Cervical traumatic spinal cord injury outcome

Cervical traumatic spinal cord injury outcome

Injury to the spine and spinal cord is one of the common cause of disability and death. Several factors affect the outcome; but which are these factors (alone and in combination), are determining the outcomes are still unknown.

Based on parameters from the International Standards, physicians are able to inform patients about the predicted long-term outcomes, including the ability to walk, with high accuracy. In those patients who cannot participate in a reliable physical neurological examination, magnetic resonance imaging and electrophysiological examinations may provide useful diagnostic and prognostic information. As clinical research on this topic continues, the prognostic value of the reviewed diagnostic assessments will become more accurate in the near future. These advances will provide useful information for physicians to counsel tSCI patients and their families during the catastrophic initial phase after the injury 1).

In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between the extent of decompression, imaging biomarker evidence of injury severity, and the outcome are incompletely understood.

Aarabi et al., investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative MRI. 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 hours), 25 early (12-24 hours), and 15 late (>24-138.5 hours) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different between groups. Motor complete patients (p=0.009) and those with fracture-dislocations (p=0.01) tended to be operated earlier. Improvement of one grade or more was present in 55.6% in AIS grade A, 60.9% in AIS grade B, and 86.4% in 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; CI, 0.862-0.957; p<0.001).

They conclude that in patients with postoperative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determine the long-term neurological outcome 2).


Preclinical and class III clinical data suggest improved outcomes by maintaining the mean arterial pressure > 85 mm Hg and avoiding hypoxemia at least for 7 days following cervical SCI, and this level of monitoring and support should occur in the ICU 3).


100 cases of patients under 18 years at accident with acute traumatic cervical spinal cord injury admitted to spinal cord injury SCI centers participating in the European Multi-center study about SCI (EMSCI) between January 2005 and April 2016 were reviewed. According to their age at the accident, age 13 to 17, patients were selected for the adolescent group. After applying in- and exclusion criteria 32 adolescents were included. Each adolescent patient was matched with two adult SCI patients for analysis.

ASIA Impairment scale (AIS) grade, neurological, sensory, motor level, total motor score, and Spinal Cord Independence Measure (SCIM III) total score.

Mean AIS conversion, neurological, motor and sensory levels, as well as total motor score, showed no significant statistical difference in adolescents compared to the adult control group after a follow up of 6 months. Significantly higher final SCIM scores (p < 0.05) in the adolescent group compared to adults as well as a strong trend for a higher gain in SCIM score (p < 0.061) between first and last follow up was found.

Neurological outcome after traumatic cervical SCI is not superior in adolescents compared to adults in this cohort. Significantly higher SCIM scores indicate more functional gain for adolescent patients after traumatic cervical SCI. Juvenile age appears to be an independent predictor for a better functional outcome. 4).


A prospective observational study at single-center with all patients with cervical spinal cord injury (SCI), attending our hospital within a week of injury during a period of October 2011 to July 2013 was included for analysis. Demographic factors such as age, gender, etiology of injury, preoperative American Spinal Injury Association (ASIA) grade, upper (C2-C4) versus lower (C5-C7) cervical level of injury, image factors on magnetic resonance imaging (MRI), and timing of intervention were studied. Change in neurological status by one or more ASIA grade from the date of admission to 6 months follow-up was taken as an improvement. Functional grading was assessed using the functional independence measure (FIM) scale at 6 months follow-up.

A total of 39 patients with an acute cervical spine injury, managed surgically were included in this study. Follow-up was available for 38 patients at 6 months. No improvement was noted in patients with ASIA Grade A. Maximum improvement was noted in ASIA Grade D group (83.3%). The improvement was more significant in lower cervical region injuries. Patients with cord contusion showed no improvement as opposed to those with just edema wherein; the improvement was seen in 62.5% of patients. The percentage of improvement in cord edema ≤3 segments (75%) was significantly higher than edema with >3 segments (42.9%). Maximum improvement in FIM score was noted in ASIA Grade C and patients who had edema (especially ≤3 segments) in MRI cervical spine.

