Surgical Decompression Of Spinal Cord Research Articles

Spinal Cord Injury Management Based on Microglia-Targeting Therapies.

Spinal cord injury is a complicated medical condition both from the clinician's point of view in terms of management and from the patient's perspective in terms of unsatisfactory recovery. Depending on the severity, this disorder can be devastating despite the rapid and appropriate use of modern imaging techniques and convenient surgical spinal cord decompression and stabilization. In this context, there is a mandatory need for novel adjunctive therapeutic approaches to classical treatments to improve rehabilitation chances and clinical outcomes. This review offers a new and original perspective on therapies targeting the microglia, one of the most relevant immune cells implicated in spinal cord disorders. The first part of the manuscript reviews the anatomical and pathophysiological importance of the blood-spinal cord barrier components, including the role of microglia in post-acute neuroinflammation. Subsequently, the authors present the emerging therapies based on microglia modulation, such as cytokines modulators, stem cell, microRNA, and nanoparticle-based treatments that could positively impact spinal cord injury management. Finally, future perspectives and challenges are also highlighted based on the ongoing clinical trials related to medications targeting microglia.

The design of a quality improvement dashboard for monitoring spinal cord and column injuries

BackgroundInteractive dashboards are a powerful tool for dynamic visualization and monitoring of patient performance and serve as a useful to for optimal decision-making. The National Spinal Column and Cord Injury Registry of Iran (NSCIR-IR) was designed to efficiently display and broadcast important patient care data. This has been achieved through an electronic dashboard display (graph and visual displays), rather than traditional static paper reports (text). ObjectivesThe objective of this study was to design and develop an electronic visual dashboard as a display system to monitor the quality of care in the NSCIR-IR collaborating centers. MethodsThe indicators chosen were 20 pre-hospital and in-hospital quality of care (QoC) assessment tool indicators. A structured query was created from the NSCIR-IR system database to create the dashboard database. The Microsoft Power BI software was used. After data cleaning, filtering of erroneous records, and modeling, visual displays were designed and evaluated. ResultsThe dashboard reported on quality of care (QoC) for 2,745 patients registered in NSCIR-IR. 17% of registered cases had at least one data error in the quality of care indicators. These errors were automatically filtered by the system. The two most prominent weaknesses in (QoC indicators were delay in patient transfer by EMS (Mean and SD were 9.54 ± 13.8 h) and timing of surgical spinal cord decompression (114.5 ± 45.3 h). ConclusionsElectronic dashboards provide efficient and concise data summaries “at a glance”. However, their value and accuracy are dependent on the entered data quality. Identifying data source errors and correcting them continuously led to improved quality of data.

Subclinical respiratory dysfunction and impaired ventilatory adaptation in degenerative cervical myelopathy

Degenerative cervical myelopathy (DCM) is a debilitating neurological condition characterized by chronic compression of the cervical spinal cord leading to impaired upper and lower limb function. Despite damage to areas of the cervical spinal cord that house the respiratory network, respiratory dysfunction is not a common symptom of DCM. However, DCM may be associated with respiratory dysfunction, and this can affect the ventilatory response to respiratory challenges during emergence from anesthesia, exercise, or pulmonary disease. Surgical spinal cord decompression, which is the primary treatment for DCM, leads to improved sensorimotor function in DCM; yet its impact on respiratory function is unknown. Here, using a clinically relevant model of DCM, we evaluate respiratory function during disease progression and assess adaptive ventilation to hypercapnic challenge before and after surgical intervention. We show that despite significant and progressive forelimb and locomotor deficits, there was no significant decline in eupneic ventilation from the early to late phases of spinal cord compression. Additionally, for the first time, we demonstrate that despite normal ventilation under resting conditions, DCM impairs acute adaptive ventilatory ability in response to hypercapnia. Remarkably, akin to DCM patients, surgical decompression treatment improved sensorimotor function in a subset of mice. In contrast, none of the mice that underwent surgical decompression recovered their ability to respond to hypercapnic ventilatory challenge. These findings underscore the impact of chronic spinal cord compression on respiratory function, highlighting the challenges associated with ventilatory response to respiratory challenges in individuals with DCM. This research highlights the impact of cervical spinal cord compression on respiratory dysfunction in DCM, as well as the persistence of adaptive ventilatory dysfunction after surgical spinal cord decompression. These results indicate the need for additional interventions to enhance recovery of respiratory function after surgery for DCM.

