Optimal Timing of Surgical Decompression for Acute Traumatic Central Cord Syndrome: A Systematic Review of the Literature

Timing of decompression in central cord syndrome: a systematic review and meta-analysis

PURPOSE

This study compared the recovery of motor function and the safety of early and delayed surgical intervention in patients with central cord syndrome (CCS).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were employed to retrieve the targeted studies published from inception to February 19, 2023. Comparative studies of early versus delayed surgical decompression in CCS based on American Spinal Injury Association motor score (AMS) recovery, complication rates, and mortality were selected. The statistical analyses were performed using STATA 16.0 and RevMan 5.4.

RESULTS

Our meta-analysis included 13 studies comprising 8424 patients. Results revealed that early surgery improved AMS scores significantly compared with delayed surgery, with an increase in MDs by 7.22 points (95% CI 1.98-12.45; P = 0.007). Additionally, early surgery reduced the complication rates than delayed surgery (OR 0.53, 95% CI 0.42-0.67, P < 0.00001). However, no significant difference was observed in mortality between the two groups (OR 0.97; 95% CI 0.75-1.26; P = 0.84).

CONCLUSIONS

Early surgical decompression for CCS can improve motor function and reduce the incidence of complications without affecting the mortality rate in patients. Future research should focus on investigating and analyzing the optimal window period for early CCS surgery. Additionally, the timing of surgery should be determined based on the patient's condition and available medical resources.

Clinical Subsets of Central Cord Syndrome: Is it a Distinct Entity from Other Forms of Incomplete Tetraplegia for Research?

Central cord syndrome (CCS) is the most prevalent and debated incomplete spinal cord injury (SCI) syndrome, with its hallmark feature being more pronounced weakness of the upper extremities compared to the lower extremities. Varying definitions encapsulate multiple clinical features under the single umbrella term of CCS, complicating evaluation of its frequency, prognosis discussions, and outcomes research. Oftentimes, people with CCS are excluded from research protocols, as it is thought to have a favorable prognosis, but the vague nature of CCS raises doubts about the validity of this practice. The objective of this study was to categorize CCS into specific subsets with clear quantifiable differences, to assess whether this would enhance the ability to determine if individuals with CCS or its subsets exhibit distinct neurological and functional outcomes relative to others with incomplete tetraplegia. This study retrospectively reviewed individuals with new motor incomplete tetraplegia from traumatic SCI who enrolled in the Spinal Cord Injury Model Systems (SCIMS) database from 2010 to 2020. Through an assessment of the prevailing criteria for CCS, coupled with data analysis, we used two key criteria, including the severity of distal upper extremity weakness (i.e., hands and fingers) and extent of symmetry, to delineate three CCS subsets: Full CCS, Unilateral CCS, and Borderline CCS. Of the 1,490 participants in our sample, 17.5% had Full, 25.6% Unilateral, and 9% Borderline CCS, together encompassing more than 50% of motor incomplete tetraplegia cases. Despite the increased sensitivity and specificity of these subsets compared to existing quantifiable criteria, substantial variability in clinical presentation was still observed. Overall, individuals meeting CCS subset criteria showed a higher likelihood of AIS D grade compared to those with motor incomplete tetraplegia without CCS, from admission to the 1-year follow-up. The upper extremity motor score (UEMS) for those with CCS was lower on admission, a difference that diminished by discharge, while their lower extremity motor score (LEMS) consistently remained higher compared to those without CCS. However, these neurological distinctions did not result in significant functional differences, as lower and upper extremity functional outcomes at discharge were mostly similar to those with motor incomplete tetraplegia, with some significant differences observed within those with AIS D grade. The AIS grade seems to remain the foremost determinant influencing neurological and functional outcomes, rather than the diagnosis of CCS. We recommend that future studies consider incorporating motor incomplete tetraplegia into their inclusion/exclusion criteria, instead of relying on criteria specific to CCS. While there remains clinical value in characterizing an injury pattern as CCS and perhaps using the different subsets to better characterize the impairments, it does not appear to be a useful research criterion.

Early versus late surgical decompression for patients with acute traumatic central cord syndrome: a systematic review and meta-analysis

BACKGROUND CONTEXT

The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking.

PURPOSE

To compare early (<24 hours) versus late (≥24 hours) surgical decompression for ATCCS.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Medline, PubMed, Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence.

RESULTS

The nine studies included reported on 5,619 patients, of whom 2,099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=.505) and admission ASIA motor score (mean difference [MD]=-0.31 [-3.61, 2.98], p=.85) were similar between the early and late decompression groups. At 6-month follow-up, the two groups were similar in ASIA motor score (MD= -3.30 [-8.24, 1.65], p=.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p<.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=.004) and lower extremities (MD=1.08 [0.34, 1.83], p=.004). Early decompression was also associated with lower VTE (odds ratio [OR]=0.41 [0.26, 0.65], p=.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p<.001, evidence: moderate), and hospital LOS (MD=-2.94 days [-3.83, -2.04], p<.001, evidence: moderate). Finally, ICU LOS (MD=-0.69 days [-1.65, 0.28], p=.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=.11, evidence: moderate) were similar between the two groups.

