Spinal cord injury following operative shoulder intervention: A case report

Abstract

Context

Cervical myelopathy is a spinal cord dysfunction that results from extrinsic compression of the spinal cord, its blood supply, or both. It is the most common cause of spinal cord dysfunction in patients greater than 55 years of age.

Findings: A

57-year-old male with right shoulder septic arthritis underwent surgical debridement of his right shoulder and sustained a spinal cord injury intraoperatively. The most likely etiology is damage to the cervical spinal cord during difficult intubation requiring multiple attempts in this patient with underlying asymptomatic severe cervical stenosis.

Conclusion

Although it is not feasible to perform imaging studies on all patients undergoing intubation for surgery, this patient's outcome would suggest consideration of inclusion of additional pre-surgical screening examination techniques, such as testing for a positive Hoffman's reflex, is appropriate to detect asymptomatic patients who may have underlying cervical stenosis.     

The Relationship between Spinal Stenosis and Neurological Outcome in Traumatic Cervical Spine Injury: An Analysis using Pavlov's Ratio, Spinal Cord Area, and Spinal Canal Area

Background

This study examined the relationship between four radiological parameters (Pavlov''s ratio, sagittal diameter, spinal cord area, and spinal canal area) in patients with a traumatic cervical spine injury, as well as the correlation between these parameters and the neurological outcome.

Methods

A total of 212 cervical spinal levels in 53 patients with a distractive-extension injury were examined. The following four parameters were measured: Pavlov''s ratio on the plain lateral radiographs, the sagittal diameter, the spinal cord area, and the spinal canal area on the MRI scans. The Pearson correlation coefficients between the parameters at each level and between the levels of each parameter were evaluated. The correlation between the radiological parameters and the spinal cord injury status classified into four categories, A (complete), B (incomplete), C (radiculopathy), and D (normal) was assessed.

Results

The mean Pavlov''s ratio, sagittal diameter, spinal cord area and spinal canal area was 0.84, 12.9 mm, 82.8 mm² and 236.8 mm², respectively. An examination of the correlation between the radiological spinal stenosis and clinical spinal cord injury revealed an increase in the values of the four radiological parameters from cohorts A to D. Pavlov''s ratio was the only parameter showing statistically significant correlation with the clinical status (p = 0.006).

Conclusions

There was a correlation between the underlying spinal stenosis and the development of neurological impairment after a traumatic cervical spine injury. In addition, it is believed that Pavlov''s ratio can be used to help determine and predict the neurological outcome.     

Spinal cord injury in Parkour sport （free runn,ng）： a rare case report

A 24-year-old male was transferred to the emergency department while being in the state of quadriplegia with a history of performing Parkour sport, which is also called double front flip. Neurological examination revealed that the patient＇s muscle power was 0/5 at all extremities. The patient did not show any sense of light touch or pain in his extremities. In radiological studies, cervical spine X-ray and CT scan images showed C4-C5 subluxation with bilateral locked facets and spinal cord injury. The results of this very rare case study revealed that exercising Parkour sport without taking into account safety standards could result in irreversible injuries to the cervical spinal cord with fatal outcome.     

Percutaneous peripheral nerve stimulation for treatment of shoulder pain after spinal cord injury: A case report

Context: This describes the first person with spinal cord injury (SCI) treated with percutaneous peripheral nerve stimulation for chronic shoulder pain.

Findings: From baseline to one-week after treatment, the subject's worst pain in the last week, rated on a 0–10 numerical rating scale (BPI-SF3), decreased by 44%. Pain interference decreased and remained below baseline 12 weeks after the end of treatment. There was an associated improvement in the mental component of quality of life.

Conclusion: This case demonstrates the feasibility of treating shoulder pain in patients with SCI with percutaneous PNS. To demonstrate efficacy further studies are required.     

Rapid progression of acute cervical syringomyelia: A case report of delayed complications following spinal cord injury

Context: Post-traumatic syringomyelia treatment usually focuses on restoring normal cerebrospinal fluid (CSF) flow. Herein, the first-reported case of delayed post-traumatic syringomyelia associated with an L2 compression fracture 30 years prior to syringomyelia symptoms that rapidly progressed to the brainstem within 5 months, leading to respiratory and circulatory impairments, is summarized. The improvement in symptoms and significant decrease in size of the syringomyelia/syringobulbia achieved in this patient suggest that the initial treatment of choice in such acute cases should be posterior fossa decompression (PFD). Intradural exploration in order to restore the normal CSF flow at the level of trauma can then be planned in a later time.Findings: A retrospective analysis of clinical manifestations and findings obtained from magnetic resonance (MR) imaging, including pre-operative and post-operative follow-up data acquired 6 months later, provided adequate comparisons of the neurological deficits and syrinx size. Interestingly, serial MR images showed that a cervical syrinx acutely progressed to the brainstem within 5 months. PFD and sectioning of the thick veil completely obstructing the foramen of Magendie resulted in partial resolution of the neurological deficits and syringomyelia regression after surgery.Conclusions: To our knowledge, this is the first case report to summarize the delayed complications of a spinal cord injury and acute syringomyelia progression to the brainstem in a short period. The symptoms were relieved by an emergency PFD, chosen due to the rapid progression of symptoms. An atypical treatment strategy is described for extremely rare cases, but with a good short-term prognosis.     

