Risk Factors for Poor Prognosis of Cervical Spinal Cord Injury with Subaxial Cervical Spine Fracture-Dislocation After Surgical Treatment: A CONSORT Study

Open Reduction in Traumatic Cervical Facet Dislocation Does Not Delay Time to Treatment

Background Cervical facet dislocation is a serious injury that can result in permanent neurologic damage. Current guidelines recommend immediate closed reduction of cervical dislocations, though the efficacy of this practice remains a debate. This study aims to evaluate whether immediate open reduction and fixation of cervical dislocations offer equal or better outcomes for patients and limit the need for follow-up operations. Methods This is a retrospective study including patients who presented to the emergency department of a single institution from 2008 to 2023 with cervical facet dislocation. Patients were divided into groups based on initial treatment: either open or closed reduction. Time to surgery was calculated as the time between arrival to the ED and incision time in the OR. Primary outcomes were improvement in motor and sensory deficits at six-week post-operative follow-up. Results There were 31 patients who met the inclusion criteria. Time to treatment did not differ significantly between the open versus closed reduction groups. There were no differences between groups in improvement in motor function, sensory function, or pain at the six-week follow-up. All patients treated with initial closed reduction ultimately required surgical stabilization. Conclusions Open reduction as a first-line treatment did not increase the time to treatment for patients with cervical facet dislocations. Patients had equivalent functional outcomes in both treatment groups. The findings suggest that current practice guidelines may delay definitive treatment without improving patient safety or outcomes.

Spinal Cord Transcutaneous Stimulation in Cervical Spinal Cord Injury: A Review Examining Upper Extremity Neuromotor Control, Recovery Mechanisms, and Future Directions

Cervical spinal cord injury (SCI) results in significant sensorimotor impairments below the injury level, notably in the upper extremities (UEs), impacting daily activities and quality of life. Regaining UE function remains the top priority for individuals post-cervical SCI. Recent advances in understanding adaptive plasticity within the sensorimotor system have led to the development of novel non-invasive neurostimulation strategies, such as spinal cord transcutaneous stimulation (scTS), to facilitate UE motor recovery after SCI. This comprehensive review investigates the neuromotor control of UE, the typical recovery trajectories following SCI, and the therapeutic potential of scTS to enhance UE motor function in individuals with cervical SCI. Although limited in number with smaller sample sizes, the included research articles consistently suggest that scTS, when combined with task-specific training, improves voluntary control of arm and hand function and sensation. Further, the reported improvements translate to the recovery of various UE functional tasks and positively impact the quality of life in individuals with cervical SCI. Several methodological limitations, including stimulation site selection and parameters, training strategies, and sensitive outcome measures, require further advancements to allow successful translation of scTS from research to clinical settings. This review also summarizes the current literature and proposes future directions to support establishing approaches for scTS as a viable neuro-rehabilitative tool.

Effects of early surgery for cervical fracture dislocation on 30-day mortality using the Japanese Diagnosis Procedure Combination database

STUDY DESIGN

Retrospective study of data abstracted from the Diagnosis Procedure Combination (DPC) database.

PURPOSE

This study aimed to investigate the effects of surgery in the early phase.

OVERVIEW OF LITERATURE

The optimal timing of surgery for cervical fracture dislocation (CFD) remains unclear because only a few clinical studies with approximately 100 patients have been published.

METHODS

This study included 4,653 adult patients with a definitive diagnosis of CFD from the DPC database. The database contains nationwide inpatient data collected from >1,000 acute care hospitals in Japan. The DPC database contains information regarding hospitalization, such as diagnosis, treatment, medical history, complications, and hospitalization outcomes. This study identified 460 pairs of patients after one-to-one propensity-score matching (PSM). Treatment outcomes were compared between patients who underwent surgery for CFD within 72 hours (early group) and later (delayed group) after admission. The main outcomes included 30-day mortality, inhospital death, and major complications. The secondary outcomes were improvement in the Barthel index, length of hospital stay, and discharged home rate.

RESULTS

After adjusting for PSM, the early group had a significantly higher 30-day mortality rates than the delayed group (3.0% vs. 0.4%, p=0.006). In the multivariate logistic regression analysis after PSM, the early group was associated with an increased risk of 30-day mortality (odds ratio, 8.05; 95% confidence interval, 2.15-5.26; p=0.007).

