Hyperextension cervical spine injuries and traumatic central cord syndrome

A Study on Interobserver and Intraobserver Reliability of the Huashan Radiologic Classification System for Cervical Spinal Cord Injury Without Fracture and Dislocation

STUDY DESIGN

Observational study.

OBJECTIVE

To assess the reproducibility and reliability of the system.

BACKGROUND

The Huashan radiologic classification system for cervical spinal cord injury without fracture and dislocation (CSCIWFD) was recently proposed and found useful for clinical practice.

PATIENTS AND METHODS

Patients diagnosed with CSCIWFD between 2015 and 2021 were recruited. Six spine surgeons from different institutions, three experienced and other inexperienced respectively, were trained as observers of the system, and these surgeons classified the recruited patients using the system. Then, 8 weeks later, they repeated the classification on the same patients in a different order. The interobserver and intraobserver agreement between the results was analyzed using percentage agreement, weighted kappa, and Cohen kappa (κ) statistics.

RESULTS

A total of 60 patients were included in the analysis. Type I was the most frequent type (29 cases, 48.3%), followed by type II (13 cases, 21.7%), type III (12 cases, 20%), and type IV (6 cases, 10%). For all the observers, experienced observers, and inexperienced observers, the overall agreement percentages were 77.6% (κ = 0.78), 84.4% (κ = 0.84), and 72.8% (κ = 0.74), respectively, indicating substantial to nearly perfect interobserver reproducibility. A higher level of agreement was found for differentiating type I from other types, with the percentage agreement ranging from 87.8% to 94.4% (κ= 0.74-0.88). For distinguishing compression on the spinal cord (types I and II vs types III and IV) among the different groups of observers, the percentage agreement was 97.8% (κ = 0.94), indicating nearly perfect reproducibility. As for intraobserver agreement, the percentage agreement ranged from 86.7% to 96.7% (κ = 0.78-0.95), indicating at least substantial reliability.

CONCLUSIONS

The Huashan radiologic classification system for CSCIWFD was easy to learn and apply in a clinical environment, showing excellent reproducibility and reliability. Therefore, it would be promising to apply and promote this system for the precise evaluation and personalized treatment strategy.

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.

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.

Effect of Cervical Stenosis and Rate of Impact on Risk of Spinal Cord Injury During Whiplash Injury

STUDY DESIGN

Finite Element Study.

OBJECTIVE

To determine the risk of spinal cord injury with pre-existing cervical stenosis during a whiplash injury.

SUMMARY OF BACKGROUND DATA

Patients with cervical spinal stenosis are often cautioned on the potential increased risk of spinal cord injury (SCI) from minor trauma such as rear impact whiplash injuries. However, there is no consensus on the degree of canal stenosis or the rate of impact that predisposes cervical SCI from minor trauma.

METHODS

A previously validated three-dimensional finite element model of the human head-neck complex with the spinal cord and activated cervical musculature was used. Rear impact acceleration was applied at 1.8 m/s and 2.6 m/s. Progressive spinal stenosis was simulated at the C5 to C6 segment, from 14 mm to 6 mm, at 2 mm intervals of ventral disk protrusion. Spinal cord von Mises stress and maximum principal strain were extracted and normalized with respect to the 14 mm spine at each cervical spine level from C2 to C7.

RESULTS

The mean segmental range of motion was 7.3 degrees at 1.8 m/s and 9.3 degrees at 2.6 m/s. Spinal cord stress above the threshold for SCI was noted at C5 to C6 for 6 mm stenosis at 1.8 m/s and 2.6 m/s. The segment (C6-C7) inferior to the level of maximum stenosis also showed increasing stress and strain with a higher rate of impact. For 8 mm stenosis, spinal cord stress exceeded SCI thresholds only at 2.6 m/s. Spinal cord strain above SCI thresholds were only noted in the 6 mm stenosis model at 2.6 m/s.

CONCLUSION

Increased spinal stenosis and rate of impact are associated with greater magnitude and spatial distribution of spinal cord stress and strain during a whiplash injury. Spinal canal stenosis of 6 mm was associated with consistent elevation of spinal cord stress and strain above SCI thresholds at 2.6 m/s.

Cerebrospinal fluid pressure dynamics reveal signs of effective spinal canal narrowing in ambiguous spine conditions