CONCLUSIONS

The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate.

A critical appraisal of clinical practice guidelines on surgical treatments for spinal cord injury

BACKGROUND CONTEXT

Spinal cord injury (SCI) is a global health problem with a heavy economic burden. Surgery is considered as the cornerstone of SCI treatment. Although various organizations have formulated different guidelines on surgical treatment for SCI, the methodological quality of these guidelines has still not been critically appraised.

PURPOSE

We aim to systematically review and appraise the current guidelines on surgical treatments of SCI and summarize the related recommendations with the quality evaluation of supporting evidence.

STUDY DESIGN

Systematic review.

METHODS

Medline, Cochrane library, Web of Science, Embase, Google Scholar, and online guideline databases were searched from January 2000 to January 2022. The most updated and recent guidelines containing evidence-based or consensus-based recommendations and established by authoritative associations were included. The Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument containing 6 domains (eg, applicability) was used to appraise the included guidelines. An evidence-grading scale (ie, level of evidence, LOE) was utilized to evaluate the quality of supporting evidence. The supporting evidence was categorized as A (the best quality), B, C, and D (the worst quality).

RESULTS

Ten guidelines from 2008 to 2020 were included, however, all of them acquired the lowest scores in the domain of applicability among all the six domains. Fourteen recommendations (eight evidence-based recommendations and six consensus-based recommendations) were totally involved. The SCI types of the population and timing of surgery were studied. Regarding the SCI types of the population, eight guidelines (8/10, 80%), two guidelines (2/10, 20%), and three guidelines (3/10, 30%) recommended surgical treatment for patients with SCI without further clarification of characteristics, incomplete SCI, and traumatic central cord syndrome (TCCS), respectively. Besides, one guideline (1/10, 10%) recommended against surgery for patients with SCI without radiographic abnormality. Regarding the timing of surgery, there were eight guidelines (8/10, 80%), two guidelines (2/10, 20%), and two guidelines (2/10, 20%) with recommendations for patients with SCI without further clarification of characteristics, incomplete SCI, and TCCS, respectively. For patients with SCI without further clarification of characteristics, all eight guidelines (8/8, 100%) recommended for early surgery and five guidelines (5/8, 62.5%) recommended for the specific timing, which ranged from within 8 hours to within 48 hours. For patients with incomplete SCI, two guidelines (2/2, 100%) recommended for early surgery, without specific time thresholds. For patients with TCCS, one guideline (1/2, 50%) recommended for surgery within 24 hours, and another guideline (1/2, 50%) simply recommended for early surgery. The LOE was B in eight recommendations, C in three recommendations, and D in three recommendations.

CONCLUSIONS

We remind the reader that even the highest quality guidelines often have significant flaws (eg, poor applicability), and some of the conclusions are based on consensus recommendations which is certainly less than ideal. With these caveats, we found most included guidelines (8/10, 80%) recommended early surgical treatment for patients after SCI, which was consistent between evidence-based recommendations and consensus-based recommendations. Regarding the specific timing of surgery, the recommended time threshold did vary, but it was usually within 8 to 48 hours, where the LOE was B to D.

A future blood test for acute traumatic spinal cord injury

Acute spinal cord injury (SCI) requires prompt diagnosis and intervention to minimize the risk of permanent neurologic deficit. Presently, SCI diagnosis and interventional planning rely on magnetic resonance imaging (MRI), which is not always available or feasible for severely injured patients. Detection of disease-specific biomarkers in biofluids via liquid biopsy may provide a more accessible and objective means of evaluating patients with suspected SCI. Cell-free DNA, which has been used for diagnosing and monitoring oncologic disease, may detect damage to spinal cord neurons via tissue-specific methylation patterns. Other types of biomarkers, including proteins and RNA species, have also been found to reflect neuronal injury and may be included as part of a multi-analyte assay to improve liquid biopsy performance. The feasibility of implementing liquid biopsy into current practices of SCI management is supported by the relative ease of blood sample collection as well as recent advancements in droplet digital polymerase chain reaction technology. In this review, we detail the current landscape of biofluid biomarkers for acute SCI and propose a framework for the incorporation of a putative blood test into the clinical management of SCI.

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

INTRODUCTION

Currently, there exists considerable debate surrounding the optimal treatment approaches for different subtypes of patients with spinal cord injury (SCI). The purpose of this study was to conduct a comparative analysis of the benefits associated with conservative treatment and treatments with different surgical periods for patients diagnosed with acute traumatic central cord syndrome (ATCCS) and multilevel cervical canal stenosis (CCS).