Workshop (Clinical/Best Practice Implementation) ID 2000428

Background/Objectives This workshop aims to overview degenerative cervical myelopathy (DCM), which is the most common cause of non-traumatic spinal cord injury across the world. DCM is estimated to affect approximately 1 in 50 adults; however, < 10% receive a diagnosis, and lifelong disability remains a common outcome. Upon completion of this workshop, attendees will (1) understand the diagnostic criteria and investigations for DCM and avoid misdiagnosis in the primary care level; (2) recognise the indications and role of surgical treatment; (3) comprehend the impact of prehabilitation and rehabilitation; (4) understand the alternatives for non-operative management of DCM; and (5) appreciate the importance of raising awareness of this disease. Methods/Overview This workshop will review the diagnostic criteria and investigations for individuals with different degrees of DCM, the current clinical practice guidelines for management of DCM with focus on the role of surgical decompression of spinal cord, the role of prehabilitation and rehabilitation, current non-operative options for patients with DCM, and some initiatives focused on raising awareness of this disease. Results This workshop will include lectures (10-15 minutes each) with illustrative cases followed by open discussion on the following topics: (i) diagnosis, misdiagnosis and investigations in DCM; (ii) surgical management of DCM; (iii) prehabilitation and rehabilitation in DCM; and (iv) non-operative management of DCM. Conclusions Although DCM is the most common cause of non-traumatic spinal cord disease, there is a need for the development of a tailored and multi-disciplinary care framework for management of DCM, which would improve patients’ outcomes. Greater awareness of DCM among healthcare professionals is urged to avoid misdiagnosis and mitigate the long-term consequences of this disease.

Cerebrospinal Fluid Pressure Dynamics as a Bedside Test in Traumatic Spinal Cord Injury to Assess Surgical Spinal Cord Decompression: Safety, Feasibility, and Proof-of-Concept

Background Sufficient and timely spinal cord decompression is a critical surgical objective for neurological recovery in spinal cord injury (SCI). Residual cord compression may be associated with disturbed cerebrospinal fluid pressure (CSFP) dynamics. Objectives This study aims to assess whether intrathecal CSFP dynamics in SCI following surgical decompression are feasible and safe, and to explore the diagnostic utility. Methods Prospective cohort study. Bedside lumbar CSFP dynamics and cervical MRI were obtained following surgical decompression in N = 9 with mostly cervical acute-subacute SCI and N = 2 patients with non-traumatic SCI. CSFP measurements included mean CSFP, cardiac-driven CSFP peak-to-valley amplitudes (CSFPp), Valsalva maneuver, and Queckenstedt’s test (firm pressure on jugular veins, QT). From QT, proxies for cerebrospinal fluid pulsatility curve were calculated (ie, relative pulse pressure coefficient; RPPC-Q). CSFP metrics were compared to spine-healthy patients. computer tomography (CT)-myelography was done in 3/8 simultaneous to CSFP measurements. Results Mean age was 45 ± 9 years (range 17-67; 3F), SCI was complete (AIS A, N = 5) or incomplete (AIS B-D, N = 6). No adverse events related to CSFP assessments. CSFP rise during QT was induced in all patients [range 9.6-26.6 mmHg]. However, CSFPp was reduced in 3/11 (0.1-0.3 mmHg), and in 3/11 RPPC-Q was abnormal (0.01-0.05). Valsalva response was reduced in 8/11 (2.6-23.4 mmHg). CSFP dynamics corresponded to CT-myelography. Conclusions Comprehensive bedside lumbar CSFP dynamics in SCI following decompression are safe, feasible, and can reveal distinct patterns of residual spinal cord compression. Longitudinal studies are required to define critical thresholds of impaired CSFP dynamics that may impact neurological recovery and requiring surgical revisions.

