Category Archives: Spine

Update: Spinal instrumentation infection

Spinal instrumentation infection

Instrumentation has become an integral component in the management of various spinal disorders. The rate of infection varies from 2% to 20% of all instrumented spinal procedures.

Surgical site infection (SSI) in the spine is a serious postoperative complication. Factors such as posterior surgical approach, arthrodesis, use of spinal instrumentation, age, obesity, diabetes, tobacco use, operating-room environment and estimated blood loss are well established in the literature to affect the risk of infection 1).

Diagnosis

There are multiple risk factors for postoperative spinal infections. Infections in the setting of instrumentation are more difficult to diagnose and treat due to biofilm. Infections may be early or delayed. C Reactive Protein (CRP) and Magnetic Resonance Imaging (MRI) are important diagnostic tools. 2).


Blood specimens were obtained from patients who underwent posterior decompression, instrumentation with pedicular screws, and posterolateral fusion from June 2009 to January 2011. CRP and ESR levels were measured on the day before surgery and on postoperative days 1, 3, 7, 11, 14, 28, and 42.

Mean CRP levels peaked on the third day postoperatively in all groups. By day 7 postoperatively, it had dropped rapidly. At the 14th and 28th postoperative days, decreases to normal CRP levels were found in 16% and 80% of all patients, respectively. The pattern of decline in CRP was similar among groups. Values of ESR increased and peaked between the third and seventh postoperative days. ESR values gradually decreased. At the 42 day postoperatively, ESR level still remain above normal values in all groups 3).


MRI is a useful tool for the early diagnosis of a deep SSI. However, the diagnosis is frequently difficult with feverish patients with clear wounds after posterior spinal instrumentation (PSI) because of artifacts from the metallic implants. There are no reports on MRI findings that are specific to a deep SSI after PSI.

Kimura et al. found that fluid collection outside the head of the PS on an axial MRI scan (PS fluid sign) strongly suggested the possibility of an abscess.

The SSI group comprised 17 patients with a deep SSI after posterior lumbar spinal instrumentation who had undergone an MRI examination at the onset of the SSI. The non-SSI group comprised 64 patients who had undergone posterior lumbar spinal instrumentation who did not develop an SSI and had an MRI examination within 4 weeks after surgery. The frequency of a positive PS fluid sign was compared between both groups.

The PS fluid sign had a sensitivity of 88.2%, specificity of 89.1%, positive predictive value of 68.1%, and negative predictive value of 96.6%. The 2 patients with a false-negative PS fluid sign in the SSI group had an infection at the disk into which the interbody cage had been inserted. Three of the 7 patients with a false-positive PS fluid sign in the non-SSI group had a dural tear during surgery.

The PS fluid sign is a valuable tool for the early diagnosis of a deep SSI. The PS fluid sign is especially useful for diagnosing a deep SSI in difficult cases, such as feverish patients without wound discharge 4).

Treatment

Optimal results are obtained with surgical debridement followed by parenteral antibiotics.

Until today the role of spinal instrumentation in the presence of a wound infection has been widely discussed and recently many authors leave the hardware in place with appropriate antibiotic therapy 5).

Removal or replacement of hardware should be considered in delayed infections.

An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight in the pathogenesis and management of infected spinal implants. It is important to accurately identify and treat postoperative spinal infections. The treatment is often multimodal and prolonged 6).

Evidence based medicine

In a study, from the Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, USA evidence based medicine was used to assess optimal surgical and medical management of patients with post-operative deep wound infection following spinal instrumentation. A computerized literature search of the PubMed database was performed. Twenty pertinent studies were identified. Studies were separated into publications addressing instrumentation retention versus removal and publications addressing antibiotic therapy regimen. The findings were classified based on level of evidence (I-III) and findings were summarized into evidentiary tables.

No level of evidence 1 or level of evidence 2 was identified. With regards to surgical management, five studies support instrumentation retention in the setting of early deep infection. In contrast, for delayed infection, the evidence favors removal of instrumentation at the time of initial debridement. Surgeons should be aware that for deformity patients, even if solid fusion is observed, removal of instrumentation may be associated with significant loss of correction. A course of intravenous antibiotics followed by long-term oral suppressive therapy should be pursued if instrumentation is retained. A shorter treatment course may be appropriate if hardware is removed 7).


The objective of a study was to investigate the morbidity and mortality associated with instrumented fusion in the setting of primary spinal infection.

A search was performed in the PubMed and Medline databases for clinical case series describing instrumented fusion in the setting of primary spinal infection between 2003 and 2013. The search was limited to the English language and case series including at least 20 patients. The primary outcome measure was postoperative infection (recurrent local infection) + surgical site infection (SSI); secondary outcome measures included reoperation rates, development of other complications, and perioperative mortality.

There were 26 publications that met the inclusion criteria, representing 931 patients with spondylodiscitis who underwent decompression, debridement, and instrumented fusion. Spinal infections occurred most commonly in the lumbosacral spine (39.1%) followed by the thoracic spine (27.1%). The most common microorganisms were Staphylococcus spp. After decompression, debridement, and instrumented fusion, the overall rate of postoperative infection was 6.3% (1.6% recurrent infection rate + 4.7% SSI rate). The perioperative complication rate was 15.4%, and the mortality rate was estimated at 2.3%. Reoperation for wound debridement, instrumentation removal, pseudoarthrosis, and/or progressive neurological deficit was performed in 4.5% of patients.

The findings in this literature review suggest that the addition of instrumentation in the setting of a primary spinal infection has a low local recurrent infection rate (1.6%). However, the combined risk of postoperative infection is 6.3% (recurrent infection + SSI), more than three-fold the current infection rate following instrumentation procedures for degenerative spine disease. Moreover, the addition of hardware does usher in complications such as instrumentation failure and pseudoarthrosis requiring reoperation 8).

Case series

2017

A retrospective, cohort study of 84 patients with deep spine infection managed at a major tertiary hospital over 14 years with a minimum follow up of 2 years.