CONCLUSIONS

This study indicated that early surgery for CFD resulted in increased 30-day mortality.

Guidelines for neuroprognostication in adults with traumatic spinal cord injury

BACKGROUND

Traumatic spinal cord injury (tSCI) impacts patients and their families acutely and often for the long term. The ability of clinicians to share prognostic information about mortality and functional outcomes allows patients and their surrogates to engage in decision-making and plan for the future. These guidelines provide recommendations on the reliability of acute-phase clinical predictors to inform neuroprognostication and guide clinicians in counseling adult patients with tSCI or their surrogates.

METHODS

A narrative systematic review was completed using Grading of Recommendations Assessment, Development, and Evaluation methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of an appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Timing/Setting question was framed as "When counseling patients or surrogates of critically ill patients with traumatic spinal cord injury, should < predictor, with time of assessment if appropriate > be considered a reliable predictor of < outcome, with time frame of assessment >?" Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four Grading of Recommendations Assessment, Development, and Evaluation criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. Good practice recommendations addressed essential principles of neuroprognostication that could not be framed in the Population/Intervention/Comparator/Outcome/Timing/Setting format. Throughout the guideline development process, an individual living with tSCI provided perspective on patient-centered priorities.

RESULTS

Six candidate clinical variables and one prediction model were selected. Out of 11,132 articles screened, 369 met inclusion criteria for full-text review and 35 articles met eligibility criteria to guide recommendations. We recommend pathologic findings on magnetic resonance imaging, neurological level of injury, and severity of injury as moderately reliable predictors of American Spinal Cord Injury Impairment Scale improvement and the Dutch Clinical Prediction Rule as a moderately reliable prediction model of independent ambulation at 1 year after injury. No other reliable or moderately reliable predictors of mortality or functional outcome were identified. Good practice recommendations include considering the complete clinical condition as opposed to a single variable and communicating the challenges of likely functional deficits as well as potential for improvement and for long-term quality of life with SCI-related deficits to patients and surrogates.

CONCLUSIONS

These guidelines provide recommendations about the reliability of acute-phase predictors of mortality, functional outcome, American Spinal Injury Association Impairment Scale grade conversion, and recovery of independent ambulation for consideration when counseling patients with tSCI or their surrogates and suggest broad principles of neuroprognostication in this context.

Extreme dislocation of the cervical spine-case report

We present the case of rare extreme dislocation of subaxial cervical spine, which was challenging regarding type and time of surgery. A 22-year-old patient was injured in a traffic accident, from very beginning with signs of spinal shock. Severe traumatic C6/C7 dislocation with resulting transection of the spinal cord was diagnosed with MDCT imaging. The main dilemmas regarding the surgical treatment of this injury referred to the timing of surgery and the choice of surgical approach. We decided to perform posterior surgery at first stage. Postoperative her condition get worsening and on the 16th postoperative day came to the fatal outcome. Despite all the available protocols, in our case, the decision had to be made on the basis of individual multidisciplinary assessment, bearing in mind the mechanism of the injury and the clinical presentation of the injured patient.

Did the Covid-19 Pandemic Impact Time to Surgery, Length of Hospital Stay, or Discharge Location for Subaxial Cervical Spine Fractures Requiring Surgical Intervention?

Background

The COVID-19 pandemic disrupted healthcare systems across the United States resources were consumed caring for COVID-19 patients. Past research on trauma activations during COVID-19 has found changes to hospital length of stay and discharge locations. Subaxial spine fractures are potentially debilitating injuries that require timely surgery and extensive rehabilitation. Accordingly, the objective of this study was to compare the severity of cervical spine injuries, time to surgery, hospital length of stay, and discharge disposition for patients presenting during COVID-19.

Methods

128 patients with subaxial fractures from a Level One Adult Trauma Center that required surgical intervention were reviewed. The primary outcomes included hospital length of stay, ICU days, time to surgery, complications, and discharge location in patients with subaxial cervical fractures during COVID-19 pandemic versus immediately before the pandemic.

Results

When comparing the pre-COVID-19 period to the COVID-19 group, there was no difference in time to surgery or overall length of stay (2.47 vs. 2.35 days and 12.93 vs. 13.82 days, p>0.05). There was no difference in number of patients discharged home during COVID-19 (41% (32/79) vs. 37% (18/49) p>0.05) or patients discharged to hospital rehab (33%, (26/79) vs. 35% (17/49), p>0.05). A similar percentage of patients had complications within 90 days of discharge (16% (12/75) vs. 22% (10/46), p>0.05).

