The potential for functional recovery of upper extremity function following cervical spinal cord injury without major bone injury

Are Clinical Prediction Rules Used in Spinal Cord Injury Care? A Survey of Practice

Background

Accurate outcome prediction is desirable post spinal cord injury (SCI), reducing uncertainty for patients and supporting personalized treatments. Numerous attempts have been made to create clinical prediction rules that identify patients who are likely to recover function. It is unknown to what extent these rules are routinely used in clinical practice.

Objectives

To better understand knowledge of, and attitudes toward, clinical prediction rules amongst SCI clinicians in the United Kingdom.

Methods

An online survey was distributed via mailing lists of clinical special interest groups and relevant National Health Service Trusts. Respondents answered questions about their knowledge of existing clinical prediction rules and their general attitudes to using them. They also provided information about their level of experience with SCI patients.

Results

One hundred SCI clinicians completed the survey. The majority (71%) were unaware of clinical prediction rules for SCI; only 8% reported using them in clinical practice. Less experienced clinicians were less likely to be aware. Lack of familiarity with prediction rules was reported as being a barrier to their use. The importance of clinical expertise when making prognostic decisions was emphasized. All respondents reported interest in using clinical prediction rules in the future.

Conclusion

The results show widespread lack of awareness of clinical prediction rules amongst SCI clinicians in the United Kingdom. However, clinicians were positive about the potential for clinical prediction rules to support decision-making. More focus should be directed toward refining current rules and improving dissemination within the SCI community.

Risk factors of AIS C incomplete cervical spinal cord injury for poor prognosis-The significance of anorectal evaluation

BACKGROUND

Although the prognosis of incomplete cervical spinal cord injury (SCI) diagnosed as American Spinal Injury Association Impairment Scale grade C (AIS C) is generally favorable, some patients remain non-ambulatory. The present study explored the clinical factors associated with the non-ambulatory state of AIS C patients.

METHODS

This study was a single-center retrospective observational study. Seventy-three participants with AIS C on admission were enrolled and divided into two groups according to ambulatory ability after one year. Prognostic factors of SCI were compared in ambulatory (A-group) and non-ambulatory participants (NA-group). Univariable and multivariable logistic regression analyses were performed on demographic information, medical history, mechanism of injury, presence of fracture, ASIA motor scores (MS) of the extremities, neurological findings, including an anorectal examination on admission, and imaging findings.

RESULTS

Forty-one patients were included in the A-group and 32 in the NA-group. Univariable analysis revealed that the following factors were related to poor outcomes (p < 0.05): older age, history of cerebrovascular disorder, impairment/absence of S4-5 sensory score, deep anal pressure (DAP) (-), voluntary anal contraction (VAC) (-), anorectal tone (-), anal wink reflex (-), and low MS of the upper and lower extremities. In the multivariable analysis using age, presence or absence of sacral abnormality, and history of cerebrovascular disorders (adjusted for these three factors), older age and presence of sacral abnormality on admission were independent risk factors for a non-ambulatory state at the 1-year follow-up.

CONCLUSIONS

Incomplete AIS C SCI individuals with older age and/or impairment of anorectal examination could remain non-ambulatory at 1-year follow-up.

Management of Cervical Spinal Cord Injury without Major Bone Injury in Adults

The incidence of cervical spinal cord injury (CSCI) without major bone injury is increasing, possibly because older people typically have pre-existing cervical spinal canal stenosis. The demographics, neurological injury, treatment, and prognosis of this type of CSCI differ from those of CSCI with bone or central cord injury. Spine surgeons worldwide are debating on the optimal management of CSCI without major bone injury. Therefore, this narrative review aimed to address unresolved clinical questions related to CSCI without major bone injury and discuss treatment strategies based on current findings. The greatest divide among spine surgeons worldwide hinges on whether surgery is necessary for patients with CSCI without major bone injury. Certain studies have recommended early surgery within 24 h after injury; however, evidence regarding its superiority over conservative treatment remains limited. Delayed MRI may be beneficial; nevertheless, reliable factors and imaging findings that predict functional prognosis during the acute phase and ascertain the necessity of surgery should be identified to determine whether surgery/early surgery is better than conservative therapy/delayed surgery. Quality-of-life assessments, including neuropathic pain, spasticity, manual dexterity, and motor function, should be performed to examine the superiority of surgery/early surgery to conservative therapy/delayed surgery.