It is often believed that implants should not be inserted in patients with deep spine infection because of the risk of persistent or recurrent infection. However, there are often concerns about spinal stability and a paucity of evidence to guide clinical practice in this field.

Dennis et al. compared the mortality, reoperation, and reinfection rates in patients with spine infection treated with antibiotics alone, antibiotics with debridement, and antibiotics with debridement and instrumentation. Significant outcome predictors were determined using multivariable logistic regression model.

Forty-nine males and 35 females with a mean age was 62.0 years had spine infection affecting the lumbar spine predominantly. The most common form of infection was osteomyelitis and spondylodiscitis (69.4%). Staphylococcus aureus was the most common causative organism (61.2%).There was no difference in terms of reoperation or relapse for patients treated with antibiotics alone, antibiotics with debridement, or antibiotics with debridement and instrumentation. However, compared with antibiotics alone, the crude inhospital mortality was lower for patients treated with instrumentation (odds ratio, OR, 0.82; P = 0.01), and antibiotics with debridement (OR 0.80; P = 0.02).

Spinal instrumentation in an infected spine is safe and not associated with higher reoperation or relapse rates. Mortality is lower for patients treated with instrumentation 9).


A retrospective review of patients with MRSE-related SSIs from 665 consecutive cases of SI surgery performed between 2007 and 2014

During the study period, SSIs occurred in 21 patients. MRSE was isolated from cultures obtained from surgical wounds in nine of the 21 patients (43%). There were four males and five females with a mean age of 63.9 ± 15.1 years. Six patients presented with inflammatory signs, such as wound drainage, pyrexia, erythema, and elevated C-reactive protein. Three patients did not have signs of infection, but had early implant failure, and were diagnosed by positive cultures collected at the time of revision surgery. The mean time from index surgery to the diagnosis of infection was 23.6 days (range, 7-88 days). In one patient, the implant was removed before antibiotic treatment was administered because of implant failure. Eight patients were managed with antibiotics and implant retention. During the follow-up period, MRSE-related SSIs in seven of the eight patients were resolved with implant retention and antibiotics without the need for further surgical intervention. One patient did not complete the antibiotic course because of side effects, and implant removal was required to control the infection.

Early detection, surgical debridement, and administration of appropriate antibiotics for a suitable duration enabled infection control without the need for implant removal in the treatment of MRSE-related SSI after SI surgery 10).


Eleven patients with SSI after undergoing spinal surgery involving instrumentation were studied. All had been refractory to conventional treatments, including intravenous antibiotic administration and conventional debridement and irrigation. Antibiotic-loaded bone cement was placed on and around the instrumentation to cover them and to occupy the surrounding dead space. Two general types of antibiotics were loaded into the polymethylmethacrylate bone cement. The recipes for the mixture were changed depending on the bacterial cultures. Sensitive antibiotics were administered generally for 2-6 weeks until the C-reactive protein level was normalized.

All patients were treated successfully using antibiotic-loaded bone cement. Only 1 patient needed a repeat of this procedure to treat an infection. Antibiotic-loaded bone cement was placed in situ in all patients during the follow-up period and there were no significant adverse events.

Antibiotic-loaded bone cement treatment reduces the dead space and achieves the targeted drug delivery simultaneously. Treatment using antibiotic-loaded bone cement is an effective treatment option for complex spinal SSI 11).


Between 2010 and 2015, 12 out of 514 patients who developed a deep infection after spinal surgery, were selected and reviewed retrospectively at multiple centers (MGM Hospital, Kamothe and Center for Orthopaedic & Spine Surgery, New Panvel, Navi Mumbai, India). Out of 12 patients, one of the patients needed a partial implant exchange although none of the cases needed complete implant removal. All patients had achieved clean closed wounds along with a retention of the instrumentation. There was no need for flap surgery to cover wound defect in any case. However, antibiotic treatment was necessary in all cases. None of the patients showed a new infection after the treatment.

The study demonstrates the usefulness of VAC therapy as an alternative management for wound conditioning of a back wound with the high complexity in nature after instrumented spine surgeries as it eliminates complex secondary surgeries, prolong use of antibiotics and removal of the implants 12).

2015

A retrospective database review of consecutive patients with traditional open lumbar spinal surgery was performed. SSIs patients were identified and reviewed for clinically relevant details, and postoperative SSIs’ incidence was calculated for the entire cohort as well as for subgroups with or without spinal implants. In 15 years, 1,176 patients underwent open lumbar spinal surgery with spinal implants and 699 without. Thirty-eight developed postoperative SSIs. Total SSI rate for the entire group was 2.03%. The incidence of postoperative SSIs in the nonimplant group was relatively low. Patients received antibiotics, hyperbaric oxygen therapy, and wet dressing.

Liu et al. provided the precise rates of postoperative SSIs in traditional open spinal surgery obtained from a single-centre data. Patients with spinal implants had higher SSIs’ incidence than those without 13).

2014

Thirty-six patients underwent only decompression, and 82 underwent decompression and instrumented fusion. In the decompression-only group, 8.33% of patients had continued osteomyelitis/discitis compared with 9.76% of patients in the instrumented group (P = 0.807). Importantly, the reoperation rate was also similar between the decompression-only group (19.44%) and the instrumented group (17.07%; P = 0.756). Similarly, subanalyses based on infection location revealed no significant increase in rates of recurrent infection or reoperation in patients who underwent instrumentation 14).


Patients who received just decompression for spinal infection had similar reoperation and continued infection rates as patients who additionally underwent instrumentation, irrespective of infection location within the spine. These findings suggest that instrumentation of the infected spine may be a safe treatment modality and should be considered when the spinal integrity is compromised 15).