A decrease in the neuroprotective effects of acute spinal cord decompression according to injury severity: introducing the concept of a ceiling effect.

Acute traumatic spinal cord injury (tSCI) is followed by a prolonged period of secondary neuroglial cell death. Neuroprotective interventions, such as surgical spinal cord decompression, aim to mitigate secondary injury. In this study, the authors explore whether the effect size of posttraumatic neuroprotective spinal cord decompression varies with injury severity. Seventy-one adult female Long Evans rats were subjected to a thoracic tSCI using a third-generation spinal contusion device. Moderate and severe tSCI were defined by recorded impact force delivered to the spinal cord. Immediately after injury (< 15 minutes), treatment cohorts underwent either a decompressive durotomy or myelotomy. Functional recovery was documented using the Basso, Beattie, and Bresnahan locomotor scale, and tissue sparing was documented using histological analysis. Moderate and severe injuries were separated at a cutoff point of 231.8 kdyn peak impact force based on locomotor recovery at 8 weeks after injury. Durotomy improved hindlimb locomotor recovery 8 weeks after moderate trauma (p < 0.01), but not after severe trauma (p > 0.05). Myelotomy led to increased tissue sparing (p < 0.0001) and a significantly higher number of spared motor neurons (p < 0.05) in moderate trauma, but no such effect was noted in severely injured rats (p > 0.05). Within the moderate injury group, myelotomy also resulted in significantly more spared tissue when compared with durotomy-only animals (p < 0.01). These results suggest that the neuroprotective effects of surgical spinal cord decompression decrease with increasing injury severity in a rodent tSCI model.

Cervical instability in a patient with rheumatoid arthritis

Introduction: Rheumatoid arthritis (RA) is a chronic autoimmune connective tissue disease characterized by symmetrical arthritis associated with extra-articular changes. Although peripheral joint involvement is the dominant symptom of RA, many patients develop cervical spine involvement in the course of the disease, manifesting as cervical instability. Aim: The aim of this study is to describe a case of an RA patient with spinal myelopathy to increase awareness of this complication, hoping that its early diagnosis may prevent further serious consequences. Case study: A 63-year-old patient, who was diagnosed with RA 18 years ago, was admitted to the Rheumatology Clinic due to suspected exacerbation of rheumatic disease. Functional X-Ray and MRI was performed, which showed instability in the C3–C4 segment with spinal cord compression. Subsequently, the patient underwent cervical spine surgery. After the surgery and rehabilitation, the patient demonstrated neurological improvement. Results and discussion: Every patient diagnosed with RA should be educated about the possibility of a complication of cervical instability and be familiar with the neurological symptoms that may result from it. If cervical instability and subsequent cervical myelopathy are detected early, the symptoms may be reversible or significantly reduced by surgical spinal cord decompression and cervical stabilization. Conclusions: It is very important to perform a functional X-ray of the cervical spine to exclude instability, especially before rehabilitation treatment. Neck pain in patients diagnosed with RA may indicate cervical instability that requires more thorough neurological examination to exclude cervical myelopathy.

Outcome of operative management of degenerative compressive myelopathy of cervical spine

Cervical spondylotic myelopathy is a serious complication of cervical spondylosis. Surgery is increasingly recommended as the preferred treatment strategy for patients with CSM as it can effectively halt disease progression and improve neurological outcomes. Aims of the study were to determine functional outcomes, perioperative complications and to compare for safety and efficacy of different surgical treatments available for CSM. Prospective case series included all consecutive patients with CSM who underwent cervical decompressive surgery from August 2015 to March 2017 at the Orthopaedic Department, New Civil Hospital, Surat. Functional disability was assessed on the basis of the mJOA score, European Myelopathy Score and Nurick’s grading. 3 Women and 17 men with ages ranging from 37 to 65 years underwent surgical spinal cord decompression. Discectomy with anterior fusion (n = 7), corpectomy with anterior fusion (n = 2), decompressive laminectomy (n= 3), laminectomy with lateral mass fixation (n = 2) and laminoplasty (n = 6) were the operative procedures in study. Preoperative functional scorings of the patients were mJOA (12.20±2.76), EMS (11.70±3.10) and Nurick’s grade (3.15±1.3) There was a statistically significant improvement in mean scores at 6 months in The Nurick’s grades (2.0±1.21) (p