The Decalcification of Cervicothoracic Spinal Metastasis of Breast Cancer Due to Discontinuation of Denosumab: A Case Report

Breast cancers frequently metastasize to bone. Several guidelines recommend denosumab to control metastasis. In the current case, denosumab allowed the calcification of cervicothoracic spinal metastases following bone decalcification by breast cancer. Six years after administration, denosumab was discontinued and the metastatic lesions became decalcified, but recalcification occurred after re-administration of denosumab. There were no reports of serious decalcification after discontinuation of denosumab.

The patient was a 71-year-old woman who was unable to walk independently because of a fracture of the seventh cervical vertebra and severe spinal cord compression. After immobilization with a halo vest, posterior fixation was performed.

Examination of the pathology of the breast and cervical spine revealed ductal carcinoma of the breast. After docetaxel for four months, tegafur-gimeracil-oteracil potassium (TS-1) was administered and monthly denosumab was initiated. CT showed postoperative recalcification of the cervicothoracic spine, and MRI revealed spinal cord decompression.

The first occurrence of medication-related osteonecrosis of the jaw (MRONJ) occurred five years after cervicothoracic spinal surgery and the second occurrence of MRONJ occurred after six years. Denosumab was discontinued and TS-1 was resumed four months after discontinuation.

Fourteen months after discontinuation of denosumab, the patient felt muscle weakness in the right upper extremity and numbness in both hands. CT showed cervicothoracic spine decalcification and MRI showed spinal cord compression. As there were no signs of recurrence in the primary lesion around the left breast, TS-1 was continued and denosumab was resumed. Three months after the re-administration of denosumab, CT showed recalcification and recovery of upper extremity muscle strength, and MRI revealed improvement in spinal cord compression.

The effects of lower extremity deep sensory impairments on walking capability in patients with incomplete cervical spinal cord injury

Objective: To analyze the impact of lower extremity deep sensory impairment on the walking capability of patients with incomplete cervical spinal cord injury.Design: Retrospective cohort study.Setting: Spinal Injuries Center, Fukuoka, Japan.Participants: Patients with incomplete cervical spinal cord injury who were transferred to the Spinal Injuries Center within 2 weeks of injury and whose progress was monitored for 6 months postinjury were included. Sixty-three patients with a lower extremity motor score of 42 points or more were enrolled. They were divided into lower extremity deep sensory impairment (16 patients) and normal (47 patients) groups, and their walking capability was compared.Interventions: Not applicable.Outcome Measures: Upper and lower extremity motor scores, the presence or absence of deep sensation impairment, and walking capability indices at 6 months postinjury were evaluated.Results: The deep sensory impairment group performed significantly worse than the normal group across items in the Walking Index for Spinal Cord Injury II and in the indoor and outdoor mobility items of the Spinal Cord Independence Measure III. Indoor and outdoor mobility independence levels decreased further in the lower extremity deep sensory impairment group than in the normal group.Conclusions: The presence of lower extremity deep sensation impairments was an important factor affecting the achievement of independent walking capabilities in patients with incomplete cervical spinal cord injury. Hence, when patients with incomplete cervical spinal cord injury undergo walking training, not only their lower extremity muscle strength but also their level of deep sensation impairment must be evaluated.

First-in-human clinical trial of transplantation of iPSC-derived NS/PCs in subacute complete spinal cord injury: Study protocol

Introduction

Our group has conducted extensive basic and preclinical studies of the use of human induced pluripotent cell (iPSC)-derived neural stem/progenitor cell (hiPSC-NS/PC) grafts in models of spinal cord injury (SCI). Evidence from animal experiments suggests this approach is safe and effective. We are preparing to initiate a first-in-human clinical study of hiPSC-NS/PC transplantation in subacute SCI.

Setting

NS/PCs were prepared at a Good Manufacturing Practice-grade cell processing facility at Osaka National Hospital using a clinical-grade integration-free hiPSC line established by the iPSC Stock Project organized by the Kyoto University Center for iPS Cell Research and Application. After performing all quality checks, the long-term safety and efficacy of cells were confirmed using immunodeficient mouse models.