仅累及上肢的急性中央颈脊髓损伤

介绍一种特殊类型的急性中央颈脊髓损伤。回顾分析24例仅仅表现为上肢运动与感觉损害症状的颈脊髓损伤患者，除1例行颈前路减压外均行保守治疗。结果有17例完全恢复正常，另7例遗留不同程度的手内在肌功能障碍。从受伤至运动功能恢复正常时间最短者为2周，最长者为4个月，平均恢复时间为2个月。而感觉功能恢复需4～6个月。作者认为其机制可能为颈脊髓前角细胞和后角细胞损害，非手术治疗多可取得满意疗效。     

Recurrent priapism in spinal cord injury: A case report

Context: Recurrent priapism is characterized by repetitive episodes of erections which are unrelated to sexual interest or stimulation. It is extremely rare in patients with spinal cord injury (SCI). There are a number of conservative agents used in the treatment.Findings: We describe the case of a 20-year-old male with cervical-5 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A tetraplegia as a result of a diving accident 2 years ago. He declared that the recurrent penile erections occurred up to 15–20 times day and night every day and lasted up to 20 min each time unrelated to sexual interest or stimulation. He was prescribed baclofen 10 mg, twice daily. The frequency and duration of erections decreased to 3–5 times/day lasting for about 5 min each and the patient reported a high treatment satisfaction.Conclusion: The presentation of this case is to remind clinicians this rare but distressing condition of recurrent priapism seen in men with complete spinal cord lesions and to summarize the use of medications, most commonly baclofen, to alleviate the condition.     

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.     

Weight gain following spinal cord injury: a pilot study

Study design

Retrospective chart review.

Objective

To define the temporal course of weight gain in persons with new spinal cord injury (SCI), and to identify predictors of weight gain in this population.

Setting

A United States Department of Veterans Affairs (VA) SCI Unit.

Methods

A retrospective chart review in a VA SCI Unit was conducted. Participants (n = 85) included all persons with new SCI completing initial rehabilitation at the center between 1998 and 2006. Outcome measures were mean change in body mass index (BMI) between rehabilitation admission and final follow-up, time of greatest BMI change, and distribution of participants by BMI classification. These measures were also examined relative to SCI level, American Spinal Injury Association Impairment Scale (AIS) grade, primary mode of mobility, and age at rehabilitation admission.

Results

Mean BMI increased by 2.3 kg/m² between rehabilitation admission (mean 45 days post-injury) and final follow-up (mean 5 years post-injury). The distribution of participants shifted from lower BMI classifications at rehabilitation admission to higher BMI classifications at final follow-up. For participants transitioning from normal to overweight or obese, the greatest increase occurred during the first year after acute rehabilitation. Neurological level, impairment category, primary mode of mobility, and age at rehabilitation admission did not significantly predict BMI change. BMI at rehabilitation admission correlated significantly with BMI at final follow-up (P < 0.0005).

Conclusions

These findings confirm a significant increase in BMI after new SCI and suggest that persons with new SCI are at greatest weight gain risk during the first year following acute rehabilitation.     

Spinal cord glioblastoma during pregnancy: Case report

Spinal Cord Glioblastoma Multiforme (SCGBM) is a very rare, debilitating and often fatal tumor. Cases of intracranial GBM during pregnancy have been reported, and as other tumor occurring in this setting, it harbors a great dilemma to attending physicians and families. We report the first case of a SCGBM diagnosed during pregnancy and discuss its management and treatment.     

Adult spinal cord injury with no radiographic bone lesion: analysis of nine consecutive patients

Background

Spinal cord injury with no radiographic bone lesion described as spinal cord injury without radiographic abnormality (SCIWORA) in childhood is less often reported in adults than in children. This study was undertaken to report our experience in the management of nine cases over 25 years.

Patients and methods

This was a retrospective study from 1985 to 2009 concerning nine adult patients who sustained spinal cord injury with no radiographic abnormality. The ratio among all cervical spine traumas for the same period was 2.21%. Magnetic resonance imaging (MRI) was performed in all the patients. The patients’ clinical status at the time of admission and discharge was evaluated using the Frankel's grading system. We report the results based on the clinical, epidemiologic and radiological findings and outcomes.