Spinal canal narrowing with consecutive spinal cord compression is considered a key mechanism in degenerative cervical myelopathy (DCM). DCM is a common spine condition associated with progressive neurological disability, and timely decompressive surgery is recommended. However, the clinical and radiological diagnostic workup is often ambiguous, challenging confident proactive treatment recommendations. Cerebrospinal fluid pressure dynamics (CSFP) are altered by spinal canal narrowing. Therefore, we aim to explore the potential value of bedside CSFP assessments for qualitative and quantitative assessment of spinal canal narrowing in DCM. In this prospective case series, seven patients with DCM underwent bedside lumbar puncture with measurement of CSFP dynamics and routine CSF analysis (NCT02170155). The patients were enrolled when standard diagnostic algorithms did not permit a clear treatment decision. Measurements include baseline CSFP, cardiac-driven CSFP peak-to-trough amplitude (CSFPp), and the Queckenstedt's test (firm pressure on jugular veins) in neutral and reclined head position. From the Queckenstedt's test, proxies for craniospinal elastance (i.e., relative pulse pressure coefficient; RPPC-Q) were calculated analogously to infusion testing. CSFP metrics were deemed suspicious of canal narrowing when numbers were lower than the minimum value from a previously tested elderly spine-healthy cohort (N = 14). Mean age was 56 ± 13 years (range, 38–75; 2F); symptom severity was mostly mild to moderate (mean mJOA, 13.5 ± 2.6; range, 9–17). All the patients showed some extent of cervical stenosis in the MRI of unclear significance (5/7 following decompressive cervical spine surgery with an adjacent level or residual stenosis). Baseline CSFP was normal except for one patient (range, 4.7–17.4 mmHg). Normal values were found for CSFPp (0.4–1.3 mmHg) and the Queckenstedt's test in normal head positioning (9.-25.3 mmHg). During reclination, the Queckenstedt's test significantly decreased in one, and CSFPp in another case (>50% compared to normal position). RPPC-Q (0.07–0.19) aligned with lower values from spine-healthy (0.10–0.44). Routine CSF examinations showed mild total protein elevation (mean, 522 ± 108 mg/ml) without further evidence for the disturbed blood brain barrier. Intrathecal CSFP measurements allow discerning disturbed from normal CSFP dynamics in this population. Prospective longitudinal studies should further evaluate the diagnostic utility of CSFP assessments in DCM.

Selective transfer of nerve to supinator to restore digital extension in central cord syndrome: An anatomical study and a case report

BACKGROUND

Nerve transfers are increasingly used to restore upper extremity function in patients with spinal cord injury. However, the role of nerve transfers for central cord syndrome is still being established. The purpose of this study is to report the anatomical feasibility and clinical use of nerve transfer of supinator motor branches (NS) to restore finger extension in a central cord syndrome patient.

MATERIALS AND METHODS

The posterior interosseous nerve (PIN), its superficial division, and branches were dissected in 14 fresh cadavers, with a mean age of 65 (58-79). Measurements included number and length of branches of donor and recipient, diameters, regeneration distance from coaptation site to motor entry point and axonal counts. A NS transfer to extensor carpi ulnaris (ECU), extensor digiti quinti (EDQ) and extensor digitorum communis (EDC) was performed in a 28-year-old patient, with central cord syndrome after a motorcycle accident, who did not recover active finger extension at 10 months post injury.

RESULTS

The PIN consistently divided into a deep and superficial branch between 1.5 cm proximal to, and 2 cm distal to the distal boundary of the supinator. The superficial branch provided a first common branch to the ECU and EDQ. In 12/14 dissections, the EDC was innervated by a 4 cm long branch that entered the muscle on its radial deep surface. In all cases, the superficial branch of the PIN could be separated in a retrograde fashion from the PIN and coapted with NS. The mean myelinated fiber count in nerve to EDC was 401 ± 190 compared to 398 ± 75 in the NS. At 48 months after surgery, with the wrist at neutral, the patient recovered full metacarpophalangeal extension scoring M4. Supination was preserved with the elbow extended or flexed.

CONCLUSIONS

Restoration of finger extension in central cord syndrome is possible with a selective transfer of the NS to EDC, and is anatomically feasible with a short regeneration distance and favorable axonal count ratio.

Elderly traumatic central cord syndrome in the United States: a review of management and outcomes

INTRODUCTION

As the incidence of elderly spinal cord injury rises, improved understanding of risk profiles and outcomes is needed. This review summarizes clinical characteristics, management, and outcomes specific to the elderly (≥65-years) with acute traumatic central cord syndrome in the United States.

EVIDENCE AQUISITION

Literature review of the PubMed, Embase, and CINAHL databases (01/2007-03/2020) regarding elderly subjects with acute traumatic central cord syndrome.

EVIDENCE SYNTHESIS

Nine studies met inclusion criteria. Acute traumatic central cord syndrome was more common among married (50%), Caucasian (22-71%) males (63-86%) with an annual income <40,999 U.S. dollars (30%). Mechanisms consisted predominantly of traumatic falls (32-55%) and motor vehicle collisions (15-34%), with admission American Spinal Injury Association Impairment Scale grades D (25-79%) and C (21-51%). Mortality was 2-3%. American Spinal Injury Association Impairment Scale motor score, maximum canal compromise, and extent of parenchymal damage were predictors of one-year recovery. Greater comorbidities (heart failure, weight loss, coagulopathy, diabetes), lower income (<51,000 U.S. dollars), and age ≥80 were predictors of mortality. A substantial cohort underwent surgery (40-45%). Elderly patients were less likely to receive surgical intervention, and surgery timing had variable effects on recovery.

CONCLUSIONS

Elderly patients with acute traumatic central cord syndrome are uniquely at risk due to cumulative comorbidities, protracted recovery times, and unclear effects of surgical timing on outcomes. Prospective research should focus on validating age-specific risk factors, formalizing surgical indications, and delineating the impact of time to surgery on acute and long-term outcomes for this condition.

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

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

Urodynamic findings and urologic management of central cord syndrome

Purpose:

Central cord syndrome is the most common incomplete spinal cord injury, although urodynamic data on this subset of patients is lacking. We aim to determine the typical urodynamic features associated with this condition.

Methods

Consecutive patients undergoing urodynamic studies in a tertiary spinal cord unit between 2014 and 2018 were retrospectively reviewed to identify those with central cord syndrome. Charts were evaluated for demographics, spinal cord injury classification, symptoms, urodynamic parameters and treatment. Data were analysed using descriptive statistics.