Methods

The forthcoming clinical study uses an open-label, single-arm design. The initial follow-up period is 1 year. The primary objective is to assess the safety of hiPSC-NS/PC transplantation in patients with subacute SCI. The secondary objective is to obtain preliminary evidence of its impact on neurological function and quality-of-life outcomes. Four patients with C3/4-Th10 level, complete subacute (within 24 days post-injury) SCI will be recruited. After obtaining consent, cryopreserved cells will be thawed and prepared following a multi-step process including treatment with a γ-secretase inhibitor to promote cell differentiation. A total of 2 × 10⁶ cells will be transplanted into the injured spinal cord parenchyma 14–28 days post-injury. Patients will also receive transient immunosuppression. This study protocol has been reviewed and approved by the Certified Committee for Regenerative Medicine and the Japanese Ministry of Health, Labor and Welfare (University Hospital Medical Information Network Clinical Trials Registry [UMIN-CTR] number, UMIN000035074; Japan Registry of Clinical Trials [jRCT] number, jRCTa031190228).

Discussion/conclusion

We plan to start recruiting a patient as soon as the COVID-19 epidemic subsides. The primary focus of this clinical study is safety, and the number of transplanted cells may be too low to confirm efficacy. After confirming safety, a dose-escalation study is planned.

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A first-in-human clinical study for spinal cord injury using iPSC-derived cells is about to begin.

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The primary objective is to assess the safety of human iPSC-derived neural stem/progenitor cells.

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Further clinical trials are expected to be conducted to statistically assess efficacy.

Phase I/II Study of Intrathecal Administration of Recombinant Human Hepatocyte Growth Factor in Patients with Acute Spinal Cord Injury: A Double-Blind, Randomized Clinical Trial of Safety and Efficacy

Spinal cord injury (SCI) is an abrupt traumatic injury that leads to permanent functional loss, and no practical treatment is available. We have developed pharmaceutical recombinant human hepatocyte growth factor (KP-100), and its efficacy for SCI has been verified using animal models. The purpose of this study was to evaluate the safety and efficacy of intrathecal KP-100 administration for SCI patients in the acute phase. This investigation was a multi-center, randomized, double-blind study. Subjects with modified Frankel grade A/B1/B2 at 72 h after SCI were included. KP-100 was administered intrathecally. Subjects were followed up for 168 days after the first administration. Outcomes were evaluated using American Spinal Injury Association (ASIA) scores and subjected to analysis of covariance. Our results demonstrated that the subjects did not show any serious adverse events caused by KP-100. Forty-three subjects underwent neurological function testing (26 in KP-100 group; 17 in placebo group), which revealed that KP-100 contributed to motor improvement at Days 140 (p = 0.050) and 168 (p = 0.079). In the subset of subjects with Frankel grade A, the proportions of subjects who gained at least 1 point on their lower-extremity motor scores were 33.3% (5/15) and 6.3% (1/16) in the KP-100 and placebo groups, respectively (p = 0.083). Therefore, KP-100 has the potential to be useful and beneficial for SCI patients during the acute phase. However, this was a phase I/II trial and did not definitely address the question of efficacy; a larger phase III trial would be required to assess the efficacy.

Surgery-related predictable risk factors influencing postoperative clinical outcomes for thoracic myelopathy caused by ossification of the posterior longitudinal ligament: a multicenter retrospective study

OBJECTIVE

Compression of the spinal cord by thoracic ossification of the posterior longitudinal ligament (T-OPLL) often causes severe thoracic myelopathy. Although surgery is the most effective treatment for T-OPLL, problems associated with surgical intervention require resolution because surgical outcomes are not always favorable, and a small number of patients experience deterioration of their neurological status after surgery. The aim of the present study was to examine the surgery-related risk factors contributing to poor clinical outcomes for myelopathy caused by T-OPLL.

METHODS

Data were extracted from the records of 55 patients with thoracic myelopathy due to T-OPLL at institutions in the Fukuoka Spine Group. The mean follow-up period was 5.3 years. Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scale. To investigate the definitive factors associated with surgical outcomes, univariate and multivariate regression analyses were performed with several patient-related and surgery-related factors, including preoperative comorbidities, radiological findings, JOA score, surgical methods, surgical outcomes, and complications.

RESULTS

Neurological status improved in 33 patients (60.0%) and deteriorated in 10 patients (18.2%) after surgery. The use of instrumentation was significantly associated with an improved outcome. In the comparison of surgical approaches, posterior decompression and fusion resulted in a significantly higher neurological recovery rate than did anterior decompression via a posterior approach and fusion or decompression alone. It was also found that postoperative neurological status was significantly poorer when there were fewer instrumented spinal levels than decompression levels. CSF leakage was a predictable risk factor for deterioration following surgery.

