Complete Neurological Deficit Research Articles

Clinical experiences and results of high-dosage methylprednisolone therapy in spinal cord trauma 1991 to 1993

Studies in animals and especially the NASCIS II study illustrated the neuroprotective effects of methylprednisolone, but they are disputed. At the University Clinic of Traumatology, Vienna, 31 patients with spinal cord injuries were given methylprednisolone as a bolus of 30 mg/kg body weight followed by a maintenance dose of 5.4 mg/kg body weight/h for another 23 hours. Twenty-seven patients were stabilised within 8 hours, 2 patients were not operated on, because of their low prognosis. Two patients could be treated conservatively, because the spinal fractures were supposed to be stabile. Then follow-up studies of these patients were between 1 and 3.2 years. All patients (100%) with incomplete neurologic deficits (n = 18) showed a significant recovery and even 3 patients (23.1%) with primarily a complete tetraplegia (n = 13) showed a nearly entire recovery. Compared to these results we look back at 113 patients with complete and incomplete neurologic deficits who were treated at the I. University Clinic of Traumatology, Vienna, and would have got methylprednisolone following our current management procedures.

Bilateral locked facets of the cervical spine

Bilateral locked facets (BLF) is a relatively common, unstable injury of the cervical spine. Severe neurologic deficit often is present due to marked narrowing of the spinal canal. Occasionally, BLF may be associated with ring-disrupting posterior element fractures. It has been suggested in the literature that associated ring-disrupting fractures decompress the spinal canal, preserving neurologic function. To evaluate this assertion, we reviewed the medical records and radiologic studies of 31 patients with BLF, collected at our institution over the past 15 years. Complete (Frankel A) or incomplete (Frankel B, C) neurologic deficit was present in 24 (77%) patients and minimal or no neurologic deficit (Frankel D, E) in the remaining 7 patients. Radiologically detected fractures associated with BLF were noted in 11 (35%) patients, of which 9 (29%) involved either bilateral laminar or pedicle fractures (ring-disrupting) at the level of dislocation, theoretically allowing decompression of the spinal canal. However, no statistically significant association between the presence of ring-disrupting fracture and minimal or no neurologic deficit was found. Our study suggests that ring-disrupting posterior element fractures associated with BLF do not necessarily offer protection to the spinal cord and that dynamic factors at the time of injury are primarily responsible for eventual neurologic outcome.

Myelographic and Enhanced Computed Tomographic Appearance of Acute Traumatic Spinal Cord Avulsion

The neuroradiological findings that revealed spinal cord transection/laceration in 6 patients with acute, blunt spinal trauma are described. Four patients suffered cervical spine injuries, and two had thoracic injuries. Initially, all patients had complete neurological deficit at the level of injury. The deficit improved in only 1 patient. On the basis of clinical history and spinal radiographs, spinal hyperflexion with distraction was the predominant mechanism of injury in our patients. Computed tomography with intrathecal contrast was performed on all patients and was always diagnostic. Visualization of intrathecal contrast material accumulating within the cord or the absence of cord shadow within the contrast column established the diagnosis in all cases. A dural tear was noted in 3 patients. Thoracic myelography was performed in 2 patients and, in both, demonstrated contrast pooling within the spinal cord at the level of the laceration. Magnetic resonance imaging was obtained in 1 patient and revealed an irregular, low-signal-intensity, intramedullary region extending to the cord surface on T1-weighted axial images. The myelographic and enhanced computed tomographic appearances of acute, traumatic spinal cord avulsion/laceration, which have been infrequently reported in the literature, are described.

Circumferential Fusion for the Management of Acute Cervical Spine Trauma

Combined, single-stage anterior and posterior approaches for acute surgical management of cervical spine injury allows for early restoration of anatomic alignment and decompression. Six patients underwent single-stage anterior decompression and posterior instrumentation and fusion at Vanderbilt University Medical Center between 1984-1989. There was no late deformity. Five patients had incomplete neurologic deficits, and each improved a minimum of one Frankel classification. One patient had complete neurologic deficit at the C5 level. The procedure is lengthy, with an average time under anesthesia of 7.7 hs. Since this procedure allows for immediate mobilization, it should be considered for the management of cervical spine fractures with both anterior and posterior column instability.