Results:

A total of 131 consecutive patients undergoing urodynamic studies were reviewed and 33 were identified with central cord syndrome. Mean age was 46 years and 91% were male. The predominant spinal cord injury classification was American Spinal Injury Association D (52%). Overall, 94% (31/33) reported volitional voiding and normal bladder sensation. Video-urodynamics demonstrated neurogenic detrusor overactivity in 70% (23/33) of patients, with 15% (5/33) demonstrating leakage with neurogenic detrusor overactivity and 21% (7/33) having reflex emptying. In total, 94% (31/33) of patients had normal compliance, 42% (14/33) of patients had detrusor sphincter or bladder neck dyssynergia and 60% (20/33) had an alteration to their management plan following urodynamic study.

Conclusion:

There is discordance between subjective patient-reported symptoms and objective urodynamic findings. About two-fifths of patients may have a potentially unsafe urodynamic bladder profile and urodynamics studies resulted in a change in bladder management in the majority of patients. Urodynamic assessment of patients with central cord syndrome is essential to determine which patients require further intervention.

Level of evidence:

Not applicable for this multicentre audit.

C2-C3 spinal fracture subluxation with ligamentous and vascular injury: a case report and review of management

Introduction

Spinal cord injury is one of the leading causes of paralysis and permanent morbidity. High cervical spine injuries, in particular, have the potential to be fatal and debilitating due to injury to multiple components, including but not limited to, discoligamentous disruption, vascular insult and spinal cord injury. To date, no unifying algorithm exists making it challenging to guide treatment decisions.

Case presentation

We present the case of a 29-year-old polytrauma patient with an unstable C2-C3 fracture subluxation secondary to hyperextension and rotation injury with complete ligamentous dissociation and vertebral artery dissection after a high-velocity injury. We review the literature on injury patterns, associated complications and neurological outcomes in subaxial cervical spine injuries.

Discussion

Our patient's injuries had several components including fracture subluxation, ligamentous disruption, central cord syndrome, and vascular insult. The lack of a unifying algorithm to guide treatment decisions highlights the variations in pathology and subsequent limitations in generalizability of current literature. Our patient underwent an open anterior C2-C3 reduction and discectomy with fusion and plating and a subsequent C2-C4 posterior instrumented fusion. The patient regained some motor function postoperatively and through rehabilitation. Careful consideration of multiple components is crucial when treating subaxial spine injuries.

Risk Factors and Prognosis for Acute Progression of Myelopathic Symptoms in Patients Ossification of the Posterior Longitudinal Ligament After Minor Trauma

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to identify the risk factors for acute progression of myelopathic symptoms (PMS) associated with ossification of the posterior longitudinal ligament (OPLL) after minor trauma and to compare the prognosis between an acute PMS group and a chronic PMS group.

SUMMARY OF BACKGROUND DATA

Although the prevalence of OPLL among patients with cervical myelopathy is high, few studies have been published regarding the risk factors for acute PMS associated with OPLL after minor trauma.

METHODS

Patients with OPLL who had histories of minor trauma and had undergone surgery were divided according to clinical course into an acute (within 48 hours, n = 38) and a chronic PMS group (n = 32). The type of trauma and the clinical and radiologic characteristics were compared. The clinical outcomes were also compared at admission and at 1 and 2 years postoperatively.

RESULTS

The types of trauma were significantly different between the two groups (P < 0.05). Univariate analysis revealed that older age, a narrower space available for the cord, and a higher rate of stenosis in the spinal canal were associated with acute PMS after minor trauma (P = 0.014, 0.020, and 0.006, respectively). However, the rate of stenosis in the spinal canal was the only risk factor that was identified in a multivariate analysis (P = 0.023; odds ratio, 0.872; 95% confidence interval, 0.774-0.982). The Japanese Orthopedic Association scores at the initial visit and at postoperative years 1 and 2 were significantly lower in the acute PMS group than in the chronic PMS group (P < 0.001, P < 0.001, and P < 0.001, respectively).

CONCLUSION

One risk factor for acute PMS in patients with OPLL after minor trauma is a higher rate of stenosis of the spinal canal. Patients with acute PMS exhibited unfavorable neurologic outcomes. Preventive surgical treatment may be recommended for patients with significant OPLL with mild cervical myelopathy.

LEVEL OF EVIDENCE

3.

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.

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.

Traumatic central cord syndrome after blunt cervical trauma: a pediatric case report

INTRODUCTION

Traumatic central cord syndrome (CCS) is the most frequently encountered incomplete spinal cord injury (SCI). The patient presents weakness, which is usually greater in the upper extremities than in the lower extremities, secondary to damage to the cervical spinal cord and anatomic distribution of the corticospinal tracts. CCS is seen commonly after a hyperextension mechanism in older patients with spondylotic changes. There are few literature reports regarding CCS in pediatric patients. We present an unusual case of traumatic CCS in a pediatric patient.

CASE PRESENTATION

A 15-year-old male patient, victim of bullying at school, received cervical blunt trauma with a plastic tube.  Within 3 h, the patient developed generalized weakness, which was greater in the upper extremities than in the lower extremities. Upon evaluation, the patient was found with marked upper extremity weakness compared to the lower extremities, with a Manual Muscle Test difference of 11 points. Imaging studies showed contusive changes in the C4-C7 central spinal cord. After rehabilitation therapies the patient gained 23 points in MMT at the day of discharge.