CONCLUSIONS

It is important to identify preventable risk factors for poor surgical outcomes for T-OPLL. The findings of the present study suggest that intraoperative CSF leakage and a lower number of instrumented spinal fusion levels than decompression levels were exacerbating factors for the neurological improvement in T-OPLL surgery.

Progression of local kyphosis after conservative treatment for compressive cervical spine fracture with spinal cord injury

Introduction

Compressive-flexion type cervical spine fracture is typically accompanied by apparent dislocation of the facet joints, undesirable cervical alignment, and devastating neurological dysfunction, which provides strong rationale for rendering prompt operative treatment. However, the validity of conservative treatment for compressive-flexion cervical spine injury in cases with preserved congruity of the facet joints has yet to be elucidated. The purpose of this study is to evaluate the long-term outcome of cervical alignment following conservative treatment for compressive-flexion cervical spine injury with preserved congruity of the facet joints.

Methods

A total of 662 patients who experienced spinal cord injury from 2007 to 2017 were included and underwent retrospective review in a single institute. Thirteen patients were identified as receiving conservative therapy following compressive-flexion cervical spine fractures with spinal cord injury. Clinical and radiological results were collected, including vertical fractures of the vertebral column, laminar fractures, progression of local kyphosis, and neurological status. The degree of the local cervical kyphosis was evaluated with two methods: the posterior tangent method and the endplate method.

Results

All 13 patients were male, and the mean age at the time of injury was 28.4 years. The mean follow-up period was 3 years. Although none of the patients presented neurological deterioration after the injury, the degree of local kyphosis was increased at the time of final follow-up compared to what was observed at the time of injury. Patient age at the time of injury and concurrent vertical fracture of vertebral body could have been influencing factors for the progression of the kyphosis. While laminar fracture affected the kyphosis at the time of injury, it was not a strong influencing factor of the overall progression of local kyphosis.

Conclusions

The conservative option for the compressive-flexion cervical injury allowed us to treat without exacerbating neurological symptoms as long as the facet joints are preserved. However, in terms of cervical alignment, surgical stabilization may have been desirable for these patients. Notably, the younger patients and the patients with vertical fracture of the cervical vertebral column in this type of injury required closer observation to help prevent the progression of local kyphosis.

Prognostic factors and optimal management for patients with cervical spinal cord injury without major bone injury

BACKGROUND

Even though the number of patients with cervical spinal cord injury (CSCI) without major bone injury is increased, the treatment with either surgery or conservative measures remains controversial. The aim of this study was to assess its prognostic value in the prediction of useful motor recovery and to clarify whether the patients should be treated surgically are present.

METHODS

We reviewed 63 patients (conservative, n = 36; surgery, n = 27) with CSCI without major bone injury (Frankel A-C). Neurological examination using modified Frankel grade at admission and 6 months after injury and International Stoke Mandeville Games (ISMG) classification at subacute phase after injury, MRI findings including rate of spinal cord compression, extent of cord damage and type of signal intensity change were assessed.

RESULTS

Thirty-five of 63 patients were improved to walk at 6 months after injury. In multivariate analysis, rate of spinal cord compression, extent of cord damage and improvement of ISMG grade were associated with useful motor recovery. There was no difference in the neurological improvement between conservative and surgical groups. However, patients with spinal cord compression of ≥33.2% showed better motor recovery at 6 months post-injury after surgery than those treated conservatively. There was a positive correlation between the improvement of ISMG grade at subacute phase and Frankel grade at 6 months post-injury. It is difficult to obtain satisfactory surgical outcome for patients with Frankel A or B1 on admission and/or extensive spinal cord damage on T2-weighted image.

CONCLUSIONS

Conservative treatment is recommended for patients with CSCI without major bone injury. However, we also recommend surgical treatment to acquire walking ability for patients with spinal cord compression of ≥33.2% and low ISMG grade at subacute phase. Among such patients, careful consideration should be given to patients with Frankel A or B1 and/or extensive spinal cord damage on MRI.

