Prevention of neurological deterioration before admission to a spinal cord injury unit

Thirty-two of 123 patients admitted to the Victorian Spinal Injuries Unit, Austin Hospital, during the period 1st March 1983 to 28th December, 1984 sustained major neurological deterioration from the time of injury to the time the patient was admitted to the Unit. The key to the prevention of major neurological deterioration in patients who have only vertebral column damage and in patients who have partial neurological dysfunction is a theoretical and practical understanding of the spinal column and cord. Suspicion about the possibility of spinal cord injury, followed by appropriate handling and immobilisation of these patients by treating personnel as soon as possible after the injury, could make major neurological deterioration before admission to a specialised spinal injuries unit a rare event.     

Traumatic lesions of lower cervical spine]

In the years 1965-1990 in the hospital department for treatment of spinal injuries 1330 patients with spinal lesions at the C5-Th1 levels were treated after admission early after trauma. The most frequent causes of injuries of this part of the spine were falls from horsecarts, jumping into water head first and traffic accidents. The relationship was analysed between the degree of spinal cord injury and the mechanism of spine injury, and also the results were compared of conservative and surgical treatment. The most severe damage to the spinal cord was observed after traumas involving the flexion mechanism. Typical crush fractures of vertebral bodies had be best prognosis. Significant neurological improvement was obtained in over 50% of the treated patients, and it was more pronounced and occurred more frequently after surgical treatment.     

Outcomes of spinal cord injury following cervical fracture in ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis (DISH): A prospective cohort study

IntroductionThe ankylosed spine is prone to increased fractures risk even after minor trauma. The lower cervical spine is most frequently injured, and fractures of the ankylosed spine tend to precipitate spinal cord injury (SCI). The objective of the current study is to assess the incidence, management, and outcomes of patients with ankylosis of the spine sustaining a cervical fracture with associated SCI over a 7-year period.Material and methodsProspective cohort study. Patients referred to the institution with a cervical fracture associated with SCI on a background of AS or DISH from 2009 to 2017 were reviewed. Demographics, mechanism of injury, fracture type, neurological level of injury, time to surgery, surgical management, neurological status (AIS), spinal cord independence measure (SCIMIII) scale at admission and discharge, and hospital length of stay. In September 2019 the summative data was analyzed using NDI, VAS, SV-QLI/SCI and length of survival were analyzed for statistical significance. Pathological fractures and dementia were excluded.Results1613 patients with traumatic SCI were admitted in this period of whom 37 (12 AS and 25 DISH) met the inclusion criteria (mean age 65 years AS; 67 DISH). Fracture-dislocation was the most frequent fracture type (33% AS patients, 24% DISH patients). C4 was the most common neurological level of injury. SCIMIII score at admission was 1 point and 59 at discharge. AIS at admission was A (50%). At time of discharge no patient had neurologically deteriorated. Post-discharge mortality was 58% in AS patients and 32% in DISH patients (p = 0.13).ConclusionsBoth AS and DISH patients have high levels of disability and mortality associated with trauma to the cervical spine. Despite their distinct clinical differences, in this cohort there were no statistically significant differences between AS and DISH patients regarding fracture type, SCIMIII, AIS, hospital stay, mortality, VAS, and SV-QLI/SCI after cervical fracture over 7 years follow-up.     

Post-surgical ischaemic myelopathy

Ischaemic myelopathy is an infrequent but well-known cause of spinal cord injury. While the overall incidence of neurological injury following thoraco-abdominal aortic surgery is low (1-14%), procedures requiring surgical cross-clamping of the aorta have been reported as the major cause of ischaemic cord injury (31%). Little has been reported regarding the clinical and functional outcomes of these injuries. Three patients with a non-penetrating aortic injury who showed evidence of ischaemic cord injury within 72 hours of surgical cross-clamping of the aorta are presented. Data includes functional assessments, muscle strength testing and electromyographic findings. All three patients showed lower thoracic incomplete motor and sensory spinal cord injuries. These findings suggest that, after a period of neurological improvement, a plateau phase is reached at approximately 3 months post injury after which no significant gain in muscle strength is made. All patients were functionally independent and able to ambulate using a straight cane.     

Head and spinal cord injury: diagnosis and management

This article reviews aspects of management of traumatic brain and spinal cord injury. A discussion of management of intracranial pressure after traumatic brain injury is followed by a discourse on cerebrovascular trauma and pediatric injuries. Specific management methods are discussed, including medical and surgical management in intracranial hypertension. A special attempt is made to include the current recommendations for management of brain and spinal cord injuries. Spinal cord injuries are discussed in the final section. With an increasing number of patients surviving after devastating spinal cord injuries, the special issues in their management are evaluated.     