DISCUSSION

Different etiologies of CCS have previously been described in pediatric patients. However, this is the first case that describes a bullying event with cervical blunt trauma and subsequent CCS. In this case, history and physical examination, along with imaging studies, helped in the diagnosis, but it is important to be aware of the possibility of SCI without radiographic abnormalities, as it is common in the pediatric population. CCS occurs rarely in pediatric patients without underlying pathology. Physicians must be aware of the symptoms and clinical presentation in order to provide treatment and start early rehabilitation program.

Magnetic Resonance Imaging of Spinal Emergencies

Like the brain, the spinal cord is subject to trauma, infection, ischemia, hemorrhage, and compression. Early diagnosis is the key to preventing significant morbidity in the form of permanent disability. MR imaging is the gold standard for assessing acute injury to the spinal cord, intervertebral discs, ligaments, and surrounding soft tissues. In this article we systematically review the MRI findings in spinal cord trauma, ligamentous injury, epidural hematoma, epidural abscess, and metastatic disease.

Imaging of Spine Trauma

Imaging with computed tomography and magnetic resonance imaging is fundamental to the evaluation of traumatic spinal injury. Specifically, neuroradiologic techniques show the exact location of injury, evaluate the stability of the spine, and determine neural element compromise. This review focuses on the complementary role of different radiologic modalities in the diagnosis of patients with traumatic injuries of the spine. The role of imaging in spinal trauma classifications will be addressed. The importance of magnetic resonance imaging in the assessment of soft tissue injury, particularly of the spinal cord, will be discussed. Last, the increasing role of advanced imaging techniques for prognostication of the traumatic spine will be explored.

Cervical stenosis in spinal cord injury and disorders

CONTEXT/OBJECTIVE

The purpose of this study was to characterize etiologies of spinal cord injury and disorders (SCI/D) in persons with and without cervical stenosis/spondylosis (CSS) and to describe clinical characteristics and underlying comorbidities in these populations.

DESIGN AND SETTING

We reviewed administrative data for 1954 Veterans who had onset of traumatic or non-traumatic tetraplegia during FY 1999-2007. This included 1037 with a diagnosis of CSS at or in the two years prior to SCI onset of SCI/D and 917 without a diagnosis of CSS.

OUTCOME MEASURES

Demographics, etiologies of SCI/D and comorbidities by CSS status.

RESULTS

Veterans with SCI/D and CSS were older, more likely to have incomplete injuries and more likely to be Black than those with SCI/D and no CSS. Of patients with traumatic etiologies for SCI, 35.1% had a diagnosis of CSS at the time of or in the 2 years prior to SCI onset. Of those with tetraplegia due to falls, 40.0% had CSS, whereas for other known traumatic etiologies the percentages with CSS were lower: vehicular (25.0%); sports (16.1%); and acts of violence (10.2%). Total comorbidity scores measured by the Charlson co morbidity index and CMS Hierarchical Condition Category (CMS-HCC) were higher in those with CSS and SCI/D compared to those with SCI/D without CSS (P < 0.0001 respectively).

CONCLUSIONS

CSS is commonly present in patients with new traumatic tetraplegia. Falls are a particularly important potentially modifiable risk for SCI in patients with CSS.

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

BACKGROUND

Traumatic central cord syndrome (TCCS) is an incomplete spinal cord injury defined by greater weakness in upper versus lower extremities, variable sensory loss, and variable bladder, bowel, and sexual dysfunction. The optimal timing of surgery for TCCS remains controversial.

OBJECTIVE

To determine whether timing of surgery for TCCS predicts neurological outcomes, length of stay, and complications.

METHODS

Five databases were searched through March 2015. Articles were appraised independently by 2 reviewers, and the evidence synthesized according to Grading of Recommendation Assessment, Development and Evaluation principles.

RESULTS

Nine studies (3 prognostic, 5 therapeutic, 1 both) satisfied inclusion criteria. Low level evidence suggests that patients operated on <24 hours after injury exhibit significantly greater improvements in postoperative American Spinal Injury Association motor scores and the functional independence measure at 1 year than those operated on >24 hours after injury. Moderate evidence suggests that patients operated on <2 weeks after injury have a higher postoperative Japanese Orthopaedic Association score and recovery rate than those operated on >2 weeks after injury. There is insufficient evidence that lengths of hospital or intensive care unit stay differ between patients who undergo early versus delayed surgery. Furthermore, there is insufficient evidence that timing between injury and surgery predicts mortality rates or serious or minor adverse events.

CONCLUSION

Surgery for TCCS <24 hours after injury appears safe and effective. Although there is insufficient evidence to provide a clear recommendation for early surgery (<24 hours), it is preferable to operate during the first hospital admission and <2 weeks after injury.

The effect of increased T2 signal intensity in the spinal cord on the injury severity and early neurological recovery in patients with central cord syndrome

OBJECTIVE

The aim of this paper was to compare the severity of the initial neurological injury as well as the early changes in the American Spinal Injury Association (ASIA) motor score (AMS) between central cord syndrome (CCS) patients with and without an increased T2 signal intensity in their spinal cord.

METHODS

Patients with CCS were identified and stratified based on the presence of increased T2 signal intensity in their spinal cord. The severity of the initial neurological injury and the progression of the neurological injury over the 1st week were measured according to the patient's AMS. The effect of age, sex, congenital stenosis, surgery within 24 hours, and surgery in the initial hospitalization on the change in AMS was determined using an analysis of variance.

