Postoperative American Spinal Injury Association Research Articles

Mobile C-arm CT scan in surgery for thoracolumbar burst fractures of type A3

Objective To discuss the application of mobile C-arm CT scan in the operations for thora-columbar burst fractures of type A3. Methods From January 2012 to December 2014, 21 patients with sin-gle-segment thoracolumbar burst fracture (AO type A3) were treated. They were 15 males and 6 females, aged from 17 to 68 years (average, 43.6 years). By the American Spinal Injury Association (ASIA) grading, one was grade A, 2 were grade B, 12 grade C, 4 grade D and 2 grade E. Preoperative CT examination was conducted. Mobile C-arm CT scan was performed to evaluate reduction of the fragments after the fracture was reset by posterior pedicle screwing. Laminotomy for canal decompression or reduction of the fragments would be performed if it was indicated by the results of mobile C-arm CT scan. CT examination was conducted postoperatively to assess the fracture re-duction and recovery of the canal calibre. Results All the patients were followed up for an average of 15.5 months (from 10 to 18 months). Their cobb angle, vertebral anterior margin compression rate, spinal occupancy rate, vertebral translocation rate and visual analogue score at postoperation and final follow-up were significantly improved compared with their preoperative values (P 0.05). Postoperative ASIA grading showed that the spinal function was improved from grade B to grade C in one, from grade C to grade D in 4 cases, from grade C to grade E in 5 cases, and from grade D to grade E in 3 cases. Conclusion Since intraoperative C-arm CT scan can help decide whether laminectomy for canal decompression is conducted or not in the surgery of thoracolumbar burst fractures, it enhances the surgical safety and reliability. Key words: Thoracic vertebrae; Lumbar vertebrae; Fractures,bone; Fracture fixation,internal; C-arm CT

Posterior instrumentation and fusion for treating ankylosing spondylitis combined with lower cervical fractures

Objective To investigate outcomes of posterior instrumentation and fusion in treating ankylosing spondylitis (AS) combined with lower cervical fractures. Methods A retrospective case series study was made on 53 AS patients combined with cervical fractures or cervical thoracic fractures treated by posterior instrumentation and fusion from January 2006 to January 2013. There were 51 male and 2 female patients. The mean age of patients was 55 years old (range, 34-69 years old). All the patients showed significant kyphosis on the thoracolumbar and cervicothoracic junction. A total of 20 patients had neurological dysfunction at different extents. According to the American spinal injury association (ASIA) classification, neurological status was scored as Grade A in 4 cases, Grade B in 5, Grade C in 4 and Grade D in 7. The operation time, total bleeding and decompression status were recorded during the surgery. Reduction, decompression condition and complications were evaluated. The neurological status and bone fusion were recorded at the follow-up. Results All surgeries were well accomplished. Mean surgical time was 3. 7 h (range, 2.9-5.3 h). Mean total bleeding was 690 ml (range, 470-1 600 ml). Two patients died within 1 year follow-up because of internal diseases (1 case caused by respiratory system disease in 13 months postoperatively and 1 case caused by acute myocardial infarction in 15 months postoperatively). The mean follow-up time of other patients was 25 months (range, 18-48 months). The CT scan manifested all patients achieved satisfactory fusion, and the mean time span of the fusion was 3.5 months (range, 3-6 months) postoperatively. Among the 20 patients with various levels of neurological deficits before operation, the postoperative ASIA score was Grade A in 4 cases, Grade C in 2, Grade D in 4, and Grade E in 10. No instrumentation failure occurred during follow-up. Conclusion The posterior instrumentation and fusion for treating AS combined with cervical fractures can obtain satisfactory neurological results, spinal stabilization and clinical results, and hence an effective clinical problem-solving algorithm for such kind of patients. Key words: Spondylitis, ankylosing; Cervical vertebrae; Fractures fixation, internal; Posterior instrumentation

Bilateral transformational thoracolumbar interbody fusion for the treatment of giant central thoracolumbar junction disc herniation: A prospective clinical and radiological study

