Thoracic spinal injuries: operative treatments and neurologic outcomes

Between January 1983 and December 1997, 29 patients with either a fracture (11 patients) or a fracture-dislocation (18 patients) of the thoracic spine were treated operatively. All patients underwent posterior decompression and stabilization within a mean time of 4 days after injury (range, 0-45 days). Patients with complete paraplegia had no postoperative improvement in neurologic status, whereas all patients with incomplete spinal cord lesions improved in neurologic status after surgery. There was no significant association between time from injury to operation and final neurologic outcome. For thoracic fractures, the procedure of surgical decompression and stabilization is safe, and neurologic recovery may be anticipated in patients with incomplete spinal cord lesions.     

Bilateral transpedicular decompression and Harrington rod stabilization in the management of severe thoracolumbar burst fractures.

Fifty-eight patients with severe thoracolumbar burst fractures were treated with bilateral transpedicular decompression, Harrington rod instrumentation, and spine fusion. Spinal realignment and stabilization was achieved by contoured dual Harrington distraction rods supplemented by segmental sublaminal wiring. Posterior element fractures were noted in 25 patients, 9 of whom had associated dural tears. Computed tomography was performed to assess the cross-sectional area of the spinal canal before surgery and after decompression. Patients at initial evaluation averaged greater than 67% spinal canal compromise. After surgery, successful decompression was accomplished in 57 patients. One patient required staged, anterior thoracoabdominal decompression and fibula strut grafting. At follow-up (average, 43 months; range, 25-70 months), neurologic improvement was found in 77% of the patients who initially presented with neurologic deficits. Thirty-four of 40 patients with incomplete paraplegia improved one or more subgroups on the Frankel scale. A solid fusion was attained in all 58 patients. No patient had a significant residual kyphotic deformity. Single-stage bilateral transpedicular decompression and dual Harrington rod instrumentation reliably provides decompression of the spinal canal and restores spinal alignment. The procedure allows early mobilization and provides an environment for solid fusion and maximum neurologic return.     

The effect of surgical intervention on rehabilitation time in patients with thoracolumbar and lumbar spinal cord injuries.

One hundred forty-seven patients with unstable low thoracic and lumbar fractures were examined. All patients had significant neurologic injuries. Ninety-one patients exhibited incomplete lesions whereas fifty-six had complete lesions. Age, sex, cause of injury, fracture location, fracture mechanism, and complications were recorded and analyzed. The average follow-up was 25 months (range 2-148). Incomplete neurologic lesions demonstrated a significant increase in ASIA motor points if both decompression and stabilization were performed at the same operative sitting. When decompression was performed before stabilization a decrease in improvement was noted. Patients with complete lesions demonstrated a significant reduction in rehabilitation time if stabilization was augmented with sublaminar wires rather than Drummond wires or Harrington rods alone.     

Anterior surgery for unstable lower cervical spine injuries

The authors reviewed the medical records of 53 patients with a lower cervical spine injury who were treated by anterior decompression, bone grafting, and instrumentation using an anterior cervical spine plate and screws. The average age of the patients was 36 years and the mean followup was 58 months. Twenty-six patients predominantly had anterior lesions and 27 patients predominantly had posterior lesions. Thirteen patients were neurologically intact. Fusion was achieved in all patients at an average of 3.4 months postoperatively. Radiographic followup detected 15% of hardware malposition. There were no pseudarthrosis, dysphagia, or neurologic complications. Incomplete spinal cord lesions improved on average one Frankel grade after surgery. Anterior decompression and stabilization is a safe and effective procedure for the treatment of acute lower cervical spine injuries and permits immediate postoperative mobilization of the patient.     