Complete cervical SCI, upper-level cervical cord injury, patients showing MRI contusion, edema >3 segments group have a worst improvement in neurological status at 6 months follow-up 5).


A total of 66 patients diagnosed with traumatic cervical SCI were selected for neurological assessment (using the International standards for neurological classification of spinal cord injury [ISNCSCI]) and functional evaluation (based on the Korean version Modified Barthel Index [K-MBI] and Functional Independence Measure [FIM]) at admission and upon discharge. All of the subjects received a preliminary electrophysiological assessment, according to which they were divided into two groups as follows: those with cervical radiculopathy (the SCI/Rad group) and those without (the SCI group).

A total of 32 patients with cervical SCI (48.5%) had cervical radiculopathy. The initial ISNCSCI scores for sensory and motor, K-MBI, and total FIM did not significantly differ between the SCI group and the SCI/Rad group. However, at discharge, the ISNCSCI scores for motor, K-MBI, and FIM of the SCI/Rad group showed less improvement (5.44±8.08, 15.19±19.39 and 10.84±11.49, respectively) than those of the SCI group (10.76±9.86, 24.79±19.65 and 17.76±15.84, respectively) (p<0.05). In the SCI/Rad group, the number of involved levels of cervical radiculopathy was negatively correlated with the initial and follow-up motors score by ISNCSCI.

Cervical radiculopathy is not rare in patients with traumatic cervical SCI, and it can impede neurological and functional improvement. Therefore, detection of combined cervical radiculopathy by electrophysiological assessment is essential for the accurate prognosis of cervical SCI patients in the rehabilitation unit 6).

References

1)

van Middendorp JJ, Goss B, Urquhart S, Atresh S, Williams RP, Schuetz M. Diagnosis and prognosis of traumatic spinal cord injury. Global Spine J. 2011 Dec;1(1):1-8. doi: 10.1055/s-0031-1296049. PubMed PMID: 24353930; PubMed Central PMCID: PMC3864437.
2)

Aarabi B, Akhtar-Danesh N, Chryssikos T, Shanmuganathan K, Schwartzbauer G, Simard MJ, Olexa J, Sansur C, Crandall K, Mushlin H, Kole M, Le E, Wessell A, Pratt N, Cannarsa G, Diaz Lomangino C, Scarboro M, Aresco C, Oliver J, Caffes N, Carbine S, Kanami M. Efficacy of Ultra-Early (<12 hours), Early (12-24 hours), and Late (>24-138.5 hours) Surgery with MRI-Confirmed Decompression in AIS grades A, B, and C Cervical Spinal Cord Injury. J Neurotrauma. 2019 Jul 16. doi: 10.1089/neu.2019.6606. [Epub ahead of print] PubMed PMID: 31310155.
3)

Schwartzbauer G, Stein D. Critical Care of Traumatic Cervical Spinal Cord Injuries: Preventing Secondary Injury. Semin Neurol. 2016 Dec;36(6):577-585. Epub 2016 Dec 1. Review. PubMed PMID: 27907962.
4)

Geuther M, Grassner L, Mach O, Klein B, Högel F, Voth M, Bühren V, Maier D, Abel R, Weidner N, Rupp R, Fürstenberg CH; EMSCI study group, Schneidmueller D. Functional outcome after traumatic cervical spinal cord injury is superior in adolescents compared to adults. Eur J Paediatr Neurol. 2018 Dec 11. pii: S1090-3798(18)30247-2. doi: 10.1016/j.ejpn.2018.12.001. [Epub ahead of print] PubMed PMID: 30579697.
5)

Srinivas BH, Rajesh A, Purohit AK. Factors affecting the outcome of acute cervical spine injury: A prospective study. Asian J Neurosurg. 2017 Jul-Sep;12(3):416-423. doi: 10.4103/1793-5482.180942. PubMed PMID: 28761518; PubMed Central PMCID: PMC5532925.
6)

Kim SY, Kim TU, Lee SJ, Hyun JK. The prognosis for patients with traumatic cervical spinal cord injury combined with cervical radiculopathy. Ann Rehabil Med. 2014 Aug;38(4):443-9. doi: 10.5535/arm.2014.38.4.443. Epub 2014 Aug 28. PubMed PMID: 25229022; PubMed Central PMCID: PMC4163583.