Study designClinical and radiological assessment of prospective single-center data. BackgroundThe optimal treatment strategy for giant central thoracolumbar junction disc herniation (TLDH) remains controversial. ObjectiveThis study aimed to report the clinical and radiological results of bilateral transformational thoracolumbar interbody fusion (bilateral TTIF) to treat giant central TLDH. MethodsSeventeen consecutive patients with giant central TLDH underwent bilateral TTIF from January 2014 to June 2014 and were followed for 9–15 months. Clinical and radiological data were prospectively examined, including operative time, blood loss, pre- and postoperative American Spinal Injury Association (ASIA) score for sensory and motor function, visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, fusion rate, extent of decompression, rate of instrumentation failure, and complications. ResultsThe average time of surgery was 160±37min, and blood loss was 884±197ml. The ASIA sensory and motor scores improved from 72.76±3.36 to 90.71±2.54 and from 68.47±4.7 to 88.0±3.2, respectively. VAS for back pain and ODI decreased from 6.65±1.93 to 2.23±0.56 and from 42.82±5.08 to 11.3±2.3, respectively. Canal encroachment improved from 50.3±6.6% to 2±0.3% at the last follow-up. Surgery complications were seen in 5 patients (29%), who experienced intraoperative dural tear and cerebrospinal fluid leak. There were no other major complications at the last follow-up. ConclusionsBilateral TTIF produced satisfactory outcomes and may be one of the surgical treatments of choice for myelopathy due to giant central TLDH.

Optimal Timing of Surgical Decompression for Acute Traumatic Central Cord Syndrome: A Systematic Review of the Literature.

Traumatic central cord syndrome (TCCS) is an incomplete spinal cord injury defined by greater weakness in upper versus lower extremities, variable sensory loss, and variable bladder, bowel, and sexual dysfunction. The optimal timing of surgery for TCCS remains controversial. To determine whether timing of surgery for TCCS predicts neurological outcomes, length of stay, and complications. Five databases were searched through March 2015. Articles were appraised independently by 2 reviewers, and the evidence synthesized according to Grading of Recommendation Assessment, Development and Evaluation principles. Nine studies (3 prognostic, 5 therapeutic, 1 both) satisfied inclusion criteria. Low level evidence suggests that patients operated on <24 hours after injury exhibit significantly greater improvements in postoperative American Spinal Injury Association motor scores and the functional independence measure at 1 year than those operated on >24 hours after injury. Moderate evidence suggests that patients operated on <2 weeks after injury have a higher postoperative Japanese Orthopaedic Association score and recovery rate than those operated on >2 weeks after injury. There is insufficient evidence that lengths of hospital or intensive care unit stay differ between patients who undergo early versus delayed surgery. Furthermore, there is insufficient evidence that timing between injury and surgery predicts mortality rates or serious or minor adverse events. Surgery for TCCS <24 hours after injury appears safe and effective. Although there is insufficient evidence to provide a clear recommendation for early surgery (<24 hours), it is preferable to operate during the first hospital admission and <2 weeks after injury.

Multiple special formed titanium mesh cages in the treatment of lumbo-sacral spinal tuberculosis via posterior approach only

To determine the clinical efficacy and feasibility of multiple special formed titanium mesh cages (TMCs) to treat lumbo-sacral spinal tuberculosis via posterior approach. From July, 2007 to June, 2013, 25 patients with lumbo-sacral spinal tuberculosis underwent one-stage posterior debridement, internal fi xation, and interbody fusion using multiple special formed titanium meshes. We compared the parameters as follow: the pre- and post-operative American Spinal Injury Association (ASIA) score, lumbo-sacral angle, the height of intervertebral space, visual analogue scale (VAS), and erythrocyte sedimentation rate (ESR), and observed operation time, intraoperative blood loss, and time of bone graft fusion. Operation time ranged from 90 to 180 min, (128±24) min in average. Blood loss in the operation ranged from 100 to 800 mL, (310±125) mL in average. The patients were followed up for 24 to 59 months, (43±7) months in average. One patient delayed healing of wound. ASIA score was improved in a certain degree in patients with neurological dysfunctions. The lumbo-sacral angle and the height of intervertebral space in the post-operation were significantly higher than those in the preoperation (P< 0.001). VAS was reduced obviously after 2 weeks of operation. The ESR recovered to the normal level 6 months after operation in all the patients. Solid fusion was achieved within 4 to 8 months, 6 months in average. No sinus tract, cerebrospinal meningitis, tuberculosis recurrence and titanium mesh subsidence were found. For lumbo-sacral tuberculosis, multiple special formed titanium mesh cages via posterior approach is safe and effective, which is good to the stability in spine reconstruction.