2008

A 10-year retrospective audit. (1) The incidence of infection; (2) causative organisms; (3) whether eradication of infection is achievable with spinal implant retention; (4) patient outcome. The reported incidence of infection following posterior spinal instrumentation is between 2.6 and 3.8%. Management of infection is controversial, with some advocating serial wound debridement while others report that infection cannot be eradicated with retention of implants. There are no published data demonstrating that propionibacteria are associated with early postoperative infection. The management of infected cases at our institution includes eventual removal of their implants. Our population was identified by studying the case notes of all patients who had undergone removal of spinal implants and cross-referencing this population with positive microbiology or histology reports. The incidence of infection was 3.7%. Propionibacteria were isolated in 45% of cases. The diagnosis of infection was unexpected in 25% of patients, following removal of implants for prominence of implants or back pain. Sixty per cent of patients with acute postoperative deep wound infection had continuing active infection on subsequent removal of implants, despite long-term antibiotics and wound debridement. Fourty-six per cent of patients had a stable, pain-free spine at the end of their treatment. This is the largest reported series of infections following posterior spinal instrumented fusions of which we are aware. Propionibacteria are a common cause of infection and successful eradication of infection cannot be reliably achieved with antibiotics and wound debridement alone 16).

1997

Twenty-three of 238 patients (9.7%) developed wound infections following segmental spinal instrumentation. When the infected group and a matched control group were compared, the infected group had a significantly higher number of patients with cerebral palsy and myelodysplasia (nonambulatory), patients with wound hematomas, patients with fusions that extended into the sacral region, and patients who were incontinent of urine. A high incidence of infections with gram-negative aerobic bacilli correlated with the extension of the surgery into the sacral region and bowel and/or bladder incontinence. Prophylactic antibiotics with broader coverage for gram-negative bacilli may be warranted for these procedures. Postoperative wound infections were managed by surgical drainage and debridement as well as antibiotics. Removal of the hardware was not necessary to control the infection in these patients who underwent segmental spinal instrumentation 17).

1)

Gerometta A, Rodriguez Olaverri JC, Bitan F. Infections in spinal instrumentation. Int Orthop. 2012 Feb;36(2):457-64. doi: 10.1007/s00264-011-1426-0. Epub 2012 Jan 5. Review. PubMed PMID: 22218913; PubMed Central PMCID: PMC3282865.

2) , 6)

Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int. 2013 Oct 29;4(Suppl 5):S392-403. doi: 10.4103/2152-7806.120783. eCollection 2013. PubMed PMID: 24340238; PubMed Central PMCID: PMC3841941.

3)

Kunakornsawat S, Tungsiripat R, Putthiwara D, Piyakulkaew C, Pluemvitayaporn T, Pruttikul P, Kittithamvongs P. Postoperative Kinetics of C-Reactive Protein and Erythrocyte Sediment Rate in One-, Two-, and Multilevel Posterior Spinal Decompressions and Instrumentations. Global Spine J. 2017 Aug;7(5):448-451. doi: 10.1177/2192568217699389. Epub 2017 Apr 11. PubMed PMID: 28811989; PubMed Central PMCID: PMC5544159.

4)

Kimura H, Shikata J, Odate S, Soeda T. Pedicle Screw Fluid Sign: An Indication on Magnetic Resonance Imaging of a Deep Infection After Posterior Spinal Instrumentation. Clin Spine Surg. 2017 May;30(4):169-175. doi: 10.1097/BSD.0000000000000040. PubMed PMID: 28437330.

5)

Dobran M, Mancini F, Nasi D, Scerrati M. A case of deep infection after instrumentation in dorsal spinal surgery: the management with antibiotics and negative wound pressure without removal of fixation. BMJ Case Rep. 2017 Jul 28;2017. pii: bcr-2017-220792. doi: 10.1136/bcr-2017-220792. PubMed PMID: 28756380.

7)

Lall RR, Wong AP, Lall RR, Lawton CD, Smith ZA, Dahdaleh NS. Evidence-based management of deep wound infection after spinal instrumentation. J Clin Neurosci. 2015 Feb;22(2):238-42. doi: 10.1016/j.jocn.2014.07.010. Epub 2014 Oct 11. Review. PubMed PMID: 25308619.

8)

DE LA Garza-Ramos R, Bydon M, Macki M, Abt NB, Rhee J, Gokaslan ZL, Bydon A. Instrumented fusion in the setting of primary spinal infection. J Neurosurg Sci. 2017 Feb;61(1):64-76. Epub 2015 Apr 15. Review. PubMed PMID: 25875732.

9)

Dennis Hey HW, Nathaniel Ng LW, Tan CS, Fisher D, Vasudevan A, Liu KG, Thambiah JS, Kumar N, Lau LL, Wong HK, Tambyah PA. Spinal Implants Can Be Inserted in Patients With Deep Spine Infection: Results From a Large Cohort Study. Spine (Phila Pa 1976). 2017 Apr 15;42(8):E490-E495. doi: 10.1097/BRS.0000000000001747. PubMed PMID: 27333342.

10)

Takizawa T, Tsutsumimoto T, Yui M, Misawa H. Surgical Site Infections Caused by Methicillin-resistant Staphylococcus epidermidis After Spinal Instrumentation Surgery. Spine (Phila Pa 1976). 2017 Apr 1;42(7):525-530. doi: 10.1097/BRS.0000000000001792. PubMed PMID: 27428392.

11)

Masuda S, Fujibayashi S, Otsuki B, Kimura H, Matsuda S. Efficacy of Target Drug Delivery and Dead Space Reduction Using Antibiotic-loaded Bone Cement for the Treatment of Complex Spinal Infection. Clin Spine Surg. 2017 Jul 7. doi: 10.1097/BSD.0000000000000567. [Epub ahead of print] PubMed PMID: 28692571.

12)

Kale M, Padalkar P, Mehta V. Vacuum-Assisted Closure in Patients with Post-operative Infections after Instrumented Spine Surgery: A Series of 12 Cases. J Orthop Case Rep. 2017 Jan-Feb;7(1):95-100. doi: 10.13107/jocr.2250-0685.706. PubMed PMID: 28630851; PubMed Central PMCID: PMC5458710.