Osteosarcoma

Osteosarcoma

An osteosarcoma is a cancerous tumor in a bone. Specifically, it is an aggressive malignant neoplasm that arises from primitive transformed cells of mesenchymal origin (and thus a sarcoma) and that exhibits osteoblastic differentiation and produces malignant osteoid.

Osteoblastoma is a rare, benign, locally recurrent tumor with a predilection for spine, that may rarely undergo sarcomatous change (to osteosarcoma, only a handful of known cases of this 1)).

Epidemiology

The most common primary bone cancer. More common in children, usually occurring near the ends of long bones, but also in the mandible, pelvis, and rarely in the spine.

Spinal osteosarcoma usually occurs in the lumbosacral region in males in their 40 s, sometimes arising from areas of osteoblastoma or Paget’s disease. If a percutaneous biopsy reveals osteosarcoma, the contaminated needle tract can increase the difficulty of subsequent surgery. Poor prognosis, median survival=10 months 2).

Diagnosis

Caution regarding needle biopsy: if the lesion turns out to be osteosarcoma, the contaminated needle tract can result in worse prognosis.


The purpose of a work was to identify and measure catecholamines, their metabolites, and the gene expression of catecholamine receptors in osteosarcoma tissue.

The levels of 3,4-dihydroxyphenylacetic acid, norepinephrine, serotonin, and 5-hydroxyindoleacetic acid in cancer tissue and in adjacent and non-oncological bone tissue were analysed by high-performance liquid chromatography, and the gene expression of catecholamine receptors and of dopamine β-hydroxylase, monoaminoxidase, ki67, and Runx2 in the osteosarcoma tissue, tissue adjacent to the tumour, non-oncological bone, and human brain tissue was analysed by RT-PCR.

Bandala et al., found significantly higher levels of 3,4-dihydroxyphenylacetic acid and norepinephrine in the cancer sample than in adjacent and non-oncological bone. We found that β-adrenergic receptors and dopaminergic receptors, dopamine β-hydroxylase, ki67, Runx2, and serotonergic receptor gene expression were significantly higher in tumour tissue than in adjacent and non-oncological bone.

Catecholamines and their receptors could be potential molecular markers for osteosarcoma progression 3).

Complications

References

1)

Amacher AL, Eltomey A. Spinal Osteoblastoma in Children and Adolescents. Childs Nerv Syst. 1985; 1:29–32
2)

Shives TC, Dahlin DC, Sim FH, Pritchard DJ, Earle JD. Osteosarcoma of the spine. J Bone Joint Surg Am. 1986; 68:660–668
3)

Bandala C, Ávila-Luna A, Gómez-López M, Estrada-Villaseñor E, Montes S, Alfaro-Rodríguez A, Miliar-García Á, Cortés-Altamirano JL, Peralta R, Ibáñez-Cervantes G, Gómez-Manzo S, Cárdenas-Rodríguez N, Lara-Padilla E. Catecholamine levels and gene expression of their receptors in tissues of adults with osteosarcoma. Arch Physiol Biochem. 2019 Jul 10:1-7. doi: 10.1080/13813455.2019.1638942. [Epub ahead of print] PubMed PMID: 31291139.

Robotic pedicle screw placement learning curve

Robotic pedicle screw placement learning curve

Siddiqui et al., described the learning curve of pedicle screw placement using Robot-Assisted Spine Surgery (RASS) of an experienceneurosurgeon and two supervised neurosurgical fellows.

The first 120 cases of RASS at the University of Texas Health Science Center at San Antoniowere assessed. Patient variables included agebody mass index (BMI), and indication for surgery. Intra-operative variables included the vertebral level of pedicle screw placement, number of screws placed by each operator, intraoperative blood loss, and operative time. Post-operative variables included Length of stay (LOS), discharge disposition, 30-day readmissions, wound complications, and hardware revisions. Screw accuracy was determined with image overlay analysis comparing planned screw trajectory on the navigation software to the intra-operative CT scan with final screw placement. 2-dimensional accuracy was determined for the tip of the screw, tail of the screw, and angle the screw was placed. The supervising physician and first fellow began utilizing the robot concurrently upon its arrival, while the second fellow began using the robot after the system had been in place for seven months.

