American Spinal Injury Association Grade Research Articles

Treatment of unstable fresh thoracolumbar burst fracture by over-bending rod reduction and fixation technique via posterior approach

To investigate the efficacy and safety of over-bending rod reduction and fixation technique via posterior approach in the treatment of unstable fresh thoracolumbar burst fracture. A clinical data of 27 patients with unstable fresh thoracolumbar burst fracture, who were met the inclusive criteria and admitted between January 2018 and October 2019, was retrospectively analyzed. There were 15 males and 12 females with an average age of 41.8 years (range, 26-64 years). The fractures were caused by falling from height in 14 cases, traffic accident in 8 cases, and crushing by a heavy objective in 5 cases. The interval between injury and operation was 1-7 days (mean, 3.2 days). The injured fracture was located at T 10 in 1 case, T 11 in 3 cases, T 12 in 6 cases, L 1 in 7 cases, L 2 in 7 cases, and L 3 in 3 cases. According to AO classification, there were 11 cases of type A3, 7 cases of type B, and 9 cases of type C. Neurological function was rated as grade A in 3 cases, grade B in 7 cases, grade C in 5 cases, and grade D in 12 cases according to the American Spinal Injury Association (ASIA) grading. All cases were treated by over-bending rod reduction and fixation technique via posterior approach, and 16 cases were combined with limited fenestration decompression. The evaluation indicators consisted of operation time, intraoperative blood loss, the compression ratio of the anterior vertebral height, the invasion rate of the injured vertebra into the spinal canal, the Cobb angle of segmental kyphosis, visual analogue scale (VAS) score, and Oswestry Disability Index (ODI). The operation time was 67-128 minutes (mean, 81.6 minutes), and the intraoperative blood loss was 105-295 mL (mean, 210 mL). All patients were followed up 12-23 months (mean, 17.2 months). A total of 178 pedicle screws were implanted during operation, and the accuracy of the implantation was 98.9% (176/178). The compression ratios of the anterior vertebral height at the early postoperatively and last follow-up were significantly increased when compared with preoperative one ( P<0.05), and the invasion rate of the injured vertebra into the spinal canal, Cobb angle, VAS score, and ODI were significantly lower than those preoperatively ( P<0.05). Except that the ODI at last follow-up was significantly lower than that of the early postoperative period ( P<0.05), there was no significant difference between the last follow-up and the early postoperative period for other indicators ( P>0.05). At last follow-up, the neurological function was rated as grade A in 1 case, grade B in 2 cases, grade C in 4 cases, grade D in 9 cases, and grade E in 11 cases according to the ASIA grading, showing significant difference when compared with that before operation ( Z=-3.446, P=0.001). Over-bending rod reduction and fixation technique can effectively restore vertebral height, reset the invaded vertebral block, and selectively perform limited decompression and posterolateral bone grafting to ensure the completeness of intravertebral decompression and stability, which is one of the effective methods to treat unstable fresh thoracolumbar burst vertebral fracture.

Civilian Gun Shot Wounds Associated With Spinal Injuries.

Study Design:RetrospectiveObjective:To evaluate functional outcomes and characteristics associated with gunshot wound (GSW) to the spine.Methods:Patients with GSW to the spine managed at a Level 1 Trauma Center from January 2003 to December 2017 were enrolled. Patient demographics, diagnoses, level of injury, American Spinal Injury Association (ASIA) score, ambulatory status at follow-up, bowel and bladder function, clinical improvement, and mortality were evaluated. Clinical improvement was defined as a progression in ambulatory status category at latest follow up.Results:51 patients with GSW of the spine were identified. 48 (94.1%) were male and 3 (5.9%) were female, with a mean age of 27 years-old (range 15-56). 38 (74.5%) were Caucasian, 7 (13.7%) were African American, 1 (2.0%) Asian-American, and 5 (9.8%) were Other/Unknown. 46 (90.2%) patients had GSW related spinal fractures and 44 (86.3%) had neurological deficits. Among patients with neurologic deficits, 5 (9.8%) had Cauda Equina Syndrome, 1 (2%) had Brown-Sequard Syndrome, and 38 (74.5%) spinal cord injuries: ASIA A 26 (68.4%); ASIA B 3 (7.9%); ASIA C 7 (18.4%); ASIA D 2 (5.3%). At mean follow-up time of 4.2 years (SD 3.9), 27 (52.9%) patients were wheelchair bound, 11 (21.6%) were ambulating with assistance, and 13 (25.5%) had normal ambulation. ASIA grade (A or B) was significantly, P < 0.00001, associated with being wheelchair bound and having neurogenic bowel or bladder at follow-up.Conclusions:Most spinal GSW patients (70.6%) did not have any clinical improvement in ambulatory status and most injuries were ASIA A.

