Relapsing White Matter Disease and Subclinical Optic Neuropathy: From the National Multiple Sclerosis Society Case Conference Proceedings

A 16-year-old adolescent boy presented with recurrent episodes of weakness and numbness. Brain MRI demonstrated subcortical, juxtacortical, and periventricular white matter T2 hyperintensities with gadolinium enhancement. CSF was positive for oligoclonal bands that were not present in serum. Despite treatment with steroids, IV immunoglobulins, plasmapheresis, and rituximab, he continued to have episodes of weakness and numbness and new areas of T2 hyperintensity on imaging. Neuro-ophthalmologic examination revealed a subclinical optic neuropathy with predominant involvement of the papillomacular bundle. Genetic evaluation and brain biopsy led to an unexpected diagnosis.

Proximal junctional kyphosis following T10-pelvis fusion presenting with neurologic compromise: case presentations and review of the literature

Purpose: Proximal Junctional Kyphosis (PJK) is a well-documented phenomenon following spinal instrumented fusion. Myelopathy associated with proximal junctional failure (PJF) is poorly described in the literature. Adjacent segment disease, fracture above the upper instrumented vertebrae and subluxation may all cause cord compression, ambulatory dysfunction, and/or lower extremity weakness in the postoperative period.Materials and methods: We review the literature on PJK and PJF, and discusses the postoperative management of three patients who experienced myelopathy associated with PJF following T9/10 to pelvis fusion at a single institution.Results and conclusions: PJF with myelopathy must be diagnosed and surgically corrected early on so as to minimize permanent neurologic injury. Patients requiring significant sagittal deformity correction are at greater risk for PJF, and may benefit from constructs terminating in the upper thoracic spine.

Predictors of Neurological Outcome Following Subaxial Cervical Spine Trauma

Background The treatment of traumatic subaxial cervical spine injuries remains controversial. The American Spinal Injury Association (ASIA) impairment scale (AIS) is a widely-used metric to score neurological function after spinal cord injury (SCI). Here, we evaluated the outcomes of patients who underwent treatment of subaxial cervical spine injuries to identify predictors of neurologic function after injury and treatment. Methods We performed a retrospective logistic regression analysis to determine predictors of neurological outcome; 76 patients met the inclusion criteria and presented for a three-month follow-up. The mean age was 50.6±18.7 years old and the majority of patients were male (n=49, 64%). Results The majority of patients had stable AIS scores at three months (n=56, 74%). A subset of patients showed improvement at three months (n=16, 21%), while a small subset of patients had neurological decline at three months (n=4, 5%). In our model, increasing patient age (odds ratio [OR] 1.39, 1.10-2.61 95% confidence interval [CI], P<0.001) and a previous or current diagnosis of cancer (OR 22.4, 1.25-820 95% CI, P=0.04) significantly increased the odds of neurological decline at three months. In patients treated surgically, we found that delay in surgical treatment (>24 hours) was associated with a decreased odds of neurological improvement (OR 0.24, 0.05-0.99 95% CI, P=0.048). Cervical spine injuries are heterogeneous and difficult to manage. Conclusion We found that increasing patient age and an oncologic history were associated with neurological deterioration while a delay in surgical treatment was associated with decreased odds of improvement. These predictors of outcome may be used to guide prognosis and treatment decisions.

Predictors of Failure of Nonoperative Management Following Subaxial Spine Trauma and Creation of Modified Subaxial Injury Classification System

BACKGROUND

Subaxial cervical spine injuries may be treated with either nonoperative stabilization or surgical fixation. The subaxial injury classification (SLIC) provides 1 method for suggesting the degree of necessity for surgery. In the current study, we examined if the SLIC score, or other preoperative metrics, can predict failure of nonoperative management.

METHODS

We performed a retrospective chart review to identify patients who presented with acute, nonpenetrating, subaxial cervical spine injury within our health system between 2007 and 2016. Patient demographics, medical comorbidities, injuries, and treatments were collected. Logistic regression analysis was used to determine potential predictors of failure of nonoperative management.

RESULTS

During the study period, 40 patients met the inclusion criteria. A small subset of patients failed nonoperative management (n = 5, 12.5%). The mean SLIC score was 3.9 ± 1.9; however, 14 (35%) patients had scores >4. Neither total SLIC score (P = 0.68) nor SLIC subscores (morphology [P = 0.96], discoligamentous complex [P = 0.83], neurologic status [P = 0.60]) predicted failure of nonoperative treatment. Time to evaluation/treatment did predict failure of nonoperative management. Evaluation within 8 hours of injury was a negative predictor of failure (odds ratio = 0.03, P = 0.001) and evaluation 24 hours or more after injury was a positive predictor of failure (odds ratio = 66.00, P < 0.001). We created a modified SLIC score on the basis of these findings, which significantly predicted failure of nonoperative management (P = 0.044).

CONCLUSIONS

Management of subaxial spine injuries is complex. In our cohort, SLIC scoring did not adequately predict odds of failure of nonoperative management. Time to evaluation, however, did. We created a modified SLIC score that significantly predicted failure of nonoperative management.