Penetrating injury of the spinal cord treated surgically

A 44-year-old man reported acute neck pain, hyperalgesia, and mild paraplegia caused by a wire-penetrating injury of the neck and was hospitalized. The foreign body was located at the C6 level. Pre- and postoperative physical examination and imaging studies were performed to assess the degree of injury. Emergent surgery was performed 30 minutes after admission to prevent the patient from potential severe neurological impairment and infection. The patient's postoperative recovery was significant. Only hyperalgesia at the ulnar side of the forearm remained, with no other positive signs of neurologic loss. Motor strength of the upper and lower extremities returned to normal. The postoperative degree of the spinal cord injury was assessed as American Spinal Injury Association grade E. Surgical removal of foreign bodies retained in the spinal canal may prevent infection, myelopathy, and delayed neurologic loss. Removal of retained intraspinal metallic fragments can improve neurologic outcome.     

Stab wound of the cervical spinal cord and ipsilateral vertebral artery injury

Stab wound of the cervical spinal cord with ipsilateral vertebral artery injury is rare. We report a case of a penetrating injury by scissors to the cervical spinal cord and right vertebral artery. The management is discussed and literature reviewed.     

Neurological outcome in surgically treated patients with incomplete closed traumatic cervical spinal cord injury

Study design:Retrospective study based on a reference paper. Neurological outcome in patients who were managed surgically with closed traumatic cervical spine injury was evaluated using the ASIA motor scoring system and Frankel grading.Objectives:To assess the accuracy of motor charting and Frankel grading as tools to evaluate neurological outcome in closed traumatic cervical spine injury, and also to evaluate how the surgically treated patients fared in their neurological recovery by measurement tools as in the reference paper.Setting:National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK.Method:Fifty-seven patients were admitted within 2 days of the injury with closed traumatic cervical spine injuries (1997-2004). Thirty-seven (65%) met the inclusion criteria as per the referenced paper, that is, were treated surgically, were Frankel grade B and above and had at least 12 months follow up. The remaining 20 patients were not included as they did not meet the inclusion criteria. The breakdown of the 20 patients is given in Table 1. The mean recovery percentage (MRP) and mean deficit percentage (MDP) were calculated as per the referenced paper.Results:An evaluation of 37 patients surgically treated, who had follow up of at least 12 months, showed that preservation of pin prick below the level of lesion, and preservation of anal tone and perianal sensation were good prognostic indicators. There was no correlation between degree of encroachment of canal or the degree of kyphosis to MDP or MRP. The mean time from injury to mobilization was 7.6 days in 25 out of 37 patients. Twelve of the 37 patients had prolonged immobilization because of ITU stay or because they were initially treated conservatively. Three out of the 37 patients developed DVT/PE. Mean hospital stay was 6.4 months.Conclusion:The neurological outcome in surgically treated patients is comparable to the conservatively treated patients. The Frankel grading and ASIA motor charting combined is a powerful tool in assessing the neurological outcome in closed traumatic cervical spinal injured patients. Until now there has been no evidence to suggest that the obvious advantages of surgical management of closed cervical spine injuries (better alignment, easier manual handling and early mobilization) is traded for poorer neurological outcome.Spinal Cord (2008) 46, 603-607; doi:10.1038/sc.2008.29; published online 13 May 2008.     