METHODS

A retrospective cohort study was conducted, and 93 patients who met inclusion and exclusion criteria in our hospital between 2015 and 2020 were followed for a minimum duration of 2 years. Among them, 30 patients (Group A) received conservative treatment, 18 patients (Group B) received early surgery (≤7 days), and 45 patients (Group C) received late surgery (>7 days). The American Spinal Injury Association (ASIA) grade, Japanese Orthopedic Association (JOA) score, and recovery rate (RR) were evaluated. Multivariate linear regression was used to analyze prognostic determinants. Cost-utility analysis was performed based on the EQ-5D scale.

RESULTS

The ASIA grade, JOA score, and RR of all three groups improved compared with the previous evaluation (P < 0.05). During follow-up, the ASIA grade, JOA score, and RR of Group B were all better than for Group A and Group C (P < 0.05), while there was no significant difference between Group A and C (P > 0.05). The EQ-5D scale in Group B was optimal at the last follow-up. The incremental cost-utility ratio (ICUR) of Group A was the lowest, while that of Group B compared to Group A was less than the threshold of patients' willingness to pay. Age, initial ASIA grade, and treatment types significantly affected the outcomes.

CONCLUSIONS

Both conservative and surgical treatments yield good results. Compared with patients who received conservative treatment and late surgery, patients who received early surgery had better clinical function and living quality. Despite the higher cost, early surgery is cost-effective when compared to conservative treatment. Younger age, initial better ASIA grade, and earlier surgery were associated with better prognosis.

Elevated high-sensitivity cardiac troponin T serum concentration in subjects with spinal cord injury

BACKGROUND

The biochemical analysis of high-sensitivity cardiac troponins (hs-cTn) from peripheral blood specimens has been established as biomarker for myocardial injury. Independently of myocardial injury, increased serum hs-cTn concentrations have been described in patients with myopathies. The relevance and frequency of noncardiac hs-cTn elevations in spinal cord injury (SCI) is unknown. Our study aimed to 1) determine the frequency of increased hs-cTn concentrations of supposedly noncardiac origin above the 99th percentile (upper reference limit, URL) in an unselected SCI population and 2) compare the two protagonist analytes cTnT and cTnI with respect to these noncardiac elevations.

METHODS

In this monocentric, cross-sectional study, we sampled blood from n = 30 SCI subjects without cardiac symptoms to test for hs-cTnT and hs-cTnI serum concentrations.

RESULTS

18/30 (60%) of SCI subjects showed increased hs-cTnT concentrations above the URL of 14 ng/l (p < 0.001). In 4 subjects (22.2%) concentrations were >50 ng/l. Moreover, 3 of these four subjects fulfilled the 6-h troponin dynamics criterion for acute myocardial injury in serial hs-cTnT testing. In contrast, no subject demonstrated increased hs-cTnI concentrations according to the URL of 40 ng/l. 6-h troponin dynamics were also unremarkable for hs-cTnI testing.

CONCLUSIONS

SCI subjects frequently have increased hs-cTnT concentrations without clinical and hs-cTnI evidence of myocardial injury. Clinicians must be aware of cTnT "skeletal muscle false-positives" in SCI, which applies to elevated baseline cTnT concentrations and troponin dynamics in serial measurements. In case of diagnostic uncertainty, simultaneous analysis of cTnI might be helpful.

Spontaneous spinal cord infarctions: a systematic review and pooled analysis protocol

INTRODUCTION

Spinal cord infarction (SCInf) is a rare ischaemic event that manifests with acute neurological deficits. It is typically classified as either spontaneous, defined as SCInf without any inciting event, or periprocedural, which typically occur in conjunction with vascular surgery with aortic manipulations. While periprocedural SCInf has recently been the subject of intensified research, especially focusing on the primary prevention of this complication, spontaneous SCInf remains less studied.

METHODS AND ANALYSIS

Electronic databases, including PubMed, Web of Science and Embase, will be searched using the keywords "spinal cord", "infarction", "ischemia" and "spontaneous". The search will be set to provide only English studies published from database inception. Editorials, letters and reviews will also be excluded. Reference lists of relevant records will also be searched. Identified studies will be screened for inclusion, by one reviewer in the first step and then three in the next step to decrease the risk of bias. The synthesis will address several topics of interest including epidemiology, presentation, diagnostics, treatment strategies, outcomes and predictors. The review aims to gather the body of evidence to summarise the current knowledge on SCInf. This will lead to a better understanding of the condition, its risk factors, diagnosis and management. Moreover, the review will also provide an understanding of the prognosis of patients with SCInf with respect to neurological function, quality of life and mortality. Finally, this overview of the literature will allow the identification of knowledge gaps to help guide future research efforts.