RESULTS

Patients with increased signal intensity had a more severe initial neurological injury (AMS 57.6 vs 75.3, respectively, p = 0.01). However, the change in AMS over the 1st week was less severe in patients with an increase in T2 signal intensity (−0.85 vs −4.3, p = 0.07). Analysis of variance did not find that age, sex, Injury Severity Score, congenital stenosis, surgery within 24 hours, or surgery during the initial hospitalization affected the change in AMS.

CONCLUSIONS

The neurological injury is different between patients with and without an increased T2 signal intensity. Patients with an increased T2 signal intensity are likely to have a more severe initial neurological deficit but will have relatively minimal early neurological deterioration. Comparatively, patients without an increase in the T2 signal intensity will likely have a less severe initial injury but can expect to have a slight decline in neurological function in the 1st week.

A model of acute central cervical spinal cord injury syndrome combined with chronic injury in goats

PURPOSE

To develop a large animal model for acute central cervical spinal cord injury syndrome (ACCSCIS.

METHODS

Twenty-four adult male goats were randomized into four groups including group A with acute compression injury, group B with anterior chronic compression, group C as the test group that received anterior chronic compression by screw and acute compression by posterior balloon insertion, and group D as normal controls that received sham surgery. Neurological function (modified Tarlov motor function), CT, MRI, cortical somatosensory evoked potentials (CSEP), and pathological analysis were evaluated. The data were analyzed statistically.

RESULTS

The motor function of the goats in group C was significantly lower than other groups. CSEP before spinal cord compression showed a stable pattern. Spinal cord compression resulted in a gradual decrement in the peak latency and significant increment in the peak amplitude. Cervical spinal canal occupying ratio was significantly lower in group C than the other groups. MRI revealed focal low signal in T1 weighted images and focal high signal in T2 weighted images in group C. Pathological analysis showed more severe lesions in the gray matter than that in the white matter in group C.

CONCLUSIONS

The model well simulated the pathogenesis and resembled the clinical characteristics of ACCSCIS. This model seems to have the potential to contribute to the development of effective therapies for ACCSCIS.

Complications and outcomes of vasopressor usage in acute traumatic central cord syndrome

OBJECT

The optimal mean arterial pressure (MAP) for spinal cord perfusion after trauma remains unclear. Although there are published data on MAP goals after spinal cord injury (SCI), the specific blood pressure management for acute traumatic central cord syndrome (ATCCS) and the implications of these interventions have yet to be elucidated. Additionally, the complications of specific vasopressors have not been fully explored in this injury condition.

METHODS

The present study is a retrospective cohort analysis of 34 patients with ATCCS who received any vasopressor to maintain blood pressure above predetermined MAP goals at a single Level 1 trauma center. The collected variables were American Spinal Injury Association (ASIA) grades at admission and discharge, administered vasopressor and associated complications, other interventions and complications, and timing of surgery. The relationship between the 2 most common vasopressors—dopamine and phenylephrine—and complications within the cohort as a whole were explored, and again after stratification by age.

RESULTS

The mean age of the ATCCS patients was 62 years. Dopamine was the most commonly used primary vasopressor (91% of patients), followed by phenylephrine (65%). Vasopressors were administered to maintain MAP goals fora mean of 101 hours. Neurological status improved by a median of 1 ASIA grade in all patients, regardless of the choice of vasopressor. Sixty-four percent of surgical patients underwent decompression within 24 hours. There was no observed relationship between the timing of surgical intervention and the complication rate. Cardiogenic complications associated with vasopressor usage were notable in 68% of patients who received dopamine and 46% of patients who received phenylephrine. These differences were not statistically significant (OR with dopamine 2.50 [95% CI 0.82–7.78], p = 0.105). However, in the subgroup of patients > 55 years, dopamine produced statistically significant increases in the complication rates when compared with phenylephrine (83% vs 50% for dopamine and phenylephrine, respectively; OR with dopamine 5.0 [95% CI 0.99–25.34], p = 0.044).

CONCLUSIONS

Vasopressor usage in ATCCS patients is associated with complication rates that are similar to the reported literature for SCI. Dopamine was associated with a higher risk of complications in patients > 55 years. Given the increased incidence of ATCCS in older populations, determination of MAP goals and vasopressor administration should be carefully considered in these patients. While a randomized control trial on this topic may not be practical, a multiinstitutional prospective study for SCI that includes ATCCS patients as a subpopulation would be useful for examining MAP goals in this population.

Risk Prediction for Development of Traumatic Cervical Spinal Cord Injury without Spinal Instability

