The optimal radiologic method for assessing spinal canal compromise and cord compression in patients with cervical spinal cord injury. Part I: An evidence-based analysis of the published literature.

A multicenter, retrospective study using computed tomographic and magnetic resonance imaging data to establish quantitative, reliable criteria of canal compromise and cord compression in patients with cervical spinal cord injury. To develop and validate a radiologic assessment tool of spinal canal compromise and cord compression in cervical spinal cord injury for use in clinical trials. There are few quantitative, reliable criteria for radiologic measurement of cervical spinal canal compromise or cord compression after acute spinal cord injury. The study included 71 patients (55 men, 16 women; mean age, 39.7 +/- 18.7 years) with acute cervical spinal cord injury. Causes of spinal cord injury included motor vehicle accidents (n = 36), falls (n = 20), water-related injuries (n = 8), sports (n = 5), assault (n = 1), and farm accidents (n = 1). Canal compromise was measured on computed tomographic scan and T1- and T2-weighted magnetic resonance imaging, and cord compression at the level of maximum injury was measured on T1- and T2-weighted magnetic resonance imaging. All films were assessed by two independent observers. There was a strong correlation of canal compromise and/or cord compression measurements between axial and midsagittal computed tomography, and between axial and midsagittal T2-weighted magnetic resonance imaging. Spinal canal compromise assessed by computed tomography showed a significant although moderate correlation with spinal cord compression assessed by T1- and T2-weighted magnetic resonance imaging. Virtually all patients with canal compromise of 25% or more on computed tomographic scan had evidence of some degree of cord compression on magnetic resonance imaging, but a large number of patients with less than 25% canal compromise on computed tomographic scan also had evidence on magnetic resonance imaging of cord compression. In patients with cervical spinal cord injury, the midsagittal T1- and T2-weighted magnetic resonance imaging provides an objective, quantifiable, and reliable assessment of spinal cord compression that cannot be adequately assessed by computed tomography alone.

Prospective, blinded validation study of an objective, quantitative measure to assess maximum canal compromise (MCC) and maximum spinal cord compression (MSCC) in individuals with acute cervical spinal cord injury (SCI). To examine the intraobserver and interobserver reliability of MCC and MSCC in individuals with acute traumatic cervical SCI. To date, few quantitative reliable radiologic methods for assessing the extent of spinal cord compression in the setting of acute SCI have been reported. MCC and MSCC, as assessed on mid-sagittal CT and T2-weighted MR images, respectively, appear to have potential clinical and prognostic value. To date, the validation of these assessment tools has been limited to a small number of observers at a single institution. However, to date no study has focused on the reliability of these radiologic parameters among a large cohort of spine surgeons from North America and abroad. This type of validation is critical to allow the broader use of these outcome measures in research studies and in clinical practice. Mid-sagittal MRI and CT images of cervical spine were selected from 10 individuals with acute traumatic cervical SCI. A total of 28 spine surgeons independently estimated CT MCC, T1-weighted MRI MCC, and T2-weighted MRI MSCC on two occasions using a calibrated ruler. In the first round of measurements, the observers estimated the radiologic parameters using only written instructions. The second measurement set was obtained after an interactive teaching session on the methodology. The order of the images was altered for the second set of measurements. Analysis using parametric and nonparametric statistics indicated high intraobserver reliability for CT MCC, T1-weighted MRI MCC, and T2-weighted MSCC with interclass correlation coefficients (ICCs) of 0.92, 0.95, and 0.97, respectively. The interobserver reliability for all three radiologic parameters was considered moderate with ICCs ranging from 0.35 to 0.56. Our results indicate that the intraobserver reliability for the MCC and MSCC was high. Although the interobserver reliability for all three radiologic parameters in the present study was below 0.75, the observed differences were small and largely accounted for by the limitations in the precision of the calibrated ruler. For cases with minimal cord compression, the measurement of canal stenosis (MCC) proved more accurate. In contrast, in cases with severe cord compression, the assessment of MSCC was more accurate. It is anticipated that the use of digital imaging technologies will further enhance the precision of these outcome measures.

