Pediatric spinal cord and vertebral column injury.

Between January 1, 1970, and December 31, 1988, 179 children (birth to age 16) were treated for spinal cord and/or vertebral column injury by the Neurosurgical Service at the University of Iowa Hospitals and Clinics. Pediatric injuries accounted for 9% of all spinal trauma seen during this period. The mean age was 10.2 years. Sixty-two children were between birth and 8 years of age and 117 were between ages 9 and 16. The cause, distribution, type of injury, and severity of neurological injury varied with age. Neurological outcome was dependent on the severity of the initial neurological injury. Children with complete or severe incomplete myelopathy uniformly remained with severe neurological dysfunction; children with mild to moderate injuries recovered normal or nearly normal neurological function. Surgical versus nonoperative management had no bearing on neurological outcome. Twelve percent of the children with severe spinal cord injuries developed posttraumatic spinal deformity. We conclude that spinal injury patterns differ between preadolescent and older children. Most injuries can be successfully managed with nonoperative therapy. Prognosis is primarily correlated with the severity of the initial neurological insult. Finally, children with severe spinal cord injury must have close, long-term follow-up to monitor the development of posttraumatic spinal deformity.     

A surgical revisitation of Pott distemper of the spine.

BACKGROUND CONTEXT: Pott disease and tuberculosis have been with humans for countless millennia. Before the mid-twentieth century, the treatment of tuberculous spondylitis was primarily supportive and typically resulted in dismal neurological, functional and cosmetic outcomes. The contemporary development of effective antituberculous medications, imaging modalities, anesthesia, operative techniques and spinal instrumentation resulted in quantum improvements in the diagnosis, management and outcome of spinal tuberculosis. With the successful treatment of tuberculosis worldwide, interest in Pott disease has faded from the surgical forefront over the last 20 years. With the recent unchecked global pandemic of human immunodeficiency virus, the number of tuberculosis and secondary spondylitis cases is again increasing at an alarming rate. A surgical revisitation of Pott disease is thus essential to prepare spinal surgeons for this impending resurgence of tuberculosis. PURPOSE: To revisit the numerous treatment modalities for Pott disease and their outcomes. From this information, a critical reappraisal of surgical nuances with regard to decision making, timing, operative approach, graft types and the use of instrumentation were conducted. STUDY DESIGN: A concise review of the diagnosis, management and surgical treatment of Pott disease. METHODS: A broad review of the literature was conducted with a particular focus on the different surgical treatment modalities for Pott disease and their outcomes regarding neurological deficit, kyphosis and spinal stability. RESULTS: Whereas a variety of management schemes have been used for the debridement and reconstruction of tuberculous spondylitis, there has also been a spectrum of outcomes regarding neurological function and deformity. Medical treatment alone remains the cornerstone of therapy for the majority of Pott disease cases. Surgical intervention should be limited primarily to cases of severe or progressive deformity and/or neurological deficit. Based on the available evidence, radical ventral debridement and grafting appears to provide reproducibly good long-term neurological outcomes. Furthermore, recurrence of infection is lowest with such techniques. Posterior operative techniques are most effective in the reduction and prevention of spinal deformity. CONCLUSIONS: Unlike historical times, effective medical and surgical management of tuberculous spondyitis is now possible. Proper selection of drug therapy and operative modalities, however, is needed to optimize functional outcomes for each individual case of Pott disease.     

Management of thoracolumbar spine trauma: An overview

Thoracolumbar spine fractures are common injuries that can result in significant disability, deformity and neurological deficit. Controversies exist regarding the appropriate radiological investigations, the indications for surgical management and the timing, approach and type of surgery. This review provides an overview of the epidemiology, biomechanical principles, radiological and clinical evaluation, classification and management principles. Literature review of all relevant articles published in PubMed covering thoracolumbar spine fractures with or without neurologic deficit was performed. The search terms used were thoracolumbar, thoracic, lumbar, fracture, trauma and management. All relevant articles and abstracts covering thoracolumbar spine fractures with and without neurologic deficit were reviewed. Biomechanically the thoracolumbar spine is predisposed to a higher incidence of spinal injuries. Computed tomography provides adequate bony detail for assessing spinal stability while magnetic resonance imaging shows injuries to soft tissues (posterior ligamentous complex [PLC]) and neurological structures. Different classification systems exist and the most recent is the AO spine knowledge forum classification of thoracolumbar trauma. Treatment includes both nonoperative and operative methods and selected based on the degree of bony injury, neurological involvement, presence of associated injuries and the integrity of the PLC. Significant advances in imaging have helped in the better understanding of thoracolumbar fractures, including information on canal morphology and injury to soft tissue structures. The ideal classification that is simple, comprehensive and guides management is still elusive. Involvement of three columns, progressive neurological deficit, significant kyphosis and canal compromise with neurological deficit are accepted indications for surgical stabilization through anterior, posterior or combined approaches.     

