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Alvi MA, Pedro KM, Quddusi AI, Fehlings MG. Advances and Challenges in Spinal Cord Injury Treatments. J Clin Med 2024; 13:4101. [PMID: 39064141 PMCID: PMC11278467 DOI: 10.3390/jcm13144101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Spinal cord injury (SCI) is a debilitating condition that is associated with long-term physical and functional disability. Our understanding of the pathogenesis of SCI has evolved significantly over the past three decades. In parallel, significant advances have been made in optimizing the management of patients with SCI. Early surgical decompression, adequate bony decompression and expansile duraplasty are surgical strategies that may improve neurological and functional outcomes in patients with SCI. Furthermore, advances in the non-surgical management of SCI have been made, including optimization of hemodynamic management in the critical care setting. Several promising therapies have also been investigated in pre-clinical studies, with some being translated into clinical trials. Given the recent interest in advancing precision medicine, several investigations have been performed to delineate the role of imaging, cerebral spinal fluid (CSF) and serum biomarkers in predicting outcomes and curating individualized treatment plans for SCI patients. Finally, technological advancements in biomechanics and bioengineering have also found a role in SCI management in the form of neuromodulation and brain-computer interfaces.
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Affiliation(s)
- Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada; (M.A.A.); (K.M.P.); (A.I.Q.)
| | - Karlo M. Pedro
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada; (M.A.A.); (K.M.P.); (A.I.Q.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Ayesha I. Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada; (M.A.A.); (K.M.P.); (A.I.Q.)
| | - Michael G. Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada; (M.A.A.); (K.M.P.); (A.I.Q.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
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Quddusi A, Pedro KM, Alvi MA, Hejrati N, Fehlings MG. Early surgical intervention for acute spinal cord injury: time is spine. Acta Neurochir (Wien) 2023; 165:2665-2674. [PMID: 37468659 DOI: 10.1007/s00701-023-05698-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/28/2023] [Indexed: 07/21/2023]
Abstract
Acute traumatic spinal cord injury (tSCI) is a devastating occurrence that significantly contributes to global morbidity and mortality. Surgical decompression with stabilization is the most effective way to minimize the damaging sequelae that follow acute tSCI. In recent years, strong evidence has emerged that supports the rationale that early surgical intervention, within 24 h following the initial injury, is associated with a better prognosis and functional outcomes. In this review, we have summarized the evidence and elaborated on the nuances of this concept. Additionally, we have reviewed further concepts that stem from "time is spine," including earlier cutoffs less than 24 h and the challenging entity of central cord syndrome, as well as the emerging concept of adequate surgical decompression. Lastly, we identify barriers to early surgical care for acute tSCI, a key aspect of spine care that needs to be globally addressed via research and policy on an urgent basis.
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Affiliation(s)
- Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Karlo M Pedro
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nader Hejrati
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.
- Toronto Western Hospital, 399 Bathurst Street, Suite 4WW-449, Toronto, ON, M5T 2S8, Canada.
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Aarabi B, Akhtar-Danesh N, Chryssikos T, Shanmuganathan K, Schwartzbauer GT, Simard JM, Olexa J, Sansur CA, Crandall KM, Mushlin H, Kole MJ, Le EJ, Wessell AP, Pratt N, Cannarsa G, Lomangino C, Scarboro M, Aresco C, Oliver J, Caffes N, Carbine S, Mori K. Efficacy of Ultra-Early (< 12 h), Early (12-24 h), and Late (>24-138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury. J Neurotrauma 2020; 37:448-457. [PMID: 31310155 PMCID: PMC6978784 DOI: 10.1089/neu.2019.6606] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12-24 h), and 15 underwent decompressive surgery late (> 24-138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862-0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Noori Akhtar-Danesh
- School of Nursing and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Timothy Chryssikos
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Gary T. Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles A. Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenneth M. Crandall
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Harry Mushlin
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Matthew J. Kole
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth J. Le
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aaron P. Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan Pratt
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cara Lomangino
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Maureen Scarboro
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Carla Aresco
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jeffrey Oliver
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicholas Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephen Carbine
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kanami Mori
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