Sequential neurological improvements after conservative treatment in patients with complete motor paralysis caused by cervical spinal cord injury without bone and disc injury

OBJECTIVE This study investigated neurological improvements after conservative treatment in patients with complete motor paralysis caused by acute cervical spinal cord injury (SCI) without bone and disc injury. METHODS This study was retrospective. The authors evaluated neurological outcomes after conservative treatment of 62 patients with complete motor paralysis caused by cervical SCI without bone and disc injury within 72 hours after trauma. The sequential changes in their American Spinal Injury Association Impairment Scale (AIS) grades were reviewed at follow-up 24-72 hours, 1 week, and 1, 3, and 6 months after treatment. RESULTS Of the 31 patients with a baseline AIS grade of A, 2 (6.5%) patients improved to grade B, 5 (16.1%) improved to grade C, and 2 (6.5%) improved to grade D by the 6-month follow-up. The 22 (71.0%) patients who remained at AIS grade A 1 month after injury showed no neurological improvement at the 6-month follow-up. Of the 31 patients with a baseline AIS grade of B, 12 (38.7%) patients showed at least a 1-grade improvement at the 1-month follow-up; 11 (35.5%) patients improved to grade C and 16 (51.6%) patients improved to grade D at the 6-month follow-up. CONCLUSIONS Even in patients with complete motor paralysis caused by cervical SCI without bone and disc injury within 72 hours after trauma, approximately 30% of the patients with an AIS grade of A and 85% of the patients with an AIS grade B improved neurologically after conservative treatment. It is very important to recognize the extent of neurological improvement possible with conservative treatment, even for severe complete motor paralysis.

Effects of Treatment of Cervical Spinal Cord Injury without Fracture and Dislocation in A Medium-to Long-Term Follow-Up Study

OBJECTIVES

The purpose of this study is to evaluate the clinical effects of cervical spinal cord injury without fracture and dislocation (CSCIWFD) treatment in a medium-to long-term follow-up study. The clinical treatment of CSCIWFD is also discussed.

METHODS

A consecutive series of 42 CSCIWFD patients with complete follow-up data were retrospectively analyzed. Among these patients, 9 received conservative treatment and 33 underwent surgical treatment from June 2009 to March 2013. Neurologic functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) scoring system and the Frankel grade on admission, during hospital discharge, and at final follow-up. The average follow-up time was 49.6 months (range, 36-68 months).

RESULTS

The 33 cases with surgical treatment showed significantly higher JOA scores at the final follow-up than those with conservative treatment. In addition, statistically significant differences were found in all of the follow-up visits between patients whose operations were performed within 7 days after injury and those performed after 7 days (P < 0.05). Early surgery promoted spinal cord recovery. However, JOA scores at 49.6 months postsurgery were not significantly different between patients treated via the anterior approach and those treated via the posterior approach (P > 0.05). On the basis of Frankel functional classification, differences were also significant between surgical treatment and conservative treatment at all of the follow-up visits.

CONCLUSIONS

Early surgical treatment for CSCIWFD can directly relieve spinal cord compression. The medium-to long-term follow-up revealed that surgery clearly promotes decompression.

The neurological outcome of radiotherapy versus surgery in patients with metastatic spinal cord compression presenting with myelopathy

PURPOSE

While radiotherapy is generally an acceptable treatment for metastatic spinal cord compression, surgical intervention is controversial due to the invasiveness and diversity of diseases in the patients being considered. The ideal treatment, therefore, depends on the situation, and the most acute treatment possible is necessary in patients presenting with myelopathy. We compared the neurological outcomes between radiotherapy and surgery in patients with metastatic spinal cord compression presenting with myelopathy.

METHODS

A total 54 patients with metastatic spinal cord compression presenting with myelopathy treated in our institution between 2006 and 2016 were analyzed retrospectively. Twenty patients were selected by radiotherapy alone (radiation group), and 36 patients were selected by decompression and stabilization surgery with or without radiotherapy (surgery group). The neurological outcomes and complications were compared between the two treatment groups.

RESULTS

Seven patients initially in the radiation group underwent surgery because of a substantial decline in their motor strength during radiotherapy. One of the remaining 13 patients (8%) in the radiation group and 30 of the 34 patients (88%) in the surgery group showed improvement in their neurological symptoms (P < 0.01). One patient (8%) in the radiation group and 21 patients (62%) in the surgery group were ambulatory after treatment (P < 0.01). There were no major complications related to radiotherapy, but surgery-related complications occurred in 9 of 34 (26%) patients, and 6 (18%) patients needed reoperation.

CONCLUSIONS

Surgical decompression and stabilization may be required to improve the neurological function in patients with metastatic spinal cord compression presenting with myelopathy. However, the high rate of complications associated with surgery should be taken into consideration.