13)

Liu JT, Liao WJ, Chang CS, Chen YH. Management of Deep Infection after Instrumentation on Lumbar Spinal Surgery in a Single Institution. Biomed Res Int. 2015;2015:842010. doi: 10.1155/2015/842010. Epub 2015 Jul 26. PubMed PMID: 26273650; PubMed Central PMCID: PMC4529929.

14) , 15)

Bydon M, De la Garza-Ramos R, Macki M, Naumann M, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. Spinal Instrumentation in Patients with Primary Spinal Infections Does Not Lead to Greater Recurrent Infection Rates: An Analysis of 118 Cases. World Neurosurg. 2014 Jun 14. pii: S1878-8750(14)00560-9. doi: 10.1016/j.wneu.2014.06.014. [Epub ahead of print] Review. PubMed PMID: 24937598.

16)

Collins I, Wilson-MacDonald J, Chami G, Burgoyne W, Vineyakam P, Berendt T, Fairbank J. The diagnosis and management of infection following instrumented spinal fusion. Eur Spine J. 2008 Mar;17(3):445-450. doi: 10.1007/s00586-007-0559-8. Epub 2007 Dec 13. Erratum in: Eur Spine J. 2017 Jul 20;:. PubMed PMID: 18075763; PubMed Central PMCID: PMC2270376.

17)

Perry JW, Montgomerie JZ, Swank S, Gilmore DS, Maeder K. Wound infections following spinal fusion with posterior segmental spinal instrumentation. Clin Infect Dis. 1997 Apr;24(4):558-61. PubMed PMID: 9145726.

Update: Spinal intramedullary tuberculosis

Spinal intramedullary tuberculosis

First reported by Cascino and Dibble 1).

Epidemiology

Intramedullary spinal tuberculosis is rare and constitute only 0.2-5% of all CNS tuberculoma2) 3). The combination of intramedullary and intracranial tuberculomas is extremely rare and only few cases have been reported in the literature so far 4) 5) 6) 7) 8).

Clinical features

Clinical presentation of spinal intramedullary tuberculosis (SIMT) is similar to intramedullary spinal cord tumor, with a characteristic subacute myelopathy, with slowly progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction.

Diagnosis

Diagnosis is strongly suspected with a clinical history of known tuberculosis in conjunction with characteristic findings on magnetic resonance imaging.

The MRI is a sensitive and non-invasive tool for diagnosing and localizing intramedullary as well as brain tuberculomas. The lesion appears as an isointense or hyperintense ring on the T1-weighted images and as an isointense or hypointense lesion on the T2-weighted images. MRI will also delineate the extent of surrounding edema. MRI also helps in determining the stage of tuberculoma formation. Presence of a bright central spot in the granuloma (target sign) is indicative of central caseation (rich foci).

Gd-DTPA enhancement MRI is more sensitive than MRI without enhancement in demonstrating the lesions of tuberculoma and arachnoiditis. In early stages of brain tuberculoma contrast MRI will show homogeneous enhancement representing the early tuberculoma stage, which may later evolve to ring enhancement with hypointense center. 9) 10) 11).

Jaiswal et al. suggest that MRI of the brain should be performed in all case of intramedullary spinal tuberculoma because of the possible presence of early asymptomatic/mild symptomatic intracranial tuberculomas 12).

Treatment

Management involves multiagent antitubercular chemotherapy without or with operative intervention.

Conservative treatment with antituberculosis medications and a short course of injectable steroids offers an effective, inexpensive, safe, and feasible option for treating intra-medullary tuberculoma, especially in developing countries 13).

Role of steroid is largely unproven. However, in patients with peri-lesional edema short-term steroids may be helpful 14). Usually, the conservative treatment is successful in achieving complete clinical neurological recovery over a period of 1 year, which is also accompanied by resolution of the tuberculomas 15).

Surgery is reserved for the patients with large lesions causing significant compression, patients who do not respond to or deteriorates during conservative treatment 16) 17) 18) 19) 20) 21) 22) 23) 24).

Case series

2009

Fifteen patients were analyzed. Mean age of presentation was 31 years (range: 18-45 years), with average duration at presentation being 11 months (2-24 months). Common locations: dorsal region: 7 cases, cervical: 5 cases, cervicodorsal: 2 cases and dorsolumbar region: 1 case. Sensori-motor involvement was noted in fourteen patients. Bowel and bladder involvement was seen in ten patients while one patient had respiratory distress. Only 40% of patients had secondary involvement of spine while the rest of the cases were having primary spinal intramedullary tuberculosis. Three patients had previous history of tubercular meningitis, while one patient had old pulmonary tuberculosis. There were one case each of cervical node involvement and intracranial granuloma. Twelve patients underwent surgery while others were conservatively managed, all patients received antitubercular therapy for 18 months. Nine of the twelve operated patients showed improvement in motor power, while two of the conservatively managed patients improved. Patients presenting late had a poorer outcome.

Spinal intramedullary tuberculosis is a non-malignant, treatable lesion giving a good outcome on management. Surgically managed patients showed a better outcome 25).

2002

During a period of 16 years (1985-2000), ten cases of intramedullary tuberculomas were diagnosed in All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. Of these, eight cases were histologically proven intramedullary tuberculomas. The clinical profile, radiological data and histological slides were reviewed.

Age ranged from 18 to 45 years (mean 29.7 years) and there was slight male preponderance (six men, four women). Duration of symptom varied from 3 to 20 months (mean 11.5 months). All of them presented with motor weakness and sensory impairment. Most common site of involvement was dorsal cord followed by cervical, cervicodorsal and dorsolumbar regions. Three patients had associated involvement of lungs, cervical lymphnodes, and brain, and one patient had past history of tuberculous meningitis. Two patients were treated conservatively but surgical excision was done in eight cases followed by medical treatment.