Treatment of posttraumatic syringomyelia

Object This paper presents results of a prospective study for patients undergoing surgery for posttraumatic syringomyelia between 1991 and 2010. Methods A group of 137 patients with posttraumatic syringomyelia were evaluated (mean age 45 ± 13 years, mean follow-up 51 ± 51 months) with pre- and postoperative MRI and clinical examinations presenting in this period and followed prospectively by outpatient visits and questionnaires. Surgery was recommended for symptomatic patients with a progressive course. Short-term results were determined within 3 months of surgery, whereas long-term outcomes in terms of clinical recurrences were studied with Kaplan-Meier statistics. Results Three groups were distinguished according to the type of trauma: Group A, patients with spinal trauma but without cord injury (ASIA E, n = 37); Group B, patients with an incomplete cord injury (ASIA C or D, n = 55); and Group C, patients with complete loss of motor function or a complete cord injury (ASIA A or B, n = 45). Overall, 61 patients with progressive symptoms underwent 71 operations. Of these operations, 61 consisted of arachnolysis, untethering, and duraplasty at the trauma level (that is, decompression), while 4 ASIA A patients underwent a cordectomy. The remaining procedures consisted of placement of a thecoperitoneal shunt, 2 opiate pump placements, and 2 anterior and 1 posterior cervical decompression and fusion. Seventy-six patients were not treated surgically due to lack of neurological progression or refusal of an operation. Neurological symptoms remained stable for 10 years in 84% of the patients for whom surgery was not recommended due to lack of neurological progression. In contrast, 60% of those who declined recommended surgery had neurological progression within 5 years. For patients presenting with neurological progression, outcome was better with decompression. Postoperatively, 61% demonstrated a reduction of syrinx size. Although neurological symptoms generally remained unchanged after surgery, 47% of affected patients reported a postoperative improvement of their pain syndrome. After 3 months, 51% considered their postoperative status improved and 41% considered it unchanged. In the long-term, favorable results were obtained for Groups A and C with rates for neurological deterioration of 6% and 14% after 5 years, respectively. In Group B, this rate was considerably higher at 39%, because arachnolysis and untethering to preserve residual cord function could not be fully achieved in all patients. Cordectomy led to neurological improvement and syrinx collapse in all 4 patients. Conclusions The technique of decompression with arachnolysis, untethering, and duraplasty at the level of the underlying trauma provides good long-term results for patients with progressive neurological symptoms following ASIA A, B and E injuries. Treatment of patients with posttraumatic syringomyelia after spinal cord injuries with preserved motor functions (ASIA C and D) remains a major challenge. Future studies will have to establish whether thecoperitoneal shunts would be a superior alternative for this subgroup.     

The neurological outcome following surgery for spinal fractures

Sixty consecutive patients with spinal injuries and encroachment upon the spinal canal of greater than 20% were assessed for neurological outcome. The patients were divided into two groups, those undergoing posterior surgery alone, and those undergoing anterior surgery for formal decompression with or without anterior or posterior instrumentation. In those patients undergoing posterior surgery, an improvement rate in the neurological function of 83% was noted in patients with incomplete lesions, whereas an 88% improvement rate was found in those undergoing the anterior procedure. There was no statistical difference in outcome between these two groups. Positive correlations were found between the level of injury and Frankel grades. The cord lesions tended to demonstrate more severe neurological deficit, whereas the cauda equina lesions were associated with a lesser severity of neurologic deficit. A component of dislocation to the injury also resulted in a more severe neurological deficit. There was no apparent difference between the degree of bony encroachment of the spinal canal and the initial Frankel grade, nor was there a clear difference between those patients undergoing anterior versus posterior surgery.     

Anterior decompression and arthrodesis of the cervical spine: long-term motor improvement. Part I--Improvement in incomplete traumatic quadriparesis.