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Aarabi B, Olexa J, Chryssikos T, Galvagno SM, Hersh DS, Wessell A, Sansur C, Schwartzbauer G, Crandall K, Shanmuganathan K, Simard JM, Mushlin H, Kole M, Le E, Pratt N, Cannarsa G, Lomangino CD, Scarboro M, Aresco C, Curry B. Extent of Spinal Cord Decompression in Motor Complete (American Spinal Injury Association Impairment Scale Grades A and B) Traumatic Spinal Cord Injury Patients: Post-Operative Magnetic Resonance Imaging Analysis of Standard Operative Approaches. J Neurotrauma 2019; 36:862-876. [PMID: 30215287 PMCID: PMC6484360 DOI: 10.1089/neu.2018.5834] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Although decompressive surgery following traumatic spinal cord injury (TSCI) is recommended, adequate surgical decompression is rarely verified via imaging. We utilized magnetic resonance imaging (MRI) to analyze the rate of spinal cord decompression after surgery. Pre-operative (within 8 h of injury) and post-operative (within 48 h of injury) MRI images of 184 motor complete patients (American Spinal Injury Association Impairment Scale [AIS] grade A = 119, AIS grade B = 65) were reviewed to verify spinal cord decompression. Decompression was defined as the presence of a patent subarachnoid space around a swollen spinal cord. Of the 184 patients, 100 (54.3%) underwent anterior cervical discectomy and fusion (ACDF), and 53 of them also underwent laminectomy. Of the 184 patients, 55 (29.9%) underwent anterior cervical corpectomy and fusion (ACCF), with (26 patients) or without (29 patients) laminectomy. Twenty-nine patients (16%) underwent stand-alone laminectomy. Decompression was verified in 121 patients (66%). The rates of decompression in patients who underwent ACDF and ACCF without laminectomy were 46.8% and 58.6%, respectively. Among these patients, performing a laminectomy increased the rate of decompression (72% and 73.1% of patients, respectively). Twenty-five of 29 (86.2%) patients who underwent a stand-alone laminectomy were found to be successfully decompressed. The rates of decompression among patients who underwent laminectomy at one, two, three, four, or five levels were 58.3%, 68%, 78%, 80%, and 100%, respectively (p < 0.001). In multi-variate logistic regression analysis, only laminectomy was significantly associated with successful decompression (odds ratio 4.85; 95% confidence interval 2.2-10.6; p < 0.001). In motor complete TSCI patients, performing a laminectomy significantly increased the rate of successful spinal cord decompression, independent of whether anterior surgery was performed.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Timothy Chryssikos
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Samuel M. Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - David S. Hersh
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aaron Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenneth Crandall
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kathirkamanathan Shanmuganathan
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Harry Mushlin
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mathew Kole
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth Le
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan Pratt
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cara D. Lomangino
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Maureen Scarboro
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Carla Aresco
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brian Curry
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Aarabi B, Sansur CA, Ibrahimi DM, Simard JM, Hersh DS, Le E, Diaz C, Massetti J, Akhtar-Danesh N. Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury. Neurosurgery 2017; 80:610-620. [PMID: 28362913 DOI: 10.1093/neuros/nyw053] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/14/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Evidence indicates that, over time, patients with spinal cord injury (SCI) improve neurologically in various degrees. We sought to further investigate indicators of grade conversion in cervical SCI. OBJECTIVE To detect predictors of ASIA impairment scale (AIS) grade conversion in SCI following surgical decompression. METHODS In a retrospective study, demographics, clinical, imaging, and surgical data from 100 consecutive patients were assessed for predictors of AIS grade conversion. RESULTS American Spinal Injury Association motor score was 17.1. AIS grade was A in 52%, B in 29%, and C in 19% of patients. Surgical decompression took place on an average of 17.6 h following trauma (≤12 h in 51 and >12 h in 49). Complete decompression was verified by magnetic resonance imaging (MRI) in 73 patients. Intramedullary lesion length (IMLL) on postoperative MRI measured 72.8 mm, and hemorrhage at the injury epicenter was noted in 71 patients. Grade conversion took place in 26.9% of AIS grade A patients, 65.5% of AIS grade B, and 78.9% of AIS grade C. AIS grade conversion had statistical relationship with injury severity score, admission AIS grade, extent of decompression, presence of intramedullary hemorrhage, American Spinal Injury Association motor score, and IMLL. A stepwise multiple logistic regression analysis indicated IMLL was the sole and strongest indicator of AIS grade conversion (odds ratio 0.950, 95% CI 0.931-0.969). For 1- and 10-mm increases in IMLL, the model indicates 4% and 40% decreases, respectively, in the odds of AIS grade conversion. CONCLUSION Compared with other surrogates, IMLL remained as the only predictor of AIS grade conversion.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.,R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles A Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David M Ibrahimi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David S Hersh
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth Le
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cara Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Massetti
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Noori Akhtar-Danesh
- School of Nursing and Depart-ment of Clinical Epidemiology and Bio-statistics, McMaster University, Hamilton, Ontario, Canada
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Jalan D, Saini N, Zaidi M, Pallottie A, Elkabes S, Heary RF. Effects of early surgical decompression on functional and histological outcomes after severe experimental thoracic spinal cord injury. J Neurosurg Spine 2017; 26:62-75. [DOI: 10.3171/2016.6.spine16343] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
In acute traumatic brain injury, decompressive craniectomy is a common treatment that involves the removal of bone from the cranium to relieve intracranial pressure. The present study investigated whether neurological function following a severe spinal cord injury improves after utilizing either a durotomy to decompress the intradural space and/or a duraplasty to maintain proper flow of cerebrospinal fluid.