Radiologically, intramedullary tuberculomas should be differentiated from other space occupying lesions (SOL) to avoid unnecessary surgery especially in those patients with tuberculosis of the other organs. The incidence of intramedullary tuberculomas is likely to increase with a rise in the incidence of AIDS 26).

Case reports

2017

A case of concurrent occurrence of intramedullary tuberculoma with multiple intracranial tuberculomas in a young 16-year-old boy, who presented with two weeks history of paresthesias and weakness of the lower limbs and diminution of vision in left eye, who had been treated for pulmonary tuberculosis. Magnetic resonance imaging (MRI) spine showed a well-circumscribed lesion opposite L1, which was diagnosed as intramedullary tuberculoma. As for vision complaint, on cranial imaging, he was found to have multiple round contrast enhancing lesions, which were diagnosed as intracranial tuberculomas based on their typical MRI findings. He had complete recovery with conventional treatment of anti-tubercular therapy and steroids, without any surgical intervention.

They suggest that MRI of the brain should be performed in all case of intramedullary spinal tuberculoma because of the possible presence of early asymptomatic/mild symptomatic intracranial tuberculomas 27).


A 9 month old boy with a retrospectively-recognized history of pulmonary TB presenting with fever and back tenderness found to have lower extremity hypertonia and clonus. Imaging revealed concurrent intracranial and spinal intramedullary tuberculomas. The patient was treated for hydrocephalus with external ventricular drainage followed by T8-10 laminectomy, drainage of abscess, and duraplasty. Parietal lobe biopsies proved the tuberculous etiology of intracranial lesions 28).


Varghese et al. report the case of a 49-year-old female with dull aching pain of both upper limbs of 1-week duration. On examination, she had no motor deficits. All the deep tendon reflexes were normal. The plantar responses were flexor bilaterally. Cervical spine imaging favored intramedullary tumor. She had partial relief of symptoms with steroid treatment. Repeat imaging done 1 month later revealed mild interval enlargement of the intramedullary lesions and multiple enlarged mediastinal and hilar nodes. Endoscopic ultrasound-guided fine-needle aspiration cytology of mediastinal nodes was suggestive of granulomatous inflammation. Hence, SIMT was considered as the probable diagnosis. The patient was started on antituberculosis therapy 29).

2015

A 25-year-old male who presented with a history of progressive paraparesis. Initial diagnosis was made as an intramedullary tumor by magnetic resonance imaging (MRI). The treatment of the patient involved is complete surgical excision of intramedullary lesion followed by appropriate antituberculous therapy. Postoperatively, his neurological symptoms were dramatically improved. With combination of both surgical and medical treatments, excellent clinical outcome was obtained.

This case illustrates the risk of misdiagnosis and the importance of histological confirmation of a pathological lesion as spinal cord tuberculoma prior to surgical therapy, which should be kept in mind as a differential diagnosis of the intramedullary spinal cord tumors 30).

2012

A patient with dorsal intramedullary tuberculoma who improved clinically as well as radiologically with antituberculous treatment and steroids 31).

References

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Cascino J, Dibble JB. Tuberculoma of spinal cord. JAMA. 1956;162(5):461–462.
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Citow JS, Ammirati M. Intramedullary tuberculoma of the spinal cord: Case report. Neurosurgery. 1994;35:327–30.
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Süzer T, Coşkun E, Tahta K, Bayramoǧlu H, Düzcan E. Intramedullary spinal tuberculoma presenting as a conus tumor: A case report and review of the literature. Eur Spine J. 1998;7:168–71.
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Huang CR, Lui CC, Chang WN, Wu HS, Chen HJ. Neuroimages of disseminated neurotuberculosis: Report of one case. Clin Imaging. 1999;23:218–22.
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Lin SK, Wu T, Wai YY. Intramedullary spinal tuberculomas during treatment of tuberculous meningitis. Clin Neurol Neurosurg. 1994;96:71–8.
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Shen WC, Cheng TY, Lee SK, Ho YJ, Lee KR. Disseminated tuberculomas in spinal cord and brain demonstrated by MRI with gadolinium-DTPA. Neuroradiology. 1993;35:213–5.
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Thacker MM, Puri AI. Concurrent intra-medullary and intra-cranial tuberculomas. J Postgrad Med. 2004;50:107–9.
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Yen HL, Lee RJ, Lin JW, Chen HJ. Multiple tuberculomas in the brain and spinal cord: A case report. Spine (Phila Pa 1976) 2003;28:E499–502.
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Shaharao VB, Pawar M, Agarwal R, Bavdekar SB. Intra-medullary tuberculoma occurring during treatment of tuberculous meningitis. Indian J Pediatr. 2004;71:107–8.
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Jaiswal M, Gandhi A, Purohit D, Mittal RS. Concurrent multiple intracranial and intramedullary conus tuberculoma: A rare case report. Asian J Neurosurg. 2017 Apr-Jun;12(2):331-333. doi: 10.4103/1793-5482.143461. PubMed PMID: 28484568; PubMed Central PMCID: PMC5409404.
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Gupta VK, Sharma BS, Khosla VK. Intramedullary tuberculoma: Report of two cases with MRI findings. Surg Neurol. 1995;44:241–3.
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Kayaoglu CR, Tuzun Y, Boga Z, Erdogan F, Gorguner M, Aydin IH. Intramedullary spinal tuberculoma: A case report. Spine (Phila Pa 1976) 2000;25:2265–8.
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Kumar R, Jain R, Kaur A, Chhabra DK. Brain stem tuberculosis in children. Br J Neurosurg. 2000;14:356–61.
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Rhoton EL, Ballinger WE, Jr, Quisling R, Sypert GW. Intramedullary spinal tuberculoma. Neurosurgery. 1988;22:733–6
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Ramdurg SR, Gupta DK, Suri A, Sharma BS, Mahapatra AK. Spinal intramedullary tuberculosis: a series of 15 cases. Clin Neurol Neurosurg. 2009 Feb;111(2):115-8. doi: 10.1016/j.clineuro.2008.09.029. Epub 2008 Dec 5. PubMed PMID: 19058910.
26)