Rapid progressive clinical deterioration of cervical spondylotic myelopathy.

Retrospective clinical study. To elucidate the pathophysiology of rapid progressive clinical deterioration following the onset of cervical myelopathy. Spinal Injuries Center, Fukuoka, Japan. A total of 43 cervical spondylotic myelopathy (CSM) patients were treated surgically by a senior surgeon. All patients showed intramedullary intensity changes on magnetic resonance (MR) imaging. Overall, eight patients suffered rapid progressive clinical deterioration; four of them had obvious anamnesis of minor trauma. We assessed the responsible injured segment by MR T2-weighted images. Clinical instabilities at the focal segment were evaluated using functional sagittal plain radiographs. Neurological evaluations were performed preoperatively and at 12 months postoperatively using American Spinal Injury Association (ASIA) motor scores and Japanese Orthopaedic Association (JOA) scores for cervical myelopathy. Intraoperatively, we evaluated the presence of adhesive scar tissue on the dura mater at the focal segment. The responsible injured segment was C3-4 in 75% of the rapid progressive (rp)-CSM and in 28.57% of the conventional CSM subjects. One with rp-CSM showed sagittal translational segmental instability. Preoperative ASIA motor scores and JOA scores in the rp-CSM were significantly lower than those in the conventional CSM subjects. Postoperative ASIA motor scores between the subjects showed no significant differences; however, postoperative JOA scores in the rp-CSM subjects were significantly lower. Moreover, an epidural membrane was observed in 62.5% of rp-CSM and 11.4% of conventional CSM subjects. We hypothesized that the pathophysiology of rp-CSM might be additional cervical cord disorder following the onset of cervical myelopathy. Early decompression surgery is recommended in such patients.

Combination of mouse nerve growth factor and mecobalamin for treatment of incomplete spinal cord injury without high-dose methylprednisolone therapy

Objective To evaluate the clinical efficacy of mouse nerve growth factor (mNGF) plus mecobalamin in the treatment of incomplete spinal cord injury (ISCI) without high-dose methylprednisolone therapy. Methods From October 2007 to September 2010,72 ISCI patients (Frankel grades B,C & D)without previous high-dose methylprednisolone therapy were treated in our department,of whom 56 were retrospectively selected for the present study and divided into 2 groups.In group A 28 patients were treated with combination of mNGF and meeobalamin; 28 patients in group B were treated with mecobalamin only.In this series,American Spinal Injury Association (ASIA) impairment scale and Activity of Daily Living (ADL) evaluation were used to observe and calculate nerve function improvement preoperation and 1 week,8 weeks,12 months postoperation. Results The mean follow-up period was 20 months (from 12 to 48 months).No mortality or incision infection was observed.Fusions of bone graft were observed 10 months postoperation on average.The ASIA and ADL scores at 1 week,8 weeks and 12 months postoperation were significant higher than those preoperation in both groups (P ＜0.05) except the ASIA score 1 week postoperation in group B.The postoperative ASIA and ADL scores in Group A were all significantly higher than those in group B ( P ＜ 0.05).The nerve function improvement at 1 week,8 weeks and 12 months postoperation in group A were 32.1％ (9/28),82.1％ (23/28) and 92.9％ (26/28) respectively,which were better than those in group B [25.0％ (7/28),50.0％ (14/28) and 71.4％ (20/28) ],with a significant difference at 8 weeks and 12 months postoperation ( P ＜ 0.05 ). Conclusion Compared with administration of sole mecobalamin,combination of mNGF and mecobalamin proves to be highly effective in promoting ISCI recovery and improving nerve functiont. Key words: Spinal cord injury; Mouse; Nerve growth factor; Mecobalamin; Nerve function

Acidic fibroblast growth factor for repair of human spinal cord injury: a clinical trial

