yoshinori Terashima
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
- Department of Orthopaedic Surgery, Matsuda Orthopedic Memorial Hospital, Sapporo, Japan
| | - Ryosuke Hirota
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
| | - Hidenori Suzuki
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Munehiro Sakata
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Orthopaedics, Saiseikai Shiga Hospital, Shiga, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yoshito Onoda
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yohei Haruta
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kenji Kato
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Hirokatsu Sawada
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Kosuke Misaki
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Koji Tamai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University, Graduate School of Medicine, Gunma, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University, Graduate School of Medicine, Gunma, Japan
| | - Koji Akeda
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Hiroyuki Tominaga
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Hiroto Tokumoto
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Chiba, Japan
- Department of Orthopaedic Surgery and Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Sakai
- Department of Orthopedics Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
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Kimura A, Shiraishi Y, Sawamura H, Sugawara R, Inoue H, Takeshita K. Ossification of the anterior longitudinal ligament affects the severity and distribution of neurological deficits following spinal cord injury without radiological abnormality. J Orthop Sci 2024; 29:718-725. [PMID: 36964115 DOI: 10.1016/j.jos.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND The incidence of spinal cord injury without radiological abnormality (SCIWORA) is increasing among older adults in developed countries. SCIWORA is commonly associated with ossification of the spinal ligament, specifically the ossification of the posterior longitudinal ligament (OPLL) and ossification of the anterior longitudinal ligament (OALL). OALL induces segmental spinal fusion and alters the biomechanical properties of the cervical spine; however, whether OALL modulates the severity of SCIWORA remains unknown. This study aimed to investigate the influence of OALL on the severity and distribution of neurological deficits following SCIWORA. METHODS This retrospective study included 122 patients with SCIWORA who were admitted to our hospital from April 2008 to March 2022. The neurological function of all the included patients was assessed via the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at admission. Magnetic resonance imaging (MRI) and computed tomography were performed within 48 h of trauma. Central cord syndrome (CCS) was defined as the upper-extremity ASIA motor score being at least 10 points lesser than the lower-extremity motor score. RESULTS The study included 122 patients with a mean age of 65.1 years. Comparing mild (AIS grades C or D) and severe (AIS grades A or B) neurological deficits revealed that the former was independently associated with ground-level falls, OALL, and absence of prevertebral T2 high-intensity area on MRI. Although 39% of patients with SCIWORA exhibited OPLL as an etiology of cervical stenosis, OPLL demonstrated no significant effect on the severity of neurological deficits. CCS occurrence was independently associated with OALL and a larger cross-sectional cord area on MRI. Patients with OALL had significantly higher lower-extremity ASIA motor scores than those without OALL. CONCLUSIONS OALL was significantly associated with mild neurological deficits in the lower extremities and with the occurrence of CCS after SCIWORA.
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Affiliation(s)
- Atsushi Kimura
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Yasuyuki Shiraishi
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hideaki Sawamura
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Ryo Sugawara
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hirokazu Inoue
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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Hirota R, Terashima Y, Ohnishi H, Yamashita T, Yokogawa N, Sasagawa T, Ando K, Nakashima H, Segi N, Funayama T, Eto F, Yamaji A, Watanabe K, Yamane J, Takeda K, Furuya T, Yunde A, Nakajima H, Yamada T, Hasegawa T, Suzuki H, Imajo Y, Ikegami S, Uehara M, Tonomura H, Sakata M, Hashimoto K, Onoda Y, Kawaguchi K, Haruta Y, Suzuki N, Kato K, Uei H, Sawada H, Nakanishi K, Misaki K, Terai H, Tamai K, Shirasawa E, Inoue G, Kakutani K, Kakiuchi Y, Kiyasu K, Tominaga H, Tokumoto H, Iizuka Y, Takasawa E, Akeda K, Takegami N, Funao H, Oshima Y, Kaito T, Sakai D, Yoshii T, Ohba T, Otsuki B, Seki S, Miyazaki M, Ishihara M, Okada S, Imagama S, Kato S. Prognostic Factors for Respiratory Dysfunction for Cervical Spinal Cord Injury and/or Cervical Fractures in Elderly Patients: A Multicenter Survey. Global Spine J 2024; 14:101-112. [PMID: 35617466 PMCID: PMC10676156 DOI: 10.1177/21925682221095470] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE The purpose of this study was to investigate the prognosis of respiratory function in elderly patients with cervical spinal cord injury (SCI) and to identify predictive factors. METHODS We included 1353 cases of elderly cervical SCI patients collected from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were defined as the respiratory disability group. Patients' background characteristics, injury mechanism, injury form, neurological disability, complications, and treatment methods were compared between the disability and non-disability groups. Multiple logistic regression analysis was used to examine the independent factors. Patients who required respiratory management for 6 months or longer after injury and those who died of respiratory complications were classified into the severe disability group and were compared with minor cases who were weaned off the respirator. RESULTS A total of 104 patients (7.8%) had impaired respiratory function. Comparisons between the disabled and non-disabled groups and between the severe and mild injury groups yielded distinct trends. In multiple logistic regression analysis, age, blood glucose level, presence of ossification of posterior longitudinal ligament (OPLL), anterior vertebral hematoma, and critical paralysis were selected as independent risk factors. CONCLUSION Age, OPLL, severe paralysis, anterior vertebral hematoma, hypoalbuminemia, and blood glucose level at the time of injury were independent factors for respiratory failure. Hyperglycemia may have a negative effect on respiratory function in this condition.
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Affiliation(s)
- Ryosuke Hirota
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
| | - Yoshinori Terashima
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
- Department of Orthopaedic Surgery, Matsuda Orthopedic Memorial Hospital, Sapporo, Japan
| | - Hirofumi Ohnishi
- Department of Public Health, Sapporo Medical University, Sapporo, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
| | - Noriaki Yokogawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Takeshi Sasagawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
- Department of Orthopedics Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Fumihiko Eto
- Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Akihiro Yamaji
- Department of Orthopaedic Surgery, Ibaraki Seinan Medical Center Hospital, Ibaraki, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Japan
| | - Junichi Yamane
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Japan
- Department of Orthopaedic Surgery, National Hospital Organization Murayama Medical Center, Musashimurayama, Japan
| | - Kazuki Takeda
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Japan
- Department of Orthopaedic Surgery, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsushi Yunde
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences University of Fukui, Yoshida-gun, Japan
| | - Tomohiro Yamada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu City, Japan
- Department of Orthopaedic Surgery, Nagoya Kyoritsu Hospital, Nagoya-shi, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu City, Japan
| | - Hidenori Suzuki
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Japan
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Munehiro Sakata
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Orthopaedics, Saiseikai Shiga Hospital, Shiga, Japan
| | - Ko Hashimoto
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshito Onoda
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenichi Kawaguchi
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yohei Haruta
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuyuki Suzuki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kenji Kato
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroshi Uei
- Department of Orthopedic Surgery, Nihon University Hospital, Chiyoda-ku, Japan
- Department of Orthopedic Surgery, Nihon University School of Medicine, Itabashi-ku, Japan
| | - Hirokatsu Sawada
- Department of Orthopedic Surgery, Nihon University School of Medicine, Itabashi-ku, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Kosuke Misaki
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Hidetomi Terai
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koji Tamai
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuji Kakiuchi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Hiroyuki Tominaga
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Hiroto Tokumoto
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Koji Akeda
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu City, Japan
| | - Norihiko Takegami
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu City, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Narita, Japan
- Department of Orthopaedic Surgery and Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, Minato-ku, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Bunkyo-ku, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Daisuke Sakai
- Department of Orthopedics Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Bunkyo-Ku, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, Chuo, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University Hospital, Hirakata, Osaka, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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Nakajima H, Honjoh K, Watanabe S, Takahashi A, Kubota A, Matsumine A. Management of Cervical Spinal Cord Injury without Major Bone Injury in Adults. J Clin Med 2023; 12:6795. [PMID: 37959260 PMCID: PMC10650636 DOI: 10.3390/jcm12216795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
The incidence of cervical spinal cord injury (CSCI) without major bone injury is increasing, possibly because older people typically have pre-existing cervical spinal canal stenosis. The demographics, neurological injury, treatment, and prognosis of this type of CSCI differ from those of CSCI with bone or central cord injury. Spine surgeons worldwide are debating on the optimal management of CSCI without major bone injury. Therefore, this narrative review aimed to address unresolved clinical questions related to CSCI without major bone injury and discuss treatment strategies based on current findings. The greatest divide among spine surgeons worldwide hinges on whether surgery is necessary for patients with CSCI without major bone injury. Certain studies have recommended early surgery within 24 h after injury; however, evidence regarding its superiority over conservative treatment remains limited. Delayed MRI may be beneficial; nevertheless, reliable factors and imaging findings that predict functional prognosis during the acute phase and ascertain the necessity of surgery should be identified to determine whether surgery/early surgery is better than conservative therapy/delayed surgery. Quality-of-life assessments, including neuropathic pain, spasticity, manual dexterity, and motor function, should be performed to examine the superiority of surgery/early surgery to conservative therapy/delayed surgery.
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Affiliation(s)
- Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, University of Fukui Faculty of Medical Sciences, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan; (K.H.); (S.W.); (A.T.); (A.K.); (A.M.)
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5
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Segi N, Nakashima H, Machino M, Ito S, Yokogawa N, Sasagawa T, Funayama T, Eto F, Yamaji A, Watanabe K, Nori S, Takeda K, Furuya T, Yunde A, Nakajima H, Yamada T, Hasegawa T, Terashima Y, Hirota R, Suzuki H, Imajo Y, Ikegami S, Uehara M, Tonomura H, Sakata M, Hashimoto K, Onoda Y, Kawaguchi K, Haruta Y, Suzuki N, Kato K, Uei H, Sawada H, Nakanishi K, Misaki K, Terai H, Tamai K, Shirasawa E, Inoue G, Kakutani K, Kakiuchi Y, Iizuka Y, Takasawa E, Akeda K, Takegami N, Kiyasu K, Tominaga H, Tokumoto H, Funao H, Oshima Y, Yoshii T, Kaito T, Sakai D, Ohba T, Seki S, Otsuki B, Ishihara M, Miyazaki M, Okada S, Imagama S, Kato S. Prognosis of Cervical Diffuse Idiopathic Skeletal Hyperostosis-Related Spine Injuries in Elderly Patients: Analyses of Both Fracture and Spinal Cord Injury Without Fracture. Global Spine J 2023:21925682231186757. [PMID: 37401179 DOI: 10.1177/21925682231186757] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVE The purpose of this study was to compare the prognosis of elderly patients with injuries related to cervical diffuse idiopathic skeletal hyperostosis (cDISH) to matched control for each group, with and without fractures. METHODS The current multicenter study was a retrospective analysis of 140 patients aged 65 years or older with cDISH-related cervical spine injuries; 106 fractures and 34 spinal cord injuries without fracture were identified. Propensity score-matched cohorts from 1363 patients without cDISH were generated and compared. Logistic regression analysis was performed to determine the risk of early mortality for patients with cDISH-related injury. RESULTS Patients with cDISH-related injuries with fracture did not differ significantly in the incidence of each complication and ambulation or severity of paralysis compared to matched controls. In patients with cDISH-related injury without fracture, those who were nonambulatory at discharge comprised 55% vs 34% of controls, indicating significantly poorer ambulation in those with cDISH-related injuries (P = .023). There was no significant difference in the incidence of complications and ambulation or paralysis severity at 6 months as compared with controls. Fourteen patients died within 3 months. Logistic regression analysis identified complete paralysis (odds ratio [OR] 36.99) and age (OR 1.24) as significant risk factors for mortality. CONCLUSIONS The current study showed no significant differences in the incidence of complications, ambulation outcomes between patients with cDISH-related injury with fracture and matched controls, and that the ambulation at discharge for patients with cDISH-related injury without fractures were significantly inferior to those of matched controls.