Subacute posttraumatic ascending myelopathy: A case report and review of literature

Subacute posttraumatic ascending myelopathy is a rare disorder, unrelated to syrinx formation or mechanical instability, which may gradually emerge within the first 1-2 weeks after a spinal cord injury and may lead to diagnostic and prognostic dilemmas. We present a case of 24-year-old female with unstable wedge compression fracture of L₁ vertebrae with signal changes in the upper lumbar cord causing complete paraplegia below D₉ with bladder and bowel involvement. In the subsequent week, she developed a delayed progressively increasing neurological deficit with cord signal abnormality on MRI extending cephalad from the injury site to the upper dorsal cord. The patient had no initial clinical improvement initially but showed a delayed recovery over months.     

Posttraumatic syringomyelia: the British Columbia experience

Posttraumatic syringomyelia is an uncommon late complication of spinal cord injury. This study identified nine patients with posttraumatic syringomyelia and examined initial presentation, neurologic status, ability to perform functional activities, and results of treatment. Pain and numbness were the most common presenting symptoms. Motor impairment occurred later but was more disabling. Functional abilities depended mainly on the level of the original spinal cord injury. Three patients were managed conservatively and have had no significant progression of their neurologic deficit. Six patients were managed with syringoperitoneal or syringosubarachnoid shunts. Pain improved most consistently after surgery. Motor power improved less and sensation least. Ability to perform activities of daily living did not significantly change after surgery. Posttraumatic syringomyelia remains a difficult therapeutic problem in the spinal cord-injured population.     

Identification of acute posttraumatic spinal cord cyst by magnetic resonance imaging: a case report and review of the literature

Posttraumatic spinal cord cysts have traditionally been diagnosed late. The condition is usually considered after the neurological sequelae of spinal cord trauma have not resolved. The diagnosis has usually required invasive radiographic techniques, or even surgical exploration. Magnetic resonance imaging is a new, non-invasive diagnostic technique that appears to be more accurate than previous procedures. Moreover, it has the ability to delineate spinal cord parenchymal lesions much earlier than other methods. We present a case report and literature review of posttraumatic spinal cord cyst.     

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.     

Approach and considerations regarding the patient with spinal injury

Spinal trauma often results in a complex interaction of injuries to the musculoskeletal and nervous systems. This combination of biomechanical and neurological considerations provides a unique challenge to those dealing with the spinally injured patient. Proper assessment of the injuries sustained by the patient remains the initial, yet key, step in determining appropriate management. The aim of the physical examination is not only to characterize the nature of the injury to the vertebral column, but also to determine the extent of actual and potential damage to the neural elements. It is also concerned with detecting associated injuries of the brain, viscera, and limbs that can impact on management and outcome, particularly of any neurological deficit. Further information about the spinal column and spinal cord is derived from appropriate radiological assessment, which is evolving with the increasing sophistication of imaging modalities. In spinal injury, classification systems are particularly important as they simplify a diverse range of injury patterns into a useable and reproducible form that may be used to aid communication among clinicians, guide management for individual patients, and provide the basis for research consistency. The medical management involves consideration of the impact of spinal injury, in particular cord injury, on aspects including resuscitation and anticoagulation, as well as the role of steroids. The definitive management of the spinal column injury may be operative or nonoperative. Factors influencing this decision are biomechanical (stabilization of the unstable spine and reduction of deformity) and neurological (improvement in deficit and decompression of neural elements). This article considers these issues and aims to present a balanced and useful algorithm for clinicians to use when faced with spinal injury.     