Can the acute magnetic resonance imaging features reflect neurologic prognosis in patients with cervical spinal cord injury?

BACKGROUND CONTEXT

Several prognostic studies looked for an association between the degree of spinal cord injury (SCI), as depicted by primary magnetic resonance imaging (MRI) within 72 hours of injury, and neurologic outcome. It was not clearly demonstrated whether the MRI at any time correlates with neurologic prognosis.

PURPOSE

The purpose of the present study was to investigate the relationship between acute MRI features and neurologic prognosis, especially walking ability of patients with cervical spinal cord injury (CSCI). Moreover, at any point, MRI was clearly correlated with the patient's prognosis.

STUDY DESIGN

Retrospective image study.

PATIENT SAMPLE

From January 2010 to October 2015, 102 patients with CSCI were treated in our hospital. Patients who were admitted to our hospital within 3 days after injury were included in this study. The diagnosis was 78 patients for CSCI with no or minor bony injury and 24 patients for CSCI with fracture or dislocation. A total of 88 men and 14 women were recruited, and the mean patient age was 62.6 years (range, 16-86 years). Paralysis at the time of admission was graded as A in 32, B in 15, C in 42, and D in 13 patients on the basis of the American Spinal Injury Association (ASIA) impairment scale. Patients with CSCI with fracture or dislocation were treated with fixation surgery and those with CSCI with no or minor bony injury were treated conservatively. Patients were followed up for an average of 168 days (range, 25-496 days).

OUTCOME MEASURES

Neurologic evaluation was performed using the ASIA motor score and the modified Frankel grade at the time of admission and discharge.

METHODS

Magnetic resonance imaging was performed for all patients at admission. Using the MRI sagittal images, we measured the vertical diameter of intramedullary high-intensity changed area with T2-weighted images at the injured segment. We studied separately the patients divided into two groups: 0-1 day admission after injury, and 2-3 days admission after injury. We evaluated the relationship between the vertical diameter of T2 high-intensity changed area in MR images and neurologic outcome in these two groups. This study does not contain any conflict of interest.

RESULTS

In the group admitted at 0-1 day after injury, there was a relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, but correlation coefficient was low (0.3766 at admission and 0.4239 at discharge). On the other hand, in the group admitted at 2-3 days after injury, there was a significant relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, and correlation coefficient was very high (0.6840 at admission and 0.5293 at discharge). In the group admitted at 2-3 days after injury, a total of 17 patients (68%) recovered to walk with or without a cane. Receiver operating characteristic (ROC) curve analysis demonstrated that the optimal vertical diameter of T2 high-intensity area cutoffvalue for patients who were able to walk at discharge was 45.8 mm. If the vertical diameter of T2 high-intensity area cutoff value was 45 mm, there was a significant positive correlation with being able to walk at discharge (p<.0001).

CONCLUSIONS

From our study, 2-3 days after injury, a significant relationship was observed between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge. Zero to 1 day after injury, the relationship between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge was weak. Neurologic prognosis is more correlated with MRI after 2-3 days after the injury. If the vertical diameter of T2 high-intensity area was <45 mm, the patients were able to walk with or without a cane at discharge. T2 high-intensity changed area can reflect the neurologic prognosis in patients with CSCI.

Posterior short fusion without neural decompression using pedicle screws and spinous process plates: A simple and effective treatment for neurological deficits following osteoporotic vertebral collapse

BACKGROUND

The optimal treatment of neurological deficits following osteoporotic vertebral collapse (OVC) is controversial, owing to complications that result from fragile bone quality. In the present study, we assessed surgical results following posterior spinal fusion without decompression. We achieved stable fusion over a short segment of the spinal column using pedicle screws and spinous process plates, maximizing the use of the preserved posterior elements.

METHODS

We reviewed surgical data, perioperative complications, clinical outcomes, and radiographic data of 20 consecutively recruited patients with delayed neurological deficits following OVC, who experienced posterior short fusion without neural decompression. The average follow-up period was 24.3 months. The spine was typically stabilized with pedicle screws and spinous process plates from one level above to one level below the collapsed vertebrae, without using neural decompression or considerable correction of kyphosis.