89. Recovery of evoked potentials in spine surgery

The role of intraoperative neurophysiologic monitoring (IOM) in detection and prevention of an jatrogenic injury has been well documented. Only few studies, however, has been focused on recovery of evoked potentials. Aim of this study is to describe the rate of reappearance of basally unexcitable muscle-motor evoked potentials (m-MEPs) and somatosensory evoked potentials (SEPs) in a large cohort of spinal surgeries. Data on 720 spinal surgeries are shown. Transcranially elicited lower limbs m-MEPs and tibial nerve SEPs were intraoperative recorded according to standard protocols. Reasons for surgey included cervical/thoracic myelopathy (300 pts, 41.7%), spinal cord tumors (190, 26.4%), lumbar stabilization (109 pts, 15.1%), scoliosis correction (83, 11.5%), trauma (32, 4.4%) and spinal vascular malformations (6 pts, 0.8%). Overall no intraoperative changes were observed in 648 surgeries (90%), 54 (7.5%) transient or persistent deterioration of evoked potentiantials and 18 (2.5%) recovery of basally unexcitable SEPs or MEPs (9 myelopathies, 4 spinal cord tumors, 2 metastasis, 3 trauma). The large majority of these “positive” modifications (17/18, 94.4%) consisted in reappearance of MEPs. Surgical decompression of spinal cord may lead to an acute improving of spinal motoneuron functionality. IOM can provide useful information even in patient with basally absent m-MEPs.

Early Versus Delayed Surgical Decompression of Spinal Cord after Traumatic Cervical Spinal Cord Injury: A Cost-Utility Analysis

This cost-utility analysis was undertaken to compare early (≤24 hours since trauma) versus delayed surgical decompression of spinal cord to determine which approach is more cost effective in the management of patients with acute traumatic cervical spinal cord injury (SCI). This study includes the patients enrolled into the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) and admitted at Toronto Western Hospital. Cases were grouped into patients with motor complete SCI and individuals with motor incomplete SCI. A cost-utility analysis was performed for each group of patients by the use of data for the first 6 months after SCI. The perspective of a public health care insurer was adopted. Costs were estimated in 2014 U.S. dollars. Utilities were estimated from the STASCIS. The baseline analysis indicates early spinal decompression is more cost-effective approach compared with the delayed spinal decompression. When we considered the delayed spinal decompression as the baseline strategy, the incremental cost-effectiveness ratio analysis revealed a saving of US$ 58,368,024.12 per quality-adjusted life years gained for patients with complete SCI and a saving of US$ 536,217.33 per quality-adjusted life years gained in patients with incomplete SCI for the early spinal decompression. The probabilistic analysis confirmed the early-decompression strategy as more cost effective than the delayed-decompression approach, even though there is no clearly dominant strategy. The results of this economic analysis suggests that early decompression of spinal cord was more cost effective than delayed surgical decompression in the management of patients with motor complete and incomplete SCI, even though no strategy was clearly dominant.

The utility of ultrasound for surgical spinal decompression.

Surgery is routinely performed to decompress the spinal cord. While a number of imaging modalities are currently used in the perioperative setting of surgical spinal cord decompression including computed tomography scan and magnetic resonance imaging, ultrasound (US) usage is relatively new. Therefore, only a few studies in the literature describe its value in the perioperative setting. US is a simple, safe, rapid, non-invasive, and inexpensive modality that constitutes a potential alternative when other modalities are not suitable or unavailable. It enables surgeons to generate high-resolution real-time images that can aid in diagnosing pathologies, guiding surgeries, and evaluating surgical outcomes. This review discusses the present literature and utility of pre-, intra-, and post-operative US in patients undergoing surgical spinal decompression. We also delineate three cases in which US was utilized at King Saud University hospital, which is considered one of the first centers in our region to report the use of US to guide treatment in spine surgery.