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Affiliation(s)
- Naoki Segi
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Sadayuki Ito
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Noriaki Yokogawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
| | - Takeshi Sasagawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
- Department of Orthopaedic Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Fumihiko Eto
- Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
| | - Akihiro Yamaji
- Department of Orthopaedic Surgery, Ibaraki Seinan Medical Center Hospital, Ibaraki, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Kazuki Takeda
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
- Department of Orthopaedic Surgery, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsushi Yunde
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tomohiro Yamada
- Department of Orthopaedic Surgery, School of Medicine, Hamamatsu University, Shizuoka, Japan
- Department of Orthopaedic Surgery, Nagoya Kyoritsu Hospital, Aichi, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, School of Medicine, Hamamatsu University, Shizuoka, Japan
| | - Yoshinori Terashima
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
- Department of Orthopaedic Surgery, Matsuda Orthopedic Memorial Hospital, Sapporo, Japan
| | - Ryosuke Hirota
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
| | - Hidenori Suzuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, School of Medicine, Shinshu University, Nagano, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, School of Medicine, Shinshu University, Nagano, Japan
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Munehiro Sakata
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Orthopaedics, Saiseikai Shiga Hospital, Shiga, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Tohoku University, Miyagi, Japan
| | - Yoshito Onoda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Tohoku University, Miyagi, Japan
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yohei Haruta
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Kenji Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
- Department of Orthopaedic Surgery, School of Medicine, Nihon University, Tokyo, Japan
| | - Hirokatsu Sawada
- Department of Orthopaedic Surgery, School of Medicine, Nihon University, Tokyo, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology, and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Kosuke Misaki
- Department of Orthopedics, Traumatology, and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Koji Tamai
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yuji Kakiuchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Gunma University, Gunma, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Graduate School of Medicine, Gunma University, Gunma, Japan
| | - Koji Akeda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Mie University, Mie, Japan
| | - Norihiko Takegami
- Department of Orthopaedic Surgery, Graduate School of Medicine, Mie University, Mie, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Hiroyuki Tominaga
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Hiroto Tokumoto
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Chiba, Japan
- Department of Orthopaedic Surgery and Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Daisuke Sakai
- Department of Orthopedics Surgery, Surgical Science, School of Medicine, Tokai University, Kanagawa, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
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6
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Uehara M, Ikegami S, Takizawa T, Oba H, Yokogawa N, Sasagawa T, Ando K, Nakashima H, Segi N, Funayama T, Eto F, Yamaji A, Watanabe K, Nori S, Takeda K, Furuya T, Yunde A, Nakajima H, Yamada T, Hasegawa T, Terashima Y, Hirota R, Suzuki H, Imajo Y, Tonomura H, Sakata M, Hashimoto K, Onoda Y, Kawaguchi K, Haruta Y, Suzuki N, Kato K, Uei H, Sawada H, Nakanishi K, Misaki K, Terai H, Tamai K, Shirasawa E, Inoue G, Kakutani K, Kakiuchi Y, Kiyasu K, Tominaga H, Tokumoto H, Iizuka Y, Takasawa E, Akeda K, Takegami N, Funao H, Oshima Y, Kaito T, Sakai D, Yoshii T, Otsuki B, Seki S, Miyazaki M, Ishihara M, Okada S, Imagama S, Kato S. Factors Affecting the Waiting Time from Injury to Surgery in Elderly Patients with a Cervical Spine Injury: A Japanese Multicenter Survey. World Neurosurg 2022; 166:e815-e822. [PMID: 35926696 DOI: 10.1016/j.wneu.2022.07.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The management of cervical spine injuries in the elderly is often complicated by the presence of multiple medical comorbidities, and it is not uncommon for preoperative testing to reveal other conditions that require the postponement of surgery. However, the factors that affect the waiting time from injury to surgery have not been clarified. The purpose of this multicenter database study was to analyze the clinical features and identify the factors affecting the number of days waited between injury and surgery in elderly patients with a cervical spine injury. METHODS We retrospectively reviewed the case histories of 1512 Japanese patients with a cervical spinal injury, who were seen at 33 institutions. After excluding patients who were not initially receiving a surgery for cervical spinal injury, 694 patients were ultimately analyzed. Based on a multivariate mixed model, we determined the factors related to the number of days from injury to surgery. RESULTS The mean time from injury to surgery was 12.3 days. Multivariate analysis revealed delays of 10.7 days for a renal disorder, 7.3 days for anticoagulant use, and 15.2 days for non-surgical thoracolumbar fracture as factors prolonging wait time. In contrast, a C3 or lower spine injury was significantly associated with a shortening of 9.5 days to surgery. CONCLUSIONS This multicenter database study identified several factors influencing the time between injury and cervical spine surgery in elderly patients. While renal impairment, anticoagulant use, and non-surgical thoracolumbar fracture may increase the number of days to surgery, trauma to C3 or lower may expedite surgical treatment.
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Affiliation(s)
- Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan.
| | - Takashi Takizawa
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Noriaki Yokogawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Takeshi Sasagawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan; Department of Orthopedics Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Fumihiko Eto
- Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Akihiro Yamaji
- Department of Orthopaedic Surgery, Ibaraki Seinan Medical Center Hospital, Sashima, Ibaraki, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuki Takeda
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan; Department of Orthopaedic Surgery, Japanese Red Cross Shizuoka Hospital, Aoi-ku, Shizuoka, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate school of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Atsushi Yunde
- Department of Orthopaedic Surgery, Graduate school of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences University of Fukui, Yoshida-gun, Fukui, Japan
| | - Tomohiro Yamada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan; Department of Orthopaedic Surgery, Nagoya Kyoritsu Hospital, Nagoya-shi, Aichi, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan
| | - Yoshinori Terashima
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan; Department of Orthopaedic Surgery, Matsuda Orthopedic Memorial Hospital, Sapporo, Japan
| | - Ryosuke Hirota
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
| | - Hidenori Suzuki
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Ube city, Yamaguchi, Japan
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Ube city, Yamaguchi, Japan
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
| | - Munehiro Sakata
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan; Department of Orthopaedics, Saiseikai Shiga Hospital, Shiga, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yoshito Onoda
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yohei Haruta
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-ku, Nagoya, Japan
| | - Kenji Kato
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-ku, Nagoya, Japan
| | - Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University Hospital, Chiyoda-ku, Tokyo, Japan; Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Hirokatsu Sawada
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kosuke Misaki
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka-city, Osaka, Japan
| | - Koji Tamai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka-city, Osaka, Japan
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan
| | - Yuji Kakiuchi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Oko-cho, Nankoku, Japan
| | - Hiroyuki Tominaga
- Department of Orthopaedic Surgery, Graduate School of medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Hiroto Tokumoto
- Department of Orthopaedic Surgery, Graduate School of medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University, Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University, Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Koji Akeda
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine, Tsu city, Mie, Japan
| | - Norihiko Takegami
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine, Tsu city, Mie, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Chiba, Japan; Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Narita, Chiba, Japan; Department of Orthopaedic Surgery and Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, Minato-ku, Tokyo, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Daisuke Sakai
- Department of Orthopedics Surgery, Surgical Science, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Bunkyo-Ku, Tokyo, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Toyama, Japan
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Yufu-shi, Oita, Japan
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University Hospital, Hirakata, Osaka, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
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Prevalence of pre-existing factors causing spinal cord compression: Is there a difference between patients suffering from cervical spinal cord injury with and without bone injury? J Orthop Sci 2022; 27:971-976. [PMID: 34233846 DOI: 10.1016/j.jos.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 05/06/2021] [Accepted: 06/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recently, the prevalence of elderly patients suffering from cervical spinal cord injury (CSCI) without bone injury has been increasing in various countries. Pre-existing factors causing spinal cord compression, such as ossification of the posterior longitudinal ligament (OPLL), can increase the risk of CSCI without bone injury. However, no study has compared the prevalence of pre-existing factors between CSCI with and without bone injury. This study aimed to compare the prevalence of pre-existing factors between CSCI with and without bone injury. METHODS In 168 consecutive patients with CSCI, pre-existing factors including OPLL, posterior spur of the vertebral body, developmental stenosis, disc bulge and calcification of yellow ligament (CYL) were evaluated on imaging studies. The prevalence of each type of pre-existing factors was compared between patients with and without bone injury. RESULTS The prevalence of pre-existing factors in patients without bone injury (86%) was significantly higher than in those with bone injury (20%) (P < 0.001; odds ratio, 23.9). The most common pre-existing factor was OPLL followed by developmental stenosis, posterior spur, disc bulge and CYL in both groups. OPLL, development stenosis and posterior spur were significantly more common in patients without bone injury compared to those with bone injury (P < 0.01). CONCLUSIONS Prevalence of pre-existing factors, such as OPLL, development stenosis and posterior spur was significantly higher in patients without bone injury than in those with bone injury. Thus, these pre-existing factors might be a potential risk of CSCI without bone injury.
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Kamei N, Nakanishi K, Nakamae T, Tamura T, Tsuchikawa Y, Moisakos T, Harada T, Maruyama T, Adachi N. Differences between spinal cord injury and cervical compressive myelopathy in intramedullary high-intensity lesions on T2-weighted magnetic resonance imaging: A retrospective study. Medicine (Baltimore) 2022; 101:e29982. [PMID: 36042590 PMCID: PMC9410606 DOI: 10.1097/md.0000000000029982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Increases in aging populations have raised the number of patients with cervical spinal cord injury (SCI) without fractures due to compression of the cervical spinal cord. In such patients, it is necessary to clarify whether SCI or cervical compressive myelopathy (CCM) is the cause of disability after trauma. This study aimed to clarify the differences in magnetic resonance imaging (MRI) features between SCI and CCM. Overall, 60 SCI patients and 60 CCM patients with intramedullary high-intensity lesions on T2-weighted MRI were included in this study. The longitudinal lengths of the intramedullary T2 high-intensity lesions were measured using sagittal MRI sections. Snake-eye appearance on axial sections was assessed as a characteristic finding of CCM. The T2 values of the high-intensity lesions and normal spinal cords at the first thoracic vertebra level were measured, and the contrast ratio was calculated using these values. The longitudinal length of T2 high-intensity lesions was significantly longer in SCI patients than in CCM patients. Snake-eye appearance was found in 26 of the 60 CCM patients, but not in SCI patients. On both the sagittal and axial images, the contrast ratio was significantly higher in the SCI group than in the CCM group. Based on these results, a diagnostic scale was created. This scale made it possible to distinguish between SCI and CCM with approximately 90% accuracy.