The study aimed to verify the safety and feasibility of applying acidic fibroblast growth factor (aFGF) with fibrin glue in combination with surgical neurolysis for nonacute spinal cord injury. This open-label, prospective, uncontrolled human clinical trial recruited 60 patients with spinal cord injuries (30 cervical and 30 thoracolumbar). The mean patient age was 36.5 ± 15.33 (mean ± SD) years, and the male/female ratio was 3:1. The mean time from injury to treatment was 25.7 ± 26.58 months, and the cause of injury included motor vehicle accident (26 patients [43.3%]), fall from a height (17 patients [28.3%]), sports (4 patients [6.7%]), and other (13 patients [21.7%]). Application of aFGF with fibrin glue and duraplasty was performed via laminectomy, and an adjuvant booster of combined aFGF and fibrin glue (2 ml) was given at 3 and 6 months postsurgery via lumbar puncture. Outcome measurements included the American Spinal Injury Association (ASIA) motor scores, sensory scores, impairment scales, and neurological levels. Examination of functional independence measures, visual analog scale, MR imaging, electrophysiological and urodynamic studies, hematology and biochemistry tests, tumor markers, and serum inflammatory cytokines were all conducted. All adverse events were monitored and reported. Exclusions were based on refusal, unrelated adverse events, or failure to participate in the planned rehabilitation. Forty-nine patients (26 with cervical and 23 with thoracolumbar injuries) completed the 24-month trial. Compared with preoperative conditions, the 24-month postoperative ASIA motor scores improved significantly in the cervical group (from 27.6 ± 15.55 to 37.0 ± 19.93, p < 0.001) and thoracolumbar group (from 56.8 ± 9.21 to 60.7 ± 10.10, p < 0.001). The ASIA sensory scores also demonstrated significant improvement in light touch and pinprick in both groups: from 55.8 ± 24.89 to 59.8 ± 26.47 (p = 0.049) and 56.3 ± 23.36 to 62.3 ± 24.87 (p = 0.003), respectively, in the cervical group and from 75.7 ± 15.65 to 79.2 ± 15.81 (p < 0.001) and 78.2 ± 14.72 to 82.7 ± 16.60 (p < 0.001), respectively, in the thoracolumbar group. At 24-month follow-up, the ASIA impairment scale improved significantly in both groups (30% cervical [p = 0.011] and 30% thoracolumbar [p = 0.003]). There was also significant improvement in neurological level in the cervical (from 5.17 ± 1.60 to 6.27 ± 3.27, p = 0.022) and thoracolumbar (from 18.03 ± 4.19 to 18.67 ± 3.96, p = 0.001) groups. The average sum of motor items in functional independence measure also had significant improvement in both groups (p < 0.05). The walking/wheelchair locomotion subscale showed increased percentages of patients who were ambulatory (from 3.4% to 13.8% and from 17.9% to 35.7% in the cervical and thoracolumbar groups, respectively). There were no related adverse events. The use of aFGF for spinal cord injury was safe and feasible in the present trial. There were significant improvements in ASIA motor and sensory scale scores, ASIA impairment scales, neurological levels, and functional independence measure at 24 months after treatment. Further large-scale, randomized, and controlled investigations are warranted to evaluate the efficacy and long-term results.

The effect of timing of surgical intervention on functional recovery of the hand and treatment of hyperextension injury to the cervical spinal cord

Objective To determine the correlations between the time of surgical intervention, effect of surgery and functional recovery of the hand in the treatment of hyperextension injury to the cervical spinal cord. Methods We treated 34 cases of cervical hyperextension injury from February 2005 to August 2009. According to the time of surgical intervention, they were classified into 3 groups. In group A, 17 cases received operation within 6 days, in group B 10 cases had operation from 6 to 14 days, and in group C, 7 cases had operation after 14 days. The 3 groups were compared respectively in terms of their preoperative and postoperative American Spinal Injury Association (ASIA) motor scores and their functional recovery of the hands' intrinsic muscle. Results They were followed up for 12 to 40 months. By ASIA scores for spinal nerve function, group A was significantly better than groups B ( P =0. 025) and C ( P =0. 042) in one month and at the last follow-up after operation but there was no significant difference between group B and C ( P =0. 849) . In strength of the intrinsic muscle in one month after operation, there was no significant difference (P = 0. 101 ) between the 3 groups. In the neural function at the last follow-up, group A was significantly better than group B ( P = 0. 034) and group C ( P = 0. 006), but there was no significant difference ( P =0. 217) between groups B and C, Conclusions Patients with hyperextension injury to the cervical spinal cord should be operated on within 6 days after injury. Early operative decompression is the key to nerve functional recovery and reduction of associated complications. The short-term functional recovery of the hand intrinsic muscle may have no obvious relation to the time of surgical intervention but the long-term recovery may be obviously related to the operative time. Key words: Cervical vertebrae; Spinal cord injuries; Treatment outcome