Sharma MC, Arora R, Deol PS, Mahapatra AK, Sinha AK, Sarkar C. Intramedullary tuberculoma of the spinal cord: a series of 10 cases. Clin Neurol Neurosurg. 2002 Sep;104(4):279-84. PubMed PMID: 12140088.
28)

Ghali MGZ, Srinivasan VM, Kim CJ, Malik A. Spinal intramedullary tuberculosis with concurrent supra- and infratentorial intracranial disease in a 9 month old boy: case report and review of the literature. World Neurosurg. 2017 May 19. pii: S1878-8750(17)30768-4. doi: 10.1016/j.wneu.2017.05.069. [Epub ahead of print] Review. PubMed PMID: 28532916.
29)

Varghese P, Abdul Jalal MJ, Kandathil JC, Mathew IL. Spinal Intramedullary Tuberculosis. Surg J (N Y). 2017 Mar 30;3(2):e53-e57. doi: 10.1055/s-0037-1599823. eCollection 2017 Apr. PubMed PMID: 28825021; PubMed Central PMCID: PMC5553513.
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Mishra SS, Das D, Das S, Mohanta I, Tripathy SR. Spinal cord compression due to primary intramedullary tuberculoma of the spinal cord presenting as paraplegia: A case report and literature review. Surg Neurol Int. 2015 Mar 23;6:42. doi: 10.4103/2152-7806.153844. eCollection 2015. PubMed PMID: 25883834; PubMed Central PMCID: PMC4392528.
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Thirunavukarasu SC, Ramachandrappa A. A rare case of intramedullary tuberculoma: Complete resolution after medical treatment and role of magnetic resonance imaging in diagnosis and follow-up. Asian J Neurosurg. 2012 Oct;7(4):223-6. doi: 10.4103/1793-5482.106661. PubMed PMID: 23559994; PubMed Central PMCID: PMC3613649.

Update: Thromboprophylaxis in Spinal Surgery

Thromboprophylaxis in Spinal Surgery

Published institutional practices for Venous thromboembolic prophylaxis are highly variable and there are no universally accepted guidelines.

While the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) was relatively low regardless of prophylaxis type, the true incidence is difficult to determine given the heterogeneous nature of the small number of studies available in the literature.

Findings suggest there may be a role for chemoprophylaxis given the relatively high rate of fatal PE. Future studies are needed to determine which patient population would benefit most from chemoprophylaxis 1)2).

Case series

2014

An institutional review board-approved retrospective review of outcomes in patients undergoing spine surgery 2 years before protocol implementation (representing the preprotocol group) and of outcomes in patients treated 2 years thereafter (the postprotocol group) was conducted. Inclusion criteria were that patients were 18 years or older and had been admitted for 1 or more days. Before 2008 (preprotocol), VTE prophylaxis was variable and provider dependent without any uniform protocol. Since 2008 (postprotocol), a new VTE-prophylaxis protocol was administered, starting either preoperatively or on the same day of surgery and continuing throughout hospitalization. The new protocol consisted of 5000 U heparin administered subcutaneously 3 times daily, except in patients older than 75 years or weighing less than 50 kg, who received this dose twice daily. All patients also received sequential compression device. The incidence of VTE in the 2 protocol phases was identified by codes of the International Classification of Diseases, Ninth Revision (ICD-9) codes for deep vein thrombosis (DVT) and pulmonary embolus (PE). Bleeding complications arising from anticoagulation treatments were evaluated by the Current Procedural Terminology (CPT) code for postoperative spinal epidural hematoma (EDH) requiring evacuation.

In total, 941 patients in the preprotocol group met the inclusion criteria: 25 had DVT (2.7%), 6 had PE (0.6%), and 6 had postoperative EDH (0.6%). In the postprotocol group, 992 patients met the criteria: 10 had DVT (1.0%), 5 had PE (0.5%), and 4 had postoperative EDH (0.4%). This reduction in DVT after the protocol’s implementation was statistically significant (p = 0.009). Despite early aggressive prophylaxis, the incidence of postoperative EDH did not increase and compared favorably to the published literature.

At a high-volume tertiary center, an aggressive protocol for early VTE prophylaxis after spine surgery decreases VTE incidence without increasing morbidity 3).


Between December 2006 and January 2011, 209 patients undergoing spinal surgery (121 males, 88 females; average age: 64 yr), who also had ultrasonographic assessments of both legs before and after surgery, were prospectively assessed. A pneumatic sequential compression device and standard compression stockings were used for primary VTE prophylaxis. In Mie University Hospital protocol, pharmacological agents were not used for VTE prophylaxis after surgery. However, when a distal type DVT was found preoperatively, an anticoagulant medication was administered until 6 hours prior to surgery. After detection of DVTs, weekly ultrasonography assessed the DVT.

Twenty-three patients (11.0%) showed VTE in the spinal surgery perioperative period. Nine patients (4.3%) had VTE (PE with proximal DVT, 1 [0.5%]; distal DVT, 8 [3.8%]) before surgery. In the one case of asymptomatic PE with proximal DVT, an inferior vena cava filter was placed before surgery. Fourteen patients (6.7%) developed new-onset VTE (PE with proximal DVT, 2 [1.0%]; distal DVT, 12 [5.9%]) after spinal surgery. New-onset PE with proximal DVT occurred in 2 patients after surgery. Follow-up ultrasonographic assessment showed that the DVT disappeared completely in 85% (17/20) of patients with a distal type DVT during the perioperative period.

DVT assessment using ultrasonography is important for proper management of VTE during the perioperative period of spinal surgery, especially for high-risk patients, such as those with advanced age or neurological deficit. The institutional protocol for VTE using pneumatic sequential compression device and compression stockings is effective, although the administration of chemoprophylaxis should be considered for high-risk patients, such as those with spinal tumors and spinal trauma 4).