Cervical dermal sinus complicated with intramedullary abscess in a child: case report and review of literature

Dermal sinus tract (DST) is an uncommon spinal dysraphism presenting in childhood along the midline neuroaxis. Cervical DST less frequent is in association with intramedullary abscess. A 9-month-old baby was admitted to our unit suffering from right hemiparesis. Physical examination showed a cervical midline cutaneous fistula dripping a yellowish thick liquid. Cervical MRI showed at C5 level a sinus tract in continuity with a C3-C6 intramedullary lesion. Total removal of the fistula and the intramedullary lesion was performed. Histopathological examination confirmed the diagnosis of dermal sinus and abscess. Post-operative cervical MRI showed a complete removal of the spinal dysraphism, fistula, and intramedullary abscess. The baby showed a progressive clinical improvement and was discharged on day 10 post-surgery. Literature review confirms that an early diagnosis followed by prompt surgical spinal cord decompression gives a functional neurological recovery.

Process Benchmarking Appraisal of Surgical Decompression of Spinal Cord following Traumatic Cervical Spinal Cord Injury: Opportunities To Reduce Delays in Surgical Management

Prior pre-clinical and clinical studies indicate that early decompression of the spinal cord (≤ 24 h post-trauma) may have benefits regarding clinical outcomes and neurological recovery after spinal cord injury (SCI). This study examines the benchmarking of management of patients with acute traumatic cervical SCI in order to determine the potential barriers and ideal timelines for each step to early surgical decompression. We reviewed patient charts and the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS) forms regarding the time and reasons for delay of each step in the management of patients with SCI. The reasons for delays were classified into: 1) health care-related ("extrinsic") factors and 2) patient-related ("intrinsic") factors. The cases were grouped into patients who underwent early surgical decompression of spinal cord (early-surgery group) and individuals who underwent later decompression (later-surgery group). Whereas both groups showed comparable time periods related to intrinsic factors, patients in the early surgery group had a significantly shorter time period associated with extrinsic factors when compared with the later surgery group. Both groups were comparable regarding pre-hospital time, time in a second general hospital prior to transfer to a spine center, and time in the trauma emergency department. Patients in the early surgery group had a significantly shorter waiting time, shorter waiting time for assessment by a spine surgeon, and a shorter waiting time for a surgical decision than did the later surgery group. Our benchmarking analysis suggests that health-related factors are key determinants of the timing from SCI to spinal cord decompression. Time in the general hospital and time of waiting for a surgical decision were the most important causes of delay of surgical spinal cord decompression. Early surgery is possible in the vast majority of the cases.

Is Early Surgical Decompression for Traumatic Cervical Spinal Cord Injury (SCI) Feasible and Cost-Effective? (S47.003)

Objective: This study compares early (≤24 hours since SCI) versus later surgical decompression of spinal cord in order to determine which approach is more cost effective in the management of patients with acute cervical SCI and to examine the potential barriers and ideal timelines for each step to early surgical decompression. Background Pre-clinical and clinical studies suggest that early surgery is potentially beneficial. Design/Methods: A cost-utility analysis was performed using data for the first year after cervical SCI. The perspective of a public health care insurer was adopted. Utilities are from the Surgical Trial in Acute SCI Study. The reasons for delays in the management steps were classified into: (a) healthcare-related (“extrinsic”) and (b) patient-related (“intrinsic”) factors. Results: When considering the late decompression as the baseline strategy, the incremental cost-effectiveness ratio is US$8,523,852 per quality-adjusted life year (QALY) for patients with complete SCI and US$275,390/QALY for patients with incomplete SCI. The probabilistic analysis indicated that there is no clearly dominant strategy. While patients who underwent early surgery had a significantly shorter time period associated with extrinsic factors than individuals who underwent later surgery (19.16 versus 71.28 hours), both groups were comparable regarding time periods related to intrinsic factors. Conclusions: The results of our economic analysis suggests that, although no strategy is clearly superior to the other, early decompression of spinal cord can be more cost effective than delayed surgery in approximately one quarter of the patients with complete SCI and one third of the individuals with incomplete SCI. Our benchmarking analysis suggests that health-related factors are key determinants of the timing from SCI to spinal cord decompression. Time in the general hospital and time of waiting for surgical decision were the most important causes of delays for surgery. Early surgery is feasible in the vast majority of the cases. Supported by: Funded by the Rick Hansen Foundation. Disclosure: Dr. Furlan has nothing to disclose. Dr. Fehlings has received personal compensation for activities with Depuy Spine as a consultant.