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Affiliation(s)
- Naosuke Kamei
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- *Correspondence: Naosuke Kamei, Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan (e-mail: )
| | | | - Toshio Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takayuki Tamura
- Department of Clinical Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuji Tsuchikawa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Taiki Moisakos
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takahiro Harada
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshiaki Maruyama
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Uehara M, Ikegami S, Takizawa T, Oba H, Yokogawa N, Sasagawa T, Ando K, Nakashima H, Segi N, Funayama T, Eto F, Yamaji A, Watanabe K, Nori S, Takeda K, Furuya T, Orita S, Nakajima H, Yamada T, Hasegawa T, Terashima Y, Hirota R, Suzuki H, Imajo Y, Tonomura H, Sakata M, Hashimoto K, Onoda Y, Kawaguchi K, Haruta Y, Suzuki N, Kato K, Uei H, Sawada H, Nakanishi K, Misaki K, Terai H, Tamai K, Shirasawa E, Inoue G, Kakutani K, Kakiuchi Y, Kiyasu K, Tominaga H, Tokumoto H, Iizuka Y, Takasawa E, Akeda K, Takegami N, Funao H, Oshima Y, Kaito T, Sakai D, Yoshii T, Ohba T, Otsuki B, Seki S, Miyazaki M, Ishihara M, Okada S, Aoki Y, Harimaya K, Murakami H, Ishii K, Ohtori S, Imagama S, Kato S. Is Blood Loss Greater in Elderly Patients under Antiplatelet or Anticoagulant Medication for Cervical Spine Injury Surgery? A Japanese Multicenter Survey. Spine Surg Relat Res 2022; 6:366-372. [PMID: 36051672 PMCID: PMC9381072 DOI: 10.22603/ssrr.2021-0183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/18/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction In elderly patients with cervical spinal cord injury, comorbidities such as cardiovascular and cerebrovascular diseases are common, with frequent administration of antiplatelet/anticoagulant (APAC) drugs. Such patients may bleed easily or unexpectedly during surgery despite prior withdrawal of APAC medication. Few reports have examined the precise relationship between intraoperative blood loss and history of APAC use regarding surgery for cervical spine injury in the elderly. The present multicenter database survey aimed to answer the question of whether the use of APAC drugs affected the amount of intraoperative blood loss in elderly patients with cervical spinal cord trauma. Methods The case histories of 1512 patients with cervical spine injury at 33 institutes were retrospectively reviewed. After excluding cases without spinal surgery or known blood loss volume, 797 patients were enrolled. Blood volume loss was the outcome of interest. We calculated propensity scores using the inverse probability of treatment weighting (IPTW) method. As an alternative sensitivity analysis, linear mixed model analyses were conducted as well. Results Of the 776 patients (mean age: 75.1±6.4 years) eligible for IPTW calculation, 157 (20.2%) were taking APAC medications before the injury. After weighting, mean estimated blood loss was 204 mL for non-APAC patients and 215 mL for APAC patients. APAC use in elderly patients was not significantly associated with surgical blood loss according to the IPTW method with propensity scoring or linear mixed model analyses. Thus, it appeared possible to perform surgery expecting comparable blood loss in APAC and non-APAC cases. Conclusions This multicenter study revealed no significant increase in surgical blood loss in elderly patients with cervical trauma taking APAC drugs. Surgeons may be able to prioritize patient background, complications, and preexisting conditions over APAC use before injury when examining the surgical indications for cervical spine trauma in the elderly.
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Affiliation(s)
- Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Takashi Takizawa
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Noriaki Yokogawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences
| | - Takeshi Sasagawa
- Department of Orthopedics Surgery, Toyama Prefectural Central Hospital
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba
| | - Fumihiko Eto
- Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba
| | - Akihiro Yamaji
- Department of Orthopaedic Surgery, Ibaraki Seinan Medical Center Hospital
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine
| | - Kazuki Takeda
- Department of Orthopaedic Surgery, Japanese Red Cross Shizuoka Hospital
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate School of Medicine
| | - Sumihisa Orita
- Chiba University Center for Frontier Medical Engineering (CFME)
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences University of Fukui
| | | | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine
| | | | - Ryosuke Hirota
- Department of Orthopaedic Surgery, Sapporo Medical University
| | - Hidenori Suzuki
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Munehiro Sakata
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Yoshito Onoda
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University
| | - Yohei Haruta
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences
| | - Kenji Kato
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences
| | - Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University Hospital
| | - Hirokatsu Sawada
- Department of Orthopaedic Surgery, Nihon University School of Medicine
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School
| | - Kosuke Misaki
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine
| | - Koji Tamai
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine
| | - Yuji Kakiuchi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University
| | - Hiroyuki Tominaga
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Hiroto Tokumoto
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine
| | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine
| | - Koji Akeda
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine
| | - Norihiko Takegami
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine
| | - Haruki Funao
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, The University of Tokyo Hospital
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine
| | - Daisuke Sakai
- Department of Orthopedics Surgery, Surgical Science, Tokai University School of Medicine
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University Hospital
| | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center
| | - Katsumi Harimaya
- Department of Orthopaedic Surgery, Kyushu University Beppu Hospital
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences
| | - Ken Ishii
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences
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Freigang V, Butz K, Seebauer CT, Karnosky J, Lang S, Alt V, Baumann F. Management and Mid-Term Outcome After "Real SCIWORA" in Children and Adolescents. Global Spine J 2022; 12:1208-1213. [PMID: 33406912 PMCID: PMC9210218 DOI: 10.1177/2192568220979131] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE The SCIWORA Syndrome (Spinal Cord Injury Without Radiographic Abnormalities) is a rare but potentially severe injury with a peak in childhood and adolescence. With a better understanding of injury patterns and advances in MRI, there is ongoing discussion regarding the "Real SCIWORA" syndrome, a clinical picture of neurologic deficits on clinical examination but absence of radiographic pathologies even on MRI. The purpose of this study was to evaluate mid-term clinical outcome and the psychological impact of the "Real SCIWORA." METHODS In this retrospective analysis, we evaluated 32 patients treated for "Real SCIWORA" between 2007-2019. Inclusion criteria were: neurologic deficit after trauma, no other cerebral or skeletal injury and a lack of pathological findings in spinal MRI. All patients were followed until complete recovery from initial symptoms. 25/32 patients were re-evaluated after 6.9 years (1-14 years) using the Oswestry Disability Index, the Frankel Score, the EQ-5D score, and the Breslau Short Screening Scale for PTSD. RESULTS Initial neurologic presentation ranged from Frankel Grade A-D. All patients recovered neurologically during 1-13 days to a Frankel Grade E. The analysis of HR-QoL revealed no difference between the cohort of SCIWORA patients and the German population norm, Oswestry Disability Index showed only minimal disabilities. 4/25 patients showed signs of PTSD. CONCLUSIONS The "Real SCIWORA" syndrome is a diagnosis per exclusionem requiring a full spinal MRI to ensure exclusion of structural and potentially serious reasons of the neurologic impairment. Further clinical re-evaluation, psychological support seems to be essential. LEVEL OF EVIDENCE IV-retrospective study.
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Affiliation(s)
- Viola Freigang
- Department of Trauma, Regensburg University Medical Center, Regensburg, Germany,Viola Freigang, Department of Trauma Surgery, Regensburg University Medical Center, Franz-Josef-Strauss Allee 11, 93053 Regensburg, Germany.
| | - Katja Butz
- Department of Trauma, Regensburg University Medical Center, Regensburg, Germany
| | | | - Julia Karnosky
- Department of Surgery, Regensburg University Medical Center, Regensburg, Germany
| | - Siegmund Lang
- Department of Trauma, Regensburg University Medical Center, Regensburg, Germany
| | - Volker Alt
- Department of Trauma, Regensburg University Medical Center, Regensburg, Germany
| | - Florian Baumann
- Department of Trauma, Regensburg University Medical Center, Regensburg, Germany
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Saleh I, Librianto D, Kamal AF, Ipang F, Widodo W, Aprilya D. Particular precautions and the role of intraoperative neuromonitoring in cervical cord injury in elder recreational cyclist: A case report. Int J Surg Case Rep 2022; 96:107285. [PMID: 35704987 PMCID: PMC9198316 DOI: 10.1016/j.ijscr.2022.107285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/04/2022] [Accepted: 06/05/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The trend in cycling nowadays affects all age groups. However, special precautions must be considered in the elderly group. Minor trauma to the cervical region can cause severe neurological deterioration, leading to fatality because of the pre-existing degenerative process. CASE PRESENTATION We present a case of a 61-year-old male recreational cyclist with acute onset of tetraplegia following a minor fall. The radiological result revealed a long-standing degenerative process. Unfortunately, the patient deceased due to the sequelae of the paralysis and cardiac event despite our prompt surgical decompression and the improvement shown on intraoperative neuromonitoring. CLINICAL DISCUSSION The degenerative process can aggravate cervical cord injury even in its mildest form of injury. In this study, immediate improvement was detected by the intraoperative neuromonitoring (IONM) - although the clinical improvement had not improved yet as the general condition is poor. CONCLUSION The elder cycling population is increasing. Safety measures and injury avoidance are advisable along with expert consultation before the exercise. In a pre-existing degenerative condition of the cervical, a special precaution is also needed during the exercise. If the surgery has been indicated, the use of intraoperative neuromonitoring is found to be useful to guide the decompression and potentially beneficial as a predictive value for the clinal outcome.
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Affiliation(s)
- Ifran Saleh
- Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Didik Librianto
- Orthopedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
| | - Achmad Fauzi Kamal
- Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Fachrisal Ipang
- Orthopedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
| | - Wahyu Widodo
- Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Dina Aprilya
- Orthopedic and Traumatology, Siloam Agora Hospital, Jakarta, Indonesia,Corresponding author.
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12
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Risk Factors for Poor Prognosis of Spinal Cord Injury without Radiographic Abnormality Associated with Cervical Ossification of the Posterior Longitudinal Ligament. BIOMED RESEARCH INTERNATIONAL 2022; 2022:1572341. [PMID: 35224091 PMCID: PMC8872685 DOI: 10.1155/2022/1572341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/04/2022] [Indexed: 01/16/2023]
Abstract
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.
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13
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The Role of Magnetic Resonance Imaging to Inform Clinical Decision-Making in Acute Spinal Cord Injury: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10214948. [PMID: 34768468 PMCID: PMC8584859 DOI: 10.3390/jcm10214948] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022] Open
Abstract
The clinical indications and added value of obtaining MRI in the acute phase of spinal cord injury (SCI) remain controversial. This review aims to critically evaluate evidence regarding the role of MRI to influence decision-making and outcomes in acute SCI. A systematic review and meta-analysis were performed according to PRISMA methodology to identify studies that address six key questions (KQs) regarding diagnostic accuracy, frequency of abnormal findings, frequency of altered decision-making, optimal timing, and differences in outcomes related to obtaining an MRI in acute SCI. A total of 32 studies were identified that addressed one or more KQs. MRI showed no adverse events in 156 patients (five studies) and frequently identified cord compression (70%, 12 studies), disc herniation (43%, 16 studies), ligamentous injury (39%, 13 studies), and epidural hematoma (10%, two studies), with good diagnostic accuracy (seven comparative studies) except for fracture detection. MRI findings often altered management, including timing of surgery (78%, three studies), decision to operate (36%, 15 studies), and surgical approach (29%, nine studies). MRI may also be useful to determine the need for instrumentation (100%, one study), which levels to decompress (100%, one study), and if reoperation is needed (34%, two studies). The available literature consistently concluded that MRI was useful prior to surgical treatment (13 studies) and after surgery to assess decompression (two studies), but utility before/after closed reduction of cervical dislocations was unclear (three studies). One study showed improved outcomes with an MRI-based protocol but had a high risk of bias. Heterogeneity was high for most findings (I2 > 0.75). MRI is safe and frequently identifies findings alter clinical management in acute SCI, although direct evidence of its impact on outcomes is lacking. MRI should be performed before and after surgery, when feasible, to facilitate improved clinical decision-making. However, further research is needed to determine its optimal timing, effect on outcomes, cost-effectiveness, and utility before and after closed reduction.