Spinal cord injury results in permanent neurological impairment and disability due to the absence of spontaneous regeneration. NG101, a recombinant human antibody, neutralises the neurite growth-inhibiting protein Nogo-A, promoting neural repair and motor recovery in animal models of spinal cord injury. We aimed to evaluate the efficacy of intrathecal NG101 on recovery in patients with acute cervical traumatic spinal cord injury. This randomised, double-blind, placebo-controlled phase 2b clinical trial was done at 13 hospitals in the Czech Republic, Germany, Spain, and Switzerland. Patients aged 18-70 years with acute, complete or incomplete cervical spinal cord injury (neurological level of injury C1-C8) within 4-28 days of injury were eligible for inclusion. Participants were initially randomly assigned 1:1 to intrathecal treatment with 45 mg NG101 or placebo (phosphate-buffered saline); 18 months into the study, the ratio was adjusted to 3:1 to achieve a final distribution of 2:1 to improve enrolment and drug exposure. Randomisation was done using a centralised, computer-based randomisation system and was stratified according to nine distinct outcome categories with a validated upper extremity motor score (UEMS) prediction model based on clinical parameters at screening. Six intrathecal injections were administered every 5 days over 4 weeks, starting within 28 days of injury. Investigators, study personnel, and study participants were masked to treatment allocation. The primary outcome was change in UEMS at 6 months, analysed alongside safety in the full analysis set. The completed trial was registered at ClinicalTrials.gov, NCT03935321. From May 20, 2019, to July 20, 2022, 463 patients with acute traumatic cervical spinal cord injury were screened, 334 were deemed ineligible and excluded, and 129 were randomly assigned to an intervention (80 patients in the NG101 group and 49 in the placebo group). The full analysis set comprised 78 patients from the NG101 group and 48 patients from the placebo group. 107 (85%) patients were male and 19 (15%) patients were female, with a median age of 51·5 years (IQR 30·0-60·0). Across all patients, the primary endpoint showed no significant difference between groups (with UEMS change at 6 months 1·37 [95% CI -1·44 to 4·18]; placebo group mean 19·20 [SD 11·78] at baseline and 30·91 [SD 15·49] at day 168; NG101 group mean 18·23 [SD 15·14] at baseline and 31·31 [19·54] at day 168). Treatment-related adverse events were similar between groups (nine in the NG101 group and six in the placebo group). 25 severe adverse events were reported: 18 in 11 (14%) patients in the NG101 group and seven in six (13%) patients in the placebo group. Although no treatment-related fatalities were reported in the NG101 group, one fatality not related to treatment occurred in the placebo group. Infections were the most common adverse event affecting 44 (92%) patients in the placebo group and 65 (83%) patients in the NG101 group. NG101 did not improve UEMS in patients with acute spinal cord injury. Post-hoc subgroup analyses assessing UEMS and Spinal Cord Independence Measure of self-care in patients with motor-incomplete injury indicated potential beneficial effects that require investigation in future studies. EU program Horizon2020; Swiss State Secretariat for Education, Research and Innovation; Wings for Life; the Swiss Paraplegic Foundation; and the CeNeReg project of Wyss Zurich (University of Zurich and Eidgenössische Technische Hochschule Zurich).

Intradural spinal cord compression impairs perfusion pressure and is putatively rate-limiting for recovery after traumatic spinal cord injury (tSCI). After cervical tSCI, even minimally improved tissue preservation may help promote neurological recovery. To assess the nature and extent of spinal cord swelling and compression post-acute cervical tSCI, we evaluated several baseline MRI parameters including BASIC score, intramedullary lesion (IML) length, maximal canal compromise (MCC), maximal spinal cord compression (MSCC), extent of cord compression (ECC), maximal swollen anteroposterior diameter adjacent to injury site (Dmax), and maximal cord swelling (MCS) in 169 consecutive patients across 2 centers. In patients with either primarily intradural or combined (MSCC ≤5% or >5%, respectively) cord compression, we examined the predictive value of clinical and imaging admission parameters on American Spinal Injury Association Impairment Scale (AIS) severity and conversion up to 1-year follow-up. 37 (21.9%) patients presented with primarily intradural while 132 (78.1%) had combined cord compression. MSCC, MCS, and Dmax values differed significantly between the two groups (p < 0.0001, < 0.01 and < 0.001, respectively). MSCC was associated with age, MCC and MCS at baseline, while MCS was associated with age, MSCC and Dmax, on multivariable analysis. Logistic regression analysis of areas under receiver operating characteristic curve (AUROC) confirmed ECC (AUC 0.678) and MCS (AUC 0.922) as good and excellent predictors, respectively of AIS-conversion at 1-year for intradural compression participants. Additionally, MCS was significantly more accurate in predicting AIS-conversion in intradural group and the probability of AIS-conversion significantly decreased with each 1% increase in MCS (p = 0.003; OR 0.949), for both compression subtypes. In conclusion, baseline measures of cord swelling predict AIS-conversion likelihood up to 1-year. The deleterious effects of intradural cord compression, either isolated or presenting with extradural compression, may benefit from supplemental decompression strategies in addition to current standard-of-care.