Neurological and skeletal outcomes in 113 patients with closed injuries to the cervical spinal cord.

Neurological and skeletal outcomes were evaluated in 113 patients for one year following closed lower cervical spinal cord injuries. The extent of neurological recovery did not depend on surgical versus nonsurgical management, or the degree of spinal angulation, vertebral displacement, spinal stenosis, or inferred mechanism of injury based on the initial plain cervical x-rays. Assessment of skeletal outcomes demonstrated significantly less vertebral angulation, more rapid stabilization, and less anterior callus formation among the patients in the surgical group. In addition, the surgical patients had marginally shorter lengths of hospitalization.     

Preliminary evaluation of epidural electric stimulation of the spinal cord]

Since 1974 clinical experiments have been conducted at the Rehabilitation Centre in Konstancin near Warsaw on the effects of electrostimulating on the damaged spinal cord. As yet stimulating electrodes were implanted in 44 cases of spinal cord injury. In the present report groups of patients with total and incomplete cervical cord injury and complete injury of the thoracic spinal cord were compared. The patients were treated by surgical decompression with simultaneous implantation of stimulation electrodes in contact with the spinal cord. The control group comprised patients operated upon in the same time period, for similar injuries, who had no stimulators implanted. The terapeutic effect was better in the stimulated patients in relation to the non-stimulated ones (this was true especially of patients with injuries to the cervical spinal cord), with a greater number of neurological improvements as well as with a better quality of these improvements. The comparison confirmed also a favourable effect of spinal cord stimulation on the development of bladder automatism which was achieved in this material twice as rapidly as in non-stimulated patients. The author thinks that these data justify further investigations along these lines and suggest that electrostimulation will extend the possibilities of treatment of spinal cord injuries.     

Myelopexy: A novel technique in posttraumatic syringomyelia

Posttraumatic syringomyelia (PTS) is a well-reported phenomenon that usually takes place in the long-term course of patients following spinal cord injury. Different surgical procedures have been described: spinal cordectomy is usually a last option technique, but might be an excellent choice in patients with severe spinal cord injuries.We present a young patient with complete spinal cord injury after spine trauma, who developed posttraumatic syringomyelia with progressive motor deterioration twelve years after fixation. We performed a novel surgical technique (myelopexy) with excellent resolution of syringomyelia, sparing the negative implications of complete cord transection. Some artistic illustrations made by one of the corresponding authors are included, to better understanding of operative details.     

Cystic cord lesions and neurological deterioration in spinal cord injury: operative considerations based on magnetic resonance imaging.

In a retrospective review of 94 consecutive patients with past spinal cord injury referred for magnetic resonance imaging (MRI) for the evaluation of new neurological symptoms, 59% were found to have cystic spinal cord lesions. Twelve of these patients underwent surgical cyst drainage, half having presented with increased myelopathy, and half with ascent of the neurological level. All of the operated cysts were greater than 2 cm in diameter (mean 15.8 cm), and 4 had areas of signal void indicating turbulent flow. All 12 patients had clinical improvement following surgery. The future prospective use of MRI in patients with longstanding spinal cord injury may prove valuable in the identification of patients with syrinx formation, at risk of developing neurological deterioration, who may benefit from early cyst drainage. At present, however, the decision to operate on these patients should be based primarily on clinical criteria.     

Severe spinal cord injury in craniocervical dislocation. Case-based update

Background

Craniocervical distraction injuries, including atlanto-axial dislocation (AAD) and atlanto-ocipital dislocation (AOD), are often associated with severe spinal cord involvement with high morbidity and mortality rates. Many patients with these injuries die at the accident scene, but advances in emergency resuscitation and transport permit that many patients arrive alive to hospitals.

Discussion

Children with craniocervical distraction injuries usually present with a severe cranioencephalic traumatism that is the most relevant lesion at admission. After resuscitation and hemodynamic stabilization, the spinal cord damage appears as the main lesion. Apnea and quadriparesis, or quadriplegia, are usually present at the onset. Early diagnosis and management perhaps decrease life-threatening manifestations of the spinal lesion. But even so, the primary spinal cord insult is often irreversible and precludes obtaining a satisfactory functional outcome.

Patients and methods

We report the findings of four children with craniocervical distraction injuries (AOD and AAD) who presented with severe spinal cord damage. All patients were admitted with respiratory distress or apnea together with significant brain injuries. The medical records pertaining to these patients are summarized in regard to clinical features, management, and outcome.