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Jentzsch T, Cadotte DW, Wilson JR, Jiang F, Badhiwala JH, Akbar MA, Rocos B, Grossman RG, Aarabi B, Harrop JS, Fehlings MG. Spinal Cord Signal Change on Magnetic Resonance Imaging May Predict Worse Clinical In- and Outpatient Outcomes in Patients with Spinal Cord Injury: A Prospective Multicenter Study in 459 Patients. J Clin Med 2021; 10:4778. [PMID: 34682902 PMCID: PMC8537526 DOI: 10.3390/jcm10204778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/22/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022] Open
Abstract
Prognostic factors for clinical outcome after spinal cord (SC) injury (SCI) are limited but important in patient management and education. There is a lack of evidence regarding magnetic resonance imaging (MRI) and clinical outcomes in SCI patients. Therefore, we aimed to investigate whether baseline MRI features predicted the clinical course of the disease. This study is an ancillary to the prospective North American Clinical Trials Network (NACTN) registry. Patients were enrolled from 2005-2017. MRI within 72 h of injury and a minimum follow-up of one year were available for 459 patients. Patients with American Spinal Injury Association impairment scale (AIS) E were excluded. Patients were grouped into those with (n = 354) versus without (n = 105) SC signal change on MRI T2-weighted images. Logistic regression analysis adjusted for commonly known a priori confounders (age and baseline AIS). Main outcomes and measures: The primary outcome was any adverse event. Secondary outcomes were AIS at the baseline and final follow-up, length of hospital stay (LOS), and mortality. A regression model adjusted for age and baseline AIS. Patients with intrinsic SC signal change were younger (46.0 (interquartile range (IQR) 29.0 vs. 50.0 (IQR 20.5) years, p = 0.039). There were no significant differences in the other baseline variables, gender, body mass index, comorbidities, and injury location. There were more adverse events in patients with SC signal change (230 (65.0%) vs. 47 (44.8%), p < 0.001; odds ratio (OR) = 2.09 (95% confidence interval (CI) 1.31-3.35), p = 0.002). The most common adverse event was cardiopulmonary (186 (40.5%)). Patients were less likely to be in the AIS D category with SC signal change at baseline (OR = 0.45 (95% CI 0.28-0.72), p = 0.001) and in the AIS D or E category at the final follow-up (OR = 0.36 (95% CI 0.16-0.82), p = 0.015). The length of stay was longer in patients with SC signal change (13.0 (IQR 17.0) vs. 11.0 (IQR 14.0), p = 0.049). There was no difference between the groups in mortality (11 (3.2%) vs. 4 (3.9%)). MRI SC signal change may predict adverse events and overall LOS in the SCI population. If present, patients are more likely to have a worse baseline clinical presentation (i.e., AIS) and in- or outpatient clinical outcome after one year. Patients with SC signal change may benefit from earlier, more aggressive treatment strategies and need to be educated about an unfavorable prognosis.
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Affiliation(s)
- Thorsten Jentzsch
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - David W. Cadotte
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary Combined Spine Program, Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, St. Michael’s Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
| | - Fan Jiang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Jetan H. Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Muhammad A. Akbar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Brett Rocos
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Robert G. Grossman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX 77030, USA;
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA;
| | - James S. Harrop
- Departments of Neurological Surgery and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (T.J.); (J.R.W.); (F.J.); (J.H.B.); (M.A.A.); (B.R.)
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5G 2C4, Canada
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Traumatic cervical spinal cord injury: relationship of MRI findings to initial neurological impairment. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3666-3675. [PMID: 34545441 DOI: 10.1007/s00586-021-06996-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/30/2021] [Accepted: 09/14/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To quantify the degree of available space for the cord and cord swelling in patients following traumatic cervical spinal cord injury (TCSCI), and to assess the relationship among the available space for the cord, cord swelling, and the severity of neurological impairment. METHODS This study included 91 patients. The following indexes were measured by two blinded observers: maximum cord available area (CAAmax) and maximum cord swelling area (CSAmax). The American Spinal Injury Association (ASIA) impairment scale (AIS) grades were used to evaluate the extent of neurological injury. Relationship among CAAmax, CSAmax, and initial AIS grades was assessed via univariate and multivariate analyses. RESULTS Patients who were AIS grade A (complete injury) demonstrated significantly greater median CAAmax and CSAmax than AIS grade C or D (incomplete injury) (P < 0.01). Multivariate analysis identified only CAAmax (OR 20.88 [95% CI 1.50-291.21]; P = 0.024) and CSAmax (OR 17.84 [95% CI 1.15-276.56]; P = 0.039) were identified as independently influencing the likelihood of complete injury at the initial assessment. The classification accuracy was best for CAAmax and CSAmax; areas under the curve were 0.8998 (95% CI 0.7881-1.0000) and 0.9167 (95% CI 0.8293-1.0000), respectively. CONCLUSION The present study provides a novel radiologic method for identifying the severity of TCSCI with T2-weighted MRI findings. Greater available space for the cord (CAAmax > 38%) and cord swelling (CSAmax > 29%) can be used to identify patients at risk for TCSCI and both imaging characteristics are associated with an increased likelihood of severe neurological deficits. LEVEL OF EVIDENCE Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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16
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Aburakawa K, Yokoyama T, Takeuchi K, Numasawa T, Wada K, Kumagai G, Tanaka S, Asari T, Otsuka H, Ishibashi Y. New Grading System for Cervical Paraspinal Soft Tissue Damage After Traumatic Cervical Spinal Cord Injury Without Major Fracture Based on the Short-T1 Inversion Recovery Mid-Sagittal MRI for Prediction of Neurological Improvements: The STIR-MRI Grade. Global Spine J 2021; 13:940-948. [PMID: 33878911 DOI: 10.1177/21925682211010122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To develop a grading method for cervical paraspinal soft tissue damage after cervical spinal cord injury (CSCI) without major fracture based on the short T1 inversion recovery (STIR) mid-sagittal magnetic resonance image (MRI) for prediction of neurological improvements. METHODS This study included 34 patients with CSCI without major fracture, treated conservatively for at least 1 year and graded using the STIR-MRI Grade. This system consists of anterior grades; A0: no high-intensity area (HIA), A1: linear HIA, and A2: fusiform HIA, and posterior grades; P0: no HIA, P1: HIA not exceeding the nuchal ligament, and P2: HIA exceeding the nuchal ligament, within 24 hours postinjury. The American Spinal Injury Association impairment scale (AIS) and the Japanese Orthopedic Association (JOA) scores were examined. RESULTS Anterior grades were not significantly correlated with the AIS and JOA score. At both injury and final follow-up, the AIS in P2 patients was significantly more severe (P = 0.007, P = 0.015, respectively) than that in P0 patients. At the injury, the AIS in P2 patients was significantly more severe (P = 0.008) than that in P1 patients. Among P2 patients only, the JOA score at the injury (1.4 points) did not improve by the final follow-up (3.9 points). The final follow-up JOA score (3.9 points) in P2 patients was significantly lower than that (13.6 points) in P0 patients (P = 0.016). CONCLUSIONS Grade P2 led to poor neurological outcomes. The STIR-MRI Grade is a prognostic indicator for neurological improvements past-CSCI.
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Affiliation(s)
- Kotaro Aburakawa
- Department of Orthopedic Surgery, Odate Municipal General Hospital, Yutaka-cho, Odate, Akita, Japan
| | - Toru Yokoyama
- Department of Orthopedic Surgery, Odate Municipal General Hospital, Yutaka-cho, Odate, Akita, Japan
| | - Kazunari Takeuchi
- Department of Orthopedic Surgery, Odate Municipal General Hospital, Yutaka-cho, Odate, Akita, Japan
| | - Takuya Numasawa
- Department of Orthopedic Surgery, Hachinohe City Hospital, Tamukai, Hachinohe, Aomori, Japan
| | - Kanichiro Wada
- Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hon-cho, Hirosaki, Aomori, Japan
| | - Gentaro Kumagai
- Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hon-cho, Hirosaki, Aomori, Japan
| | - Sunao Tanaka
- Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hon-cho, Hirosaki, Aomori, Japan
| | - Toru Asari
- Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hon-cho, Hirosaki, Aomori, Japan
| | - Hironori Otsuka
- Department of Orthopedic Surgery, JCHO Akita Hospital, Midori-cho, Noshiro, Akita Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hon-cho, Hirosaki, Aomori, Japan
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Machino M, Ando K, Kobayashi K, Nakashima H, Kanbara S, Ito S, Inoue T, Yamaguchi H, Koshimizu H, Ito K, Kato F, Ishiguro N, Imagama S. Postoperative changes in spinal cord signal intensity in patients with spinal cord injury without major bone injury: comparison between preoperative and postoperative magnetic resonance images. J Neurosurg Spine 2021; 34:259-266. [PMID: 33126220 DOI: 10.3171/2020.6.spine20761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although increased signal intensity (ISI) on MRI is observed in patients with cervical spinal cord injury (SCI) without major bone injury, alterations in ISI have not been evaluated. The association between postoperative ISI and surgical outcomes remains unclear. This study elucidated whether or not the postoperative classification and alterations in MRI-based ISI of the spinal cord reflected the postoperative symptom severity and surgical outcomes in patients with SCI without major bone injury. METHODS One hundred consecutive patients with SCI without major bone injury (79 male and 21 female) with a mean age of 55 years (range 20-87 years) were included. All patients were treated with laminoplasty and underwent MRI pre- and postoperatively (mean 12.5 ± 0.8 months). ISI was classified into three groups on the basis of sagittal T2-weighted MRI: grade 0, none; grade 1, light (obscure); and grade 2, intense (bright). The neurological statuses were evaluated according to the Japanese Orthopaedic Association (JOA) scoring system and the American Spinal Injury Association Impairment Scale (AIS). RESULTS Preoperatively, 8 patients had grade 0 ISI, 49 had grade 1, and 43 had grade 2; and postoperatively, 20 patients had grade 0, 24 had grade 1, and 56 had grade 2. The postoperative JOA scores and recovery rate (RR) decreased significantly with increasing postoperative ISI grade. The postoperative ISI grade tended to increase with the postoperative AIS grade. Postoperative grade 2 ISI was observed in severely paralyzed patients. The postoperative ISI grade improved in 23 patients (23%), worsened in 25 (25%), and remained unchanged in 52 (52%). Patients with an improved ISI grade had a better RR than those with a worsened ISI grade. CONCLUSIONS Postoperative ISI reflected postoperative symptom severity and surgical outcomes. Alterations in ISI were seen postoperatively in 48 patients (48%) and were associated with surgical outcomes.
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Affiliation(s)
- Masaaki Machino
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Kei Ando
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Kazuyoshi Kobayashi
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Hiroaki Nakashima
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Shunsuke Kanbara
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Sadayuki Ito
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Taro Inoue
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Hidetoshi Yamaguchi
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Hiroyuki Koshimizu
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Keigo Ito
- 2Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
| | - Fumihiko Kato
- 2Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
| | - Naoki Ishiguro
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
| | - Shiro Imagama
- 1Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine; and
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18
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Konomi T, Suda K, Ozaki M, Harmon SM, Komatsu M, Iimoto S, Tsuji O, Minami A, Takahata M, Iwasaki N, Matsumoto M, Nakamura M. Predictive factors for irreversible motor paralysis following cervical spinal cord injury. Spinal Cord 2020; 59:554-562. [PMID: 32632174 DOI: 10.1038/s41393-020-0513-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A retrospective observational study. OBJECTIVES To elucidate predictive clinical factors associated with irreversible complete motor paralysis following traumatic cervical spinal cord injury (CSCI). SETTING Hokkaido Spinal Cord Injury Center, Japan. METHODS A consecutive series of 447 traumatic CSCI persons were eligible for this study. Individuals with complete motor paralysis at admission were selected and divided into two groups according to the motor functional outcomes at discharge. Initial findings in magnetic resonance imaging (MRI) and other clinical factors that could affect functional outcomes were compared between two groups of participants: those with and those without motor recovery below the level of injury at the time of discharge. RESULTS Of the 73 consecutive participants with total motor paralysis at initial examination, 28 showed some recovery of motor function, whereas 45 remained complete motor paralysis at discharge, respectively. Multivariate logistic regression analysis showed that the presence of intramedullary hemorrhage manifested as a confined low intensity changes in diffuse high-intensity area and more than 50% of cord compression on MRI were significant predictors of irreversible complete motor paralysis (odds ratio [OR]: 8.4; 95% confidence interval [CI]: 1.2-58.2 and OR: 14.4; 95% CI: 2.5-82.8, respectively). CONCLUSION The presence of intramedullary hemorrhage and/or severe cord compression on initial MRI were closely associated with irreversible paralysis in persons with motor complete paralysis following CSCI. Conversely, subjects with a negligible potential for recovery could be identified by referring to these negative findings.