Cervical spinal cord injury results in severe cardiorespiratory impairments due to interruptions of bulbospinal pathways innervating to phrenic motoneurons and thoracic sympathetic preganglionic neurons. Additionally, the injury substantially impacts spinal cord blood flow, attributed to damage to the spinal vessels and the blood–spinal cord barrier. Current clinical guidelines suggest maintaining the mean arterial pressure between 85–90 mmHg during the acute phase of spinal cord injury; however, there is no preclinical animal evidence to examine the optimal timing and effect of hemodynamic management on respiratory function and spinal microcirculation following injury. Accordingly, the present study aimed to comprehensively investigate the therapeutic efficacy of hemodynamic agent (i.e., norepinephrine) on cardiorespiratory function and spinal cord blood flow during compression vs. decompression phases of acute cervical spinal cord injury. Adult male rats underwent mid-cervical spinal cord compression followed by decompression were received an intravenous infusion of 1) saline (7 ml/kg/hr), 2) norepinephrine (125 μg/kg/hr) during compression, or 3) norepinephrine during decompression. Respiratory and cardiovascular patterns were measured in conjunction with monitoring of spinal cord blood flow utilizing a laser speckle contrast imaging device. There are three major findings in the present study. First, saline infusion during cervical spinal cord compression resulted in a significant reduction in the minute ventilation (45 ± 10% of baseline, p&lt;0.01) and the mean arterial blood pressure (71 ± 10% of baseline, p&lt;0.01), which is accompanied by a hypoperfusion of spinal cord blood flow (62 ± 11% of baseline, p&lt;0.01). Second, infusion of norepinephrine during compression significantly enhanced the minute ventilation (75 ± 21% of baseline, p&lt;0.01) and improved spinal cord blood flow (92 ± 22% of baseline, p&lt;0.01), with mean arterial blood pressure returning to the normal values. The improvement of physiological function could be still maintained even norepinephrine was no longer administrated during decompression phase. Importantly, the ischemia-reperfusion rebound of spinal cord blood flow during the decompression phase was significantly mitigated by infusion of norepinephrine during compression. Third, norepinephrine infusion during decompression was surprisingly unable to improve the minute ventilation despite the mean arterial blood pressure could be maintained at the normal level. Furthermore, the ischemia-reperfusion effect on spinal cord blood flow was significantly exaggerated (136 ± 17% of baseline, p&lt;0.01). These data indicated that norepinephrine exerts differential effects on the cardiorespiratory function and spinal cord blood flow depending on the time point of administration. Our results suggest that infusion of norepinephrine during compression is beneficial for functional improvement, while norepinephrine may aggravate ischemia reperfusion injury when infusing during decompression. This study provides essential pre-clinical evidence underscoring the importance of determining the optimal timepoint of hemodynamic management to achieve the maximal therapeutic efficacy and prevent the potential side effects during acute cervical spinal cord injury. Support for this work was provided by grants from the National Science and Technology Council (NSTC 112-2628-B-110-003-MY3). This abstract was presented at the American Physiology Summit 2025 and is only available in HTML format. There is no downloadable file or PDF version. The Physiology editorial board was not involved in the peer review process.

Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries

Retrospective cohort study. Acute cervical spinal cord injury (CSCI) leads to severe and variable neurological outcomes. Early, accurate prognosis is crucial for clinical decisions and patient counseling. This study aimed to identify key prognostic factors and develop a reliable, imaging-based nomogram for predicting neurological recovery after surgical treatment. Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China. In a retrospective cohort of 103 surgically treated acute traumatic CSCI patients, neurological recovery was defined as ≥1 grade improvement on the ASIA Impairment Scale at 6 months. We analyzed clinical variables and MRI parameters: intramedullary edema length (IEL), intramedullary hemorrhage length (IHL), and maximum spinal cord compression (MSCC). Independent predictors were identified via multivariate logistic regression. A nomogram was built and internally validated using the C-index, calibration curves, ROC analysis, and DCA. Neurological recovery occurred in 73 patients (70.9%). Multivariate analysis identified IEL (OR = 0.904), IHL (OR = 0.808), and MSCC (OR = 0.812) as independent predictors (all p < 0.05). IEL showed a threshold effect at 48 mm, beyond which recovery probability declined markedly. The nomogram demonstrated excellent predictive performance, with C-indices of 0.969 (modeling) and 0.936 (validation). ROC and DCA confirmed its superior accuracy and clinical utility over single parameters. IEL, IHL, and MSCC are key imaging-based predictors of recovery after acute CSCI. The developed nomogram provides an accurate, practical tool for individualized prognosis, supporting precision clinical management. MRI-based parameters including intramedullary edema length (IEL), intramedullary hemorrhage length (IHL), and maximum spinal cord compression (MSCC) were integrated into a nomogram model to predict neurological recovery in patients with acute cervical spinal cord injury.

The role of decompressing the intradural space through a durotomy as a treatment option for acute traumatic cervical spinal cord injury has not been explored in an animal model, to our knowledge. We sought to determine the role of durotomy and duraplasty in the treatment of acute cervical spinal cord injury and its effects on inflammation, scar formation, and functional recovery. Seventy-two adult female Sprague-Dawley rats were assigned to three groups: contusion injury alone, contusion injury with a decompressive durotomy, and contusion injury with a decompressive durotomy followed by placement of a dural allograft. A mild (200-kdyn [2-N]) contusive injury was delivered to the exposed spinal cord at C5. The injured segment was reexposed four hours after injury, and a durotomy with decompression was performed. When a dural allograft was used it was affixed to the surrounding intact dura with use of a fibrin sealant. The Grip Strength Meter was used to assess forelimb function. Animals were killed at two and four weeks, and immunohistochemical analysis was performed to assess scar formation, inflammatory cell infiltration, and lesional volume. Immunohistochemical analysis revealed increased scar formation, cavitation, and inflammatory response in the animals treated only with a decompressive durotomy. Relative to the group with a contusion injury alone, the animals treated with a durotomy followed by a dural allograft had decreased cavitation and scar formation. Lesional volume measurements showed a significantly increased cavitation size at four weeks in both the contusion-only (mean and standard deviation, 12.6 +/- 0.5 mm(3)) and durotomy-only (15.1 +/- 1 mm(3)) groups relative to the animals that had received a dural allograft following durotomy (6.8 +/- 1.4 mm(3)). Functional recovery after acute cervical spinal cord injury was better in animals treated with decompression of the intradural space and placement of a dural allograft than it was in animals treated with decompression alone. These functional data correlated directly with histological evidence of a decrease in spinal cord cavitation, inflammation, and scar formation.

The goal of this study was to determine the prognostic and clinical value of magnetic resonance imaging (MRI) performed within hours after cervical spinal cord injuries in human patients. Fifty-five patients with acute cervical vertebral column and spinal cord injuries underwent MRI as part of their initial treatment at the University of Michigan Medical Center. All images were obtained within 21 hours after injury (mean, 7.8 h) and were interpreted by an attending neuroradiologist who was blinded to the clinical status of the patients. Neurological function at presentation and in long-term follow-up examinations was compared with MRI characteristics assessed immediately after the injury. The presence and rostrocaudal length of intra-axial hematoma, the rostrocaudal length of spinal cord edema, the presence of spinal cord compression, and spinal cord compression by extra-axial hematoma were each significantly associated with poor neurological function at presentation and in long-term follow-up examinations. Although the best single predictor of long-term improvement in neurological function was the neurological function at presentation, four MRI characteristics, i.e., the presence of intra-axial hematoma, the extent of spinal cord hematoma, the extent of spinal cord edema, and spinal cord compression by extra-axial hematoma, provided significant additional prognostic information. MRI data demonstrated spinal cord compression for 27 of 55 patients (49%), leading to emergency surgery. Among patients who underwent imaging after restoration of normal vertebral alignment using closed cervical traction, 13 of 26 (50%) underwent emergency surgery for treatment of persistent, MRI-demonstrated, spinal cord compression. Emergency MRI after spinal cord injury provides accurate prognostic information regarding neurological function and aids in the diagnosis and treatment of persistent spinal cord compression after vertebral realignment.