扩大半椎板切除术治疗颈脊髓损伤

OBJECTIVE: To treat cervical spinal cord injury (SCI) accompanied with narrowing spinal canal by expanded hemilaminectomy. METHODS: From 1995 January to 1998 April 51 patients of cervical SCI were treated by expanded hemilaminectomy. Spinal injury classified in to 3 types: no fracture-dislocation (39 patients) fracture dislocation at the lower cervical spine (11), and burst fracture (1). The types of SCI included central cord injury (18 patients) incomplete cord injury (19), and complete cord injury (14). MR imaging in 23 patients showed degenerative changes with normal intensity of the cord in 14 patients, multiple level hyperintensity in 3, cystic changes in 3, myelomalasia in 3, and cord brocken in 1. Expanded hemilaminectomy was performed in 24 hours in 3 patients, in 48 hours in 9, in one week in 2, after one week in 35, and after one year in 2. The left or right laminae were removed from C(7) to C(3) in 42 patients, C(3) - T(1) in 3, C(2) - C(7) in 2, C(3) - C(6) in 3 and C(4) - C(7) in 3. Hemilaminectomy was expanded lateral to the inner of apophyseal joint and medial to the inner lamina beneath the spinal process. RESULTS: Follow-up lasted for 1 year and 7 months. Six patients with complete cord injury had of the no recovery lower extremity but recovery of the brachialis and extensor radial longus. 12 patients of central cord injury had full recovery except intrinsic muscles of the hand (5). They operated were on 2 weeks after injury. 17 patients of incomplete cord injury recovered to Frankel IV. CONCLUSIONS: Expanded hemilaminectomy is indicated for patients of cervical SCI with narrowing spinal canal or without fracture dislocation. Best results can be obtained in patients of central cord injury, and incomplete cord injury. Even in complete cord injury, 1 - 2 forearm muscle may recover (24.8%), securing a pinch grip reconstruction.     

Stab wound of the spinal cord complicated by meningitis and subarachnoid fistula

We describe a case of penetrating spinal cord injuries in an 20-year-old man after stab wound attack. The outcome was complicated with subarachnoid fistula and meningitis. The diagnosis and management of these complications are discussed.     

Old spinal cord injury treated by pulsed electric stimulation]

From March 1989 to May 1990, 80 cases of old spinal cord injury were treated with pulsed electric stimulation. The pulsed electric field was formed by utilizing paradural needle electrodes positioned cephalad and caudad to the site of spinal cord injury, with the stimulator connected with the electrodes being turned on. This stimulation was given 30 minutes once daily. 13 cases were treated for 3-6 months, 57 for 6-12 months, and 10 for 12-18 months. The nerve functions recovered in 78.5% of the cases (63/80), with the rate of useful recovery of 47.5% (38/80). The rate of EMG and gait improvement were 75.5% and 77.7%, respectively. The effect of pulsed electric stimulations was related to the extent of spinal cord injury, the depth and position of needle electrodes, the frequency and intensity of pulsed current and whether the spinal cord was compressed.     

Histologic characterization of acute spinal cord injury treated with intravenous methylprednisolone

OBJECTIVE: Many substances have been investigated for attenuation of spinal cord injury after acute trauma; however, pharmacologically only steroid administration has shown clinical benefits. This study attempts to characterize local spinal cord histologic response to human dose equivalent (HDE) intravenous methylprednisolone (MP) administration in a rodent model of acute spinal cord injury. DESIGN: Forty-eight Sprague-Dawley rats were divided equally into control and experimental groups. Each group was subdivided into eight sets of three animals each, according to postinjury intervals. Paraplegia after lower thoracic laminectomy was achieved using a standardized weight drop technique. INTERVENTION: Within one hour, experimental animals were treated with HDE MP followed by 23-hour continuous infusion of HDE MP. Spinal cords were harvested at variable intervals postinjury and prepared for histologic/immunohistochemistry examination. MAIN OUTCOME MEASUREMENTS: Edema, necrosis, and glial fibrillary acidic protein (GFAP) positivity in the specimens from treated/control groups were graded by microscopy and immunohistochemistry staining and compared in a blinded manner by a qualified neuropathologist and senior authors. RESULTS: Minimal differences were observed between control and MP-treated animals at zero and four hours. At eight hours, increased white matter and medullary edema was evident in control versus MP-treated rats. This trend continued through twelve, sixteen, twenty-four, forty-eight, and seventy-two hours. No difference was observed in the astrocytic response to injury by GFAP immunohistochemistry between the groups. CONCLUSIONS: Histologically, MP reduces the development of severe edema and preserves spinal cord architecture adjacent to the site of injury. In contrast, MP does not alter the development of spinal cord necrosis or astrocytic response at the zone of injury.     

Progressive cystic degeneration of the spinal cord following spinal cord injury

From a group of 520 spinal cord injury patients treated at Rancho Los Amigos Hospital, two cases of progressive myelopathy secondary to cystic degeneration of the spinal cord have been identified. The cyst may dissect proximately to produce progressive neurologic deficit. Surgical treatment with shunting can allow stabilization and improvement with return of newly lost function.     