Results

The mean age of our population was 37.43 years, ranging from 18 to 60 years. All the patients were men. The main etiology was falls (5/9) followed by road traffic accidents (4/9). According to the Frankel's grading system, four patients (44.45%) were grade A, four were grade B (44.45%), and one was grade C (11.11%). On MRI, medullar lesions were: contusion, non-compressive cervical disc herniation, cervical spine stenosis, and two cases of normal cervical spine. Four patients were operated on via the posterior cervical spine approach (laminectomy, C3-C7 in three cases and C1-C3 in one case). The other five patients were treated orthopaedically for 6 to 8 weeks. Three patients (3/9), who were Frankel's grade B and C with no demonstrable injury on MRI, improved to Frankel a useful neurological grade (Frankel's grades D or E) at the time of discharge. One patient evaluated as Frankel's grade A died from cardiovascular disturbance.

Conclusion

Spinal cord injury with no radiographic abnormality accounted for 2.21% of cases of spinal cord injury in our series. MRI is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to identify surgically correctable abnormalities.     

脊髓损伤后血流改变

选用成年狗１０只，于胸９－０给以２０ｇ×２５ｃｍ打击量，应用氢清除法于伤后１５ｍｉｎ～４ｂ测定脊髓血流量（ＳＣＢＦ）。结果显示伤后不同时期灰质血流量均较白质血流量（ｗＳＣＢＦ）为高，近侧节较远侧节亦高，伤后２ｈ，ｗＳＣＢＦ稍升高，但４ｈ恢复正常。作者认为，伤后头几个小时为关键时刻，此时如能采用有效措施，对不全瘫还能逆转。本文结果与文献相比有些差异，可能与实验条件不同及观察时间较短有关。     

Transient anisocoria after a traumatic cervical spinal cord injury: A case report

Context: Autonomic dysreflexia and dysautonomia can be a common complication following spinal cord injury, especially at levels of T6 and above and can lead to complications associated with the pupil. In this case report, we review autonomic dysreflexia, the anatomy and physiology of the sympathetic nervous system of the eye, as well as review the clinical relevance in understanding autonomic and pupillary changes in response to autonomic dysfunction.

Findings: We present a patient with an incomplete C4 level injury who was found to have isolated anisocoria on two separate occasions during his acute inpatient rehabilitation stay.

Conclusion/Clinical Relevance: Anisocoria associated with abnormal sympathetic activation may be a clinical sign of dysautonomia.     

Spinal cord injury providers’ perspectives on managing sublesional osteoporosis

Objective: Persons with spinal cord injuries (SCI) experience rapid sublesional bone loss following injury (1, 3). Evidence on preventing/managing osteoporosis in SCI is lacking. This project examined how providers manage bone loss in SCI.

Design: Telephone interviews with SCI providers.

Setting: VA SCI centers and clinics.

Participants: Veterans Administration SCI centers and clinics were categorized on their average number of dual-energy X-ray absorptiometry (DXA) scans (FY2014-2016). Twelve SCI providers from high and low DXA-ordering sites were interviewed. Questions included osteoporosis screening/diagnosis, prevention/treatment strategies, secondary causes of osteoporosis, and osteoporotic fracture complications. Interviews were audio-recorded, transcribed, and analyzed.

Results: Providers described a lack of standardized guidelines for managing osteoporosis in SCI. They most often screened for osteoporosis using DXA when: (1) considering use of a new device or activity, (2) for patients with a history of fracture. Some providers assumed that non-ambulatory SCI patients already have osteoporosis so infrequently ordered DXAs. Assessment of secondary causes of osteoporosis was uncommon. Fracture prevention strategies identified included weight-bearing and engaging in activities like adaptive sports. Vitamin D and calcium were frequently prescribed as a result of deficiencies identified during lab testing. Providers seldom prescribed FDA-approved medications for osteoporosis. Post-fracture complications encountered included nonunion/malunion and compartment syndrome. Providers indicated that patients often experienced psychological stress, anxiety and depression following fractures.

Conclusion: Providers described a lack of evidence for screening and management of patients with SCI and osteoporosis. Future efforts should include developing evidence-informed guidelines to aid providers in osteoporosis management.     