ETHICS AND DISSEMINATION

Ethics approval was not required for our review as it is based on existing publications. The final manuscript will be submitted to a peer-reviewed journal.

Treatment of acute traumatic central cord syndrome: a score-based approach based on the literature

PURPOSE

Acute traumatic central cord syndrome (ATCCS) accounts for up to 70% of incomplete spinal cord injuries, and modern improvements in surgical and anaesthetic techniques have given surgeons more treatment options for the ATCCS patient. We present a literature review of ATCCS, with the aim of elucidating the best treatment option for the varying ATCCS patient characteristics and profiles. We aim to synthesise the available literature into a simple-to-use format to aid in the decision-making process.

METHODS

The MEDLINE, EMBASE, CENTRAL, Web of Science and CINAHL databases were searched for relevant studies and improvement in functional outcomes were calculated. To allow for direct comparison of functional outcomes, we chose to focus solely on studies which utilised the ASIA motor score and improvements in ASIA motor score.

RESULTS

A total of 16 studies were included for review. There were a total of 749 patients, of which 564 were treated surgically and 185 were treated conservatively. There was a significantly higher average motor recovery percentage amongst surgically-treated patients as compared to conservatively treated patients (76.1% vs. 66.1%, p value = 0.04). There was no significant difference between the ASIA motor recovery percentage of patients treated with early surgery and delayed surgery (69.9 vs. 77.2, p value = 0.31). Delayed surgery after a trial of conservative management is also an appropriate treatment strategy for certain patients, and the presence of multiple comorbidities portend poor outcomes. We propose a score-based approach to decision making in ATCCS, by allocating a numerical score for the patient's clinical neurological condition, imaging findings on CT or MRI, history of cervical spondylosis and comorbidity profile.

CONCLUSIONS

An individualised approach to each ATCCS patient, considering their unique characteristics will lead to the best outcomes, and the use of a simple scoring system, can aid clinicians in choosing the best treatment for ATCCS patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Time is spine: What's over the horizon

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

Acute Traumatic Myelopathy: Rethinking Central Cord Syndrome

Central cord syndrome (CCS) is an incomplete spinal cord injury that consists of both sensory and motor changes of the upper and lower extremities. CCS most commonly occurs after trauma to the cervical spine leading to acute neurological changes. Despite being the most common incomplete spinal cord injury with the best outcomes, optimal treatment remains controversial. Although clinical practice has shifted from primarily conservative management to early surgical intervention, many questions remain unanswered and treatment remains varied. One of the most limiting aspects of CCS remains the diagnosis itself. CCS, by definition, is a syndrome with a very specific pattern of neurological deficits. In practice and in the literature, CCS has been used to describe a spectrum of neurological conditions and traumatic morphologies. Establishing clarity will allow for more accurate decision making by clinicians involved in the care of these injuries. The authors emphasize that a more precise term for the clinical condition in question is acute traumatic myelopathy: an acute cervical cord injury in the setting of a stable spine with either congenital and/or degenerative stenosis.

Current knowledge on spinal meningiomas: a systematic review protocol

INTRODUCTION

Meningiomas are primary central nervous system tumours that arise from both cranial and spinal meninges. Spinal meningiomas occur less frequently than their cranial counterparts and are consequently given less attention in the literature. Therefore, systematic studies are needed to summarise the current knowledge on spinal meningiomas, providing a solid evidence base for treatment strategies. This systematic review of the literature will therefore assess studies describing spinal meningiomas, their epidemiology, diagnostics, treatment and outcomes.

METHODS AND ANALYSIS

Electronic databases, including PubMed, Web of Science and Embase, will be searched using the keywords "spinal" and "meningioma". The search will be set to provide only English studies published after 2000 to avoid any conflicts regarding terminology and classification, as well as to reflect the current status. Case reports, editorials, letters and reviews will also be excluded. Reference lists of relevant records will also be searched. Identified studies will be screened for inclusion, by one reviewer in a first step and then three in the next step to decrease the risk of bias. The results will be categorised to allow for a structured summary of the outcomes and their evidence grade conforming to the Grading of Recommendations, Assessment, Development and Evaluation approach. Categories may include: epidemiology, histopathology, radiological diagnostics, surgery, complications, non-surgical or adjuvant treatments, disease outcomes and predictors, and lastly recurrence. This review will summarise the current knowledge on spinal meningiomas to allow for a better understanding of the disease and contribute to improve its management. For clinicians, the systematic collection and grading of available evidence may aid in decision making and for those seeking to further the scientific field, this review may help to identify areas where knowledge is currently lacking.

ETHICS AND DISSEMINATION

Ethics approval was not required for our systematic review as it is based on existing publications. The results will be disseminated via submission for publication in a peer-reviewed journal.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Early surgery improves peripheral motor axonal dysfunction in acute traumatic central cord syndrome: A prospective cohort study

OBJECTIVE

To investigate the impact of early vs. delayed surgical decompression on peripheral motor axonal dysfunction following acute traumatic central cord syndrome (ATCCS).