Cervical corpectomy in delayed presentation of irreducible cervical dislocation: experience with eight cases

Objective To describe a single-staged procedure for the management of neglected subaxial cervical spine injuries. Methods Between January 2012 and December 2014, 12 patients presented to us with healed cervical sub axial dislocations. The deformities could not be reduced using skull traction. Eight were operated with anterior cervical corpectomy. American spinal injury Association (ASIA) grade, Neck Disability index (NDI), and Visual analog scale (VAS) score were recorded throughout the patient course and CT was done at 12 months for assessment of fusion. Results Four patients improved from ASIA C to ASIA D, two patients improved from ASIA B to ASIA E, one patient improved from ASIA D to ASIA E and one patient remained static at ASIA B. All patients except one showed evidence of fusion on CT scan at 12 months. NDI improved from preoperative range (18–32, mean 25) to postoperative range (8–16 mean, 11.25), VAS from preoperative range (3–6, mean 4.25) to postoperative range (1–3, mean 1.75). Conclusions Single-stage in situ fixation does not disrupt ongoing natural healing and has good clinical and radiological outcomes.

Clinical efficacy and safety of ultra-short-course chemotherapy in treatment of spinal tuberculosis after complete debridement: an observational study.

ObjectiveTo evaluate the clinical efficacy and safety of ultra-short-course chemotherapy (<4 months) in treating spinal tuberculosis following complete debridement.MethodsClinical data of patients diagnosed with spinal tuberculosis, who underwent surgery with postoperative chemotherapy for < 4 months at the General Hospital of Ningxia Medical University between January 2005 and March 2015, were retrospectively analysed. Clinical manifestations, American Spinal Injury Association grades, states of bone fusion and lesion healing, deformity correction, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels and adverse drug reactions, observed before and after surgery and at the final follow-up, were assessed.ResultsSixty patients were included, comprising 26 male and 34 female patients aged 16–78 years (mean, 40.85 years). Patients received postoperative chemotherapy for 3–4 months (mean, 3.61 months) and were followed for 25–129 months (mean, 70.61 months). Spinal tuberculosis recurred after surgery in one patient, who was cured by subsequent surgery. At the final follow-up, no symptoms of tuberculosis, local pain, abscess or sinus were observed. Daily life and working abilities were almost recovered in all patients. ESR and CRP levels were restored to normal, bone grafts fused, lesions healed and neurological functions were recovered. Postoperative chemotherapy-induced complications occurred in 10 patients (16.67%).ConclusionsComplete debridement plus ultra-short-course chemotherapy for 3–4 months may be safe and efficacious in treating spinal tuberculosis, and requires further investigation.

Treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of interlocking facet through the Luschka joint and anterior lamina space

To investigate the effectiveness of treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of the interlocking facet through the Luschka joint and anterior lamina space. Twelve patients with lower cervical interlocking fracture and dislocation were analyzed retrospectively between January 2013 and June 2015. There were 7 males and 5 females, aged 25-59 years with an average age of 38.4 years. The disease duration was 9.6 hours to 100 days with an average of 7.3 days. There were 8 cases of unilateral locking and 4 cases of bilateral locking; 4 cases of old injury and 8 cases of fresh injury. The injured segments were 2 cases of C 3, 4, 5 cases of C 4, 5, 3 cases of C 5, 6, and 2 cases of C 6, 7. According to Meyerding classification, there were 9 cases of grade Ⅰ and 3 cases of grade Ⅱ. According to the functional classification of American Spinal Injury Association (ASIA), there were 2 cases of grade C, 6 cases of grade D, and 4 cases of grade E. The interlocking facet was released through the Luschka joint and anterior lamina space, and the anterior cervical fusion and internal fixation were used to treat the fracture and dislocation of the lower cervical spine. The recovery of spinal cord function was judged by the functional classification of ASIA; visual analogue scale (VAS) score, neck disability index (NDI) score, modified Japanese Orthopaedic Association (m-JOA) score were used to evaluate the clinical efficacy; the Cobb angle of fusion segment were observed by X-ray film. The intervertebral bone graft fusion was evaluated at 6 months after operation. The average operation time was 78.30 minutes, the average intraoperative blood loss was 167.30 mL, and the average postoperative drainage volume was 58.12 mL. No blood transfusion was given during or after operation. During the operation, there was no accidental injury of large blood vessels, esophagus, and trachea; no laryngo edema, dysphagia, hoarseness, and cerebrospinal fluid leakage occurred after operation; no spinal cord injury or nerve root injury aggravated; the incision healed by first intention, and no infection occurred. All 12 cases were followed up 15-20 months, with an average of 16.5 months. The symptoms and function of the nerve injury were significantly improved when compared with that before operation. Re-examination of the cervical spine X-ray film at 6 months after operation showed that the Cage or bone graft was not displaced or broken, the screw was not loosened or detached, and the intervertebral graft fusion rate was up to 100%. At last follow-up, the ASIA grade, Cobb angle of fusion segment, neck pain VAS score, m-JOA score, and NDI score were significantly improved when compared with preoperative one ( P<0.05). The effectiveness of treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of the interlocking facet through the Luschka joint and anterior lamina space is clear, which not only can make the injured segment get satisfactory reduction, immediate stability and reconstruction, and full decompression, but also can effectively prevent the secondary injury of spinal cord.