Both experienced surgeon and first fellow displayed a learning curve and achieved statistically significant improvement of accuracy after 30 screws. The second fellow had significantly better accuracy than the experienced surgeon in his first 30 screws. There were no complications from hardware placement in either group. There were no returns to the operating room for hardware issues.

RASS is a safe, accurate method of pedicle screw instrumentation. This data shows similar learning adaptation rates for the first fellow and the experienced surgeon. Techniques learned by attending were immediately transferable to a new learner, who was able to achieve a faster learning curve than both first fellow and experienced surgeon 1).


A major peak in screw inaccuracies occurred between cases 10 and 20, and a second, smaller one at about 40 surgeries. One potential explanation could be a transition from decreased supervision (unskilled but aware) to increased confidence of a surgeon (unskilled but unaware) who adopts this new technique prior to mastering it (skilled). Schatloet al., therefore advocate ensuring competent supervision for new surgeons at least during the first 25 procedures of robotic spine surgery to optimise the accuracy of robot-assisted pedicle screws 2).


Between June 2010 and August 2012, the senior surgeon (IHL) performed 174 posterior spinal procedures using pedicle screws, 162 of which were attempted with robotic assistance. The use of the robotic system was aborted in 12 of the 162 procedures due to technical issues (registration failure, software crash, etc). The robotic system was successfully used in the remaining 150 procedures. These were the first procedures performed with the robot by the senior surgeon, and in this study, we divided the early learning curve into five groups: Group 1 (Patients 1-30), Group 2 (Patients 31-60), Group 3 (Patients 61-90), Group 4 (Patients 91-120), and Group 5 (Patients 121-150). One hundred twelve patients (75%) had spinal deformity and 80 patients (53%) had previous spine surgery. The accuracy of screw placement in the groups was assessed based on intraoperative biplanar fluoroscopy and postoperative radiographs. The results from these five groups were compared to determine the effect on the learning curve. The numbers of attempted pedicle screw placements were 359, 312, 349, 359, and 320 in Groups 1 to 5, respectively.

The rates of successfully placed screws using robotic guidance were 82%, 93%, 91%, 95%, and 93% in Groups 1 to 5. The rates of screws converted to manual placement were 17%, 7%, 8%, 4%, and 7%. Of the robotically placed screws, the screw malposition rates were 0.8%, 0.3%, 1.4%, 0.8%, and 0%.

The rate of successfully placed pedicle screws improved with increasing experience. The rate of the screws that were converted to manual placement decreased with increasing experience. The frequency of screw malposition was similar over the learning curve at 0% to 1.4%. Future studies will need to determine whether this finding is generalizable to others 3).

References

1)

Siddiqui MI, Wallace DJ, Salazar LM, Vardiman AB. Robot-assisted pedicle screw placement is safe and accurate in both experienced and two supervised, in-training surgeons. World Neurosurg. 2019 Jun 24. pii: S1878-8750(19)31659-6. doi: 10.1016/j.wneu.2019.06.107. [Epub ahead of print] PubMed PMID: 31247356.
2)

Schatlo B, Martinez R, Alaid A, von Eckardstein K, Akhavan-Sigari R, Hahn A, Stockhammer F, Rohde V. Unskilled unawareness and the learning curve in robotic spine surgery. Acta Neurochir (Wien). 2015 Oct;157(10):1819-23; discussion 1823. doi: 10.1007/s00701-015-2535-0. Epub 2015 Aug 19. PubMed PMID: 26287268.
3)

Hu X, Lieberman IH. What is the learning curve for robotic-assisted pedicle screw placement in spine surgery? Clin Orthop Relat Res. 2014 Jun;472(6):1839-44. doi: 10.1007/s11999-013-3291-1. PubMed PMID: 24048889; PubMed Central PMCID: PMC4016454.
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