2011

Yu et al., separated 298 spinal patients who had different VTE risk factors into low-, medium- and high-risk groups for 22 cases, 48 cases and 228 cases respectively. Physical prevention measures such as thigh-length thromboembolic deterrent stockings (TEDS) and pneumatic sequential compression device (PSCD) were used in low- and medium-risk groups. In high-risk groups, low molecular weight heparin(LMWH) was applied in addition to physical prevention measures. Lower limb vascular doppler ultrasonography was used to monitor thrombosis pre- and postoperatively. Simultaneously the occurrences of epidural or wound hematoma, mucosal bleeding, thrombocytopenia caused by low molecular heparin and nerve damage caused by extradural hemorrhage were monitored.

Among the 298 cases of patients with spinal surgery, DVT occurred in 23 cases, the incidence of DVT was 7.7%. There were 0, 2 and 21 patients with positive findings of deep vein thrombosis on duplex ultrasonograph respectively in low-, medium- and high-risk groups. There was no case of PE. All DVT was thrombosis in calf which was distal to the knee. There was no clinical symptom of VTE. The DVT needed no therapy. The vein with thrombosis was recanalized 3 months after operation. No case caught epidural or wound hematoma, mucosal bleeding, thrombocytopenia caused by low molecular heparin or nerve damage caused by extradural hemorrhage.

Individual VTE prophylaxis was taken according to risk stratifications. No VTE of clinical value or no complications from prophylaxis happened. So our prophylaxis is effective and safe. But more prospective, case-control studies are needed to assess the efficacy and safety of VTE prophylaxis5).

1)

Mosenthal WP, Landy DC, Boyajian HH, Idowu OA, Shi LL, Ramos E, Lee MJ. Thromboprophylaxis in Spinal Surgery. Spine (Phila Pa 1976). 2017 Aug 17. doi: 10.1097/BRS.0000000000002379. [Epub ahead of print] PubMed PMID: 28820759.
2)

Bryson DJ, Uzoigwe CE, Braybrooke J. Thromboprophylaxis in spinal surgery: a survey. J Orthop Surg Res. 2012 Mar 29;7:14. doi: 10.1186/1749-799X-7-14. PubMed PMID: 22458927; PubMed Central PMCID: PMC3349591.
3)

Cox JB, Weaver KJ, Neal DW, Jacob RP, Hoh DJ. Decreased incidence of venous thromboembolism after spine surgery with early multimodal prophylaxis: Clinical article. J Neurosurg Spine. 2014 Oct;21(4):677-84. doi: 10.3171/2014.6.SPINE13447. PubMed PMID: 25105337.
4)

Akeda K, Matsunaga H, Imanishi T, Hasegawa M, Sakakibara T, Kasai Y, Sudo A. Prevalence and countermeasures for venous thromboembolic diseases associated with spinal surgery: a follow-up study of an institutional protocol in 209 patients. Spine (Phila Pa 1976). 2014 May 1;39(10):791-7. doi: 10.1097/BRS.0000000000000295. PubMed PMID: 24583727.
5)

Yu ZR, Li CD, Yi XD, Lin JR, Liu XY, Liu H, Lu HL. [Prevention for venous thromboembolism prophylaxis after spinal surgery]. Beijing Da Xue Xue Bao. 2011 Oct 18;43(5):661-5. Chinese. PubMed PMID: 22008671.

Update: Spine injury

Spine injury

Controversies

At this moment there is persistent controversy within the spinal trauma community, which can be grouped under 6 headings:

First of all there is still no unanimity on the role and timing of medical and surgical interventions for patients with associated neurologic injury.

Type and timing of surgical intervention in multiply injured patients.

In some common injury types like odontoid fractures and thoracolumbar burst fracture, there is wide variation in practice between operative versus nonoperative management without clear reasons.

The role of different surgical approaches and techniques in certain injury types are not clarified yet.

Methods of nonoperative management and care of elderly patients with concurrent complex disorders are also areas where there is no consensus1).

Types

Spinal cord injury

Whiplash-associated disorders

Pediatric spine injury

Cervical spine injury

Thoracolumbar spine fracture

Sacral fracture

Osteoporotic vertebral fracture

Spinal gunshot wound

Penetrating neck trauma


Traumatic spine injuries are often transferred to regional tertiary trauma centers from OSH and subsequently discharged from the trauma center’s emergency department (ED) suggesting secondary overtriage of such injuries.

A study to investigate interfacility transfers with spine injuries found high rate of secondary overtriage of neurologically intact patients with isolated spine injuries. Potential solutions include increasing spine coverage in community EDs, increasing direct communication between the OSH and spine specialist at the tertiary center, and utilization of teleradiology 2).

Complications

Hydrocephalus is a rare complication of traumatic spine injury. A literature review reflects the rare occurrence with cervical spine injury.

Dragojlovic et al present a case of traumatic injury to the lumbar spine from a gunshot wound, which caused communicating hydrocephalus. The patient sustained a gunshot wound to the lumbar spine and had an L4-5 laminectomy with exploration and removal of foreign bodies. At the time of surgery, the patient was found to have dense subarachnoid hemorrhage in the spinal column. He subsequently had intermittent headaches and altered mental status that resolved without intervention. The headaches worsened, so a computed tomography scan of the brain was obtained, which revealed hydrocephalus. A ventriculoperitoneal shunt was placed, and subsequent computed tomography scan of the brain showed reduced ventricle size. The patient returned to rehabilitation with complete resolution of hydrocephalus symptoms. Intrathecal hemorrhage with subsequent obstruction or decreased absorption of cerebrospinal fluid at the distal spinal cord was thought to lead to communicating hydrocephalus in this case of lumbar penetrating trauma. In patients with a history of hemorrhagic, traumatic spinal injury who subsequently experience headaches or altered mental status, hydrocephalus should be included in the differential diagnosis and adequately investigated 3).