METHODS
Sixty-four adult female rats (n = 64) were randomly assigned to receive either a 3- or 5-level decompressive laminectomy (Groups A and B), laminectomy + durotomy (Groups C and D), or laminectomy + duraplasty with graft (Group E and F) at 24 hours following a severe thoracic contusion injury (200 kilodynes). Duraplasty involved the use of DuraSeal, a hydrogel dural sealant. Uninjured and injured control groups were included (Groups G, H). Hindlimb locomotor function was assessed by open field locomotor testing (BBB) and CatWalk gait analysis at 35 days postinjury. Bladder function was analyzed and bladder wall thickness was assessed histologically. At 35 days postinjury, mechanical and thermal allodynia were assessed by the Von Frey hair filament and hotplate paw withdrawal tests, respectively. Thereafter, the spinal cords were dissected, examined for gross anomalies at the injury site, and harvested for histological analyses to assess lesion volumes and white matter sparing. ANOVA was used for statistical analyses.
RESULTS
There was no significant improvement in motor function recovery in any treatment groups compared with injured controls. CatWalk gait analysis indicated a significant decrease in interlimb coordination in Groups B, C, and D (p < 0.05) and swing speed in Groups A, B, and D. Increased mechanical pain sensitivity was observed in Groups A, C, and F (p < 0.05). Rats in Group C also developed thermal pain hypersensitivity. Examination of spinal cords demonstrated increased lesion volumes in Groups C and F and increased white matter sparing in Group E (p < 0.05). The return of bladder automaticity was similar in all groups. Examination of the injury site during tissue harvest revealed that, in some instances, expansion of the hydrogel dural sealant caused compression of the spinal cord.
CONCLUSIONS
Surgical decompression provided no benefit in terms of neurological improvement in the setting of a severe thoracic spinal cord contusion injury in rats at 24 hours postinjury. Decompressive laminectomy and durotomy did not improve motor function recovery, and rats in both of these treatment modalities developed neuropathic pain. Performing a durotomy also led to increased lesion volumes. Placement of DuraSeal was shown to cause compression in some rats in the duraplasty treatment groups. Decompressive duraplasty of 3 levels does not affect functional outcomes after injury but did increase white matter sparing. Decompressive duraplasty of 5 levels led to neuropathic pain development and increased lesion volumes. Further comparison of dural repair techniques is necessary.
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Affiliation(s)
- Devesh Jalan
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
| | - Neginder Saini
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
| | - Mohammad Zaidi
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
| | - Alexandra Pallottie
- 2Graduate School of Biomedical Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey
| | - Stella Elkabes
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
| | - Robert F. Heary
- 1Department of Neurological Surgery, Rutgers, The State University of New Jersey–New Jersey Medical School; and
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Complete fracture of the lamina of the sixth cervical vertebra with hemiplegia: a case report. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25 Suppl 1:49-52. [PMID: 26071947 DOI: 10.1007/s00586-015-4067-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 04/28/2015] [Accepted: 06/07/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We report the rare case of a 27-year-old man who presented a right sided complete hemiplegia after a neck trauma due to a road traffic accident. MATERIALS AND METHODS Computed tomography revealed a complete fracture of the C6 lamina including a partial fracture of the right articular process with complete rotation of the fragment into the spinal canal with a major compression of the right side of the cord. The patient was operated urgently and underwent posterior approach for C6 arch removal followed by a C6C7 anterior fusion as T2 weighted magnetic resonance imaging revealed a completely torn C6C7 disc with a hematoma under the posterior longitudinal ligament associated with an increased cord signal. Patient could walk normally 6 weeks after the accident. At 2 years follow-up, he recovered full sensation of his right body but had a residual intrinsic muscle weakness in his right hand. CONCLUSION This is the first paper, in the literature, to describe a complete laminar fracture at the cervical spine level with hemiplegia. Early surgical intervention probably provides the better neurological outcome.