Treatment of lumbar tuberculosis with percutaneous pedicle screw internal fixation and minimally invasive lateral small incisions lesion debridement and bone graft fusion via dilated channels

To explore the efficacy of percutaneous pedicle screw internal fixation and minimally invasive lateral small incisions lesion debridement and bone graft fusion via dilated channels in the treatment of lumbar tuberculosis. The clinical data of 22 cases of lumbar tuberculosis treated with percutaneous pedicle screw internal fixation combined with dilated channels with minimally invasive lateral small incision lesion debridement and bone graft fusion between January 2016 and June 2018 were retrospectively analyzed. There were 12 males and 10 females, with an average age of 47.5 years (range, 22-75 years). The affected segments were L 2, 3 in 5 cases, L 3, 4 in 8 cases, and L 4, 5 in 9 cases, with an average disease duration of 8.6 months (range, 4-14 months). Preoperative neurological function was classified according to the American Spinal Injury Association (ASIA), with 3 cases of grade C, 9 cases of grade D, and 10 cases of grade E. The operation time, intraoperative blood loss, and postoperative complications were recorded. At preoperation, 3 months after operation, and last follow-up, the C reactive protein (CRP) and erythrocyte sedimen- tation rate (ESR) were tested to evaluate tuberculosis control; the pain visual analogue scale (VAS) score was used to evaluate the recovery of pain, and the Oswestry disability index (ODI) was used to evaluate the function recovery of the patient's lower back; the kyphosis Cobb angle was measured, and the loss of Cobb angle (the difference between the Cobb angle at last follow-up and 3 months after operation) was calculated. At last follow-up, the ASIA classification was used to evaluate the recovery of neurological function, and the effectiveness was evaluated according to the modified MacNab standard. The operation time was 110-148 minutes (mean, 132.8 minutes) and the intraoperative blood loss was 70-110 mL (mean, 89.9 mL). Two patients experienced fat liquefaction of the incision and delayed healing; the incisions of the remaining patients healed by first intention. All patients were followed up 18-24 months, with an average of 21.3 months. All bone grafts achieved osseous fusion, the pedicle screws were fixed in reliable positions, without loosening, displacement, or broken rods. There was no recurrence of tuberculosis. The ESR, CRP, VAS scores, ODI scores, and kyphosis Cobb angle of the affected segment at 3 months after operation and last follow-up were significantly improved ( P<0.05); there were no significant differences between at last follow-up and 3 months after operation ( P>0.05), and the loss of Cobb angle was (0.6±0.5)°. The patient's neurological function recovered significantly. At last follow-up, the ASIA grades were classified into 1 case with grade C, 1 case with grade D, and 20 cases with grade E, which were significantly improved when compared with preoperative grading ( Z=-3.066, P=0.002). According to the modified MacNab standard, 16 cases were excellent, 3 cases were good, 2 cases were fair, and 1 case was poor. The excellent and good rate was 86.4%. Percutaneous pedicle screw internal fixation combined with dilated channels with minimally invasive lateral small incisions lesion debridement and bone graft fusion has the advantages of less bleeding, less trauma, and faster recovery, which is safe and effective in the treatment of lumbar tuberculosis.

Nonstructural bone graft for single-segment lumbar tuberculosis: surgical indications, clinical efficacy, and preliminary experiences in 34 patients.

ObjectiveThis study was performed to evaluate the surgical indications, clinical efficacy, and preliminary experiences of nonstructural bone grafts for lumbar tuberculosis (TB).MethodsThirty-four patients with lumbar TB who were treated with nonstructural bone grafts were retrospectively assessed. The operative time, operative blood loss, hospital stay, bone graft fusion time, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) concentration, visual analog scale (VAS) score, Oswestry Disability Index (ODI), American Spinal Injury Association (ASIA) impairment grade, and Cobb angle were recorded and analyzed.ResultsThe mean operative time, operative blood loss, hospital stay, Cobb angle correction, and Cobb angle loss were 192.59 ± 42.16 minutes, 385.29 ± 251.82 mL, 14.91 ± 5.06 days, 9.02° ± 3.16°, and 5.54° ± 1.09°, respectively. During the mean follow-up of 27.53 ± 8.90 months, significant improvements were observed in the ESR, CRP concentration, VAS score, ODI, and ASIA grade. The mean bone graft fusion time was 5.15 ± 1.13 months. Three complications occurred, and all were cured after active treatment.ConclusionsNonstructural bone grafts may achieve satisfactory clinical efficacy for appropriately selected patients with lumbar TB.