Pediatric Spinal Cord Injury Without Radiographic Abnormalities

Spinal cord injury without radiographic abnormality (SCIWORA) occurs primarily in the pediatric population but is less common than other forms of spinal injury among children. Between 1972 and 1990, 159 pediatric patients were admitted to the Barrow Neurological Institute with acute traumatic spinal cord or vertebral column injuries. Of these, 26 children (16%) sustained SCIWORA. The mechanism of injury, its severity, and the prognosis for recovery were related to the patient's age. In young children, SCIWORA accounted for 32% of all spinal injuries and tended to be severe; 70% were complete injuries. In older children, SCIWORA accounted for only 12% of the spinal injuries, was rarely associated with a complete injury, and had an excellent prognosis for complete recovery of neurologic function. As with other types of spinal cord injuries, the severity of neurological injury was the most important predictor of outcome. Patients with complete neurological deficits from SCIWORA had a poor prognosis for recovery of neurological function.

Experience with a spinal cord unit in Brasilia, Brazil

We have analysed our experiences in a Spinal Cord Unit in Brasilia, Brazil in the last 5 years (1982-1986). There were 738 outpatients and 243 inpatients. One hundred and six patients were operated on by the neurosurgical staff, and the indications for operation are discussed. Some patients showed neurological recovery with surgery and some without surgery. Patients with a complete neurological deficit on admission did not show any improvement, and those with a severe but incomplete deficit showed improvement with surgery (18%), which was better than those without an operation. We conclude that a surgical procedure seems to be indicated in those with a comminuted, or with an unstable fracture, if there is an incomplete neurological deficit with an unreduced spinal deformity. There was a possibility of recovery of some nerve root function. The goal of surgical treatment is to restore and maintain the anatomical relationships between the spinal canal, spinal cord and nerve roots with the simplest possible surgical procedure, returning the patient as soon as possible to his functional capacity and social life.

Traumatic cervical spine injuries in childhood and adolescence.

Of 84 consecutive children and adolescents with traumatic cervical spine injuries treated over a 10-year period, 61 (73%) were available for review. Age ranged from the newborn period to 17 years. Analysis of injury type revealed four groups of roughly equal incidence: atlantoaxial rotary subluxation, upper cervical fracture or dislocation, lower cervical injury, and spinal cord injury without radiographic abnormality. Forty-four percent of patients incurred a neurologic injury. Falling from a height was the most common mechanism of injury. Apart from patients with complete neurologic deficits, the prognosis for these injuries is good.

Anterior plate stabilization for bursting teardrop fractures of the cervical spine.

This report details eight patients who had bursting teardrop fractures of the cervical spinal column treated by decompressive vertebral corpectomy and anterior fusion with plate stabilization. The fracture involved C5 in six patients, C6 in one patient, and C7 in one patient. The neurologic deficit was complete in five and incomplete in three patients. At an average follow-up of 3 years, all grafts were fully incorporated, all cervical spinal columns were stable and had no deformity, and none of the fixation devices had loosened. All complete neurologic deficits have remained complete, and all patients with incomplete deficits have had significant recovery and are walking independently. There were no operative complications. After decompressive vertebral corpectomy, anterior plate stabilization followed by short-term halo-vest fixation is a safe and useful alternative for unstable bursting teardrop fractures of the cervical spinal column.

UNSTABLE FRACTURES OF THE THORACO-LUMBAR SPINE. A TEN-YEAR EXPERIENCE AT SACRE-COEUR HOSPITAL

In a 10-year period, 108 unstable fractures involving the thoracolumbar junction (T11 to L2) were treated. This study evaluates the influence of the different treatments on the rate of complication, reduction of the fracture, and neurological recovery. mechanism of injury, initial treatment and delay, neurologic deficit, operative findings, and duration of hospitalization were recorded. X-rays were reviewed for classification of fracture, measurement of deformity, and for instability scoring according to White and Panjabi's criteria. Seventy-seven patients were examined and nine more interviewed by telephone. a flexion-rotation injury occurred in 65% and a burst-fracture in 29%. A laminectomy was performed in 30 patients and Harrington instrumentation and fusion in 71 patients. Sixteen patients were treated conservatively. Fifty-five patients presented either a complete or partial neurological deficit. Seventy-five complications were noted and were more frequent in the laminectomy group. The instrumented group showed a clear tendency for earlier ambulation and discharge and pain level was found to be less. An increased residual deformity was found in patients treated by laminectomy, short fusion, and by nonsurgical modality. The neurologic recovery in the laminectomy and the nonlaminectomy group was not significantly different. Spinal realignment was better in the group where an instrumentation of five levels or more was performed and where posterior elements were not removed by laminectomy.