METHODS

Both axonal excitability testing and motor unit number estimation (MUNE) were performed in 30 ATCCS patients (early- vs. delayed-surgical treatment: 12 vs. 18) before operation and 28 healthy subjects. Axonal excitability testing was repeated 3-5 days and 1-year after operation, and MUNE was re-evaluated 1-year after operation.

RESULTS

Preoperatively, an obvious modification in membrane potentials was observed in ATCCS patients that mostly coincided with depolarization-like features, and MUNE further revealed reduced motor units in tested muscles (P < 0.05). Unlike delayed-surgical cases, early-surgical cases showed recoveries of most measurements of axonal excitabilities soon after operation (P < 0.05). Postoperative one-year follow-up demonstrated that greater motor unit numbers in tested muscles were obtained in early-surgical cases than in delayed-surgical cases (P < 0.05).

CONCLUSIONS

ATCCS has adverse downstream effects on peripheral nervous system, even in the early stage of ATCCS. Early surgical treatment can ameliorate both excitability abnormalities and motor unit loss in distal motor axons.

SIGNIFICANCE

Optimizing axonal excitability in the early phases of ATCCS may alleviate peripheral nerve injury secondary to lesions of upper motor neuron and improve clinical outcomes.

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

STUDY DESIGN

This was a retrospective comparative study.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III.

[Acute Traumatic Central Cord Syndrome: Etiology, Pathophysiology, Clinical Manifestation, and Treatment]

Acute Traumatic Central Cord Syndrome: Etiology, Pathophysiology, Clinical Manifestation, and Treatment Abstract. The acute traumatic central cord syndrome (ATCCS) represents an injury to the spinal cord with disproportionately greater motor impairment of the upper than the lower extremities, with bladder dysfunction and with varying degrees of sensory loss below the level of the respective lesion. The mechanism of ATCCS is most commonly a traumatic hyperextension injury of the cervical spine at the base of an underlying spondylosis and spinal stenosis. The mean age is 53 years, and segments C4 to Th1 are most frequently affected. In addition to medical history and clinical examination, the definitive diagnosis is made by magnetic resonance imaging, where T2-hyperintense lesions are typically observed in the affected spinal cord segment. Surgical decompression (and fusion) of the respective segment is recommended to prevent repetitive trauma to the spinal cord and to stop progression of clinical symptoms. Patients with diagnosed ATCCS and who are treated adequately usually have a good prognosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Assessment of Dynamic Spinal Cord Impingement by Kinematic Magnetic Resonance Imaging in Patients with Traumatic Central Cord Syndrome

Background

There are few reports describing the imaging features of traumatic central cord syndrome (TCCS) in kinematic magnetic resonance imaging (kMRI) scans. The current study aimed to assess and characterize dynamic spinal cord impingement (DSCI) using kMRI and evaluate the risk factors for poor outcomes in patients with TCCS after surgery.

Methods

This retrospective study included 63 patients with TCCS who underwent surgery in the authors' hospital. The American Spinal Injury Association impairment scale grade and Japanese Orthopedic Association (JOA) score were collected preoperatively and at the final follow-up to assess neurological function. Patients were divided into two groups based on the JOA score (> or <50%), and clinical and radiographic evaluations were compared. The metrics examined included age at the time of surgery, gender, type of trauma, the interval from injury to surgery, surgical approach, pathological signs, range of motion, DSCI and the length of intramedullary hyperintensity signal (LIHS).

Results

There were statistical differences in the LIHS, DSCI and preoperative JOA score between good (JOA >50%; n = 50) and poor (JOA <50%, n =13) recovery patient groups (P<0.05). Logistic regression, with poor outcomes as the dependent variable, suggested independent risk associations with preoperative JOA score (P<0.05), DSCI (P<0.05) and LIHS (P<0.05).

Conclusion

kMRI can be effective for decision-making in the treatment of TCCS. The lower preoperative JOA score, longer high signal cord and higher dynamic spinal cord impingement were risk factors for poor outcomes in patients with TCCS after surgery.