Spinal cord injury

In the UK, the annual incidence of acute spinal cord injury (SCI) is 19 new cases per million population, contributing to an estimated 50,000 people who are currently living with SCI. Trauma is the most common cause of SCI, predominantly from falls and road traffic accidents. Damage to the spinal cord occurs both at the time of injury (primary) and in its aftermath (secondary). Effectively treating and preventing secondary cord injury, and managing complications associated with SCI, can make a significant improvement to patient outcomes. Improving outcomes in this patient population mean more patients with established SCIs are presenting for routine operations. Anaesthetists should be aware of the unique challenges posed by these patients, both in the acute and chronic settings.     

无骨折脱位型颈髓损伤的临床研究进展

无骨折脱位型颈髓损伤是指没有骨折或脱位的颈部创伤所导致的急性颈脊髓损伤。通常多见于儿童,具体损伤机制至今仍不明了。X线、CT检查提示颈椎无骨折脱位,MRI检查有脊髓损伤的表现。临床表现多种多样,以脊髓中央型损伤综合征常见。临床治疗可分为保守治疗和手术治疗,如何选择合适的治疗方法仍存在争议。本文就无骨折脱位型颈髓损伤的病因、损伤机制、临床治疗等方面的研究进展作一综述。     

Neuroarthropathy of the hip following spinal cord injury

We present the case of a 33-year-old male who sustained a burst fracture D12 vertebrae with spinal cord injury (ASIA impairment scale A) and a right mid-diaphysial femoral shaft fracture around 1.5 years back. The patient reported 1.5 years later with a swelling over the right buttock. Arthrotomy revealed serous fluid and fragmented bone debris. The biopsy showed a normal bony architecture with no evidence of infection and malignant cells. Hence, a diagnosis of Charcot’s hip was made. Charcot’s neuroarthropathy of the feet is a well-recognized entity in the setting of insensate feet resulting from causes such as diabetes or spina bifida. Although Charcot’s disease of the hips has been described, it is uncommon in association with spinal cord injury, syphilis and even with the use of epidural injection. The present case highlights the fact that neuroarthropathy of the hip can occur in isolation in the setting of a spinal cord injury, and this can lead to considerable morbidity.     

COVID-19 in spinal cord injury patients at a veterans administration hospital: A case series

ObjectiveTo describe the clinical features and disease course of COVID-19 in veterans with spinal cord injury (SCI).DesignCase series of consecutive veterans with SCI treated at a single center.SettingSCI Unit at an urban Veterans Administration hospital at the epicenter of the COVID-19 pandemic in the US.ParticipantsSeven SCI veterans with confirmed COVID-19 infection by PCR; all veterans were male, mean age was 60.6. Five had cervical level of injury, and five had complete injury (AIS A). Six veterans had a BMI > 22; three had chronic obstructive pulmonary disease; three had chronic kidney disease.InterventionsNone.Outcome MeasuresPresence of co-morbidities, diagnostic values, and clinical findings.ResultsEach case presented differently; the most common presenting sign was fever. In the three individuals with critical and fatal infection, pre-existing comorbidities were more common and inflammatory markers were markedly elevated.ConclusionLevel and completeness of SCI did not appear to correlate with COVID-19 severity, as mild and asymptomatic illness was noted in persons with high grade SCI. As has been shown to be the case in the general population, pre-existing comorbidities are the most reliable predictors of severe SARS-CoV-2 infection currently available for persons with chronic SCI. Contrary to concerns that SCI may mask the cardinal signs of COVID-19, such as fever and cough, by way of compromised thermoregulation and thoracoabdominal musculature, such signs were common in our series. To facilitate early detection, prompt treatment, and minimized viral spread, the implementation of preventive strategies by SCI units is recommended.     

陈旧性颈椎过伸伤伴脊髓损伤的临床研究

目的 探讨陈旧性颈椎过伸伤伴脊髓损伤患者的临床特点及其转归.方法 回顾性分析30例陈旧性颈椎过伸伤患者的临床资料,从损伤到就诊时间为3个月～8年,根据就诊时间分为三组,第1组:3～6个月,17例;第2组:6～12个月,8例;第3组:12个月～8年,5例.分别在术前、术后3个月、术后1年进行JOA评分,观察神经功能的改善率,比较各组的恢复情况.26例行颈椎前路减压植骨内固定术,4例行颈椎后路减压植骨内固定术.结果 三组之间的患者例数构成存在显著性差异.30例均获随访,随访时间18～39个月,平均23个月.术后1年,第1组平均改善率为23.8%,第2组平均改善率为53.9%,第3组平均改善率为54.3%.术后3个月、术后1年,第1组和第2组、第1组和第3组的JOA评分存在显著性差异,第2组和第3组无显著性差异.结论 陈旧性颈椎过伸伤伴迟发性脊髓损伤的发生在时间上有逐渐减少的趋势,迟发性脊髓损伤发生越早的患者损伤越严重,手术后的恢复越差.