Conclusion

Despite the burden COVID-19 placed on healthcare systems, it did not affect post-operative hospital course of subaxial fracture patients with potentially debilitating injuries. This vulnerable subset of patients presenting during COVID-19 was still able to undergo timely surgery, have an appropriate hospital length of stay, and be discharged to rehabilitation centers. In future stresses to the healthcare system, deferring elective and non-emergent procedures can allow proper care for emergencies such as subaxial fractures. Level of Evidence: II.

Timing of Surgery and Pre-operative Physiological Parameters as Clinical Predictors of Surgical Outcomes in Traumatic Subaxial Cervical Spine Fractures and Dislocations

Objective  To evaluate the risk factors and outcomes in patients surgically treated for subaxial cervical spine injuries with respect of the timing of surgery and preoperative physiological parameters of the patient. Methods  26 patients with sub-axial cervical spine fractures and dislocations were enrolled. Demographic data of patients, appropriate radiological investigation, and physiological parameters like respiratory rate, blood pressure, heart rate, PaO2 and ASIA impairment scale were documented. They were divided pre-operatively into 2 groups. Group U with patients having abnormal physiological parameters and Group S including patients having physiological parameters within normal range. They were further subdivided into early and late groups according to the timing of surgery as U early , U late, S early and S late . All the patients were called for follow-up at 1, 6 and 12 months. Results  56 percent of patients in Group S had neurological improvement by one ASIA grade and a good outcome irrespective of the timing of surgery. Patients in Group U having unstable physiological parameters and undergoing early surgical intervention had poor outcomes. Conclusion  This study concludes that early surgical intervention in physiologically unstable patients had a strong association as a risk factor in the final outcome of the patients in terms of mortality and morbidity. Also, no positive association of improvement in physiologically stable patients with respect to the timing of surgery could be established.

A Silver Lining of Neuropathic Pain: Predicting Favorable Functional Outcome in Spinal Cord Injury

Background

Neuropathic pain (NP) is a common and severe problem following spinal cord injury (SCI). However, its relationship with functional outcome remains unclear.

Methods

A retrospective explorative analysis was performed on SCI patients admitted to a tertiary academic medical center between January 2018 and June 2022. The candidate predictor variables, including demographics, clinical characteristics and complications, were analyzed with logistic and linear regression. Spinal Cord Independence Measure (SCIM) scores at discharge and mean relative functional gain (mRFG) of SCIM were as outcome parameters.

Results

A total of 140 SCI patients included for the final analysis. Among them, 44 (31.43%) patients were tetraplegics, and 96 (68.57%) patients were paraplegics; 68 (48.57%) patients developed NP, and 72 (51.43%) patients did not. Logistic and linear regression analyses of SCIM at discharge both showed that NP [OR=3.10, 95% CI (1.29,7.45), P=0.01; unstandardized β=11.47, 95% CI (4.95,17.99), P<0.01; respectively] was significantly independent predictors for a favorable outcome (SCIM at discharge ≥ 50, logistic regression results) and higher SCIM total score at discharge (linear regression results). Besides, NP [unstandardized β=15.67, 95% CI (8.94,22.41), P<0.01] was also independently associated with higher mRFG of SCIM scores. Furthermore, the NP group had significantly higher mRFG, SCIM total scores and subscales (self-care, respiration and sphincter management, and mobility) at discharge compared to the non-NP group. However, there were no significant differences in mRFG, SCIM total score or subscales at discharge among the NP subgroups in terms of locations (at level pain, below level pain, and both) or timing of occurrence (within and after one month after SCI). This study also showed that incomplete injury, lumbar-sacral injury level and non-anemia were significantly independent predictors for a favorable outcome, and higher mRFG of SCIM scores (except for non-anemia).

Conclusion

NP appears independently associated with better functional recovery in SCI patients, suggesting the bright side of this undesirable complication. These findings may help to alleviate the psychological burden of NP patients and ultimately restore their confidence in rehabilitation.