Conclusions

In spite of timely and aggressive management, craniocervical injuries with spinal cord involvement continue to have a dismal prognosis. Outcome is closely related to the severity of the initial brain and spinal cord damage and is nearly always fatal in cases of complete spinal cord transection. Priority should be given to life-threatening complications. Ethic issues on indications for surgery deserve a detailed discussion with the children’s parents.     

Emergency Neurological Life Support: Traumatic Spine Injury

Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant health care costs from associated medical needs following injury. For these reasons, TSI was chosen as an ENLS protocol. This article offers a comprehensive review on the management of spinal column injuries using the best available evidence. Alhough the review focuses primarily on cervical spinal column injuries, thoracolumbar injuries are briefly discussed as well. The initial emergency department clinical evaluation of possible spinal fractures and cord injuries, along with the definitive early management of confirmed injuries, is also covered.     

Cervical spinal cord injury complicating ankylosing spondylitis

Within a period of 12 years 466 patients with acute spinal cord injury were admitted to our Centre, seven of these having ankylosing spondylitis (AS). A history of alcohol consumption preceding the accident was present in five patients, and in four there was a history of neurological deterioration before their admission. An epidural hematoma was found in one patient and four expired within 3 months of their injury. The incidence of ankylosing spondylitis in cervical cord injury was 1.5%, and an associated epidural hematoma was present in some 14% of the patients. The mortality rate was 57%. There was a high incidence of alcoholic use before the accident. Neurological deterioration commonly occurred before admission.     

Suggested MRI criteria for surgical decompression in acute spinal cord injury. Preliminary observations.

The effect of spinal cord compression identified with magnetic resonance imaging (MRI), on neurological prognosis, was retrospectively evaluated in 36 patients with acute spinal cord injury. Of the 21 patients without cord compression, 16 had potentially reversible injury (normal spinal cord or cord oedema), all having functional recovery. Of the 15 patients with cord compression, 3 had operative decompression. In the 12 patients who did not undergo surgery, the degree of recovery was directly related to the magnitude of spinal cord compression, only one of the patients with moderate or marked cord compression having useful motor function at follow up. In contrast, the 3 patients with surgical decompression had at least 2 grades of improvement, all having functional recovery. These findings raise the possibility that MRI may be used to identify a patient group who will benefit from surgical decompression. A numerical index is proposed to prospectively identify patients for surgical decompression, and further studies are underway to evaluate this.     

Emergency Neurological Life Support: Traumatic Spine Injury

Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant health care costs from associated medical needs following injury. For these reasons, TSI was chosen as an ENLS protocol. This article offers a comprehensive review on the management of spinal column injuries using the best available evidence. Though the review focuses primarily on cervical spinal column injuries, thoracolumbar injuries are briefly discussed as well. The initial emergency department (ED) clinical evaluation of possible spinal fractures and cord injuries, along with the definitive early management of confirmed injuries, are also covered.     

Traumatic fracture of the thoracic spine T1-T10

We describe the incidence, causes, management and prognosis of traumatic fractures of the thoracic spine from T1 to T10 in surgical cases of traumatic fractures of spine during the period from June 1994 to June 2003 studied retrospectively. The type of fracture was determined according to the Gertzbein classification, and the degree of stability using the Denis classification. The neurological picture at admission and 30 days after surgery was evaluated using the ASIA/IMSOP classification. Surgery was performed in patients with complete spinal cord injury (n=7) for the purpose of stabilization using the posterior approach. In cases without spinal cord injury or incomplete injury (n=12), the surgical procedure was performed aiming to decompress the nerve tissue, to correct the alignment of the spine and to stabilize the spine.     

Recurrent tethered cord: radiological investigation and management

Introduction

Recurrent tethered cord (RTC) is almost the rule after the repair of myelomeningocele and quite frequent after the repair of lipomyelomeningocele, resulting from the adhesions of the placode within a too narrow spinal canal. About one-third of patients with myelomeningocele and 10 % of those with spinal lipoma develop symptomatic RTC, mainly caused by the ischemic–metabolic injuries due to the cord stretching. The goal of this review is to provide information about the pathophysiology, the radiological picture, and the management of RTV according to the pertinent literature and the authors’ experience.

Radiological investigation

The magnetic resonance imaging (MRI) picture is characterized by a low position of the conus and by tethering of the spinal cord to the subcutaneous scar or to the inner surface of the spinal canal. The radiological work-up always includes brain MRI, to rule out other possible causes of late neurological deterioration (as shunt malfunction), and MRI of the whole spinal cord, to detect possible associated lesions (syringomyelia, dermoids, etc.). X-rays and/or computed tomography scan of the spine is required for the assessment of scoliosis or other bony malformations.