Study Design Retrospective comparative study. Objective A narrow spinal canal is an important risk factor for predicting a spinal cord injury (SCI); however, the radiologic parameters have not been fully established. The authors conducted a comparative study to forecast SCI risk by determining a predictive spinal canal diameter (SCD) cutoff value from magnetic resonance image (MRI) in the Korean population. Methods On T2-weighted MRI of the cervical spine, the SCD at the pedicle (SCDpedicle) and the intervertebral disk level (SCDdisk) were measured in patients with SCI without spinal instability and in healthy subjects. Additionally, the vertebral body diameter (Dvertebral body) and intervertebral disk diameter (Dintervertebral disk) were measured, and the two ratios (SCDpedicle to Dvertebral body and SCDdisk to Dintervertebral disk) were calculated. In the SCI group, the extent of high signal intensity on the T2-weighted midsagittal MRI was determined. Results The data obtained from 20 patients in the SCI group (18 men, mean age 61.35 years) and 65 individuals in the control group (47 men, mean age 57.05 years) was compared. All the parameters including the SCD and the calculated ratios were significantly smaller in the SCI group than in the control group. Among them, the area under the receiver operating curve (AUC) value for the SCDdisk-to-Dintervertebral disk ratio at C2-C3, with a cutoff ratio value of 0.59, provided the greatest positive predictive value. A low SCDdisk-to-Dintervertebral disk ratio at C4-C5 and the presence of >40 mm of high signal intensity on the MRI were related with the presence of complete SCI. Conclusion Because the C2-C3 level is relatively wide compared with the subaxial cervical spine, a small ratio at C2-C3 provided the greatest positive predictive value in SCI. Complete SCI is associated with a small SCDdisk-to-Dintervertebral disk ratio at C4-C5 and with extensive high signal intensity on MRI.

Diagnosis and management of traumatic cervical central spinal cord injury: A review

Background:

The classical clinical presentation, neuroradiographic features, and conservative vs. surgical management of traumatic cervical central spinal cord (CSS) injury remain controversial.

Methods:

CSS injuries, occurring in approximately 9.2% of all cord injuries, are usually attributed to significant hyperextension trauma combined with congenital/acquired cervical stenosis/spondylosis. Patients typically present with greater motor deficits in the upper vs. lower extremities accompanied by patchy sensory loss. T2-weighted magnetic resonance (MR) scans usually show hyperintense T2 intramedullary signals reflecting acute edema along with ligamentous injury, while noncontrast computed tomography (CT) studies typically show no attendant bony pathology (e.g. no fracture, dislocation).

Results:

CSS constitute only a small percentage of all traumatic spinal cord injuries. Aarabi et al. found CSS patients averaged 58.3 years of age, 83% were male and 52.4% involved accidents/falls in patients with narrowed spinal canals (average 5.6 mm); their average American Spinal Injury Association (ASIA) motor score was 63.8, and most pathology was at the C3-C4 and C4-C5 levels (71%). Surgery was performed within 24 h (9 patients), 24–48 h (10 patients), or after 48 h (23 patients). In the Brodell et al. study of 16,134 patients with CSS, 39.7% had surgery. In the Gu et al. series, those with CSS and stenosis/ossification of the posterior longitudinal ligament (OPLL) exhibited better outcomes following laminoplasty.

Conclusions:

Recognizing the unique features of CSS is critical, as the clinical, neuroradiological, and management strategies (e.g. conservative vs. surgical management: early vs. late) differ from those utilized for other spinal cord trauma. Increased T2-weighted MR images best document CSS, while CT studies confirm the absence of fracture/dislocation.

Traumatic central cord syndrome in a 2-year-old child: minor trauma but major complication

BACKGROUND

Traumatic central cord syndrome (TCCS) is the most frequently encountered incomplete spinal cord injury, and it is a relatively rare situation in children younger than 15 years, but may have serious consequences.

METHODS

We report the case of a 2-year-old female child with upper extremity weakness following a simple fall. All vitals and systemic examination findings were normal, except for 2/5 muscular strength in the upper extremities. While radiographic imaging showed no pathologic findings, MRI exposed spinal injury. The patient was treated conservatively with medication only. The medical treatment of the patient consisted of anti-edema treatment with methylprednisolone in the first 24 hours; 330 mg of methylprednisolone infused in the first hour, followed by 59 mg per hour during the next 23 hours. Along with pharmacological treatment, she received physiotherapy sessions during her 11-day hospitalization period.

RESULTS

The child had full recovery within 6 months after conservative treatment.

CONCLUSION

Neurological deficit without plain radiographic evidence in pediatric spinal trauma patients is a rare but significant incident.

Cervical injuries scored according to the Subaxial Injury Classification system: An analysis of the literature

INTRODUCTION

The Subaxial Injury Classification (SLIC) system and severity score has been developed to help surgeons in the decision-making process of treatment of subaxial cervical spine injuries. A detailed description of all potential scored injures of the SLIC is lacking.

MATERIALS AND METHODS

We performed a systematic review in the PubMed database from 2007 to 2014 to describe the relationship between the scored injuries in the SLIC and their eventual treatment according to the system score.

RESULTS

Patients with an SLIC of 1-3 points (conservative treatment) are neurologically intact with the spinous process, laminar or small facet fractures. Patients with compression and burst fractures who are neurologically intact are also treated nonsurgically. Patients with an SLIC of 4 points may have an incomplete spinal cord injury such as a central cord syndrome, compression injuries with incomplete neurologic deficits and burst fractures with complete neurologic deficits. SLIC of 5-10 points includes distraction and rotational injuries, traumatic disc herniation in the setting of a neurological deficit and burst fractures with an incomplete neurologic deficit.

CONCLUSION

The SLIC injury severity score can help surgeons guide fracture treatment. Knowledge of the potential scored injures and their relationships with the SLIC are of paramount importance for spine surgeons who treated subaxial cervical spine injuries.