Between 1973 and 1983, fifty-eight patients who had an incomplete spinal-cord injury secondary to a fracture or dislocation of the cervical spine were managed by anterior cervical decompression and arthrodesis with iliac bone grafts. In all patients, myelography showed that displaced fragments of bone or disc were compressing the anterior aspect of the spinal cord. Anterior decompression was performed in an attempt to improve function in the upper and lower extremities. The average interval from the injury to the decompression was thirteen months (range, one month to nine years). Two patients died of cardiopulmonary disease within two months after the operation, and one patient died eighteen months after the operation. The remaining fifty-five patients were followed for an average of six years (range, two to seventeen years). Twenty-nine patients became functional ambulators after the operation. An additional six patients who could walk before the operation had improvement in the ability to walk. Noteworthy improvement in motor-root function in the upper extremities was seen in thirty-nine patients. Only nine patients had no signs of improvement of motor function. Improvement was less in the patients in whom operative decompression had been done more than twelve months after the injury. The patients who had an extension injury to a spondylotic spine were older, and fewer of them had improvement. No patient lost neurological function as a result of the operation. Anterior decompression and arthrodesis, even when performed late after the injury, can improve neurological function in both the upper and lower extremities in many patients who have incomplete quadriplegia due to a fracture or dislocation of the cervical spine.     

Anterior decompression and stabilization of thoracolumbar burst fractures by the use of the Slot-Zielke device

Between July 1983 and November 1986, 29 patients with thoracolumbar burst fractures underwent a one-stage operation consisting of anterior decompression by subtotal vertebrectomy, reduction, and stabilization with the Slot-Zielke device. The mean follow-up was 3.1 years. Most patients with incomplete neurologic lesions showed postoperative improvement and were upgraded one or two steps in the Frankel scale. No patient showed neurologic deterioration after surgery. In all patients, bony union occurred. Loss of reduction of more than 5 degrees occurred in 41% of the patients. Because of this high rate of loss of reduction in patients and the low degree of flexion-bending loading and torsional stability in biomechanical evaluation in vitro of the Slot-Zielke device on human cadaveric spines, an additional posterior stabilization of the spine after an anterior approach for anterior- and middle-column fractures should be considered.     

Moss Miami内固定及椎管减压治疗胸腰椎骨折的探讨

目的: 探讨MossMiami内固定及椎管减压治疗胸腰椎骨折的临床疗效。方法:对 18例胸腰椎骨折患者应用MossMiami内固定系统进行复位内固定。结果: 18例患者术中均获得良好复位, 平均随访 14个月 (9~20个月), 骨折全部愈合, 无断钉、断棒、内固定松动等情况。结论: MossMiami内固定操作简便,复位满意, 固定牢靠, 是治疗胸腰椎骨折有效治疗方法之一。     

肿瘤切除手术与姑息减压手术治疗脊柱转移瘤的临床疗效和生存期分析

[目的]比较肿瘤切除手术与姑息减压手术治疗脊柱转移瘤的临床疗效、并发症和生存时间,以利于更好的适应证选择.[方法]对2002年11月～2010年11月38例行肿瘤切除手术和45例行姑息切除减压手术的脊柱转移瘤患者临床评估并进行随访,平均随访17个月(3 ～91个月).采用VAS评分、ECOG评分、Frankel分级对疼痛、功能状况和脊髓功能进行评价.使用Kaplan-Meier法评估生存率.[结果]切除组中位手术时间360 min,姑息组240 min (P＜0.000 1).切除组中位出血量3 500 ml,姑息组中位出血量1 200ml (P＜0.000 1).切除手术和姑息减压手术的VAS评分和ECOG评分在术后1个月均显著降低,两组间疼痛缓解和功能状况改善比较差异无统计学意义(P＞0.05).切除组术前有脊髓功能障碍的患者术后85％ Frankel分级得到改善,姑息组为83％.术后切除组18％神经功能再次恶化,中位时间13个月.姑息组31％神经功能再次恶化,中位时间6个月.切除手术组8例发生并发症(21.1％),姑息组9例(20％).切除组中位生存时间为22个月,姑息组为9个月(P =0.001).[结论]肿瘤姑息切除减压手术出血少,时间短,风险小,适用于有严重不稳定疼痛、硬膜或神经根压迫的一般情况较差、预期生存期3～6个月的患者,是有价值的治疗方法.对于预期生存期＞6个月的患者,尽可能切除肿瘤,达到中长期的局部控制.     