Polymethylmethacrylate-augmented screw fixation in treatment of senile thoracolumbar tuberculosis combined with severe osteoporosis

To explore the safety and effectiveness of polymethylmethacrylate-augmented screw fixation (PASF) in the treatment of elderly thoracolumbar tuberculosis combined with severe osteoporosis. The clinical data of 20 elderly patients with thoracolumbar tuberculosis and severe osteoporosis who underwent PASF after anterior or posterior debridement and bone grafting and met the selection criteria between December 2012 and December 2014 were retrospectively analyzed. There were 8 males and 12 females with an average age of 68.5 years (range, 65-72 years). T value of bone mineral density was -4.2 to -3.6, with an average of -3.9. There were 12 cases of thoracic tuberculosis, 3 cases of thoracolumbar tuberculosis, and 5 cases of lumbar tuberculosis. The diseased segments involved T 3-L 4, including 11 cases of single-segment disease, 6 cases of double-segment disease, and 3 cases of multi-segment disease. The disease duration was 3-9 months, with an average of 6 months. The preoperative spinal nerve function of the patients was evaluated by the American Spinal Injury Association (ASIA) grading. There were 2 cases of grade A, 5 cases of grade B, 6 cases of grade C, 4 cases of grade D, and 3 cases of grade E. Postoperative imaging examination was used to evaluate the bone graft fusion and paravertebral abscess absorption, and to measure the Cobb angle of the segment to evaluate the improvement of kyphosis. The levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were tested. The visual analogue scale (VAS) score, Oswestry disability index (ODI), and ASIA grading were used to evaluate the effectivreness before operation, at 1 month after operation, and at last follow-up. The clinical cure of tuberculosis was also evaluated. All operation successfully completed. The operation time was 154-250 minutes, with an average of 202 minutes; the intraoperative blood loss was 368-656 mL, with an average of 512 mL. All 20 patients were followed up 18-42 months, with an average of 26.8 months. The postoperative pain and symptoms of tuberculosis in all patients relieved, and the paravertebral abscess was absorbed, reaching the cure standard for spinal tuberculosis. All bone grafts fusion achieved within 1 year after operation. Only 1 case had asymptomatic bone cement leakage into the paravertebral veins, and the remaining patients had no serious complications such as bone cement leakage in the spinal canal, pulmonary embolism, and neurovascular injury. At last follow-up, spinal cord nerve function significantly improved when compared with preoperative one. Among them, ASIA grading were 7 cases of grade C, 8 cases of grade D, and 5 cases of grade E, showing significant difference when compared with preoperative one ( Z=2.139, P=0.000). VAS score, ODI score, segmental Cobb angle, ESR, and CRP at 1 month after operation and at last follow-up were significantly improved when compared with preoperative ones ( P<0.05); there was no significant difference between 1 month after operation and last follow-up ( P>0.05). During the follow-up, no complications such as failure of internal fixation, proximal junctional kyphosis, or tuberculosis recurrence occurred. For elderly patients with thoracolumbar tuberculosis and severe osteoporosis, PASF treatment is safe and effective.

Treatment of tuberculosis in craniovertebral junction

To investigate the method of treating tuberculosis in the craniovertebral junction and its effectiveness. The clinical data of 18 patients with tuberculosis in the craniovertebral junction between July 2010 and January 2019 was analyzed retrospectively. There were 14 males and 4 females, aged 21 months to 75 years (median, 35 years). The disease duration ranged from 2 weeks to 60 months (median, 4 months), and the affected segment was C 0-C 3. Preoperative visual analogue scale (VAS) score was 6.7±1.5 and the Japanese Orthopaedic Association (JOA) score was 16.1±1.8. The American Spinal Cord Injury Association (ASIA) grading system was applied to classify their neurological functions, according to which there were 6 cases of grade D and 12 cases of grade E. Among 18 patients, 4 patients underwent conservative treatment, 1 patient removed tuberculosis via transoral approach, 1 patient removed tuberculosis via posterior cervical approach, and 12 patients removed tuberculosis via transoral approach immediately after posterior cervical (atlantoaxial or occipitalcervical) fusion and internal fixation. The VAS score, ASIA grading, and JOA score were applied to evaluate effectiveness. X-ray film, CT, and MRI were taken after treatment to evaluate the tubercular recurrence, cervical stability, and bone healing. All the patients were followed up 3 to 42 months (median, 12 months). At 3 months after treatment, the VAS score was 1.7±1.0, showing significant difference when compared with preoperative score ( t=15.000, P=0.000); and the JOA score was 16.7±1.0, showing no significant difference when compared with preoperative score ( t=1.317, P=0.205). According to ASIA grading, 6 patients with grade D before treatment had upgraded to grade E after treatment, while the remaining patients with grade E had no change in grading. The imaging examinations showed the good stability of the cervical spine. All patients had complete tuberculosis resection and no recurrence, and the patients who underwent internal fixation via posterior cervical approach achieved atlantoaxial or occipitalcervical bone fusion. On the premise of regular chemotherapy, if there is no huge abscess causing dysphagia or dyspnea, atlantoaxial instability, and neurological symptoms, patients can undergo conservative treatment. If not, however, the transoral approach can be used to completely remove the tuberculosis lesion in the craniovertebral junction. One-stage debridement via transoral approach combined with posterior cervical fusion and internal fixation can achieve satisfactory effectiveness.

