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.

Lumbar spinal stenosis risk factors

Lumbar spinal stenosis risk factors

Risk factors for the disease include some comorbidities such as obesity or smoking, daily habits such as an active lifestyle, but also genetic factors that are not completely elucidated yet 1).

Lumbar spinal stenosis (LSS) is frequently observed in obese patients and the elderly especially due to the aging of the spine.

Increased Spinal inclination angle (SIA) and Body Mass Index BMI might be the most relevant risk factors for LSS 2).

DM and low ankle-brachial index values (ABI)s are significantly associated with sLSS in patients with moderate radiographic stenosis. Neither factor is associated with sLSS in patients with severe stenosis. Notably, the effects of intrinsic factors on symptomology may be masked when anatomic stenosis is severe 3).


Kitab et al., performed a re-analysis of data from their previously reported prospective MRI-based study, stratifying data from the 709 cases into 3 age categories of equal size (instead of the original < 60 vs ≥ 60 years). Relative lumbar spinal canal dimensions, as well as radiological degenerative variables from L1 to S1, were analyzed across age groups in a multivariate mode. The total degenerative scale score (TDSS) for each lumbar segment from L1 to S1 was calculated for each patient. The relationships between age and qualitative stenosis grades, TDSS, disc degeneration, and facet degeneration were analyzed using Pearson’s product-moment correlation and multiple regression.

Multivariate analysis of TDSS and spinal canal dimensions revealed highly significant differences across the 3 age groups at L2-3 and L3-4 and a weaker, but still significant, association with changes at L5-S1. Age helped to explain only 9.6% and 12.2% of the variance in TDSS at L1-2 and L2-3, respectively, with a moderate positive correlation, and 7.8%, 1.2%, and 1.9% of the variance in TDSS at L3-4, L4-5, and L5-S1, respectively, with weak positive correlation. Age explained 24%, 26%, and 18.4% of the variance in lumbar intervertebral disc (LID) degeneration at L1-2, L2-3, and L3-4, respectively, while it explained only 6.2% and 7.2% of the variance of LID degeneration at L4-5 and L5-S1, respectively. Age explained only 2.5%, 4.0%, 1.2%, 0.8%, and 0.8% of the variance in facet degeneration at L1-2, L2-3, L3-4, L4-5, and L5-S1, respectively.

Age at presentation correlated weakly with degeneration variables and spinal canal morphometries in LSS segments. Age correlated with upper lumbar segment (L1-4) degeneration more than with lower segment (L4-S1) degeneration. The actual chronological age of the patients did not significantly correlate with the extent of degenerative pathology of the lumbar spinal stenosis segments. These study results lend support for a developmental contribution to LSS 4).

References

1)

Bagley C, MacAllister M, Dosselman L, Moreno J, Aoun S, El Ahmadieh T. Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Res. 2019 Jan 31;8. pii: F1000 Faculty Rev-137. doi: 10.12688/f1000research.16082.1. eCollection 2019. Review. PubMed PMID: 30774933; PubMed Central PMCID: PMC6357993.
2)

Hirano K, Imagama S, Hasegawa Y, Muramoto A, Ishiguro N. Impact of spinal imbalance and BMI on lumbar spinal canal stenosis determined by a diagnostic support tool: cohort study in community‑living people. Arch Orthop Trauma Surg. 2013 Nov;133(11):1477-82. doi: 10.1007/s00402-013-1832-4. PubMed PMID: 23959069.
3)

Maeda T, Hashizume H, Yoshimura N, Oka H, Ishimoto Y, Nagata K, Takami M, Tsutsui S, Iwasaki H, Minamide A, Nakagawa Y, Yukawa Y, Muraki S, Tanaka S, Yamada H, Yoshida M. Factors associated with lumbar spinal stenosis in a large-scale, population-based cohort: The Wakayama Spine Study. PLoS One. 2018 Jul 18;13(7):e0200208. doi: 10.1371/journal.pone.0200208. eCollection 2018. PubMed PMID: 30020970; PubMed Central PMCID: PMC6051614.
4)

Kitab S, Habboub G, Abdulkareem SB, Alimidhatti MB, Benzel E. Redefining lumbar spinal stenosis as a developmental syndrome: does age matter? J Neurosurg Spine. 2019 May 17:1-9. doi: 10.3171/2019.2.SPINE181383. [Epub ahead of print] PubMed PMID: 31100722.

Occult Spinal Dysraphism Book

Occult Spinal Dysraphism

by R. Shane Tubbs (Editor), Rod J. Oskouian (Editor), Jeffrey P. Blount (Editor), W. Jerry Oakes (Editor)

$142.49

Buy

This volume covers the known details of all subtypes of occult spinal dysraphism in unprecedented detail. This 21 chapter invaluable resource begins with a deep dive into the history and embryology of occult spinal dysraphisms. Following this, subtypes of occult spinal dysraphism are thoroughly explored ­­― of which include split cord malformations, tethered cord syndromes, adult presentations/outcomes of occult spinal dysraphism, cutaneous stigmata. Chapters will cover the clinical presentation, radiological features, and surgical nuances of each of the occult spinal dysraphisms. Throughout the book, expertly written text is supplemented by a number of high quality figures and tables, as well as a video documenting surgical treatment of type 1 split cord malformation.

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