Hyperextension injury of the cervical spine with central cord syndrome

PURPOSE

Traumatic central cord syndrome (TCCS) is the most commonly encountered type of incomplete spinal cord injury. TCCS typically occurs in patients over the age of 50 with a narrow spinal canal and follows an acute hyperextension injury of the cervical spine. Here, we report on the demographics of TCCS patients, their clinical course and outcomes, and the factors that may have influenced these outcomes.

METHODS

We conducted a retrospective folder review of patients who presented to our facility between January 2004 and December 2008 following hyperextension injury of the cervical spine and with the clinical manifestations of a central cord syndrome. Patient details were obtained from the acute spinal cord injury register at Groote Schuur Hospital and the patient folders, radiographs and magnetic resonance imaging films were reviewed. Predetermined data points were identified, tabulated and analysed, with only information from the injury-related admission being included.

RESULTS

An ASIA motor score of ≥60 on admission or discharge correlated with an 80 % chance of being able to walk at discharge from hospital. An ASIA motor score of ≤50 on admission correlated with an 80 % chance of not walking at discharge. An ASIA motor score of ≤50 at discharge meant a patient was not only unable to walk, but required placement in a spinal injury rehabilitation centre. Further, if a patient had a cervical spinal canal diameter of ≥8 mm they had a 50 % chance of clinical improvement and nearly 80 % chance of a functional outcome.

CONCLUSION

The Groote Schuur Hospital patient population differs from the international norm, particularly with respect to age and mechanism of injury. The ASIA motor score and cervical spine canal diameter proved to be useful predictors of outcome. Within our patient group, timing of surgery did not appear to influence the outcome.

A case of paraparesis with thoracic ossification of the posterior longitudinal ligament and the ligamentum flavum induced by falling down on the abdomen

Aim

To describe an educational case.

Methods

Case report.

Results

A 71-year-old female was transported to our emergency department with complaints of lower abdominal pain and gate disturbance after falling down on her abdomen. She had lower abdominal painful paresthesia in the dermatome from the twelfth thoracic to the first lumbar level without signs of peritoneal stimulation. Paraparesis and dysesthesia of the lower extremities was predominant on the left side. Abdominal computed tomography revealed severe thoracic ossification of the posterior longitudinal ligament and the ligamentum flavum at the thoracic level 10/11. Laminectomy and spinal fusion with rods resulted in recovery of the patient's symptoms.

Conclusion

Physician should pay attention to thoracic spinal cord injury induced by hyperextensive stress on the spine, even in cases of minor trauma, among patients with preexisting bony pathologies at the thoracolumbar level.

Predictors of pulmonary complications in blunt traumatic spinal cord injury

OBJECT

Pulmonary complications are the most common acute systemic adverse events following spinal cord injury (SCI), and contribute to morbidity, mortality, and increased length of hospital stay (LOS). Identification of factors associated with pulmonary complications would be of value in prevention and acute care management. Predictors of pulmonary complications after SCI and their effect on neurological recovery were prospectively studied between 2005 and 2009 at the 9 hospitals in the North American Clinical Trials Network (NACTN).

METHODS

The authors sought to address 2 specific aims: 1) define and analyze the predictors of moderate and severe pulmonary complications following SCI; and 2) investigate whether pulmonary complications negatively affected the American Spinal Injury Association (ASIA) Impairment Scale conversion rate of patients with SCI. The NACTN registry of the demographic data, neurological findings, imaging studies, and acute hospitalization duration of patients with SCI was used to analyze the incidence and severity of pulmonary complications in 109 patients with early MR imaging and long-term follow-up (mean 9.5 months). Univariate and Bayesian logistic regression analyses were used to analyze the data.

RESULTS

In this study, 86 patients were male, and the mean age was 43 years. The causes of injury were motor vehicle accidents and falls in 80 patients. The SCI segmental level was in the cervical, thoracic, and conus medullaris regions in 87, 14, and 8 patients, respectively. Sixty-four patients were neurologically motor complete at the time of admission. The authors encountered 87 complications in 51 patients: ventilator-dependent respiratory failure (26); pneumonia (25); pleural effusion (17); acute lung injury (6); lobar collapse (4); pneumothorax (4); pulmonary embolism (2); hemothorax (2), and mucus plug (1). Univariate analysis indicated associations between pulmonary complications and younger age, sports injuries, ASIA Impairment Scale grade, ascending neurological level, and lesion length on the MRI studies at admission. Bayesian logistic regression indicated a significant relationship between pulmonary complications and ASIA Impairment Scale Grades A (p = 0.0002) and B (p = 0.04) at admission. Pulmonary complications did not affect long-term conversion of ASIA Impairment Scale grades.

CONCLUSIONS

The ASIA Impairment Scale grade was the fundamental clinical entity predicting pulmonary complications. Although pulmonary complications significantly increased LOS, they did not increase mortality rates and did not adversely affect the rate of conversion to a better ASIA Impairment Scale grade in patients with SCI. Maximum canal compromise, maximum spinal cord compression, and Acute Physiology and Chronic Health Evaluation-II score had no relationship to pulmonary complications.

Risk factors for acute cervical spinal cord injury associated with ossification of the posterior longitudinal ligament

STUDY DESIGN

Retrospective review.

OBJECTIVE

To identify risk factors for traumatic cervical spinal cord injury (SCI) associated with ossification of the posterior longitudinal ligament (OPLL) by comparing patients with SCI and those with cervical myelopathy (CM) associated with OPLL.