Cordectomy for the treatment of posttraumatic syringomyelia. Report of four cases and review of the literature

Cordectomy is an effective treatment option in patients in whom posttraumatic syringomyelia develops following complete spinal cord injuries. Since the introduction of cordectomy, numerous approaches to the surgical treatment of posttraumatic syringomyelia have been developed. These newer developments have drawn the attention of surgeons and researchers away from cordectomy. In this report, the authors encourage a reconsideration of cordectomy for the treatment of posttraumatic syringomyelia after complete spinal cord injury. They describe four patients with posttraumatic syringomyelia who were treated successfully with cordectomy and review appropriate literature, examining the effectiveness of cordectomy in the treatment of posttraumatic syringomyelia. The findings of this review indicate that neurological improvement or stabilization occurred in 88% of patients in published reports of posttraumatic syringomyelia treated with cordectomy. The indications for cordectomy as well as factors that may contribute to the procedure's success are discussed.     

Lateral lumbar interbody fusion in adult spine deformity – A review of literature

IntroductionSurgery for adult spine deformity presents a challenging issue for spinal surgeons with high morbidity rates reported in the literature. The minimally invasive lateral approach aims at reducing these complications while maintaining similar outcomes as associated with open spinal surgeries. The aim of this paper is to review the literature on the use of lateral lumbar interbody fusion in the cases of adult spinal deformity.MethodsA literature review was done using the healthcare database Advanced Research on NICE and NHS website using Medline. Search terms were “XLIF” or “LLIF” or “DLIF” or “lateral lumbar interbody fusion” or “minimal invasive lateral fusion” and “adult spinal deformity” or “spinal deformity”.ResultsA total of 417 studies were considered for the review and 44 studies were shortlisted after going through the selection criteria. The data of 1722 patients and 4057 fusion levels were analysed for this review. The mean age of the patients was 65.18 years with L4/5 being the most common level fused in this review. We found significant improvement in the radiological parameters (lordosis, scoliosis, and disk height) in the pooled data. Transient neurological symptoms and cage subsidence were the two most common complications reported.ConclusionLLIF is a safe and effective approach in managing adult spinal deformity with low morbidity and acceptable complication rates. It can be used alone for lower grades of deformity and as an adjuvant procedure to decrease the magnitude of open surgeries in high-grade deformities.     

Spinal canal restoration by posterior distraction or anterior decompression in thoracolumbar spinal fractures and its influence on neurological outcome

Summary Thirty consecutive patients who had suffered unstable fractures and dislocations of the thoracolumbar spine mostly associated with neurologic impairment and bony encroachment on the spinal canal were treated either with Harrington distraction rods combined with sublaminar wires or with the Zielke-VDS device. These patients were subsequently assessed for neurologic outcome, spinal canal clearance, sagittal and coronal spinal deformity correction preoperatively and postoperatively with a minimum follow-up of 26 months. In the follow-up evaluation, the patients who underwent surgery with Harrington rods showed an overall improvement of their neurologic function of 90.9%, whereas all patients who underwent the Zielke operation improved. Preoperatively, positive correlations were found between the level of injury and Frankel grades; the cord lesion tended to demonstrate more severe neurologic deficit when compared with cauda equina ones (P < 0.001). Furthermore, dislocation accompanying the injury resulted in a more severe neurological deficit (P < 0.05). Harrington rods and Zielke device offer sufficient initial correction of the frontal spinal deformity but did not significantly either restore or maintain sagittal plane alignment. The Harrington series showed an overallimprovement of the segmental kyphosis of 26% (NS), with a subsequent loss of correction of 7.38% (NS) on the follow-up observation. The Zielke device produced an immediate, much better correction of the segmental posttraumatic kyphosis of 45% (NS), but a loss of correction of 22.9% (NS) was measured in the follow-up evaluation. Correction of the anterior and posterior vertebral height was shown to be better for the Zielke patient group. The coronal deformity was completely corrected equally well by the Harrington and Zielke devices. There was no statistically significant correlation between the degree of bony encroachment of the spinal canal and the initial Frankel grade. Additionally, no statistically significant correlation was found between correction of the sagittal deformity, restoration of anterior and posterior vertebral height, coronal deformity correction, and clearance of the vertebral canal. Concerning neurological status, no patient in either group was worse in the follow-up evaluation. A significant correlation was found between the age of the patient and the neurological improvement favoring young patients (P < 0.001).     