Penetrating injury of the spinal cord

We describe 2 cases of penetrating injury of the thoracic spinal cord complicating stab wounds of the chest. Both patients exhibited the Brown-Séquard syndrome, with disturbances of sphincters as well as motor and sensory changes; both developed meningitis. The diagnosis and management of these patients are discussed.     

Acute spinal cord injury

Acute spinal cord injuries may arise due to blunt injuries or to penetrating trauma, such as stab or gunshot injuries. The severity of injury is best described in terms of the orthopaedic injury and the sensorimotor pattern of neurological deficit (American Spinal Injury Association category). Advanced Trauma Life Support assessment of all trauma patients includes a thorough neurological examination to identify acute spinal cord injury, the management of which requires discussion with a dedicated spinal injuries unit, and, if appropriate, transfer for specialist care. Spinal injuries centres have multidisciplinary teams that can manage the medical and surgical aspects of patient care together with nursing expertise to avoid decubitus ulceration and other complications of spinal cord injury, and a full rehabilitation team to manage the physical, social, financial, and emotional aspects of rehabilitation. People with medical causes of spinal cord injury (e.g. transverse myelitis) experience many of the same problems as people with traumatic spinal cord injury.     

Gunshot injury of the spinal cord

108 pigs were shot at the level of lumbar 1 to investigate the changes of spinal cord in relation to the speed of shooting and the trajectory through which the bullet passed. The cord lesions of the specimens could be divided, according to its severity, into 4 grades: (1) transection in 41; (2) complete destruction in 43; both lesion 1&2 resulted in permanent paraplegia; (3) incomplete destruction in 13, those resulted in incomplete paraplegia eventually recovered; (4) mild damage, that was concussion in 11, resumed perfectly. Through a transducer sealed into the spinal canal, the intracanal pressure was recorded: (1) Shooting through spinal canal with a pressure over 5 kg caused cord transection. (2) shooting through canal wall with a pressure of 2.5 to 5; 0 kg caused complete cord destruction. (3) shooting nearby the outer margin of vertebra with a pressure less than 1.0 kg caused mild cord damage. It was found that the speed of bullet, the trajectory with relation to cord and the grade of cord lesion are in agreement with each other. The mutual effects among them would make one think it reasonable to classify cord injury as follows: 1. Injury from bullet through spinal canal or vertebral body usually causes cord transaction; 2. Injury from bullet through canal wall at high speed would make a chance of complete destruction in 94%; at low speed, a chance of either complete or incomplete lesion in 50% each. 3. Injury nearby vertebra, high speed bullet would cause a chance of complete cord lesion in 86%; low speed one would make a chance of incomplete lesion in 1/3 and mild lesion in 2/3.     

Acute spinal cord injury

Opinion statement Acute spinal cord injury is a devastating disease with enormous repercussions, not only for the victims and their families but for society as a whole. Despite the advent of novel medical therapies for the treatment of these injuries, many patients with spinal cord injury remain severely incapacitated and dependent on their families and/or specialized nursing care. Much of the controversy in the treatment of these injuries stems from insufficient knowledge about the pathophysiology of the disease as well as the timing of certain treatments such as surgery. We discuss the diagnosis and management of these injuries as well as novel therapies on the horizon. The recent emphasis on evidence-based medicine has resulted in the creation of guidelines from the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, which will hopefully result in some standardization of care. It is our opinion that early recognition of spinal cord injury and careful management in an intensive care setting can prevent many of the medical complications that are the major source of morbidity and mortality in these patients.     

小儿脊柱脊髓损伤

小儿脊柱脊髓损伤相对少见,占全部脊柱脊髓损伤的1%～10%.由于处于生长发育阶段的小儿脊柱在解剖和生物力学方面的特殊性,小儿脊柱脊髓损伤的诊断、治疗和成人有一定区别.幼儿以颈椎高位损伤相对常见,2岁以下幼儿的颈椎损伤约80%表现为高位损伤.随着年龄增大(＞8岁),儿童脊柱解剖特点和损伤类型逐渐接近于成人表现.尽管小儿脊柱脊髓损伤相对少见,由于影像学特征以及幼儿不能很好配合的特点,使得小儿脊柱脊髓损伤的准确诊治比较困难.本文针对这一情况,结合小儿不间发育阶段脊柱解剖特点、脊柱脊髓损伤特点及其具体诊治进行综述.