Management

The surgical treatment is planned after a multidisciplinary neurological, urological, orthopedic, physiatric, and radiological evaluation. The surgical detethering is carried out cautiously, possibly with electrophysiological intraoperative monitoring. Surgery ensures improvement or stability of the clinical picture in 70–80 % of cases, the remaining 20–30 % of patients needing multiple operations for their recovery. Complications may affect up to one-third of operated patients, being mainly represented by CSF leak, pseudomeningocele, and shunt malfunction.     

Benefits of early admission to an organised spinal cord injury care system

Patients admitted to the University of Alabama Hospital between 1973 and 1985 were studied to determine the benefits, if any, of early admission to an organised, multidisciplinary spinal cord injury (SCI) care system. Patients admitted within 1 day of injury who received all subsequent care within the system were compared with patients who received their acute care services elsewhere and who were admitted to the system solely for rehabilitation. Both patient groups were comparable with respect to age, neurologic level and extent of spinal cord lesion, pre-existing major medical conditions, associated injuries, ventilator dependency and acute surgical procedure experience. Findings included statistically significant reductions in acute care and total lengths of stay coupled with a highly significant reduction in the incidence of pressure ulcers for patients admitted within 1 day of injury. Moreover, for patients admitted within 1 day of injury, mortality rates were lower than reported previously for patients not admitted to an organised SCI care system.     

Prophylactic low dose heparin anticoagulant therapy in patients with spinal cord injuries: a retrospective study.

A retrospective study was performed of 100 consecutive acute traumatic spinal injury patients with neurological deficit admitted to the Yorkshire regional spinal injuries centre prior to May 1990. Ninety-seven of these patients received prophylactic low dose subcutaneous heparin and 3 patients were excluded because of noted complications. Twenty-six patients developed thromboembolic complications. Apart from the fact that acute spinal cord injury patients are considered to be in an hypercoaguable state, the occurrence of deep vein thrombosis/pulmonary embolism (DVT/PE) in our study, even though these patients were on prophylactic low dose subcutaneous heparin, was related to delay in transfers, operative intervention, level of spinal cord injury and was possibly due to loss of some amount of heparin solution from the prefilled syringe during removal of air bubbles prior to the subcutaneous heparin injection.     

Características clínicas y pronóstico de la lesión medular traumática en pacientes mayores de 75 años

ObjectiveTo analyze the incidence and characteristics of traumatic spinal cord injury (SCI) in geriatric population of Galicia (Spain), hospital management and functional prognosis.MethodsComparative retrospective study. Patients admitted with acute traumatic SCI during the time period between January 2010 and December 2016 were included. Two groups established: The elderly over and under 75 years of age, with the latter acting as a control group.ResultsThree hundred seventy-nine patients were studied (27.2% ≥75 years). The main etiology in the >75 years group were falls: 80.6%. There were 65.7% who presented incomplete spinal cord injuries with mean motor index (MI) of 44.9/100. Upon discharge, 90.8% were dependent. Hospital mortality was 34.9%. Those >75 years suffered from more cervical injuries (74.8 vs. 51.2%; p<0.001), longer delay in diagnosis (31.1 vs. 9.2%; p<0.001) and higher hospital mortality (34.9 vs. 3.2%; p<0.001). Fewer surgical interventions were performed, with a longer delay. Percentages for admission into ICU, mechanical ventilation and performing a tracheostomy proved to be similar. There were no significant differences found in the evolution according to the ASIA scale or the MI.Conclusions1) The frequency of traumatic SCI in the elderly in Galicia is high; 2) Neurological evolution is similar to younger patients but the level of dependence is higher; 3) The level of care provided is similar in both groups, except for the surgical indication, and 4) Hospital mortality is high.     

Experience with a spinal cord unit in Brasilia, Brazil

We have analysed our experiences in a Spinal Cord Unit in Brasilia, Brazil in the last 5 years (1982-1986). There were 738 outpatients and 243 inpatients. One hundred and six patients were operated on by the neurosurgical staff, and the indications for operation are discussed. Some patients showed neurological recovery with surgery and some without surgery. Patients with a complete neurological deficit on admission did not show any improvement, and those with a severe but incomplete deficit showed improvement with surgery (18%), which was better than those without an operation. We conclude that a surgical procedure seems to be indicated in those with a comminuted, or with an unstable fracture, if there is an incomplete neurological deficit with an unreduced spinal deformity. There was a possibility of recovery of some nerve root function. The goal of surgical treatment is to restore and maintain the anatomical relationships between the spinal canal, spinal cord and nerve roots with the simplest possible surgical procedure, returning the patient as soon as possible to his functional capacity and social life.