Surgery for posttraumatic syringomyelia： a retrospective study of seven patients

Objective： To analyze retrospectively the clinical symptoms, signs, radiological findings and results of treatment of posttraumatic syringomyelia. Methods： The data of 7 patients with posttraumatic syringomyelia confirmed by computerized tomography （CT） and magnetic resonance imaging （MRI） in our hospital between 1999 and 2004 were reviewed retrospectively. The patients underwent decompressive laminectomy or syringo-subarachnoid （S-S） shunting with microsurgery. Long-term follow-up was available （range： 13-65 months）. Results： The major dinical manifestations of posttraumatic syringomyelia usually included the onset of increasing signs and the development of new symptoms after an apparently stable period. The clinical symptoms included pain, sensory disturbance, weakness, and problems in autonomic nerves. Syrinx existed merely at the cervical level in 4 cases and extended downward to the thoracic levels in the other 3 cases. One case underwent decompressive laminectomy, 6 cases were treated by S-S shunting. During the early postoperative period, all the patients showed an improvement of symptoms of syrinx without major complication or death. The decreased size or collapse of the syrinx was demonstrated by postoperative MRI. Conclusions ： Posttraumatic syringomyelia is a disabling sequela of spinal cord injury, developing months to years after spinal injury. MRI is the standard diagnostic technique for syringomyelia. The patients with posttraunmtic syringomyelia combined with progressive neurological deterioration should be treated with operations. S-S shunting procedure is effective in some patients with posttraumatic syringomyelia. Decompressive procedure may be an alternative primary surgical treatment for patients with kyphosis and cord compression.     

One-stage anterior cervical decompression and posterior stabilization with circumferential arthrodesis. A study of twenty-four patients who had a traumatic or a neoplastic lesion

Twenty-four patients had a combined anterior cervical decompression and posterior stabilization with circumferential spinal arthrodesis for treatment of either a tumor or an injury. The indication for operation was a fixed kyphosis and an incomplete neurological deficit or cervical instability. All but two patients had substantial improvement, having regained strength or had a reduction in the deformity, or both. The two exceptional patients, both of whom were quadriparetic, had no change. The operation is formidable and requires an average of 6.9 hours of general anesthesia; however, its use is justified in patients who have the appropriate indications.     

Thoracolumbar Spine Trauma: I. Evaluation and Classification

A timely and thorough evaluation of thoracolumbar injuries and rational treatment based on a complete understanding of the mechanism of bone, soft-tissue, and nerve injury is essential for maximizing the patient's neurologic and functional recovery and minimizing associated complications, the time to recovery, and the problems of long-term pain and deformity. The initial evaluation includes both clinical and radiologic assessment. Clinical evaluation includes the general trauma examination as well as a detailed spinal and neurologic examination to determine the level (or levels) of spinal injury. Radiologic evaluation includes both plain radiography and the appropriate use of advanced imaging modalities. A review of the evolution of thoracolumbar injury classifications is presented.     

Congenital scoliosis: a review and update

Vertebral anomalies causing congenital scoliosis are classified on the basis of failures of formation, segmentation, or both. The natural history depends on the type of anomaly and the location of anomaly. Patient evaluation focuses on the history and physical examination, followed by appropriate imaging modalities. The hallmark of surgical treatment is early intervention before the development of large curvatures. The surgical treatment of a congenital deformity mandates the use of neurological monitoring to minimize the risk of perioperative neurological deficit. Modern surgical techniques have evolved to include the routine use of spinal instrumentation. Patients with associated chest wall deformities or large compensatory curves may be candidates for vertical expansion prosthetic titanium rib placement or growing rods insertion to maximize growth.     

Post-laminectomy rotokyphoscoliosis causing paraplegia in long term: case report

CONTEXT: Childhood laminectomy can lead to spinal deformity. This is a report of a case of paraplegia caused by rotokyphoscoliosis, a late complication of laminectomy. FINDINGS: A 55-year-old woman developed paraplegia due to post-laminectomy kyphoscoliosis. She had surgery for a spinal tumor at age 13 years. She developed kyphosis 2 years after the laminectomy, which has been gradually progressing over the years. She experienced weakness of lower limbs that progressed to paraplegia. There was no evidence for tumor recurrence. To our knowledge, this is the first reported case of post-laminectomy kyphoscoliosis causing late-onset paraplegia. Conclusions/clinical relevance: This case highlights a possible long-term complication of laminectomy without stabilization or untreated kyphoscoliosis. Children should be followed closely after laminectomy because development of spinal deformity is very common. Without intervention, the kyphosis might progress and in the long term, serious neurological complications may result, including paraplegia.     