Midterm surgical results of the lamina with spinous process in treating one-level thoracic or lumbar tuberculosis: a retrospective study

A retrospective study investigated the results of the lamina with spinous process (LSP) as a bone graft in one-level thoracic or lumbar spinal tuberculosis with the one-stage posterior approach of debridement, fusion and internal instrumentation. Data from 35 patients from January 2013 to December 2015 were analysed. Surgery time, blood loss, hospitalization time, drainage volume, and follow-up (FU) duration were recorded. The visual analogue scale (VAS), Oswestry Disability Index (ODI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), American Spinal Injury Association (ASIA) grade, segmental angle, and bone fusion were compared between preoperative and final FU. All of the patients were followed up for a mean 43.90 ± 10.39 months. The mean age, surgery time, blood loss, hospitalization time, hospital cost and drainage volume were 33.65 ± 11.06 years, 182.40 ± 23.82 min, 280.80 ± 76.82 mL, 14.05 ± 3.58 days, 74,382.00 ± 11,938.00 yuan, and 340.00 ± 167.20 mL, respectively. VAS and ODI were significantly improved at the final FU. The ESR and CRP recovered to normal. The mean angle of 24.35 ± 5.74°preoperatively showed a significant difference between 1 week, postoperatively and final FU. Although there were the loss of angle at final FU comparing with the 1 week postoperatively, it still maintain the good alignment and the segmental stability. All patients achieved bony fusion with a mean time of 12.90 ± 3.91 months. In conclusion, the LSP as a structural bone graft is reliable, safe and effective for segmental stability reconstruction, which could be one choice for surgical management of thoracic or lumbar spinal TB.

Preoperative Halo-Gravity Traction for Patients with Severe Focal Kyphosis in the Upper Thoracic Spine: A Safe and Effective Alternative for Three-Column Osteotomy.

Retrospective review. To evaluate the effect of preoperative Halo-gravity traction (HGT) in the treatment of severe focal kyphosis in the upper thoracic spine (UTS), and to propose the indications that HGT could serve as an alternative for three-column osteotomy (3CO) among these patients. The HGT has been proven to be effective for severe kyphoscoliosis secondary to multiple etiologies. However, the safety and efficacy of HGT in severe focal kyphosis in UTS was still unclear. Patients with focal kyphosis in UTS undergoing HGT and without 3CO operation were reviewed. The sagittal focal kyphosis was measured at pre-, posttraction, and postoperation. The neurologic function at pretraction, posttraction, and postoperation were assessed according to the American Spinal Injury Association (ASIA) grading. The complications during HGT, operation, and follow-up were recorded. The comparison between pretraction and posttraction was performed using paired samples t test. A total of 19 patients were included in this study, with a mean age of 13.2 ± 5.8 years. The average duration of HGT was 62.6 ± 8.4 days, during which the average kyphosis decreased from 95.3 ± 16.4° to 64.1 ± 19.2° (P < 0.001). After HGT, the ASIA grade improved from C to D in three patients and from C to E in three patients, from D to E in seven patients, from B to D in one patient. No deterioration in neurologic function was observed during HGT. The neurological status in one patient improved from ASIA C at pretraction to ASIA E at postoperation, but deteriorated to C at 4 years follow-up. Preoperative HGT could help to correct deformity and improve neurological deficit. 3CO procedure might be unnecessary in patients with severe focal kyphosis in UTS with the utilization of HGT.Level of Evidence: 4.

Factors related to improved American Spinal Injury Association grade of acute traumatic spinal cord injury.

BACKGROUNDAcute traumatic spinal cord injury (ATSCI) usually results in disability, yet data on contemporary national trends of ATSCI incidence are limited.AIMTo provide a systematic and basic theoretical basis for improving the treatment of acute spinal cord injury.METHODSData from the Peking University Third Hospital Inpatient Sample databases were analyzed. A total of 304 patients with ATSCI were included from 2012 to 2017. The epidemiological data, treatment, complications and clinical outcomes of these patients were reviewed.RESULTSOf the 304 patients, 257 (84.5%) were male, and 75% of the patients were 55 years old or younger. 135 patients had improved follow-up American Spinal Injury Association (ASIA) grades (44.4%). Only 14 patients with ASIA grade A improved. A statistically significant difference in prognosis between patients who underwent surgery within 72 h and those who underwent surgery after 72 h was observed (P < 0.05). Surgery within 72 h resulted in better prognosis. The Steroid group and the Non-Steroid group showed a significant difference in outcome among patients with ASIA grades A and B (P < 0.05). Patients with pneumonia had a poorer prognosis than patients without pneumonia (P < 0.05). Surgery within 72 h resulted in better prognosis.CONCLUSIONThis study found that there was no significant difference in hospitalization time and prognosis between the Steroid group and the Non-Steroid group, but the patients with severe spinal cord injury (ASIA grades A and B) who underwent surgery combined with steroid therapy had a better prognosis than those who underwent surgery alone. The disastrous consequences of ATSCI and lack of consensus on the management strategy are obvious. Further improvements in treatment planns are needed in order to obtain more reliable functional outcomes.

Single-Stage Posterior Vertebral Column Resection With Circumferential Reconstruction for Thoracic/Thoracolumbar Burst Fractures With or Without Neurological Deficit: Clinical Neurological and Radiological Outcomes.