Outcomes of Spinal Cord Injury: WFNS Spine Committee Recommendations

This comprehensive review article aims to provide some definitive statements on the factors like clinical syndromes, radiological findings, and decompressive surgery, that may influence the outcomes in cervical spinal cord injury management. Literature search on these factors published in the last decade were analyzed and definite statements prepared and voted for consensus opinion by the WFNS Spine Committee members and experts in this field at a meeting in Moscow in June 2019 using Delphi method. This was re-evaluated in a meeting in Pakistan in November 2019. Finally, the consensus statements were brought out as recommendations by the committee to the world literature. Traumatic Spinal Cord Syndromes have good prognosis except in elderly and when the presenting neurological deficit was very poor. Though conservative management provides satisfactory results, results can be improved with surgery when instability and progressive compression was present. Locked facet with spinal cord injury denotes poor prognosis. Magnetic resonance imaging T2 imaging is the essential prognostic indicator that apart from sagittal grade, length of injury, maximum canal compromise, maximum spinal cord compression, axial grading (BASIC) score. Diffusion tensor imaging is the next promising predictor in the pipeline. Decompressive surgery when done earlier especially within 24 hours of injury provides better result and there is no clear evidence to show medical management is better or equivalent to delayed surgical management. Clinical syndromes, radiological syndromes, and surgical decompression have strong impact on the out comes in the management of cervical spinal cord injury. Our comprehensive review and final recommendations on this subject will be of great importance in understanding the complex treatment methods in use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early Surgical Decompression Ameliorates Dysfunction of Spinal Motor Neuron in Patients With Acute Traumatic Central Cord Syndrome: An Ambispective Cohort Analysis

STUDY DESIGN

An ambispective cohort analysis.

OBJECTIVE

The aim of this study was to investigate the impact of early (≤2 weeks) versus delayed (>2 weeks) surgical intervention on the spinal motor neurons at and distal to injury site in acute traumatic central cord syndrome (ATCCS).

SUMMARY OF BACKGROUND DATA

Accumulating evidence demonstrated degeneration in distal lower motor neurons (LMNs) following spinal cord injury, and this secondary degeneration may exacerbate motor impairments and limit spontaneous motor recovery. However, few studies involved this pathological process in ATCCS.

METHODS

Motor unit number estimation (MUNE) was performed on both abductor pollicis brevis (APB) and extensor digitorum brevis (EDB) in 69 ATCCS patients (early vs. delayed surgical-treatment: 29 vs. 35) and 42 healthy subjects. All patients were assessed by American spinal injury association and Medical Research Council scales. These examinations and disabilities of arm, shoulder, and hand (c) questionnaire were administered approximately 21 months after operation in 65 of these patients.

RESULTS

Preoperatively, MUNE values were lower in cervical-innervated muscles of ATCCS patients than in those of controls, and reduced motor units were observed in lumbosacral-innervated muscles in ATCCS patients with preoperative duration over 6 months (P < 0.05). Increased motor unit size without modification of MUNE values was found in delayed-surgical patients, whereas early-surgical patients mainly showed increased MUNE values in tested muscles between two assessments (P < 0.05). The postoperative follow-up analysis identified larger motor unit size and relatively fewer motor units in tested muscles, as well as higher DASH scores, in delayed-surgical patients than in early-surgical patients (P < 0.05).

CONCLUSION

ATCCS has adverse downstream effects on the LMNs distal to injury site. Surgical intervention within 2 weeks after injury in ATCCS patients may be beneficial in ameliorating dysfunction of spinal motor neurons at and distal to injury site, reducing secondary motor neuron loss, and eventually improving neurologic outcomes.

LEVEL OF EVIDENCE

3.

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

STUDY DESIGN

Retrospective, cohort study of a prospectively collected database.

OBJECTIVES

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

SETTING

Tertiary referral hospital.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12-24 h), and 15 underwent decompressive surgery late (> 24-138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862-0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.

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

Background

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

Methods

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

Results

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

Conclusions

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

Time is spine: a review of translational advances in spinal cord injury

Acute traumatic spinal cord injury (SCI) is a devastating event with far-reaching physical, emotional, and economic consequences for patients, families, and society at large. Timely delivery of specialized care has reduced mortality; however, long-term neurological recovery continues to be limited. In recent years, a number of exciting neuroprotective and regenerative strategies have emerged and have come under active investigation in clinical trials, and several more are coming down the translational pipeline. Among ongoing trials are RISCIS (riluzole), INSPIRE (Neuro-Spinal Scaffold), MASC (minocycline), and SPRING (VX-210). Microstructural MRI techniques have improved our ability to image the injured spinal cord at high resolution. This innovation, combined with serum and cerebrospinal fluid (CSF) analysis, holds the promise of providing a quantitative biomarker readout of spinal cord neural tissue injury, which may improve prognostication and facilitate stratification of patients for enrollment into clinical trials. Given evidence of the effectiveness of early surgical decompression and growing recognition of the concept that "time is spine," infrastructural changes at a systems level are being implemented in many regions around the world to provide a streamlined process for transfer of patients with acute SCI to a specialized unit. With the continued aging of the population, central cord syndrome is soon expected to become the most common form of acute traumatic SCI; characterization of the pathophysiology, natural history, and optimal treatment of these injuries is hence a key public health priority. Collaborative international efforts have led to the development of clinical practice guidelines for traumatic SCI based on robust evaluation of current evidence. The current article provides an in-depth review of progress in SCI, covering the above areas.