Timing for Exploration of Nerve Lesions and Evaluation of the Neuroma-in-Continuity

Despite complete distal neurologic deficit, not all sharp injuries to an extremity transect or even partially divide nerve. These injuries may require delayed intraoperative electrophysiologic evaluation to determine whether neurolysis or resection and repair is necessary. On the other hand, where nerve is sharply and completely divided, there are many advantages to acute or primary repair, especially with brachial, plexus, and sciatic nerve transections. Where nerves are bluntly divided, stumps should be tacked down to adjacent fascial or muscular planes and repair delayed for two to three weeks carved out so that the stumps can be sectioned back to healthy neural tissue. A partially lacerated nerve, if explored in a delayed fashion, may require suture or more likely a nerve graft repair of some fasicular groups, and neurolysis of others or what can be referred to as a split procedure. Urgent or very acute indications for operative intervention are few but are important ot keep in mind. Blunt injuries are responsible for the majority of lesions-in-continuity. These injuries can be followed clinically and electrically for two to three months. If there is no clinical or electrical reversal of the proximal portion of the distal loss, then exploration is in order. A decision whether or not to resect a lesion-in-continuity, based on gross or even operating microscopic appearance, has been difficult to make. For this reason, stimulation and stimulation and recording techniques were used to measure early regeneration in 600 cases with acceptable results.

Anterior decompression and fusion for thoracolumbar fractures with neurological deficits.

Anterior spinal decompression and fusion was used as the primary treatment for thoracolumbar fractures in eleven patients with neurological deficits. Each patient achieved stability by interbody fusion. Significant progressive kyphosis did not occur. No patients with a complete neurological deficit was improved by operation, but all eight patients with partial neurological deficits showed improved lower extremity motor function postoperatively. Bladder function improved in five of the eight patients with incomplete lesions. The authors recommend this operative approach for spinal stabilization and removal of anteriorly located bone or disc fragments causing progressing and stable partial neurological deficits, and find second-stage posterior fixation with Harrington rods unnecessary in the great majority of cases.

Outcome of Late Anterior Surgery and Arthrodesis of Lower Cervical Spinal Cord Injury

Objective: To evaluate the efficacy and outcome of late anterior surgery and arthrodesis of lower cervical spinal cord injury. Study design: Prospective Analysis. Setting: Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka; Bangladesh. Subjects and Methods: 32 consecutive patients with sub axial cervical spinal cord injury managed surgically from January 2000 to July 2005 by late anterior surgery and autologous bone graft stabilization considered as study unit. The indications of surgery were persistent cervical spinal cord compression and / or instability of cervical spine. Most cases were admitted late and operations were carried out as late 1 week to 27 weeks after injury. All the patients were investigated by radiograph and MRI of cervical spine accordingly. Post operative patient were followed up for twice, just before discharge from hospital and there-after minimum 3 months to 3 years. Quantification of deficit and neurological outcome were rated by American Spinal Injury Association (ASIA) classification system. Results: Males were found predominant with 93.75% over the female 6.25%; with ratio is 15: 1. Minimum age of the patient is 16 years and maximum age is 55 years. Most frequently (37.50%) encountered group were between the age of 31 to 40 years. Mean age is 32.29±10.09 years. Falling due to slip while carrying heavy load on head and / or neck (37.50%) was the most common cause of sub axial cervical spinal injury followed by road traffic accidents (31.25%), which may not be reported elsewhere till to-date. 31.25% suffered a single vertebral level, 62.50% patients suffered two vertebral levels and 6.25% patients suffered three level vertebral levels. The commonest skeletal level was C5/6 (46.87%) followed by C5 (25.00%) but C5 (46.87%) was commonest neurological level followed by C4 (18.75%). 81.25% of patients sustained a neurological injury. Of these, 75.00% had incomplete neurological deficit. After the operative procedure these incomplete neurological deficit patients have shown very attractive neurological recoveries. 6.25% of total population, who had complete neurological deficit, was graded as ASIA grade - A did not show any neurological recovery. In the current series none of the patients had worsening of neurological deficit due surgical intervention. Conclusion: This study offer significant potential for repairing some of the damage caused by cervical spinal cord injury. Further more, though controversy exists as to the ideal approach and timing (early versus late surgery) we have seen that benefits derived from late anterior surgery in our patients. Key words: Spinal Cord Injury; ASIA impairment scale; Neurological outcome. DOI: 10.3329/jdmc.v18i1.6306 J Dhaka Med Coll. 2009; 18(1) : 47-53