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Affiliation(s)
- Tsunehiko Konomi
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan. .,Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, 2-37-1 Gakuen, Musashimurayama, Tokyo, 208-0011, Japan.
| | - Kota Suda
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
| | - Masahiro Ozaki
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.,Department of Orthopaedic Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi, Yokohama, Kanagawa, 230-8765, Japan
| | - Satoko Matsumoto Harmon
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
| | - Miki Komatsu
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
| | - Seiji Iimoto
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.,Department of Orthopaedic Surgery, Ehime Prefectural Central Hospital, 83 Kasugamachi, Matsuyama, Ehime, 790-0024, Japan
| | - Osahiko Tsuji
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.,Department of Orthopaedic Surgery, Graduate School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Kita 8, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-0808, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Kita 8, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-0808, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
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Koike H, Hatta Y, Tonomura H, Nonomura M, Takatori R, Nagae M, Ikoma K, Mikami Y. Can a relatively large spinal cord for the dural sac influence severity of paralysis in elderly patients with cervical spinal cord injury caused by minor trauma? Medicine (Baltimore) 2020; 99:e20929. [PMID: 32590805 PMCID: PMC7328921 DOI: 10.1097/md.0000000000020929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Retrospective reviewThe degree of spinal cord compression and bony spinal canal stenosis are risk factors for the occurrence of spinal cord injury (SCI) without major fracture or dislocation, but they do not affect the severity of neurological symptoms. However, whether a relatively large spinal cord for the dural sac influences the severity of symptoms in SCI cases is unknown.The purpose of this study was to verify the influence of spinal cord size relative to dural sac on the severity of paralysis in elderly patients with cervical SCI caused by minor trauma.Subjects were 50 elderly patients with SCI caused by falls on flat ground. At 72 hours after injury, neurological assessment was performed using the Japanese Orthopaedic Association (JOA) scoring system. Bony canal anteroposterior diameters (APD) at mid C5 vertebral body were measured with computed tomography. We measured dural sac and spinal cord APD at the injured level and mid C5 with magnetic resonance imaging. Spinal cord compression ratio was calculated by dividing spinal cord at the injured level by spinal cord at mid C5. As the evaluation of spinal cord size relative to the dural sac, spinal cord/dural sac ratio was calculated at the injured level and mid C5. To clarify the factors influencing the severity of paralysis, the relationships between JOA score and those parameters were examined statistically.A significant negative correlation was observed between JOA score and spinal cord/dural sac ratio at mid C5. No clear relationship was observed between JOA score and bony canal APD or spinal cord compression ratio.In elderly patients with SCI caused by minor trauma, a relatively large spinal cord for the dural sac was shown to be a factor that influences the severity of paralysis. This result can be useful for the treatment and prevention of SCI in the elderly.
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Affiliation(s)
- Hironori Koike
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji
| | - Yoichiro Hatta
- Department of Orthopaedics, Japanese Red Cross Kyoto Daini Hospital, Kamanza-Marutamachi
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji
| | - Masaru Nonomura
- Department of Orthopaedics, Japanese Red Cross Kyoto Daini Hospital, Kamanza-Marutamachi
| | - Ryota Takatori
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji
| | - Masateru Nagae
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji
| | - Kazuya Ikoma
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji
| | - Yasuo Mikami
- Department of Rehabilitation Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
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20
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Qi C, Xia H, Miao D, Wang X, Li Z. The influence of timing of surgery in the outcome of spinal cord injury without radiographic abnormality (SCIWORA). J Orthop Surg Res 2020; 15:223. [PMID: 32546184 PMCID: PMC7298776 DOI: 10.1186/s13018-020-01743-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 06/04/2020] [Indexed: 11/20/2022] Open
Abstract
Background Spinal cord injury without radiographic abnormality (SCIWORA) is a rare traumatic myelopathy. Although surgery is one of the most important treatments, the surgery for SCIWORA is controversial, especially the time of surgery is a topic of controversy. Here, we investigate the effects of difference in duration from injury to surgery on the outcome of SCIWORA. Methods This retrospective study was performed in all patients with spinal cord injury admitted to the Third Affiliated Hospital of Hebei Medical University from January 2013 to April 2017. Fifty-seven patients who met the study requirements were divided into 3 groups according to the duration from injury to surgery. Group A (surgery within 3 days of injury) had 18 patients, group B (surgery within 3–7 days) had 18 patients, and group C (surgery later than 7 days) had 21 patients. All the groups were compared with Mann–Whitney U test; the functional improvement of spinal cord was compared and analyzed using the ASIA sports score and ASIA Impairment Scale (AIS). Results There was a significant improvement in the long-term AIS (final follow-up) in all the 3 groups compared to before surgery. The final follow-up recovery rate of group C was worse than group A and group B. The curative effect of operation within 7 days was significantly better than the surgery done 7 days later. The recovery rate of group C was worse than group A and B. The ASIA sports score showed that recovery was quicker in the early stage and slow in the later stage. Conclusions The optimal schedule of surgical treatment was 3–7 days after injury, which can significantly improve the short-term and long-term follow-up effects. Longer the time to surgery from the time of injury, the worse was the prognosis.
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Affiliation(s)
- Can Qi
- Department of Orthopedics, The Third Affiliated Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Hehuan Xia
- Department of Orthopedics, The Third Affiliated Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Dechao Miao
- Department of Spinal Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xingui Wang
- Department of Orthopedics, The Third Affiliated Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Zengyan Li
- Department of Orthopedics, The Third Affiliated Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China.
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21
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Machino M, Ando K, Kobayashi K, Morozumi M, Tanaka S, Ito K, Kato F, Ishiguro N, Imagama S. Differences in clinical outcomes between traumatic cervical myelopathy and degenerative cervical myelopathy: A comparative study of cervical spinal cord injury without major bone injury and cervical spondylotic myelopathy. J Clin Neurosci 2019; 70:127-131. [PMID: 31427237 DOI: 10.1016/j.jocn.2019.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
A comparative study to examine the surgical outcomes of traumatic cervical myelopathy (TCM) patients was designed. The study aim was to compare the surgical outcomes between TCM and degenerative cervical myelopathy (DCM) and to characterize the preoperative symptoms and postoperative residual symptoms in TCM patients. One hundred consecutive patients with TCM (81 men, 19 women; mean age, 57.7 years; range, 31-79 years) and 100 consecutive patients with DCM (88 men, 12 women; mean age, 58.4 years; range, 36-78 years) were included in this study. All patients were treated by laminoplasty. The pre- and postoperative neurological statuses were evaluated according to the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy. The recovery rate (RR) of each function was compared between the two groups. The mean preoperative JOA scores of motor function of the upper extremity in the TCM and DCM groups were 1.9 and 2.3, respectively (P < 0.01). After surgery, the mean RRs of motor function of the upper extremity in the TDM and DCM groups were 36.4% and 55.7%, respectively (P < 0.01) and in the lower extremity were 32.3% and 46.5%, respectively (P < 0.05). The RR for sensory function of the lower extremity was significantly lower in TCM patients than in DCM patients (39.6 vs 68.2, respectively; P < 0.0001). Motor function impairments of the upper and lower extremities and sensory function impairments of the lower extremities after surgery were more persistent in the TCM group than in the DCM group.
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Affiliation(s)
- Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayoshi Morozumi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Tanaka
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keigo Ito
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
| | - Fumihiko Kato
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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22
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Khorasanizadeh M, Yousefifard M, Eskian M, Lu Y, Chalangari M, Harrop JS, Jazayeri SB, Seyedpour S, Khodaei B, Hosseini M, Rahimi-Movaghar V. Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis. J Neurosurg Spine 2019; 30:683-699. [PMID: 30771786 DOI: 10.3171/2018.10.spine18802] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/11/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance. METHODS A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis. RESULTS A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups. CONCLUSIONS The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.
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Affiliation(s)
| | - Mahmoud Yousefifard
- 2Physiology Research Center and Department of Physiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahsa Eskian
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Yi Lu
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryam Chalangari
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - James S Harrop
- 4Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia
- 5Neurosurgery, Delaware Valley Regional Spinal Cord Injury Center, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | | | - Simin Seyedpour
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Behzad Khodaei
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Mostafa Hosseini
- 6Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Nakajima H, Takahashi A, Kitade I, Watanabe S, Honjoh K, Matsumine A. Prognostic factors and optimal management for patients with cervical spinal cord injury without major bone injury. J Orthop Sci 2019; 24:230-236. [PMID: 30361169 DOI: 10.1016/j.jos.2018.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/05/2018] [Accepted: 10/01/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Even though the number of patients with cervical spinal cord injury (CSCI) without major bone injury is increased, the treatment with either surgery or conservative measures remains controversial. The aim of this study was to assess its prognostic value in the prediction of useful motor recovery and to clarify whether the patients should be treated surgically are present. METHODS We reviewed 63 patients (conservative, n = 36; surgery, n = 27) with CSCI without major bone injury (Frankel A-C). Neurological examination using modified Frankel grade at admission and 6 months after injury and International Stoke Mandeville Games (ISMG) classification at subacute phase after injury, MRI findings including rate of spinal cord compression, extent of cord damage and type of signal intensity change were assessed. RESULTS Thirty-five of 63 patients were improved to walk at 6 months after injury. In multivariate analysis, rate of spinal cord compression, extent of cord damage and improvement of ISMG grade were associated with useful motor recovery. There was no difference in the neurological improvement between conservative and surgical groups. However, patients with spinal cord compression of ≥33.2% showed better motor recovery at 6 months post-injury after surgery than those treated conservatively. There was a positive correlation between the improvement of ISMG grade at subacute phase and Frankel grade at 6 months post-injury. It is difficult to obtain satisfactory surgical outcome for patients with Frankel A or B1 on admission and/or extensive spinal cord damage on T2-weighted image. CONCLUSIONS Conservative treatment is recommended for patients with CSCI without major bone injury. However, we also recommend surgical treatment to acquire walking ability for patients with spinal cord compression of ≥33.2% and low ISMG grade at subacute phase. Among such patients, careful consideration should be given to patients with Frankel A or B1 and/or extensive spinal cord damage on MRI.
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Affiliation(s)
- Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.
| | - Ai Takahashi
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Ippei Kitade
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Shuji Watanabe
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Kazuya Honjoh
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Akihiko Matsumine
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
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MR Imaging for Assessing Injury Severity and Prognosis in Acute Traumatic Spinal Cord Injury. Radiol Clin North Am 2019; 57:319-339. [DOI: 10.1016/j.rcl.2018.09.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Machino M, Imagama S, Ito K, Ando K, Kobayashi K, Kato F, Nishida Y, Ishiguro N. Thoracic spinal cord injury without major bone injury associated with ossification of the ligamentum flavum. J Orthop Sci 2019; 24:174-177. [PMID: 27793439 DOI: 10.1016/j.jos.2016.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/18/2016] [Accepted: 10/04/2016] [Indexed: 02/09/2023]
Affiliation(s)
- Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Keigo Ito
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, Nagoya, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumihiko Kato
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan Labor Health and Welfare Organization, Nagoya, Japan
| | - Yoshihiro Nishida
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Machino M, Ando K, Kobayashi K, Ota K, Morozumi M, Tanaka S, Ito K, Kato F, Ishiguro N, Imagama S. MR T2 image classification in adult patients of cervical spinal cord injury without radiographic abnormality: A predictor of surgical outcome. Clin Neurol Neurosurg 2018; 177:1-5. [PMID: 30579047 DOI: 10.1016/j.clineuro.2018.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/05/2018] [Accepted: 12/13/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Although patients with cervical spinal cord injury without radiographic abnormality (SCIWORA) present increased signal intensity (ISI) on magnetic resonance imaging (MRI), its degree has not been examined. This study evaluated the clinical effectiveness of MRI-based ISI in adult patients of SCIWORA. Its predictive value for symptom severity was also evaluated. PATIENTS AND METHODS One-hundred consecutive SCIWORA patients who had undergone expansive laminoplasty were enrolled. Among them, 79 were male and 21 were female. The mean age was 55 years (range 20-87). All patients underwent MRI in the acute phase, and ISI was classified into three groups based on sagittal T2-weighted MRI: Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The pre- and postoperative neurological status was evaluated using the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score) and the ASIA impairment scale (AIS). RESULTS Preoperative MRI showed Grade 0 in 8 patients, Grade 1 in 49 patients, and Grade 2 in 43 patients. There were no differences in age and gender among three groups. The pre- and postoperative JOA scores decreased significantly with an increasing ISI grade. The recovery rate of JOA score decreased with the ISI grade. The ISI grade tended to increase with the pre- and postoperative AIS grades. ISI Grade 2 on MRI was observed in severely paralyzed cases. CONCLUSIONS MRI-based ISI classification is correlated with preoperative symptom severity in adult patients with SCIWORA and can be a predictor of surgical outcome.