Influence of halo vest treatment on vital capacity

Respiratory function (vital capacity) was studied in 20 consecutive patients with unstable cervical spine injuries treated with a halo vest. Eight patients were neurologically intact. Twelve patients had incomplete spinal cord injuries that were classified on a neurologic function scale (Sunny-brook) immediately and 3 months after injury. Spirometric tests were done within 1 week of halo vest fixation, after 3 months of treatment, and 1 week after dismounting of the halo vest. The results showed that initial vital capacity was smaller than predicted normal in all patients and 30% less in neurologically impaired patients. Both groups improved during the treatment and somewhat more after removal of the halo vest. In neurologically intact patients, the halo vest caused a respiratory restriction of 10%, which was fully regained after removal of the halo vest. The difference between the groups remained throughout the study. There was no evidence that the halo vest itself affects the vital capacity more in patients with incomplete cord lesions than in neurologically intact patients. All of the cervical spine injuries healed uneventfully.     

Pediatric spine fractures: a review of 137 hospital admissions

OBJECTIVE: The anatomy and biomechanics of the growing spine produce failure patterns different from those in adults. Spinal injury in the pediatric patient is a concern as prevention of further neurologic damage and deformity and the good potential for recovery make timely identification and appropriate treatment of such injury critical. A retrospective clinical case series was conducted to present data from a large series of pediatric patients with spine injuries from a single regional trauma center. METHODS: One hundred thirty-seven children with spine injuries were seen over 10 years and were divided into three age groups: 0-9, 10-14, and 15-17 years. Analysis of variance and chi2 were used to analyze differences between groups. RESULTS: There were 36 patients aged 0-9, 49 aged 10-14, and 52 aged 15-17. Spine injury incidence increased with age. Motor vehicular accidents were the most common cause in this series. There were 36% cervical, 34% thoracic, 29% lumbar, 34% multilevel contiguous, and 7% multilevel noncontiguous involvement. Nineteen percent had spinal cord injury. Thirteen of 21 complete neurologic injuries and all 3 incomplete injuries improved. Cord injury was more common in the 0-9 age group. Four of five patients with spinal cord injury without radiographic abnormality (SCIWORA) were in the 0-9 age group and had complete neurologic injuries. Young children with cervical injuries were more likely to die than older children. Fifty-three percent had associated injuries. Eighteen percent underwent decompression, fusion, and instrumentation. Two patients developed scoliosis. The complication rate in surgical patients was higher than in patients treated nonsurgically and in polytrauma patients. This may be related to the severity of the initial injury. CONCLUSIONS: Our results suggest age-related patterns of injury that differ from previous work. The incidence of cord injury is 20% with higher frequencies in the young child. Potential for neurologic recovery is good. Young children have a higher risk for death than older children. There was no predominance of cervical injuries in the young child. The incidence of SCIWORA was low. Higher complication rates were seen in polytrauma and surgical patients.     

Profiles of spinal cord injury and recovery after gunshot injury

Prospective motor and sensory examinations were conducted on 135 patients with neurologic deficits caused by spinal cord injuries resulting from gunshot wounds. Annual follow-up motor and sensory examinations were conducted for 67 patients. The neurologic data (motor and sensory neurologic levels of injury, zone of injury, and completeness of lesion) were assessed in terms of the vertebral level of injury, region of injury, bullet caliber, direction of bullet entry, and whether the bullet penetrated the spinal canal, completely traversed the spinal canal, or entered and remained lodged in the spinal canal. Seventy-seven of the patients sustained complete lesions and 58 sustained incomplete lesions. Anatomically, 19.3% of the injuries were in the cervical region, 51.8% in the thoracic, and 28.9% in the thoracolumbar. In 93 cases, the neurologic level was at least one level higher than vertebral level of injury. Although twice as many individuals were shot from the back as from the front and from the left as from the right, the point of bullet entry did not appear to be related to the severity of the injury. At the annual follow-up examinations, 66.7% of the patients with complete lesions and 64.0% of the patients with incomplete lesions had no improvement in the neurologic level of injury. Nevertheless, there was a significant (p less than 0.0001) improvement in the American Spinal Injury Association motor index scores one year after injury.     