Study Design:Retrospective study.Objective:The aim of this study is to evaluate the clinical, neurological, and radiological outcomes of posterior vertebral column resection (PVCR) technique for treatment of thoracic and thoracolumbar burst fractures.Methods:Fifty-one patients (18 male, 33 female) with thoracic/thoracolumbar burst fractures who had been treated with PVCR technique were retrospectively reviewed. Preoperative and most recent radiographs were evaluated and local kyphosis angle (LKA), sagittal and coronal spinal parameters were measured. Neurological and functional results were assessed by the American Spinal Injury Association (ASIA) Impairment Scale, visual analogue scale score, Oswestry Disability Index, and Short Form 36 version 2.Results:The mean age was 49 years (range 22-83 years). The mean follow-up period was 69 months (range 28-216 months). Fractures were thoracic in 16 and thoracolumbar in 35 of the patients. AO spine thoracolumbar injury morphological types were as follows: 1 type A3, 15 type A4, 4 type B1, 23 type B2, 8 type C injuries. PVCR was performed in a single level in 48 of the patients and in 2 levels in 3 patients. The mean operative time was 434 minutes (range 270-530 minutes) and mean intraoperative blood loss was 520 mL (range 360-1100 mL). The mean LKA improved from 34.7° to 4.9° (85.9%). For 27 patients, the initial neurological deficit (ASIA A in 8, ASIA B in 3, ASIA C in 5, and ASIA D in 11) improved at least 1 ASIA grade (1-3 grades) in 22 patients (81.5%). Solid fusion, assessed with computed tomography at the final follow-up, was achieved in all patients.Conclusion:Single-stage PVCR provides complete spinal canal decompression, ideal kyphosis correction with gradual lengthening of anterior column together with sequential posterior column compression. Anterior column support, avoidance of the morbidity of anterior approach and improvement of neurological deficit are the other advantages of the single stage PVCR technique in patients with thoracic/thoracolumbar burst fractures.

Ceftriaxone Plus Methylprednisolone Combination Therapy Versus Methylprednisolone Monotherapy in Patients With Acute Spinal Cord Injury: A Randomized, Triple-Blind Clinical Trial.

Guidelines do not suggest the routine use of methylprednisolone (MP) in patients with acute traumatic spinal cord injury (SCI). We tested the hypothesis regarding whether combination therapy with ceftriaxone and MP is superior to MP monotherapy in patients with acute traumatic SCI. In a randomized, triple-blind clinical trial, 60 patients with acute (first 8 hours of the injury) traumatic SCI were enrolled at the Tabriz University of Medical Sciences, Tabriz, Iran, between December 2016 and June 2017. Accordingly, the patients were randomly divided into 2 case and control groups (n = 30 each). Upon admission, all included patients received a bolus dose of MP at 33 mg/kg intravenously (IV) for 15 minutes. Then, after 45 minutes, MP infusion was continued for 24 to 48 hours at a 5.4 mg/kg IV dose. The case group received an additional dose of ceftriaxone at 1 g 2 times a day for 7 days through an IV route. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were checked and compared between case and control groups upon admission and on the fourth and eighth days. Also, sensory and motor functions were evaluated according to the American Spinal Injury Association (ASIA) grading score upon admission, on the third and seventh days, upon discharge and 6 months after admission. Analyses showed a significant statistical difference between groups in the changes in CRP levels during days 1 and 4 (P = .001) and also during days 4 and 8 (P = .001). However, no significant statistical difference was detected in ESR levels changes between groups during days 1 and 4 (P = .073), and during days 4 and 8 (P = .069). ASIA scale was found to be significantly different between the MP plus ceftriaxone group and MP monotherapy upon admission and 6 months after treatment (P = .001 for both comparisons). However, the number of variations in the ASIA score had no significant statistical difference between groups 6 months after intervention (P = .465). The addition of ceftriaxone to the routine therapeutic protocol of acute SCI is accompanied by improved inflammation markers and functional outcomes 6 months after the intervention.

Mean arterial pressure maintenance following spinal cord injury: Does meeting the target matter?

Neurosurgical guidelines recommend maintaining mean arterial pressure (MAP) between 85 and 90 mm Hg following acute spinal cord injury (SCI). In our hospital, SCI patients receive orders for MAP targeting for 72 hours following admission, but it is unclear how often the patient's MAP meets the target and whether or not this affects outcome. We hypothesized that the proportion of MAP measurements ≥85 mm Hg would be associated with neurologic recovery. Spinal cord injury patients with blunt mechanism of injury admitted between 2014 and 2019 were identified from the registry of a level 1 trauma center. Proportion of MAP values ≥85 mm Hg was calculated for each patient. Neurologic improvement, as measured by positive change in American Spinal Injury Association (ASIA) impairment scale by ≥1 level from admission to discharge was evaluated with respect to proportion of elevated MAP values. A total of 136 SCI patients were evaluated. Average proportion of elevated MAP values was 75%. Admission ASIA grades were as follows: A, 30 (22.1%); B, 20 (14.7%); C, 28 (20.6%); and D, 58 (42.6%). One hundred six patients (77.9%) required vasopressors to elevate MAP (ASIA A, 86.7%; B, 95.0%; C, 92.9%; D, 60.3%). Forty patients (29.4%) were observed to have improvement in ASIA grade by discharge (admission ASIA A, 15%; B, 33%; C, 40%; D, 13%). The proportion of elevated MAP values was higher for patients with neurologic improvement (0.81 ± 0.15 vs. 0.72 ± 0.25, p = 0.014). Multivariate modeling demonstrated a significant association between proportion of elevated MAP values and neurologic improvement (p = 0.028). An interaction revealed this association to be moderated by vasopressor dose (p = 0.032). The proportion of MAP measurements ≥85 mm Hg was determined to be an independent predictor of neurologic improvement. Increased vigilance regarding MAP maintenance above 85 mm Hg is warranted to optimize neurologic recovery following SCI. Therapeutic/care management, level IV.