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Affiliation(s)
- Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyotaro Ota
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayoshi Morozumi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Tanaka
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keigo Ito
- Department of Orthopedic Surgery and Radiology, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
| | - Fumihiko Kato
- Department of Orthopedic Surgery and Radiology, Chubu Rosai Hospital, Japan Organization of Occupational Health and Safety, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Abstract
“Spinal Cord Injury without Radiographic Abnormality” (SCIWORA) is a term that denotes objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine. SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood. However, SCIWORA can also be seen in adults and, in rare cases, the thoracolumbar spinal cord can be affected too. Magnetic resonance imaging (MRI) has become a valuable diagnostic tool in patients with SCIWORA because of its superior ability to identify soft tissue lesions such as cord edema, hematomas and transections, and discoligamentous injuries that may not be visualized in plain radiographs and CT. The mainstay of treatment in patients with SCIWORA is nonoperative management including steroid therapy, immobilization, and avoidance of activities that may increase the risk of exacerbation or recurrent injury. Although the role of operative treatment in SCIWORA can be controversial, surgical alternatives such as decompression and fusion should be considered in selected patients with clinical and MRI evidence of persistent spinal cord compression and instability.
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Inoue T, Suzuki S, Endo T, Uenohara H, Tominaga T. Efficacy of Early Surgery for Neurological Improvement in Spinal Cord Injury without Radiographic Evidence of Trauma in the Elderly. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Matsushita A, Maeda T, Mori E, Yuge I, Kawano O, Ueta T, Shiba K. Can the acute magnetic resonance imaging features reflect neurologic prognosis in patients with cervical spinal cord injury? Spine J 2017; 17:1319-1324. [PMID: 28501580 DOI: 10.1016/j.spinee.2017.05.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/07/2017] [Accepted: 05/08/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Several prognostic studies looked for an association between the degree of spinal cord injury (SCI), as depicted by primary magnetic resonance imaging (MRI) within 72 hours of injury, and neurologic outcome. It was not clearly demonstrated whether the MRI at any time correlates with neurologic prognosis. PURPOSE The purpose of the present study was to investigate the relationship between acute MRI features and neurologic prognosis, especially walking ability of patients with cervical spinal cord injury (CSCI). Moreover, at any point, MRI was clearly correlated with the patient's prognosis. STUDY DESIGN Retrospective image study. PATIENT SAMPLE From January 2010 to October 2015, 102 patients with CSCI were treated in our hospital. Patients who were admitted to our hospital within 3 days after injury were included in this study. The diagnosis was 78 patients for CSCI with no or minor bony injury and 24 patients for CSCI with fracture or dislocation. A total of 88 men and 14 women were recruited, and the mean patient age was 62.6 years (range, 16-86 years). Paralysis at the time of admission was graded as A in 32, B in 15, C in 42, and D in 13 patients on the basis of the American Spinal Injury Association (ASIA) impairment scale. Patients with CSCI with fracture or dislocation were treated with fixation surgery and those with CSCI with no or minor bony injury were treated conservatively. Patients were followed up for an average of 168 days (range, 25-496 days). OUTCOME MEASURES Neurologic evaluation was performed using the ASIA motor score and the modified Frankel grade at the time of admission and discharge. METHODS Magnetic resonance imaging was performed for all patients at admission. Using the MRI sagittal images, we measured the vertical diameter of intramedullary high-intensity changed area with T2-weighted images at the injured segment. We studied separately the patients divided into two groups: 0-1 day admission after injury, and 2-3 days admission after injury. We evaluated the relationship between the vertical diameter of T2 high-intensity changed area in MR images and neurologic outcome in these two groups. This study does not contain any conflict of interest. RESULTS In the group admitted at 0-1 day after injury, there was a relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, but correlation coefficient was low (0.3766 at admission and 0.4239 at discharge). On the other hand, in the group admitted at 2-3 days after injury, there was a significant relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, and correlation coefficient was very high (0.6840 at admission and 0.5293 at discharge). In the group admitted at 2-3 days after injury, a total of 17 patients (68%) recovered to walk with or without a cane. Receiver operating characteristic (ROC) curve analysis demonstrated that the optimal vertical diameter of T2 high-intensity area cutoffvalue for patients who were able to walk at discharge was 45.8 mm. If the vertical diameter of T2 high-intensity area cutoff value was 45 mm, there was a significant positive correlation with being able to walk at discharge (p<.0001). CONCLUSIONS From our study, 2-3 days after injury, a significant relationship was observed between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge. Zero to 1 day after injury, the relationship between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge was weak. Neurologic prognosis is more correlated with MRI after 2-3 days after the injury. If the vertical diameter of T2 high-intensity area was <45 mm, the patients were able to walk with or without a cane at discharge. T2 high-intensity changed area can reflect the neurologic prognosis in patients with CSCI.
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Affiliation(s)
- Akinobu Matsushita
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan.
| | - Takeshi Maeda
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan
| | - Eiji Mori
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan
| | - Itaru Yuge
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan
| | - Osamu Kawano
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan
| | - Takayoshi Ueta
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan
| | - Keiichiro Shiba
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan
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Nagasawa H, Ishikawa K, Takahashi R, Takeuchi I, Jitsuiki K, Ohsaka H, Omori K, Yanagawa Y. A case of real spinal cord injury without radiologic abnormality in a pediatric patient with spinal cord concussion. Spinal Cord Ser Cases 2017; 3:17051. [PMID: 28839952 DOI: 10.1038/scsandc.2017.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Real spinal cord injury without radiologic abnormality (SCIWORA) is a rare clinical entity. CASE PRESENTATION The patient was a 13-year-old girl whose body was overturned anteriorly after crashing her bicycle into a curb. Following the accident, in which her neck and upper back hit the ground, she could not move due to paralysis. On arrival, she had paresis of the bilateral upper extremities and experienced a painful sensation when her upper extremities were touched. Cervical roentgenography and whole-body computed tomography revealed no traumatic lesions in either the intracranium or the cervical bone. Urgent spinal magnetic resonance imaging (MRI) showed no significant spinal cord lesions or spinal canal stenosis. She was put on complete bed rest with a cervical collar. On the 2nd hospital day (24 h after the accident), her motor weakness had almost completely subsided, and she felt only mild dysesthesia in both forearms. Roentgenography revealed no instability. Her motor weakness completely recovered on the third day after accident and she was diagnosed with spinal cord concussion. DISCUSSION The present case study, in which MRI was performed, showed that an immediate improvement was obtained in a patient who experienced real SCIWORA. The importance of not only spinal cord lesions, but also perispinal soft tissue injury on MRI has been emphasized for predicting patient outcomes. Accordingly, immediate MRI is essential for evaluating patients with signs and symptoms of spinal cord injury, even when plain neck roentgenography and cervical CT are negative.
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Affiliation(s)
- Hiroki Nagasawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Ryosuke Takahashi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Kazuhiko Omori
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
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Abstract
PURPOSE OF REVIEW The current review describes the current evidence on pediatric spinal cord injury without radiographic abnormality (SCIWORA) with attention to the definition, epidemiology, and clinical presentation of the condition, as well as common MRI findings, management strategies, and outcomes. RECENT FINDINGS Recent literature demonstrates that with more widespread MRI use, our understanding of SCIWORA has improved. The new literature, although still limited, provides a more granular conceptualization of patterns of injury as well as potential prognostic stratification of patients based on MRI findings. Through case studies and national database analyses, researchers have further defined the epidemiology and outcomes of SCIWORA. SUMMARY Although SCIWORA occurs infrequently, thus making robust research a challenge, maintaining a high suspicion in the appropriate clinical setting ought to prompt acquisition of advanced imaging. For patients with persisting neurologic symptoms after trauma, despite negative plain films and cervical spine computed tomography, MRI can be helpful diagnostically as well as prognostically. Once SCIWORA is diagnosed, patients are treated nonoperatively with hard collar immobilization and physical therapy.
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Martinez-Perez R, Paredes I, Lagares A. In Reply to "Spinal Cord Injury without Radiographic Abnormality in Adults". World Neurosurg 2017; 101:799-800. [PMID: 28531936 DOI: 10.1016/j.wneu.2017.03.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Rafael Martinez-Perez
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain.
| | - Igor Paredes
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
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Cervical Spinal Cord Injury without Computed Tomography Evidence of Trauma in Adults: Magnetic Resonance Imaging Prognostic Factors. World Neurosurg 2017; 99:192-199. [DOI: 10.1016/j.wneu.2016.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/01/2016] [Accepted: 12/02/2016] [Indexed: 11/18/2022]
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Delayed Magnetic Resonance Imaging in Patients With Cervical Spinal Cord Injury Without Radiographic Abnormality. Spine (Phila Pa 1976) 2016; 41:E981-E986. [PMID: 26890959 DOI: 10.1097/brs.0000000000001505] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective imaging study to develop diagnostic criteria. OBJECTIVE The aim of this study was to investigate image findings on delayed magnetic resonance imaging (MRI) after the acute phase of spinal cord injury without radiographic abnormality (SCIWORA) and their relationship with symptom severity. SUMMARY OF BACKGROUND DATA MRI is used to diagnose acute neurological injury, with increased signal intensity (ISI) and prevertebral hyperintensity (PVH) often seen in patients with SCIWORA; however, changes after the acute phase are unclear. METHODS We included 68 patients diagnosed with SCIWORA within 48 hours of injury. We then compared their acute (within 2 days) and delayed (after 2 weeks) MRI images. ISI grade (0-3) and ISI and PVH ranges (relative to the C3 vertebral height) were measured. Neurological status at admission and 2 weeks after injury was assessed by the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score) and the American Spinal Injury Association impairment scale. RESULTS For acute MRI, the rates of grade 0, 1, and 2 ISI were 4, 54, and 10 patients, respectively. For delayed MRI, the rates of grade 0, 1, and 2 ISI changed to 3, 31, and 34 patients, respectively. ISI ranges reduced in delayed MRI, but there was no significance. PVH ranges were 3.0 ± 1.7 in acute MRI, and reduced to 1.3 ± 0.9 with significant difference (P < 0.001). There were significant negative correlations with the JOA score for ISI grades on delayed MRI only (r = -0.49). However, there were significant negative correlations with the JOA score for the PVH range on both the acute (r = -0.55) and delayed (r = -0.46) MRI. CONCLUSION When comparing acute and delayed MRI, there were significant differences in ISI and PVH findings. Delayed MRI also reflected the clinical symptom severity, giving useful information about the state of the spinal cord. LEVEL OF EVIDENCE 3.
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Clinical Influence of Cervical Spinal Canal Stenosis on Neurological Outcome after Traumatic Cervical Spinal Cord Injury without Major Fracture or Dislocation. Asian Spine J 2016; 10:536-42. [PMID: 27340535 PMCID: PMC4917774 DOI: 10.4184/asj.2016.10.3.536] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 10/25/2015] [Accepted: 10/26/2015] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective case series. Purpose To clarify the influence of cervical spinal canal stenosis (CSCS) on neurological functional recovery after traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation. Overview of Literature The biomechanical etiology of traumatic CSCI remains under discussion and its relationship with CSCS is one of the most controversial issues in the clinical management of traumatic CSCI. Methods To obtain a relatively uniform background, patients non-surgically treated for an acute C3–4 level CSCI without major fracture or dislocation were selected. We analyzed 58 subjects with traumatic CSCI using T2-weighted mid-sagittal magnetic resonance imaging. The sagittal diameter of the cerebrospinal fluid (CSF) column, degree of canal stenosis, and neurologic outcomes in motor function, including improvement rate, were assessed. Results There were no significant relationships between sagittal diameter of the CSF column at the C3–4 segment and their American Spinal Injury Association motor scores at both admission and discharge. Moreover, no significant relationships were observed between the sagittal diameter of the CSF column at the C3–4 segment and their neurological recovery during the following period. Conclusions No relationships between pre-existing CSCS and neurological outcomes were evident after traumatic CSCI. These results suggest that decompression surgery might not be recommended for traumatic CSCI without major fracture or dislocation despite pre-existing CSCS.