Complications associated with the halo-vest. A review of 245 cases

The cases of all patients treated with halo-vests for cervical trauma at the University of Virginia since 1977 were analyzed retrospectively. A standardized chart and radiographic review protocol were used to identify complications associated with the use of the orthosis. Two hundred and forty-five patients satisfied the criteria for inclusion in the study. No patient developed or suffered progression of a neurological deficit while immobilized. Complications included: pneumonia causing death (one patient); loss of reduction or progression of the spinal deformity (23 patients); spinal instability following orthotic immobilization for 3 months (24 patients); pin-track infection (13 patients); migration of anteriorly placed iliac-strut grafts (two patients); cerebrospinal fluid leakage from a halo pinhole (one patient); and miscellaneous (seven patients). The findings indicate several conclusions. The halo-vest protects patients with cervical instability from neurological injury. It does not absolutely immobilize the cervical spine nor does it prevent progressive deformity of malpositioned strut grafts. Even after a 3-month orthotic treatment period, surgery may be required on ligamentous and osseous injuries to provide spinal stability. Elderly kyphotic patients may require custom-made vests. A small subset of patients exists for whom the confining nature of the halo-vest is intolerable for 3 months.     

Magnetic resonance imaging of posttraumatic syringomyelia and its surgical treatment

Posttraumatic syringomyelia is an uncommon but significant late complication of spinal cord injury. It occurs in approximately 1.1 - 3.2% of cases of spinal injuries. With the increasing availability of CT and magnetic resonance imaging (MRI), the incidence of posttraumatic syringomyelia is increasing. The purpose of this report is to show MRI of posttraumatic syringomyelia and to assess the results of surgical treatment. Materials and Methods This series included 16 cases of posttraumatic syringomyelia studied with MRI. 9 out of 16 cases showed delayed deterioration of neurological symptoms following spinal injuries. The interval between the trauma and the delayed symptoms of deterioration was from 2 years 2 months to 32 years (mean, 8 years and 5 months). There were 13 men and 3 women. The age ranged from 22 to 69 years, with a mean age of 42 years. The initial spinal cord injury was located in the lower cervical region in 4 cases, the thoracic region in 8, and the upper lumbar region in 4. All the patients were studied with resistive 0.15T system (Toshiba MRT 15 A) or a superconductive 0.5T system (Toshiba MRT 50 A) or a superconductive 1.5T system (GE Sigma or Siemens Magnetom). Six patients underwent 8 operative procedures for posttraumatic syringomyelia. Syringoperitoneal shunt was performed in 4 patients, syringosubarachnoid shunt in 3 and ventriculoperitoneal shunt in one. Results 1. MRI In all cases, the posttraumatic syringomyelia was easily diagnosed by MRI. The syrinx extended superiorly and/or inferiorly from the area of the old trauma. In 4 out of 16 cases, the syrinx extended into the medulla oblongata.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neurological injuries associated with regional anesthesia

A peripheral nerve or spinal cord injury is a rare but significant complication of regional anesthesia. Evaluation of acute nerve injury includes a focused history and examination to localize the lesion. Confirmatory testing should include electromyography and appropriate imaging. In most cases magnetic resonance imaging (MRI) is preferred to computed tomography (CT) or ultrasound given the better resolution of the nerves and soft tissue. Most cases of peripheral nerve injury will improve and resolve without deficit. In mild cases reassurance and observation is all that is necessary. In more severe cases, if the deficit is progressive or complete, surgical exploration should be considered. If there is no recovery by 2 to 5 months then referral to a peripheral nerve surgeon should be considered. The prognosis for cauda equina or spinal cord lesions is more guarded. Recovery from these is commonly incomplete. Early diagnosis and intervention is the key to preventing catastrophic neurological outcomes.     

Spinal fractures in adults

Spinal fractures are an important clinical problem. It is widely accepted that patients with unstable injuries are best treated by early stabilization and patients with stable injuries and no significant deformity or neurological defect are best treated conservatively. The treatment of patients with potential instability or neurological deficit remains rather controversial. We are still looking for an ideal classification with numerous classification schemes for spinal fractures having been published over the past 40 years. An understanding of the concepts of spinal stability and fracture classifications is useful in the management of these cases. The goals of treatment for spinal fractures are the same as for any other musculoskeletal injury: to save life (and limb), restore and maintain stability, preserve function, prevent pain and promote rehabilitation.