Comparison of Early Surgical Treatment With Conservative Treatment of Incomplete Cervical Spinal Cord Injury Without Major Fracture or Dislocation in Patients With Pre-existing Cervical Spinal Stenosis.

This was a retrospective comparative study. The objective of this study was to evaluate the clinical outcomes of early surgical treatment (<24 h) and conservative treatment of incomplete cervical spinal cord injury (CSCI) without major fracture or dislocation in patients with pre-existing cervical spinal canal stenosis (CSCS). The relative benefits of surgery, especially early surgical treatment, and conservative treatment for CSCI without major fracture or dislocation in patients with pre-existing CSCS remain unclear. Animal models of CSCI have demonstrated that early surgical decompression immediately after the initial insult may prevent or reverse secondary injury. However, the clinical outcomes of early surgery for incomplete CSCI in patients with pre-existing CSCS are still unclear. The medical records and radiographic data of 54 patients admitted to our facility between 2005 and 2015 with American Spinal Injury Association (ASIA) impairment scale grade B or C and pre-existing CSCS without major fracture or dislocation were retrospectively reviewed. Thirty-three patients (mean age, 57.4±14.0 y) underwent early surgical treatment within 24 hours after initial trauma (S group), and 21 patients (mean age, 56.9±13.6 y) underwent conservative treatment (C group) performed by 2 spinal surgeons in accordance with their policies. The primary outcome was the degree of improvement in ASIA grade after 2 years. During the 2-year follow-up period, higher percentages of patients in the S group than in the C group showed ≥1 grade (90.9% vs. 57.1%, P=0.0051) and 2 grade (30.3% vs. 9.5%) improvements in ASIA grade. Multivariate analysis showed that treatment type, specifically early surgical treatment, was the only factor significantly associated with ASIA grade improvement after 2 years (P=0.0044). Early surgery yielded better neurological outcomes than conservative treatment in patients with incomplete CSCI without major fracture or dislocation and pre-existing CSCS. Level III.

A new transpedicular lag screw fixation for treatment of unstable Hangman\u2019s fracture: a minimum 2-year follow-up study

BackgroundA new C2 transpedicular lag screw designed by our team has been used in human cadaver spines for biomechanical testing, and the results showed that the biomechanical properties of the new C2 transpedicular lag screw were better than ordinary screws. The objective of this study is to analyze the clinical efficacy and safety of the new C2 transpedicular lag screw fixation for the treatment of unstable Hangman’s fracture.MethodsFrom March 2013 to June 2017, 25 patients who had unstable Hangman’s fractures were operated on with a new C2 transpedicular lag screw fixation. The patients included 18 males and 7 females whose ages ranged from 31 to 62 years (average 45.4 ± 9.3 years). The cause of the injury was a traffic accident in 17 patients and a fall from height in 8 patients. Other associated lesions included rupture of the spleen (1 patient) and rib fractures (2 patients). According to the Levine-Edwards classification, 17 patients were type II and 8 patients were type IIA, and according to the Frankel Neurological Performance scale, 8 cases and 17 cases were graded as spinal cord injury D and E, respectively. Twenty-three cases received bilateral screw fixation, and 2 cases had unilateral screw fixation because another pedicle was chipped. The whole procedure was accomplished with monitoring by “C”-arm fluoroscopy.ResultsThe mean follow-up time was 36 ± 12 months and ranged from 24 to 60 months. No obvious symptomatic or radiologic postoperative complications were found during the follow-up period. Six cases were restored from D to E while 2 cases remained D according to the American Spinal Injury Association (ASIA) grade. Pre- and postoperative visual analogue scale (VAS) and Neck Disability Index (NDI) were statistically different (P < 0.001). Osseous union was achieved in all cases, and the range of cervical motion recovered to the normal level up to the last follow-up.ConclusionsThe primary clinical and radiographic efficacies of a new C2 transpedicular lag screw fixation for the treatment of unstable Hangman’s fracture were satisfactory. This approach could be considered a simple, effective, reliable, and economic surgical method for managing unstable Hangman’s fractures.

Surgical treatment of spinal thoracic metastases with nerve injury in patients with moderate-to-severe spinal cord injury.