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Abstract
STUDY DESIGN A retrospective, consecutive case series. OBJECTIVE To determine the risk factors for a tracheostomy in patients with a cervical spinal cord injury. SUMMARY AND BACKGROUND DATE Respiratory status cannot be stabilized in patients with a cervical spinal cord injury (CSCI) for various reasons, so a number of these patients require long-term respiratory care and a tracheostomy. Various studies have described risk factors for a tracheostomy, but none have indicated a relationship between imaging assessment and the need for a tracheostomy. The current study used imaging assessment and other approaches to assess and examine the risk factors for a tracheostomy in patients with a CSCI. METHODS Subjects were 199 patients who were treated at the Spinal Injuries Center within 72 hours of a CSCI over 8-year period. Risk factors for a tracheostomy were retrospectively studied. Patients were assessed in terms of 10 items: age, sex, the presence of a vertebral fracture or dislocation, ASIA Impairment Scale, the neurological level of injury (NLI), PaO2, PaCO2, the level of injury on magnetic resonance imaging (MRI), the presence of hematoma-like changes (a hypointense core surrounded by a hyperintense rim in T2-weighted images) on MRI, and the Injury Severity Score.Items were analyzed multivariate logistic regression, and P < 0.05 was considered to indicate a significant difference. RESULTS Twenty-three of the 199 patients required a tracheostomy, accounting for 11.6% of patients with a CSCI. Univariate analyses of the risk factors for tracheostomy revealed significant differences for six items: age, Injury Severity Score, presence of fracture or dislocation, ASIA Impairment Scale A, NLI C4 or above, and MRI scans revealing hematoma-like changes. Multivariate logistic regression analyses revealed significant differences in terms of two items: NLI C4 or above and MRI scans revealing hematoma-like changes. Thirty patients had both an NLI C4 or above and MRI scans revealing hematoma-like changes. Of these, 17 (56.7%) required a tracheostomy. CONCLUSION Patients with an NLI C4 or above and MRI scans revealing hematoma-like changes were likely to require a tracheostomy. An early tracheostomy should be considered for patients with both of these characteristics. LEVEL OF EVIDENCE 3.
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Spinal cord injury without radiographic abnormality (SCIWORA) in adults: MRI type predicts early neurologic outcome. Spinal Cord 2016; 54:878-883. [PMID: 26882492 DOI: 10.1038/sc.2016.13] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/15/2015] [Accepted: 12/18/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The present study aimed to analyse the clinical and neuroimaging features of a consecutive series of adult patients with spinal cord injury without radiographic abnormality (SCIWORA) receiving early magnetic resonance imaging (MRI), and to apply the recently proposed MRI classification system. METHODS Grade of neurologic impairment at admission and discharge was reported according to the American Spinal Injury Association Impairment Scale (AIS). A detailed analysis and categorisation of the extra- and intramedullary MRI findings was performed, and the relationship between imaging type and neurological outcome was described. RESULTS Twenty-six adult patients (17 male and 9 female) with SCIWORA were identified (mean age of 52 years). The distribution of the initial AIS grade was 8% A (n=2), 19% B (n=5), 31% C (n=8) and 42% D (n=11) at admission and 15% (n=4) C, 58% (n=15) D and 27% (n=7) E at discharge, respectively. Type I SCIWORA was found in 23% (n=6) and type II in 77% (n=20) (IIa: 0%, IIb: 25%, IIc: 75%). The mean improvement of AIS grade in patients with type I lesions was 1.5 (median 1, range 1-3) and 0.9 (median 1, range 0-3) in type II. CONCLUSION The findings underline the prognostic role of early MRI for adult patients with SCIWORA and support the use of the recently introduced MRI classification system. LEVEL OF EVIDENCE Prognostic study, level III.
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Chen J, Liu Y, Jiang W. A naming clutter and special type of spinal cord injury. Injury 2015; 46:2521. [PMID: 26546237 DOI: 10.1016/j.injury.2015.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/12/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Jie Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, China.
| | - Yijie Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, China.
| | - Weimin Jiang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, China.
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Roth CJ, Angevine PD, Aulino JM, Berger KL, Choudhri AF, Fries IB, Holly LT, Kendi ATK, Kessler MM, Kirsch CF, Luttrull MD, Mechtler LL, O'Toole JE, Sharma A, Shetty VS, West OC, Cornelius RS, Bykowski J. ACR Appropriateness Criteria Myelopathy. J Am Coll Radiol 2015; 13:38-44. [PMID: 26653797 DOI: 10.1016/j.jacr.2015.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/04/2015] [Indexed: 12/11/2022]
Abstract
Patients presenting with myelopathic symptoms may have a number of causative intradural and extradural etiologies, including disc degenerative diseases, spinal masses, infectious or inflammatory processes, vascular compromise, and vertebral fracture. Patients may present acutely or insidiously and may progress toward long-term paralysis if not treated promptly and effectively. Noncontrast CT is the most appropriate first examination in acute trauma cases to diagnose vertebral fracture as the cause of acute myelopathy. In most nontraumatic cases, MRI is the modality of choice to evaluate the location, severity, and causative etiology of spinal cord myelopathy, and predicts which patients may benefit from surgery. Myelopathy from spinal stenosis and spinal osteoarthritis is best confirmed without MRI intravenous contrast. Many other myelopathic conditions are more easily visualized after contrast administration. Imaging performed should be limited to the appropriate spinal levels, based on history, physical examination, and clinical judgment. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
| | - Peter D Angevine
- Columbia University Medical Center, New York, New York, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | | | | | - Asim F Choudhri
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ian Blair Fries
- Bone, Spine and Hand Surgery, Chartered, Brick, New Jersey, American Academy of Orthopaedic Surgeons
| | - Langston T Holly
- University of California Los Angeles, Los Angeles, California, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | | | - Marcus M Kessler
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Laszlo L Mechtler
- Dent Neurologic Institute, Amherst, New York, American Academy of Neurology
| | - John E O'Toole
- Rush University, Chicago, Illinois, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | - Aseem Sharma
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | | | | | | | - Julie Bykowski
- University of California San Diego Health Center, San Diego, California
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Talbott JF, Whetstone WD, Readdy WJ, Ferguson AR, Bresnahan JC, Saigal R, Hawryluk GWJ, Beattie MS, Mabray MC, Pan JZ, Manley GT, Dhall SS. The Brain and Spinal Injury Center score: a novel, simple, and reproducible method for assessing the severity of acute cervical spinal cord injury with axial T2-weighted MRI findings. J Neurosurg Spine 2015; 23:495-504. [DOI: 10.3171/2015.1.spine141033] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Previous studies that have evaluated the prognostic value of abnormal changes in signals on T2-weighted MRI scans of an injured spinal cord have focused on the longitudinal extent of this signal abnormality in the sagittal plane. Although the transverse extent of injury and the degree of spared spinal cord white matter have been shown to be important for predicting outcomes in preclinical animal models of spinal cord injury (SCI), surprisingly little is known about the prognostic value of altered T2 relaxivity in humans in the axial plane.
METHODS
The authors undertook a retrospective chart review of 60 patients who met the inclusion criteria of this study and presented to the authors’ Level I trauma center with an acute blunt traumatic cervical SCI. Within 48 hours of admission, all patients underwent MRI examination, which included axial and sagittal T2 images. Neurological symptoms, evaluated with the grades according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS), at the time of admission and at hospital discharge were correlated with MRI findings. Five distinct patterns of intramedullary spinal cord T2 signal abnormality were defined in the axial plane at the injury epicenter. These patterns were assigned ordinal values ranging from 0 to 4, referred to as the Brain and Spinal Injury Center (BASIC) scores, which encompassed the spectrum of SCI severity.
RESULTS
The BASIC score strongly correlated with neurological symptoms at the time of both hospital admission and discharge. It also distinguished patients initially presenting with complete injury who improved by at least one AIS grade by the time of discharge from those whose injury did not improve. The authors’ proposed score was rapid to apply and showed excellent interrater reliability.
CONCLUSIONS
The authors describe a novel 5-point ordinal MRI score for classifying acute SCIs on the basis of axial T2-weighted imaging. The proposed BASIC score stratifies the SCIs according to the extent of transverse T2 signal abnormality during the acute phase of the injury. The new score improves on current MRI-based prognostic descriptions for SCI by reflecting functionally and anatomically significant patterns of intramedullary T2 signal abnormality in the axial plane.
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Affiliation(s)
- Jason F. Talbott
- Departments of 1Radiology and Biomedical Imaging,
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | | | | | - Adam R. Ferguson
- 3Neurological Surgery, and
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Jacqueline C. Bresnahan
- 3Neurological Surgery, and
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Rajiv Saigal
- 3Neurological Surgery, and
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Gregory W. J. Hawryluk
- 3Neurological Surgery, and
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Michael S. Beattie
- 3Neurological Surgery, and
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | | | - Jonathan Z. Pan
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
- 5Anesthesia and Perioperative Care, University of California; and
| | - Geoffrey T. Manley
- 3Neurological Surgery, and
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Sanjay S. Dhall
- 3Neurological Surgery, and
- 4Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
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Preexisting severe cervical spinal cord compression is a significant risk factor for severe paralysis development in patients with traumatic cervical spinal cord injury without bone injury: a retrospective cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015. [DOI: 10.1007/s00586-015-4142-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Subacute T1-low intensity area reflects neurological prognosis for patients with cervical spinal cord injury without major bone injury. Spinal Cord 2015; 54:24-8. [PMID: 26078230 DOI: 10.1038/sc.2015.84] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 03/28/2015] [Accepted: 04/14/2015] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN A retrospective imaging and clinical study. OBJECTIVES To evaluate the relationship between magnetic resonance imaging (MRI) features and neurological prognosis in patients with traumatic cervical spinal cord injury (CSCI) without major bone injury. METHODS A total of 72 patients with CSCI without major bone injury were treated conservatively in our hospital. MRI was performed for all patients at admission and 1 month following injury. We measured the antero-posterior and cranio-caudal diameter of intramedullary intensity changed area with T1-weighted images at the injured segment. Neurological evaluations were performed using the American Spinal Injury Association (ASIA) motor score and the modified Frankel grade at the time of admission and discharge. RESULTS There was a significant relationship between the antero-posterior diameter ratio of the T1-weighted low-intensity area on MRI at the subacute stage and the ASIA motor score. The optimal threshold of the T1-weighted low-intensity diameter ratio for predicting the patient's ability to walk with or without assistance at discharge was determined to be 46%. Moreover, 96.8% of the patients with <50% T1-weighted low-intensity area recovered to walk with or without a cane at discharge. CONCLUSION The T1-low intensity area may be an important predictive factor for the neurological recovery of CSCI without major bone injury.
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Kanwar R, Delasobera BE, Hudson K, Frohna W. Emergency department evaluation and treatment of cervical spine injuries. Emerg Med Clin North Am 2015; 33:241-82. [PMID: 25892721 DOI: 10.1016/j.emc.2014.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Most spinal cord injuries involve the cervical spine, highlighting the importance of recognition and proper management by emergency physicians. Initial cervical spine injury management should follow the ABCDE (airway, breathing, circulation, disability, exposure) procedure detailed by Advanced Trauma Life Support. NEXUS (National Emergency X-Radiography Utilization Study) criteria and Canadian C-spine Rule are clinical decision-making tools providing guidelines of when to obtain imaging. Computed tomography scans are the preferred initial imaging modality. Consider administering intravenous methylprednisolone after discussion with the neurosurgical consultant in patients who present with spinal cord injuries within 8 hours.