RESULTS

All patients experienced relief from back pain and neurological improvements of at least one modified Frankel grade. Bone unions of the collapsed vertebrae were achieved in all patients, and spinal fusions of the instrumented segments were achieved in all but one patient. The mean loss of correction was 5.9°, and the average spinal canal compromise by bone fragments was 32.4% before surgery as against 26.0% at the final follow-up time point. Fractures in adjacent or upper instrumented vertebrae were observed in four cases (20%).

CONCLUSIONS

Rigid augmentation by spinous process plates and an enough bed for the bone grafts were available in patients with severe osteoporosis, without neural decompression. All patients had satisfactory neurological recovery regardless of the extent of spinal canal remodeling, demonstrating that dynamic factors are the primary contributor to neurological deficits following OVC.

Effects of brain‑derived neurotrophic factor and neurotrophin‑3 on the neuronal differentiation of rat adipose‑derived stem cells

Tissue engineering is a promising method that may be used to treat spinal cord injury (SCI). The underlying repair mechanism of tissue engineering involves the stable secretion of neurotrophins from seed cells, which eventually differentiate into neurons; therefore, the selection of appropriate seed cells, which stably secrete neurotrophins that easily differentiate into neurons requires investigation. Adipose‑derived stem cells (ADSCs), which are adult SCs, are advantageous due to convenience sampling and easy expansion; therefore, ADSCs are currently the most popular type of seed cell. Brain‑derived neurotrophic factor (BDNF) and neurotrophin‑3 (NT‑3) possess superior properties, when compared with other neurotrophic factors, in the maintenance of neuronal survival and promotion of SC differentiation into neurons. The present study used two lentiviruses, which specifically express BDNF and NT‑3 [Lenti‑BDNF‑green fluorescent protein (GFP), Lenti‑NT‑3‑red fluorescent protein (RFP)], to transfect third‑generation ADSCs. Three types of seed cell were obtained: i) Seed cells overexpressing BDNF (ADSC/Lenti‑BDNF‑GFP); ii) seed cells overexpressing NT‑3 (ADSC/Lenti‑NT‑3‑RFP); and iii) seed cells overexpressing BDNF and NT‑3 (ADSC/Lenti‑BDNF‑GFP and NT‑3‑RFP). The transfected cells were then induced to differentiate into neurons and were divided into a further four groups: i) The BDNF and NT‑3 co‑overexpression group; ii) the BDNF overexpression group; iii) the NT‑3 overexpression group; and iv) the control group, which consisted of untransfected ADSCs. The results of the present study demonstrate that BDNF and NT‑3 expression was higher 10 days after induction, as detected by reverse transcription‑quantitative polymerase chain reaction (RT‑qPCR) and western blotting. Neuron‑specific enolase is a neuronal marker, the expression of which was highest in the BDNF and NT‑3 co‑overexpression group, followed by the BDNF overexpression group and then by the NT‑3 overexpression group. The lowest expression levels of NSE were detected in the control group, as determined by RT‑qPCR, western blotting and immunofluorescent staining. These results indicate that BDNF and NT‑3 exert a synergistic effect, which may promote the neuronal differentiation of ADSCs. The present study provides a solid theoretical foundation for future experiments regarding the use of tissue engineering technology for the treatment of SCI.

Subacute T1-low intensity area reflects neurological prognosis for patients with cervical spinal cord injury without major bone injury

STUDY DESIGN

A retrospective imaging and clinical study.

OBJECTIVES

To evaluate the relationship between magnetic resonance imaging (MRI) features and neurological prognosis in patients with traumatic cervical spinal cord injury (CSCI) without major bone injury.

METHODS

A total of 72 patients with CSCI without major bone injury were treated conservatively in our hospital. MRI was performed for all patients at admission and 1 month following injury. We measured the antero-posterior and cranio-caudal diameter of intramedullary intensity changed area with T1-weighted images at the injured segment. Neurological evaluations were performed using the American Spinal Injury Association (ASIA) motor score and the modified Frankel grade at the time of admission and discharge.

RESULTS

There was a significant relationship between the antero-posterior diameter ratio of the T1-weighted low-intensity area on MRI at the subacute stage and the ASIA motor score. The optimal threshold of the T1-weighted low-intensity diameter ratio for predicting the patient's ability to walk with or without assistance at discharge was determined to be 46%. Moreover, 96.8% of the patients with <50% T1-weighted low-intensity area recovered to walk with or without a cane at discharge.

CONCLUSION

The T1-low intensity area may be an important predictive factor for the neurological recovery of CSCI without major bone injury.