Breaking Down Silos to Protect the Spinal Cord

Objective To compare and analyze the clinical characteristics of acute central cervical spinal cord injury with only upper extremity involvement and with both upper and lower extremity involvement. Methods A retrospective case control study was made on clinical data of 76 patients with acute central cervical spinal cord injury hospitalized from January 2010 to December 2013. Nerve injury involved was only upper extremity in 39 patients (upper extremity group), but both upper and lower extremities in 37 patients (upper-and lower-extremity group). In upper extremity group, there were 35 males and four females, age was 21-80 years [(52.5±13.4)years], injury resulted from traffic accidents in 24 patients, ground-level falls in eight, high-level falls in six and heavy-object hit in one, and level of injury was C3/4in 16 patients, C4/5in 14 and C5/6in nine. In upper- and lower-extremity group, there were 30 males and seven females, age was 36-78 years [(59.6±9.7)years], injury resulted from traffic accidents in 16 patients, ground-level falls in 11, high-level falls in seven and heavy-object hit in three, and level of injury was C3/4in nine patients, C4/5in 18 and C5/6in 10. Sagittal diameter of the cervical spinal canal, maximal canal compromise, maximal spinal cord compression, degenerating factors of the cervical spine and treatment protocols were determined. Upper extremity function was assessed with the American spinal injury association (ASIA) score. Results There were significant differences between upper extremity group and upper- and lower-extremity group in sagittal diameter of the cervical spinal canal [(7.5±1.5)mm ∶(6.8±1.2)mm], maximal canal compromise [(28.9±9.6)% ∶(34.9±10.6)%], ASIA score at admission[(31.6±11.8)points ∶(22.7±11.3)points)] and ASIA score at last follow-up [(46.2±4.2)points ∶(40.2±4.0)points](P 0.05). Lower prevalence of posterior osteophyte of the vertebral body was noted in upper extremity group than upper- and lower-extremity group (15% ∶51%) (P<0.01). Twenty patients (49%) in upper extremity group were surgically treated, while 31 patients (84%) in upper-and lower-extremity group (P<0.05). Conclusions Compared to acute central cervical spinal cord injury with both upper and lower extremity involvement, the injury with only upper extremity involvement is much common in younger patients and is characterized by lowered frequency of osteophyte, large buffer space, mild nerve damage, preferred non-operation treatment and good prognosis. Key words: Spinal cord injuries; Magnetic resonance imaging; Neurological status

A modified Delphi study. To assess current practice patterns in the management of cervical spinal cord injury (SCI) and develop a simplified, practical classification system which offers ease of use in the acute setting, incorporates modern diagnostic tools and provides utility in determining treatment strategies for cervical SCI. A three-phase modified Delphi procedure was performed between April 2020 and December 2021. During the first phase, members of the AOSpine SCI Knowledge forum proposed variables of importance for classifying and treating cervical SCI. The second phase involved an international survey of spine surgeons gauging practices surrounding the role and timing of surgery for cervical SCI and opinions regarding factors which most influence these practices. For the third phase, information obtained from phases 1 and 2 were used to draft a new classification system. 396 surgeons responded to the survey. Neurological status, spinal stability and cord compression were the most important variables influencing decisions surrounding the role and timing of surgery. The majority (>50%) of respondents preferred to perform surgery within 24hours post-SCI in clinical scenarios in which there was instability, severe cord compression or severe neurology. Situations in which <50% of respondents were inclined to operate early included: SCI with mild neurological impairments, with cord compression but without instability (with or without medical comorbidities), and SCI without cord compression or instability. Spinal stability, cord compression and neurological status are the most important variables influencing surgeons' practices surrounding the surgical management of cervical SCI. Based on these results, a simplified classification system for acute cervical SCI has been proposed.

Introduction to the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic-therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail.

3:51 118. Correlation of Qualitative and Quantitative MRI Findings With Neurological Outcome after C-Spine Trauma: A Multi-Center Prospective Study of 100 Patients With Acute Cervical Spinal Cord Injury