Among spine metastases of malignant tumors, thoracic spine metastases account for about 70%. Spinal metastases cause spinal instability, compression of nerve structures, and function damage, which has a serious impact on patients' quality of life (QOL). At present, surgery is main choice in the treatment of spinal metastases. However, conventional surgery still has certain limitations. This study explored the surgical strategy of nerve rescue in patients with spinal thoracic metastases and moderate-to-severe spinal cord injury. In this history case-control study, 42 patients received conventional operation were enrolled as control group, while 38 patients who underwent conventional decompression of laminectomy combined with durotomy were selected as observation group. Perioperative data were recorded for comparisons between the two groups. Visual analogue scale (VAS) of pain, QOL, and 36-item short-form health survey (SF-36) were compared before operation and 3, 6, and 12 months after operation. American Spinal Injury Association (ASIA) grade was evaluated before operation and 1 month after. Complications, recurrence rate, and mortality were also recorded. The VAS scores of the observation group at 3, 6, and 12 months after operation were significantly lower than those before the operation. The QOL and SF-36 scores were increased compared with those taken preoperatively (P<0.05). The VAS score of the observation group was lower than that of the control group, and the QOL and SF-36 scores were higher than those in the control group (P<0.05). The neurological grades of ASIA 3 months after operation in both groups were significantly improved. The improvement in the observation group was greater than that in the control group (P<0.05). The incidences of postoperative complications in the control group and observation group were 19.05% (8/42) and 7.89% (3/38), respectively; the recurrence rates of the two groups were 14.29% (6/42) and 5.26% (2/38), respectively; and the mortality rates of the two groups were 26.19% (11/42) and 18.42%, respectively (7/38) (P>0.05). Durotomy based on conventional decompression of laminectomy can effectively save nerve function in metastases of the thoracic spine with moderate or severe spinal cord injury, improve QOL, and is thus worthy of being applied in clinic.

Reliability and application of the new morphological classification system for chronic symptomatic osteoporotic thoracolumbar fracture

BackgroundWe propose a new classification system for chronic symptomatic osteoporotic thoracolumbar fracture (CSOTF) based on fracture morphology. Research on CSOTF has increased in recent years; however, the lack of a standard classification system has resulted in inconvenient communication, research, and treatment. Previous CSOTF classification studies exhibit different symptoms, with none being widely accepted.MethodsImaging data of 368 patients with CSOTF treated at our hospital from January 2010 to June 2017 were systematically analyzed to develop a classification system. Imaging examinations included dynamic radiography, computed tomography scans, and magnetic resonance imaging. Ten investigators methodically studied the classification system grading in 40 cases on two occasions, examined 1 month apart. Kappa coefficients (κ) were calculated to determine intraobserver and interobserver reliability. Based on the radiographic characteristics, the patients were divided into 5 types, and different treatments were suggested for each type. Clinical outcome evaluation included using the visual analog score (VAS), the Oswestry disability index (ODI), and the American Spinal Injury Association (ASIA) impairment scale.ResultsThe new classification system for CSOTF was divided into types I–V according to whether the CSOTF exhibited dynamic instability, spinal stenosis or kyphosis deformity. Intra- and interobserver reliability were excellent for all types (κ = 0.83 and 0.85, respectively). The VAS score and ODI of each type were significantly improved at the final follow-up compared with those before surgery. In all patients with neurological impairment, the ASIA grading after surgery was significantly improved compared with that before surgery (P < 0.001).ConclusionsThe new classification system for CSOTF demonstrated excellent reliability in this initial assessment. The treatment algorithm based on the classification can result in satisfactory improvement of clinical efficacy for the patients of CSOFT.

Relationship Between Paralysis and the Epidural Spinal Cord Compression Scale in Spinal Metastasis.

Patients with metastatic spinal tumors often experience paralysis caused by spinal cord compression. Several studies have investigated metastatic lesion-related spinal cord compression. This study is the first to examine the relationship between the epidural spinal cord compression (ESCC) scale, which measures circumferential compression, and the functional outcomes of treatment, which were assessed at regular intervals after treatment until death. A total of 191 patients who had grade D or worse paralysis on the American Spinal Injury Association (ASIA) classification scale and a grade 1b or more severe cord compression on the ESCC scale were included in the study. Patients had been treated with surgery combined with radiotherapy (n=146) or radiotherapy alone (n=45). Three spinal surgeons assessed the ESCC grade of for patient, and the grade agreed to by at least 2 surgeons was adopted. After 4 weeks, re-evaluations were conducted by the same examiners. The authors also calculated the mean kappa coefficients for inter- and intra-examiner variability (0.88 and 0.93, respectively). The distribution of the ASIA grade differed significantly among the ESCC scale grades (P=.0102). However, the degree of improvement in paralysis in terms of the ASIA grade (≥1 grade of improvement, no change, or ≥1 grade of aggravation) was not significantly associated with the ESCC grade (P=.2334). The ESCC scale was found to be a useful indicator of circumferential spinal cord compression but was not identified as a significant functional prognostic factor for paralysis. [Orthopedics. 2020;43(6):e567-e573.].