Outcome of Surgical Treatment for Spinal Cord Compression in Patients With Hematological Malignancy

Background

We investigated the outcome of surgical treatment of patients with radiosensitive hematological malignancies presenting with spinal cord compression.

Methods

Retrospective review of 50 patients who had treatment between 1993 and 2012.

Results

The neurological outcome was favorable in 35 patients, stable in 12, whereas 3 patients deteriorated. Decompression within 48 hours from referral was associated with a superior neurological recovery (P = .001). Complications were noted in 11 patients, and 6 of these underwent secondary surgery. Early (30-day) mortality was 8%. Radiotherapy was associated with increased incidence of complications (χ² = 0.009). Patients who had low blood hemoglobin preoperatively as well as those who remained totally bedridden postoperatively had an inferior overall survival rate (P < .001).

Conclusion

Patients with cord compression from hematological malignancy benefit from early surgical decompression. There is an inherent high risk for complications, which increases further if radiotherapy is given. Patients failing to ambulate after surgery have a poor prognosis.

Current Concepts: Central Cord Syndrome

Central cord syndrome (CCS) represents a clinical phenomenon characterized by disproportionately greater motor impairment of the upper than of the lower extremities, bladder dysfunction. CSS is the most common form of incomplete traumatic spinal cord injury. The initial description of CSS was reported in 1887 secondary to cervical spinal trauma. However, recent literature describes a heterogenous injury patterns including high-energy and low-energy mechanisms and bimodal patient age distributions. Pathophysiology of clinical symptoms and neurological deficits often is affected by preexisting cervical spondylosis. Urgent clinical diagnosis is dependent on neurological examination and imaging studies. Treatment of CSS is dependent on injury mechanism and compressive lesions, neurological examination, preexisting cervical pathology, and patient-specific comorbidities. This article will review the current concepts in diagnosis, pathophysiology, and treatment of CSS with a highlighted case example.

Surgical reduction technique (transpedicle) for unstable thoracolumbar burst fractures with retropulsion resulting in severe spinal canal stenosis: a preliminary case report

Thoracolumbar burst fractures are common entity in polytraumatized patients. The retropulsed burst vertebral fracture may result in spinal canal invasion with or without neurological deficit. In this situation, early surgical stabilization with decompression is vital to restore neurological function. We employed a posterior approach with a unique transpedicular reduction technique at the level of fracture for decompression and stabilisation.

The impact of spine stability on cervical spinal cord injury with respect to demographics, management, and outcome: a prospective cohort from a national spinal cord injury registry

BACKGROUND CONTEXT

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

PURPOSE

The study aimed to test the authors' hypothesis that spine stability can identify a unique group of patients with regard to demographics, management, and outcomes, which classic CCS definitions do not.

STUDY DESIGN/SETTING

This is a prospective observational study.

PATIENT SAMPLE

The sample included participants with cervical SCI included in a prospective Canadian registry.

OUTCOME MEASURES

The outcome measures were initial hospitalization length of stay, change in total motor score from admission to discharge, and in-hospital mortality.

METHODS

Patients with cervical SCI from a prospective Canadian SCI registry were grouped into stable and unstable spine cohorts. Bivariate analyses were used to identify differences in demographic, injury, management, and outcomes. Multivariate analysis was used to better understand the impact of spine stability on motor score improvement. No conflicts of interest were identified.

RESULTS

Compared with those with an unstable spine, patients with cervical SCI and a stable spine were older (58.8 vs. 44.1 years, p<.0001), more likely male (86.4% vs. 76.1%, p=.0059), and have more medical comorbidities. Patients with stable spine cervical SCI were more likely to have sustained their injury by a fall (67.4% vs. 34.9%, p<.0001), and have high cervical (C1-C4; 58.5% vs. 43.3%, p=.0009) and less severe neurologic injuries (ASIA Impairment Scale C or D; 81.3% vs. 47.5%, p<.0001). Those with stable spine injuries were less likely to have surgery (67.6% vs. 92.6%, p<.0001), had shorter in-hospital lengths of stay (median 84.0 vs. 100.5 days, p=.0062), and higher total motor score change (20.7 vs. 19.4 points, p=.0014). Multivariate modeling revealed that neurologic severity of injury and spine stability were significantly related to motor score improvement; patients with stable spine injuries had more motor score improvement.

CONCLUSIONS

We propose that classification of stable cervical SCI is more clinically relevant than classic CCS classification as this group was found to be unique with regard to demographics, neurologic injury, management, and outcome, whereas classic CCS classifications do not . This classification can be used to assess optimal management in patients where it is less clear if and when surgery should be performed.