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Affiliation(s)
- Rajdeep Kanwar
- Department of Emergency Medicine, MedStar Washington Hospital Center, MedStar Georgetown University/Washington Hospital Center Emergency Medicine Residency, 110 Irving Street Northwest, NA-1177, Washington, DC 20010, USA.
| | - Bronson E Delasobera
- Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving Street Northwest, NA-1177, Washington, DC 20010, USA.
| | - Korin Hudson
- Department of Emergency Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Ground Floor CCC Building, Washington, DC 20007, USA
| | - William Frohna
- Department of Emergency Medicine, MedStar Washington Hospital Center, MedStar Georgetown University/Washington Hospital Center Emergency Medicine Residency, 110 Irving Street Northwest, NA-1177, Washington, DC 20010, USA
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Rüegg TB, Wicki AG, Aebli N, Wisianowsky C, Krebs J. The diagnostic value of magnetic resonance imaging measurements for assessing cervical spinal canal stenosis. J Neurosurg Spine 2015; 22:230-6. [DOI: 10.3171/2014.10.spine14346] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The authors investigated the relevance of 2D MRI measurements for the diagnosis of critical cervical spinal canal stenosis. Among patients who had sustained a minor cervical spine trauma, they compared MRI measurements of the cervical spine between those with acute cervical spinal cord injury (CSCI) and those without. They also investigated the correlation between the MRI measurements and the severity of CSCI as well as classification accuracy concerning the diagnosis of critical spinal canal stenosis for acute CSCI after a minor trauma.
METHODS
The authors conducted a single-center retrospective radiological case-control study of patients who had sustained CSCI after a minor trauma to the cervical spine from January 2000 to August 2010. The controls were patients who had sustained a cervical trauma without clinical or radiological signs of cervical spinal cord pathology.
On axial T2-weighted MR images, the following were measured: the transverse spinal canal and cord area, the transverse and sagittal cord diameter, and the sagittal canal diameter of the cervical spine (C3–7). Using these measurements, the authors calculated the cord-canal-area ratio by dividing the transverse cord area by the transverse canal area, the space available for the cord by subtracting the sagittal canal diameter from the sagittal cord diameter, and the compression ratio by dividing the transverse cord diameter by its sagittal diameter.
The severity of CSCI was assessed by using the motor index scores of 10 key muscles at different time points (initially, 1, 3, and 12 months after injury) obtained from the clinical records.
The intra- and interobserver reliability of the MRI measurements, intra- and intergroup differences, and correlations between variables were also investigated. Receiver operating characteristic curves were calculated for evaluating the classification accuracy of the imaging variables for CSCI.
RESULTS
Data for 52 CSCI patients and 77 control patients were analyzed. The intra- and interobserver reliability regarding the MRI measurements ranged from good (0.72) to perfect (0.99). Differences between the CSCI group and the control group were significant (p < 0.001) for all parameters, except for the cord area. The most prominent differences between the groups existed for the spinal canal area, cord-canal-area ratio, and space available for the cord. The classification accuracy was best for the cord-canal-area ratio and the space available for the cord; areas under the curve were 0.99 (95% CI 0.97–1.0) and 0.98 (95% CI 0.95–0.99), respectively. There was no significant (p > 0.05) correlation between any of the imaging parameters and the motor index score at any time point.
CONCLUSIONS
The cord-canal-area ratio (> 0.8) or the space available for the cord (< 1.2 mm) measured on MR images can be used to reliably identify patients at risk for acute CSCI after a minor trauma to the cervical spine. However, there does not seem to be any association between spinal canal imaging characteristics and the severity of or recovery from CSCI after a minor trauma.
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Affiliation(s)
| | | | - Nikolaus Aebli
- 2Spinal Medicine and Surgery, AndreasKlinik, Cham Zug
- 3Orthopaedic Department, Medical Faculty, University of Basel, Switzerland
- 4School of Medicine, Griffith University, Gold Coast, Queensland, Australia; and
| | | | - Jörg Krebs
- 1Clinical Trial Unit, Swiss Paraplegic Centre, Nottwil
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Spinal Cord Injuries With Normal Postmortem CT Findings: A Pitfall of Virtual Autopsy for Detecting Traumatic Death. AJR Am J Roentgenol 2014; 203:240-4. [DOI: 10.2214/ajr.13.11775] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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46
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Quantitative magnetic resonance imaging analysis correlates with surgical outcome of cervical spinal cord injury without radiologic evidence of trauma. Spinal Cord 2014; 52:541-6. [DOI: 10.1038/sc.2014.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 03/08/2014] [Accepted: 03/28/2014] [Indexed: 11/08/2022]
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Sun LQ, Shen Y, Li YM, Cao JM. Prediction of prognosis in patients with cervical spinal cord injury without radiologic evidence of trauma using MRI. Orthopedics 2014; 37:e302-6. [PMID: 24762160 DOI: 10.3928/01477447-20140225-65] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/11/2013] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to investigate whether pre- to postoperative changes of increased signal intensity (ISI) of the spinal cord as seen on T2-weighted magnetic resonance imaging (MRI) reflect the surgical outcome in patients with cervical spinal cord injury without radiologic evidence of trauma (SCIWORET). In this study, 54 patients with SCIWORET who underwent expansive laminoplasty were retrospectively analyzed. All patients underwent MRI at an average of 1.9 days (range, 1-5 days) after injury and 7.9 days (range, 6-10 days) postoperatively. The pre- and postoperative range and degree of ISI were measured on computer software using the same sagittal view on T2-weighted MRI. Then, the post-preoperative ratio of range and degree of ISI were calculated. Pre- and postoperative neurologic evaluations were performed according to the criteria proposed by the Japanese Orthopedic Association (JOA). A significant negative correlation existed between the ratio of range of ISI and the recovery rate (r=-0.504, P<.01). The ratio of degree of ISI negatively correlated with the recovery rate, but this was not statistically significant. Patients were divided into 2 groups according to the ratio of degree of ISI: group A included patients with a ratio of degree of ISI of ≤1 (n=24) and group B included patients with a ratio of degree of ISI of >1 (n=30). Patients' mean recovery rate was 65.0%±6.3% in group A and 52.4%±7.4% in group B. A significant difference was found between the 2 groups (P<.001, Student's t test) when comparing recovery rate. The pre- to postoperative changes of the range and degree of ISI significantly reflected prognosis for surgical outcome in patients with SCIWORET.
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Impact of diabetes on the outcomes of cervical laminoplasty: a prospective cohort study of more than 500 patients with cervical spondylotic myelopathy. Spine (Phila Pa 1976) 2014; 39:220-7. [PMID: 24173020 DOI: 10.1097/brs.0000000000000102] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective cohort study. OBJECTIVE This study aimed to compare the outcome of cervical laminoplasty between diabetic patients and nondiabetic patients with cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA A few retrospective studies have investigated the outcomes of cervical myelopathy in diabetic patients; therefore, our large-scale cohort study was designed to assess these outcomes in cervical spondylotic myelopathy. METHODS In total, 505 consecutive patients with cervical spondylotic myelopathy (311 males, 194 females; mean age, 66.6 yr; range, 41-91 yr) who underwent double-door laminoplasty were prospectively enrolled. They were followed up for more than 12 months after surgery (mean follow-up period, 25.6 ± 12.6 mo). The patients were divided on the basis of diabetic criteria for glucose intolerance into 2 groups: the diabetic group (n = 105) and nondiabetic group (n = 400). We evaluated differences in pre- and postoperative Japanese Orthopaedic Association (JOA) scores, recovery rate, achieved JOA scores (postoperative JOA score - preoperative JOA score), and complications between both groups. RESULTS The mean JOA scores in the diabetic and nondiabetic groups were 10.1 and 10.8 points before surgery and 13.1 and 13.9 points after surgery, respectively. The diabetic group showed significantly low pre- and postoperative JOA scores and low recovery rate of JOA scores compared with the nondiabetic group (47.3% vs. 53.6%, P < 0.05). However, mean achieved JOA scores in the diabetic and nondiabetic groups were 3.0 and 3.1 points respectively, with no significant difference between both groups (P = 0.343). The groups showed no significant difference in the postoperative complication rate. CONCLUSION Pre- and postoperative JOA scores and recovery rates were lower in the diabetic group than the nondiabetic group. However, the achieved JOA scores were not significantly different between both groups. Diabetic and nondiabetic patients experienced similar benefits from laminoplasty. LEVEL OF EVIDENCE 3.
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Dynamic changes in spinal cord compression by cervical ossification of the posterior longitudinal ligament evaluated by kinematic computed tomography myelography. Spine (Phila Pa 1976) 2014; 39:113-9. [PMID: 24153172 DOI: 10.1097/brs.0000000000000086] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective clinical study. OBJECTIVE To investigate the dynamic causative factor in the pathogenesis of myelopathy in patients with cervical ossification of the posterior longitudinal ligament (OPLL) using kinematic computed tomography (CT) myelography. SUMMARY OF BACKGROUND DATA Kinematic CT myelography is useful for dynamically evaluating the cervical spine with high-resolution images, particularly in bony compressive lesions. However, no studies have evaluated the dynamic factors in patients with OPLL using kinematic CT myelography. METHODS From 2008 to 2013, 51 consecutive patients with OPLL who presented with myelopathy were prospectively enrolled in this study. The patients were examined with kinematic (flexion-extension) CT myelography using a multidetector CT scanner. The range of motion at C2-C7 from flexion to extension was measured in the sagittal view. The segmental range of motion, anterior-posterior diameter and cross-sectional area (CSA) of the spinal cord were measured at the level where the spinal cord was most compressed by OPLL. RESULTS The neurological condition of the patients evaluated by Japanese Orthopaedic Association scores were 10.8 ± 2.4 points. The mean range of motion at C2-C7 and at the most compressed segment were 23.1 ± 11.7 and 7.0 ± 4.4°, respectively. Both the anterior-posterior diameter and the CSA at the most compressed levels were significantly decreased during neck extension compared with flexion. Interestingly, the anterior-posterior diameter and the CSA were decreased during neck flexion in 13.7% (7/51) of the patients. All 7 of these patients had massive OPLL with an occupying rate 60% or more. The dynamic change rate of CSA (flexion/extension) was significantly smaller in patients with an OPLL occupying rate 60% or more compared with patients with an occupying rate less than 60%. CONCLUSION Although spinal cord compression was increased during neck extension in most of the patients, greater levels of compression could be placed on the spinal cord during neck flexion when the patients had OPLL with a high occupying rate. LEVEL OF EVIDENCE 4.
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Abstract
OBJETIVOS: Analizar cinemática, reconocer cuadro clínico de presentación, describir imágenes, considerar posibilidades terapéuticas y evaluar evolución. MÉTODO: Se analizan 13 pacientes del sexo masculino que presentaron SCIWORA (en inglés Spinal cord injury without radiographic abnormality) entre el 2005 al 2012. Se evalúan cuadro clínico, tratamiento, complicaciones y evolución. RESULTADOS: 10 pacientes mayores de 45 años presentaban signos de espondiloartrosis con mínimos síntomas. De los tres menores de esta edad solo uno presentaba estenosis de canal constitucional asintomática. Todos sufrieron trauma de baja energía. En la resonancia magnética prevaleció el hematoma intramedular y clínicamente todos los pacientes presentaban un síndrome medular central, con cuadro severo (ASIA A-B) en los mayores de 45 años. Siete pacientes fueron tratados inicialmente en forma conservadora; un paciente empeoró y tuvo que ser sometido a intervención quirúrgica 18 meses después y otro falleció en las primeras horas, el resto de los pacientes tuvieron buena evolución. Seis pacientes requirieron cirugía (laminoplastía) en los primeros 10 días; tres fallecieron y el resto mejoro por lo menos un nivel ASIA. CONCLUSIONES: La menor edad, los cuadros leves y el edema intramedular son factores de buen pronóstico y se ven favorecidos con el tratamiento conservador. La mayor edad, la espondiloartrosis y los cuadros severos o progresivos, son factores de mal pronóstico y puede ser necesario su tratamiento quirúrgico.
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