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Yılmaz T, Kaptanoğlu E. Current and future medical therapeutic strategies for the functional repair of spinal cord injury. World J Orthop 2015; 6:42-55. [PMID: 25621210 PMCID: PMC4303789 DOI: 10.5312/wjo.v6.i1.42] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Spinal cord injury (SCI) leads to social and psychological problems in patients and requires costly treatment and care. In recent years, various pharmacological agents have been tested for acute SCI. Large scale, prospective, randomized, controlled clinical trials have failed to demonstrate marked neurological benefit in contrast to their success in the laboratory. Today, the most important problem is ineffectiveness of nonsurgical treatment choices in human SCI that showed neuroprotective effects in animal studies. Recently, attempted cellular therapy and transplantations are promising. A better understanding of the pathophysiology of SCI started in the early 1980s. Research had been looking at neuroprotection in the 1980s and the first half of 1990s and regeneration studies started in the second half of the 1990s. A number of studies on surgical timing suggest that early surgical intervention is safe and feasible, can improve clinical and neurological outcomes and reduce health care costs, and minimize the secondary damage caused by compression of the spinal cord after trauma. This article reviews current evidence for early surgical decompression and nonsurgical treatment options, including pharmacological and cellular therapy, as the treatment choices for SCI.
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Harrop JS, Ghobrial GM, Chitale R, Krespan K, Odorizzi L, Fried T, Maltenfort M, Cohen M, Vaccaro A. Evaluating initial spine trauma response: injury time to trauma center in PA, USA. J Clin Neurosci 2014; 21:1725-9. [PMID: 24932590 DOI: 10.1016/j.jocn.2014.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 03/28/2014] [Indexed: 11/24/2022]
Abstract
Historical perceptions regarding the severity of traumatic spinal cord injury has led to considerable disparity in triage to tertiary care centers. This article retrospectively reviews a large regional trauma database to analyze whether the diagnosis of spinal trauma affected patient transfer timing and patterns. The Pennsylvania Trauma database was retrospectively reviewed. All acute trauma patient entries for level I and II centers were categorized for diagnosis, mechanism, and location of injury, analyzing transportation modality and its influence on time of arrival. A total of 1162 trauma patients were identified (1014 blunt injuries, 135 penetrating injuries and 12 other) with a mean transport time of 3.9 hours and a majority of patients arriving within 7 hours (>75%). Spine trauma patients had the longest mean arrival time (5.2 hours) compared to blunt trauma (4.2 hours), cranial neurologic injuries (4.35 hours), and penetrating injuries (2.13 hours, p<0.0001). There was a statistically significant correlation between earlier arrivals and both cranial trauma (p=0.0085) and penetrating trauma (p<0.0001). The fastest modality was a fire rescue (0.93 hours) or police (0.63 hours) vehicle with Philadelphia County (1.1 hour) having the quickest arrival times. Most trauma patients arrived to a specialty center within 7 hours of injury. However subsets analysis revealed that spine trauma patients had the greatest transit times. Present research trials for spinal cord injuries suggest earlier intervention may lead to improved recovery. Therefore, it is important to focus on improvement of the transportation triage system for traumatic spinal patients.
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Affiliation(s)
- James S Harrop
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA.
| | - George M Ghobrial
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Rohan Chitale
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Kelly Krespan
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Laura Odorizzi
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Tristan Fried
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Mitchell Maltenfort
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Murray Cohen
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Alexander Vaccaro
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
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Mac-Thiong JM, Feldman DE, Thompson C, Bourassa-Moreau E, Parent S. Does timing of surgery affect hospitalization costs and length of stay for acute care following a traumatic spinal cord injury? J Neurotrauma 2012; 29:2816-22. [PMID: 22920942 DOI: 10.1089/neu.2012.2503] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Although there is a trend toward performing early surgery for traumatic spinal cord injury (SCI), it remains unclear whether this tendency leads to decreased costs and length of stay (LOS) for acute care. This study determined the impact of surgical timing on costs and LOS after a traumatic SCI. A total of 477 consecutive patients sustaining an acute traumatic SCI and receiving surgery at a level I trauma center were included. A general linear model was used to assess the relationship among costs, LOS, and surgical delay, while accounting for various sociodemographic and clinical covariables. The analysis was also repeated with surgical delay dichotomized within 24 h or later after the trauma. Mean costs and LOS for all patients were respectively 24,156 ± 17,244 $CAD and 35.0 ± 39.4 days. The costs of acute care hospitalization were related to the surgical delay between the trauma and the surgery, in addition to age, injury severity score (ISS), American Spinal Injury Association (ASIA) grade, and neurological level. LOS was associated with the surgical delay dichotomized into two groups (<24 vs. ≥24 h), as well as with age, ISS, ASIA grade, and neurological level. This study suggests that resource utilization in terms of costs and LOS for the acute hospitalization is decreased with early surgery after an acute traumatic SCI, particularly if the procedure is performed within 24 h following the trauma. Performing the surgery as early as possible when the patient is cleared for surgery could lower the financial burden on the healthcare system, while optimizing the neurological recovery.
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Head and Spinal Cord Injury: Diagnosis and Management. Neurol Clin 2012; 30:241-76, ix. [DOI: 10.1016/j.ncl.2011.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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