Risk Factors for Poor Prognosis of Spinal Cord Injury without Radiographic Abnormality Associated with Cervical Ossification of the Posterior Longitudinal Ligament

Purpose

To investigate the factors associated with the prognosis of spinal cord injury without radiographic abnormality (SCIWORA) accompanied by cervical ossification of the posterior longitudinal ligament (C-OPLL).

Methods

We retrospectively investigated 287 patients with SCIWORA associated with C-OPLL, who were admitted within 30 days after trauma to our facility between August 2014 and August 2018. All patients were divided into the good or poor prognosis group. Patient demographics were analyzed. Besides, occupying ratio on CT and spinal cord high signal changes in MRI T2WI were measured and recorded. Multivariate linear regression was applied to analyze the correlation of prognosis with spinal cord high signal changes in MRI T2WI, cause of injury, and occupying ratio.

Results

Occupying ratio of ossification mass was 43.5 ± 10.7% in the poor prognosis group and 27.3 ± 7.7% in the good prognosis group. The occurrence rate of high signal changes in MRI T2WI was 84.2% in the poor prognosis group and 41.3% in the good prognosis group. Poor prognosis was correlated with high occupying ratio and spinal cord high signal changes in MRI T2WI. In the patient with SCIWORA associated with C-OPLL, ROC curve of occupying ratio showed 30% as a predictor for the poor prognosis. Among the 92 patients with occupying ratio ≤ 30%, poor prognosis was observed in 5 cases (5.4%), whereas in the 72 cases with occupying ratio > 30%, poor prognosis was seen in 33 cases (45.8%). Postoperative AIS grade at final follow-up in occupying ratio > 30% group was significantly worse.

Conclusions

Patients suffering from SCIWORA with C-OPLL have poor prognosis when they have higher occupying ratio of ossification mass and spinal cord high signal changes in MRI T2WI. The cut-off value of occupying ratio for predicting the poor prognosis was 30% in patients with SCIWORA associated with C-OPLL.

Admission Prevalence and Risk Factors of Deep Vein Thrombosis in Patients with Spinal Cord Injury Complicated with Cervical Fractures

The purpose of this study was to investigate the prevalence of deep vein thrombosis (DVT) and to clarify the risk factors of DVT in patients with acute spinal cord injury (SCI) complicated with cervical fractures at admission. From January 2018 to December 2021, a total of 175 patients with acute SCI complicated with cervical fractures in our hospital were retrospectively analyzed. Duplex ultrasound was used to diagnose the DVT. All patients' medical record data, including demographic variables, medical history, and laboratory results, were collected. The patients were divided into DVT group and non-DVT group according to ultrasound results. The prevalence of DVT was determined and risk factors of DVT were identified. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic value of different factors. The prevalence of DVT at admission was 21.71%(38/175), including one (2.63%) with central DVT, thirty-two (84.21%) with peripheral DVT and five (13.16%) with mixed DVT. The multivariate analysis revealed that decreased lower extremity muscle strength, time from injury to admission, and D-dimer were risk factors for DVT at admission. The diagnostic value of D-dimer was the highest among these risk factors. In conclusion, in patients with acute SCI complicated with cervical fractures, the risk of DVT at admission is very high. Decreased lower extremity muscle strength, time from injury to admission, and D-dimer are risk factors for DVT. Moreover, D-dimer has the highest diagnostic value among these risk factors.

Traumatic cervical spine injury: Short-and medium-term prognostic factors in 102 patients

Background:

Traumatic cervical spine injuries (CSIs) can be defined as osteodiscoligamentous lesions and are frequent in the young and active population. These lesions are often associated with significant devastating neurological deficits. Here, we sought to establish short-and medium-term prognostic factors that could help predict future outcomes.

Methods:

We retrospectively reviewed 102 adults admitted for traumatic CSI over an 11-year period (January 2004–December 2014). Patients were graded using Frankel scale as exhibiting good or poor outcomes.

Results:

Two risk factors that significantly predicted results for CSI included original poor Frankel grades (e.g., A and B) and initial neurovegetative disorders (e.g., respectively, P = 0.019 and P = 0.001). However, we did not anticipate that two other risk factors, operative delay and mechanism of trauma, would not significantly adversely impact outcomes.

Conclusion:

Here, we identified two significant risk factors for predicting poor outcomes following CSI; poor initial Frankel Grades A and B and neurovegetative disorders at the time of original presentation.