Early versus delayed surgery for acute cervical spinal cord injury

The optimal timing of surgical intervention in cervical spinal cord injuries has not been defined. The goals of the study were to investigate changes in neurologic status, length of hospitalization, and acute complications associated with surgery within 3 days of injury versus surgery more than 3 days after the injury. All patients undergoing surgical treatment for an acute cervical spinal injury with neurologic deficit at two institutions between March 1989 and May 1991 were reviewed retrospectively. Forty-three patients initially were evaluated. At one institution, patients with neurologic spinal injuries had surgical intervention within 72 hours of injury. At the other institution, patients underwent immediate closed reduction with subsequent observation of neurologic status for 10 to 14 days before undergoing surgical stabilization. This study indicates that patients who sustain acute traumatic injuries of the cervical spine with associated neurologic deficit may benefit from surgical decompression and stabilization within 72 hours of injury. Surgery within 72 hours of injury in patients sustaining acute cervical spinal injuries with neurologic involvement is not associated with a higher complication rate. Early surgery may improve neurologic recovery and decrease hospitalization time in patients with cervical spinal cord injuries.     

Posterior instrumentation surgery for thoracolumbar junction injury causing neurologic deficit

Thoracolumbar junction (TLJ) injury is one of the most common spine injuries. TLJ injury manifesting as neurologic deficit usually requires surgery because of the underlying spinal instability and/or neural compression. The objectives of surgical treatment are to restore biomechanical stability of the spine and/or to achieve neural decompression. The short-term outcomes were evaluated of 32 patients with symptomatic TLJ (T11-L2) injury who underwent posterior instrumentation surgery in the acute stage between 2000 and 2004. Seventeen patients had unstable burst fracture and 15 patients had either flexion-distraction or fracture-dislocation injury of the TLJ. Fifteen patients had American Spinal Injury Association (ASIA) classification Grade-A, eight had Grade-B, seven had Grade-C, and two had Grade-D preoperative neurologic deficits. All patients underwent posterior instrumentation surgery using pedicle screws and connecting rods, fixed to two vertebral levels above and below the injured segment. No patient experienced neurologic deterioration perioperatively. Postoperative recovery evaluated 3 months after discharge heavily depended on the preoperative neurologic status: patients with ASIA Grade-A deficits usually had limited neurologic recovery, whereas some with Grade-C or D became ambulatory. Complications occurred in five patients, but none suffered death or permanent morbidity. Posterior instrumentation surgery is a safe and efficacious treatment for patients with symptomatic TLJ injury. Long-term efficacy of the posterior instrumentation surgery is less clear, because of the limited duration of the follow-up period.     

Vertebral body replacement with femoral neck allograft and vascularized rib strut graft. A technique for treating post-traumatic kyphosis with neurologic deficit

A technique using a vascularized rib pedicle graft and femoral neck allograft is presented as a new method of anterior spine fusion in the treatment of symptomatic post-traumatic kyphosis. The cases of six patients are reviewed who were treated surgically from seven months to 24 years following their initial injury. Substantial neurologic improvement was achieved in four patients with incomplete neurologic deficits when the procedure was combined with an anterior spine decompression. Two patients, one who was neurologically normal and one with complete paraplegia and L-1 pseudarthrosis were relieved of chronic back and radicular pain following this procedure. At the time of followup, complete anterior spine decompression was verified by lateral planography or computerized axial tomography. All patients were found to have solid anterior spine fusions with a 63% mean improvement in preoperative kyphosis. Early and rapid incorporation of bone grafts had been demonstrated, thus requiring shorter external immobilization periods for the patients.     