SUMMARY OF BACKGROUND DATA

Although the prevalence of OPLL among patients with cervical SCI is high, little is published about the risk factors for SCI associated with OPLL.

METHODS

We evaluated 3 groups of patients: 34 with SCI associated with OPLL, 32 with CM associated with OPLL, and 32 normal controls. Developmental canal diameter, spinal canal stenosis, type of OPLL, and presence of ossification of the anterior longitudinal ligament (OALL) were evaluated using 3-dimensional computed tomography.

RESULTS

The mean age of the SCI group was 71.5 years, significantly more than that of the CM group (63.3 years). The SCI and CM groups had significantly smaller developmental canals than controls. Canal stenosis caused by OPLL was significantly more severe in the CM group than in the SCI group. There were no significant differences in sex distribution or the type of OPLL. Mixed or segmental types of OPLL were the main cause of SCI and CM. The SCI group showed a significantly higher incidence of OALL (56%) than the CM group (22%). Cervical SCI occurred at the edge of the OPLL or OALL in 20 patients (59%). If limited to mixed or continuous types of OPLL, 18 of the 19 patients (95%) sustained SCI at the edge of the OPLL or OALL.

CONCLUSION

Risk factors for cervical SCI associated with OPLL were being elderly, having a mixed or segmental type of OPLL, and presence of OALL. Most instances of SCI occurred at edges of the OPLL or OALL. Severe spinal canal stenosis caused by OPLL was not an essential risk factor for developing SCI.

MR imaging of acute cervical spinal ligamentous and soft tissue trauma

The increasing availability of magnetic resonance imaging (MRI) and the high sensitivity of MRI for soft tissue injury are resulting in the increased use of MRI for the evaluation of acute trauma. As cervical spine injury can have a devastating consequence, MRI is being more commonly used to evaluate cervical spine injury in the acute setting, necessitating emergent interpretation by the on-call radiologist. Unless one is formally trained in a trauma center, the MRI findings of soft tissue and ligamentous cervical spine injury may not be fully appreciated. The goal of this pictorial review is to familiarize the reader with some of the more common soft tissue, vascular, and ligamentous injuries seen on MRI of the cervical spine in the emergent setting.

Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis

Object

The objective of this study was to elucidate the relationship between admission demographic data, validated injury severity measures on imaging studies, and clinical indicators on the American Spinal Injury Association (ASIA) motor score, Functional Independence Measure (FIM), manual dexterity, and dysesthetic pain at least 12 months after surgery for acute traumatic central cord syndrome (ATCCS) due to spinal stenosis.

Methods

Over a 100-month period (January 2000 to April 2008), of 211 patients treated for ATCCS, 59 cases were due to spinal stenosis, and these patients underwent surgical decompression. Five of these patients died, 2 were lost to follow-up, 10 were not eligible for the study, and the remaining 42 were followed for at least 12 months.

Results

In the cohort of 42 patients, mean age was 58.3 years, 83% of the patients were men, and 52.4% of the accidents were due to falls. Mean admission ASIA motor score was 63.8 (upper extremities score, 25.8 and lower extremities score, 39.8), the spinal cord was most frequently compressed at skeletal segments C3–4 and C4–5 (71%), mean midsagittal diameter at the point of maximum compression was 5.6 mm, maximum canal compromise (MCC) was 50.5%, maximum spinal cord compression was 16.5%, and length of parenchymal damage on T2-weighted MR imaging was 29.4 mm. Time after injury until surgery was within 24 hours in 9 patients, 24–48 hours in 10 patients, and more than 48 hours in 23 patients. At the 1-year follow-up, the mean ASIA motor score was 94.1 (upper extremities score, 45.7 and lower extremities score, 47.6), FIM was 111.1, manual dexterity was 64.4% of baseline, and pain level was 3.5. Stepwise regression analysis of 10 independent variables indicated significant relationships between ASIA motor score at follow-up and admission ASIA motor score (p = 0.003), MCC (p = 0.02), and midsagittal diameter (p = 0.02); FIM and admission ASIA motor score (p = 0.03), MCC (p = 0.02), and age (p = 0.02); manual dexterity and admission ASIA motor score (p = 0.0002) and length of parenchymal damage on T2-weighted MR imaging (p = 0.002); and pain level and age (p = 0.02) and length of parenchymal lesion on T2-weighted MR imaging (p = 0.04).

Conclusions

The main indicators of long-term ASIA motor score, FIM, manual dexterity, and dysesthetic pain were admission ASIA motor score, midsagittal diameter, MCC, length of parenchymal damage on T2-weighted MR imaging, and age, but different domains of outcome were determined by different predictors.

Traumatic cervical cord transection without facet dislocations--a proposal of combined hyperflexion-hyperextension mechanism: a case report

A patient is presented with a cervical spinal cord transection which occurred after a motor vehicle accident in which the air bag deployed and the seat belt was not in use. The patient had complete quadriplegia below the C5 level and his imaging study showed cervical cord transection at the level of the C5/6 disc space with C5, C6 vertebral bodies and laminar fractures. He underwent a C5 laminectomy and a C4-7 posterior fusion with lateral mass screw fixation. Previous reports have described central cord syndromes occurring in hyperextension injuries, but in adults, acute spinal cord transections have only developed after fracture-dislocations of the spine. A case involving a post-traumatic spinal cord transection without any evidence of radiologic facet dislocations is reported. Also, we propose a combined hyperflexion-hyperextension mechanism to explain this type of injury.