Posttraumatic spinal cord tethering and syringomyelia: surgical treatment and long-term outcome

Permanent neurological loss after spinal cord injury (SCI) is a well-known phenomenon. There has also been a growing recognition and improved understanding of the pathophysiological mechanisms of late progressive neurological loss, which may occur after SCI as a result of posttraumatic spinal cord tethering (SCT), myelomalacia, and syringomyelia. A clinical study of 404 patients sustaining traumatic SCIs and undergoing surgery to arrest a progressive myelopathy caused by SCT, with or without progressive myelomalacia and cystic cavitation (syringomyelia) was undertaken. Both objective and subjective long-term outcomes were evaluated. To the authors' knowledge, this is the first series of this size correlating long-term patient perception of outcome with long-term objective outcome analyses. During the period from January 1993 to November 2003, 404 patients who had previously sustained traumatic SCIs underwent 468 surgeries for progressive myelopathies attributed to tethering of the spinal cord to the surrounding spinal canal, with or without myelomalacia and syrinx formation. Forty-two patients were excluded because of additional pathological entities that were known to contribute to a progressive myelopathy. All surgeries were performed by the same neurosurgeon at a single SCI treatment center and by using a consistent surgical technique of spinal cord detethering, expansion duraplasty, and when indicated, cyst shunting. Outcome data were collected up to 12 years postoperatively. Comparisons of pre- and postoperative American Spinal Injury Association sensory and motor index scores showed no significant change when only a single surgery was required (86% of patients). An outcome questionnaire and phone interview resulted in > 90% of patients self-assessing arrest of functional loss; > 50% of patients self-assessing improvement of function; 17 and 18% self-assessing improvement of motor and sensory functions to a point greater than that achieved at any time postinjury, respectively; 59% reporting improvement of spasticity; and 77% reporting improvement of hyperhidrosis. Surgery for spinal cord detethering, expansion duraplasty, and when indicated, cyst shunting, is a successful treatment strategy for arresting a progressive myelopathy related to posttraumatic SCT and syringomyelia. Results suggest that surgery leads to functional return in ~ 50% of patients, and that in some patients posttraumatic SCT limits maximal recovery of spinal cord function postinjury. A patient's perception of surgery's failure to arrest the progressive myelopathy corresponds closely with the need for repeat surgery because of retethering, cyst reexpansion, and pseudomeningocele formation.

Short segmental pedicle screw fixation combined with percutaneous vertebroplasty in treatment of nonadjacent thoracolumbar fractures

To evaluate the short-term outcomes of short segmental pedicle screw fixation combined with percutaneous vertebroplasty in treatment of nonadjacent thoracolumbar fractures. Twenty patients who suffered from nonadjacent thoracolumbar fractures were treated by short segmental pedicle screw fixation for burst fracture and by percutaneous vertebroplasty for compression fracture. X-rays, CT and MRI scans were conducted using the same protocol before and after surgery and during follow-up. Pre-and post-operative American Spinal Injury Association (ASIA) grades, fusion of fracture sites, visual analog scale (VAS) of back pain, and Oswestry disability index (ODI) were accessed. All patients were followed up for an average period of 12 months. The sagittal profile of the thoracolumbar spine was restored satisfactorily. No patient had neurologic deterioration after surgery, and 9 patients with incomplete lesions improved postoperatively by at least one ASIA grade. The fusion rate was 100%. The average VAS of back pain was 7.6 preoperatively and 3.2 postoperatively. The average ODI was 72.5 preoperatively and 35.5 postoperatively. Short segmental pedicle screw fixation combined with percutaneous vertebroplasty in treatment of nonadjacent thoracolumbar fractures exhibits such advantages as preserving functional segment units, reliable fixation, good neurologic recovery and early mobilization and, therefore, is suitable for treating nonadjacent thoracolumbar fractures.