椎管侧前方减压内固定治疗胸腰段脊柱骨折合并脊髓损伤

目的阐述椎管侧前方减压在胸腰椎骨折中的应用及疗效。方法对本院2001~2004年胸腰椎骨折98例行侧前方减压内固定治疗,其中男65例,女33例。随访时间4个月~3a,平均2.5a。结果不全瘫患者术后Frankel至少进步一级,所有患者术后椎体稳定性好,无继发性椎体压缩。结论椎管侧前方减压治疗胸腰椎骨折具有减压直接彻底,对后柱韧带复合体干扰小的优点;以中柱为轴心的重建符合脊柱的生物力学特征;采用骶棘肌腰方肌间隙入路损伤小,出血少。     

Subclavian-axillary vascular trauma

Traumatic vascular injuries to the subclavian and axillary vessels are often associated with permanent neurologic impairment either by direct injury to the brachial plexus or by compression from an expanding hematoma. Prompt decompression of the plexus by evacuation of the hematoma may avoid permanent neurologic damage and decrease the morbidity of these injuries. We reviewed our experience with these injuries with particular reference to the effect of early decompression of the brachial plexus. From 1963 to 1984 we treated 40 patients. The causes of the injuries were penetrating trauma in 85% and blunt trauma in 15%. The results of arterial repair were excellent with only two failed repairs; neither resulted in severe ischemia. Two patients were suspected of having thrombosed venous repairs. Among the 12 patients with direct injury to the brachial plexus (partial or complete transection), only six had subsequent improvement of their neurologic dysfunction. In contrast, six of seven patients in whom there was only compression of the plexus by hematoma but no direct injury, had neurologic improvement following evacuation of the hematoma. This finding suggests that prompt decompression of the brachial plexus following these injuries may reduce the amount of neurologic impairment and reduce the morbidity of these injuries.     

颈椎后纵韧带骨化症的前路骨化灶悬切减压治疗

目的 探讨颈椎后纵韧带骨化症采取颈前路骨化灶悬切减压治疗效果.方法 颈椎后纵韧带骨化症42例136个骨化节段.颈前路椎体开槽,深至椎体后缘,与硬膜严重粘连不宜切除的骨化灶可用丝线缝穿骨化灶一侧残余的后纵韧带或骨化灶周围的纤维组织,轻轻提起系在植骨块或颈长肌上,使骨化灶完全缩入骨槽内;对体积较小、与硬膜粘连轻的骨化灶予以...     

Efficacy of surgical decompression in the setting of complete thoracic spinal cord injury

BACKGROUND/OBJECTIVE: An assessment of neurological improvement after surgical intervention in the setting of traumatic thoracic spinal cord injury (SCI). METHODS: A retrospective evaluation of a nonconsecutive cohort of patients with a thoracic SCI from T2 to T11. The analysis included a total of 12 eligible patients. The neurologic and functional outcomes were recorded from the acute hospital admission to the most recent follow-up. Data included patient age, level of injury, neurologic examination according to the Frankel grading system, the performance of surgery, and the mechanism of the time-related SCI decompression. RESULTS: All patients had a complete thoracic SCI. The median interval from injury to surgery was 11 days (range, 1-36 days). Decompression, bone fusion, and instrumentation were the most common surgical procedures performed. The median length of follow-up was 18 months after surgery (range, 9-132 months). Motor functional improvement was seen in 1 patient (Frankel A to C). CONCLUSION: Surgical decompression and fusion imparts no apparent benefit in terms of neurologic improvement (spinal cord) in the setting of a complete traumatic thoracic SCI. To better define the role of surgical decompression and stabilization in the setting of a complete SCI, randomized, controlled, prospective studies are necessary.