Surgical treatment for suicidal jumper's fracture (unstable sacral fracture) with thoracolumbar burst fracture: a report of three cases

Introduction

Suicidal jumper's fracture (unstable sacral fracture) is characterized not only by multiple fractures including thoracolumbar fractures, but also major chest and abdominal injuries. Early stabilization of these fractures and early ambulation are required for the treatment and management of chest and abdominal injuries. We present 3 cases of suicidal jumper's fracture with thoracolumbar burst fracture, treated with minimally invasive posterior fixation surgery, which is a combination of percutaneous pedicle screws (PPS) and the mini-open Galveston technique.

Case reports

Case 1. A 50-year-old woman was injured by a fall from the 5th floor of a building as the result of a suicide attempt. Computed tomography revealed an H-shaped unstable sacral fracture and thoracolumbar fractures with major chest and abdominal injuries. For early stabilization of spinopelvic instability and early ambulation, we treated the patient with PPS and the mini-open Galveston technique. Her early postoperative emergence from bedrest contributed to the improvement of her general condition. One year after surgery at the final follow-up, she was able to walk with a T-cane without any motor, bladder, or bowel dysfunction (BBD) and achieved almost complete healing of the fractures. Cases 2 and 3. A 25-year-old woman (Case 2) and a 43-year-old woman were injured in falls. They had multiple injuries including unstable sacral fractures, and thoracolumbar fractures with major chest and abdominal injuries. We treated these patients with PPS and the mini-open Galveston technique. One year after surgery, they were able to walk with a T-cane and achieved almost complete healing of thoracolumbar fractures, but delayed healing of an unstable sacral fracture in Case 2, and remaining BBD in Case 3.

Conclusion

PPS and the mini-open Galveston technique is a good approach to fixation because they are minimally invasive and provide moderately rigid fixation, especially in patients with multiple trauma whose general condition is poor.

Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury

BACKGROUND

Evidence indicates that, over time, patients with spinal cord injury (SCI) improve neurologically in various degrees. We sought to further investigate indicators of grade conversion in cervical SCI.

OBJECTIVE

To detect predictors of ASIA impairment scale (AIS) grade conversion in SCI following surgical decompression.

METHODS

In a retrospective study, demographics, clinical, imaging, and surgical data from 100 consecutive patients were assessed for predictors of AIS grade conversion.

RESULTS

American Spinal Injury Association motor score was 17.1. AIS grade was A in 52%, B in 29%, and C in 19% of patients. Surgical decompression took place on an average of 17.6 h following trauma (≤12 h in 51 and >12 h in 49). Complete decompression was verified by magnetic resonance imaging (MRI) in 73 patients. Intramedullary lesion length (IMLL) on postoperative MRI measured 72.8 mm, and hemorrhage at the injury epicenter was noted in 71 patients. Grade conversion took place in 26.9% of AIS grade A patients, 65.5% of AIS grade B, and 78.9% of AIS grade C. AIS grade conversion had statistical relationship with injury severity score, admission AIS grade, extent of decompression, presence of intramedullary hemorrhage, American Spinal Injury Association motor score, and IMLL. A stepwise multiple logistic regression analysis indicated IMLL was the sole and strongest indicator of AIS grade conversion (odds ratio 0.950, 95% CI 0.931-0.969). For 1- and 10-mm increases in IMLL, the model indicates 4% and 40% decreases, respectively, in the odds of AIS grade conversion.

CONCLUSION

Compared with other surrogates, IMLL remained as the only predictor of AIS grade conversion.

Role of surgery in spinal cord injury

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

A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope

Acute spinal cord injury (SCI) is a traumatic event that results in disturbances to normal sensory, motor, or autonomic function and ultimately affects a patient's physical, psychological, and social well-being. The management of patients with SCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding available management strategies for the treatment of SCI, including the use of corticosteroids such as methylprednisolone sodium succinate, the optimal timing of surgical intervention, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and among the various disciplines that encounter patients with SCI. The objective of this guideline is to form evidence-based recommendations for these areas of controversy and outline how to best manage patients with SCI. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.

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

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

Surgical Neurostimulation for Spinal Cord Injury

Traumatic spinal cord injury (SCI) is a devastating neurological condition characterized by a constellation of symptoms including paralysis, paraesthesia, pain, cardiovascular, bladder, bowel and sexual dysfunction. Current treatment for SCI involves acute resuscitation, aggressive rehabilitation and symptomatic treatment for complications. Despite the progress in scientific understanding, regenerative therapies are lacking. In this review, we outline the current state and future potential of invasive and non-invasive neuromodulation strategies including deep brain stimulation (DBS), spinal cord stimulation (SCS), motor cortex stimulation (MCS), transcutaneous direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in the context of SCI. We consider the ability of these therapies to address pain, sensorimotor symptoms and autonomic dysregulation associated with SCI. In addition to the potential to make important contributions to SCI treatment, neuromodulation has the added ability to contribute to our understanding of spinal cord neurobiology and the pathophysiology of SCI.