Myelodysplasia presenting as thoracic spinal epidural extramedullary hematopoiesis: a rare treatable cause of spinal cord myelopathy

We present clinical, magnetic resonance imaging, and pathological findings of a 61-year-old patient with an otherwise asymptomatic myelodysplastic syndrome presenting with progressive paraparesis from epidural thoracic spinal extramedullary hematopoiesis. Surgical spinal cord decompression resulted in complete clinical remission.

Laser‐Doppler Measurements of Spinal Cord Blood Flow Changes During Hemilaminectomy in Chondrodystrophic Dogs with Disk Extrusion

(1) To assess spinal cord blood flow (SCBF) during surgical treatment of disk extrusion in dogs and (2) to investigate associations between SCBF, clinical signs, presurgical MRI images, and 24-hour surgical outcome. Cohort study. Chondrodystrophic dogs with thoracolumbar disk extrusion (n=12). Diagnosis was based on clinical signs and MRI findings, and confirmed at surgery. Regional SCBF was measured intraoperatively by laser-Doppler flowmetry before, immediately after surgical spinal cord decompression, and after 15 minutes of lavaging the lesion. Care was taken to ensure a standardized surgical procedure to minimize factors that could influence measurement readings. A significant increase in intraoperative SCBF was found in all dogs (Wilcoxon's signed-rank test; P=.05) immediately after spinal cord decompression and after 15 minutes. Changes in SCBF were not associated with duration of clinical signs; initial or 24-hour neurologic status; or degree of spinal cord compression assessed by MRI. SCBF increases immediately after spinal cord decompression in dogs with disk herniation; however, increased SCBF was not associated with a diminished 24-hour neurologic status. An increase in SCBF does not appear to be either associated with the degree of spinal cord compression or of a magnitude sufficient to outweigh the benefit of surgical decompression by resulting in clinically relevant changes in 24-hour outcome.

Intradural Extramedullary Aspergilloma Complicating Acute Lymphatic Leukaemia

A case of thoracic spinal cord compression caused by intradural extramedullary fungal granulomatous lesion associated with acute lymphatic leukaemia is presented. The specific diagnosis on imaging was difficult and required specialized histopathological studies. A high index of clinical suspicion of fungal infection, surgical decompression of spinal cord, and tissue biopsy confirmation are particular features of our case.

超音波メスの使用経験

The advantages and limitations of the ultrasonic surgical system in spinal surgery are disccused in this report.We used SUMISONIC ME-24000, which transmits ultrasonic vibrations (maximum vibration 2400times/sec, maximum amplitude 200μm) to the horn tip. Since the horn tip is very thin, accurate, precise cutting and resection of hard tissue is possible using a light touch.Cool water is discharged by the horn tip, minimizing heat gererated from cutting, and also washs away dissolved tissue.It was very useful in spinal surgery, especially in surgical decompression of spinal cord of OPLL and OYL.The risk of damage to soft tissue appears to be very low, in comparison with surgiairtome.

Destructive spondyloarthropathy presenting with progressive paraplegia in a dialysis patient. Recovery after surgical spinal cord decompression and parathyroidectomy

Destructive spondyloarthropathy presenting with progressive paraplegia in a dialysis patient. Recovery after surgical spinal cord decompression and parathyroidectomy

Spinal subdural hematoma

Although spinal subdural hematoma is a rare condition, it has a higher incidence in persons with a bleeding diathesis and in those with a bleeding diathesis who have had a lumbar puncture. We report a case of a 65-year-old woman on oral anticoagulants presenting with atypical symptoms who developed a spinal subdural hematoma over a six-hour period. This resulted in complete paraplegia of her lower extremities with no improvement after surgical spinal cord decompression.