Assessment

ATLS® algorithm and spine trauma assessment. In Step „A“ cervical spine (C-Spine) protection is indispensable. Every unconscious patient is stabilized by stiff-neck. Patients with signs of chest injury in step „B” and abdominal injury in step „C“, especially retroperitoneal are highly suspicious for thoracic (T-) and/or (L-) lumbar spine injury. Normal motor exam and reflexes do not rule out significant spine injury in the comatose patient. Abnormal neurologic exam is a sign for substantial spinal column injury including spinal cord injury (SCI). Log roll in step „E” is important to assess the dorsum of the cervical to the sacral spine and to look out for any signs of bruising, open wounds, tender points and to palpate the paravertebral tissue and posterior processus in search for distraction injury. Spine precautions should only be discontinued when patients gain back consciousness and are alert to communicate sufficiently on spinal discomfort or neurologic sensations before the spine is cleared 4).

Data on all patients with traumatic spine injuries admitted to the Alfred Hospital, Melbourne between May 1, 2009, and January 1, 2011, were collected:

There were 965 patients with traumatic spine injuries with 2,333 spine trauma levels. The general cohort showed a trimodal age distribution, male-to-female ratio of 2:2, motor vehicle accidents as the primary spine trauma mechanism, 47.7% patients with severe polytrauma as graded using the Injury Severity Score (ISS), 17.3% with traumatic brain injury (TBI), the majority of patients with one spine injury level, 7% neurological deficit rate, 12.8% spine trauma operative rate, and 5.2% mortality rate. Variables with statistical significance trending toward mortality were the elderly, motor vehicle occupants, severe ISS, TBI, C1-2 dissociations, and American Spinal Injury Association (ASIA) A, B, and C neurological grades. Variables with statistical significance trending toward the elderly were females; low falls; one spine injury level; type 2 odontoid fractures; subaxial cervical spine distraction injuries; ASIA A, B, and C neurological grades; and patients without neurological deficits. Of the general cohort, 50.3% of spine trauma survivors were discharged home, and 48.1% were discharged to rehabilitation facilities. This study provides baseline spine trauma epidemiological data. The trimodal age distribution of patients with traumatic spine injuries calls for further studies and intervention targeted toward the 46- to 55-year age group as this group represents the main providers of financial and social security. The study’s unique feature of delineating variables with statistical significance trending toward both mortality and the elderly also provides useful data to guide future research studies, benchmarking, public health policy, and efficient resource allocation for the management of spine trauma 5).

Outcome

There is no universally accepted outcome instrument available that is specifically designed or validated for spinal trauma patients, contributing to controversies related to the optimal treatment and evaluation of many types of spinal injuries. Therefore, the AOSpine Knowledge Forum Trauma aims to develop such an instrument using the International Classification of Functioning Disability and Health (ICF) as its basis.

Experts from the 5 AOSpine International world regions were asked to give their opinion on the relevance of a compilation of 143 ICF categories for spinal trauma patients on a 3-point scale: “not relevant,” “probably relevant,” or “definitely relevant.” The responses were analyzed using frequency analysis. Possible differences in responses between the 5 world regions were analyzed with the Fisher exact test and descriptive statistics.

Of the 895 invited AOSpine International members, 150 (16.8%) participated in this study. A total of 13 (9.1%) ICF categories were identified as definitely relevant by more than 80% of the participants. Most of these categories were related to the ICF component “activities and participation” (n = 8), followed by “body functions” (n = 4), and “body structures” (n = 1). Only some minor regional differences were observed in the pattern of answers.

More than 80% of an international group of health care professionals experienced in the clinical care of adult spinal trauma patients indicated 13 of 143 ICF categories as definitely relevant to measure outcomes after spinal trauma. This study creates an evidence base to define a core set of ICF categories for outcome measurement in adult spinal trauma patients 6).

Early independent risk factors predictive of suboptimal physical health status identified in a level 1 trauma center in polytrauma patients with spine injuries were tachycardia, hyperglycemia, multiple chronic medical comorbidities, and thoracic spine injuries. Early spine trauma risk factors were shown not to predict suboptimal mental health status outcomes 7).

References

1)

Oner C, Rajasekaran S, Chapman JR, Fehlings MG, Vaccaro AR, Schroeder GD, Sadiqi S, Harrop J. Spine Trauma-What Are the Current Controversies? J Orthop Trauma. 2017 Sep;31 Suppl 4:S1-S6. doi: 10.1097/BOT.0000000000000950. PubMed PMID: 28816869.
2)

Bible JE, Kadakia RJ, Kay HF, Zhang CE, Casimir GE, Devin CJ. How often are interfacility transfers of spine injury patients truly necessary? Spine J. 2014 Apr 14. pii: S1529-9430(14)00379-9. doi: 10.1016/j.spinee.2014.01.065. [Epub ahead of print] PubMed PMID: 24743061.
3)

Dragojlovic N, Stampas A, Kitagawa RS, Schmitt KM, Donovan W. Communicating Hydrocephalus Due to Traumatic Lumbar Spine Injury: Case Report and Literature Review. Am J Phys Med Rehabil. 2016 Jun 17. [Epub ahead of print] PubMed PMID: 27323322.
5)

Tee JW, Chan CH, Fitzgerald MC, Liew SM, Rosenfeld JV. Epidemiological trends of spine trauma: an Australian level 1 trauma centre study. Global Spine J. 2013 Jun;3(2):75-84. doi: 10.1055/s-0033-1337124. Epub 2013 Mar 19. PubMed PMID: 24436855; PubMed Central PMCID: PMC3854579.
6)

Oner FC, Sadiqi S, Lehr AM, Aarabi B, Dunn RN, Dvorak MF, Fehlings MG, Kandziora F, Post MW, Rajasekaran S, Vialle L, Vaccaro AR. Toward Developing a Specific Outcome Instrument for Spine Trauma: An Empirical Cross-sectional Multicenter ICF-Based Study by AOSpine Knowledge Forum Trauma. Spine (Phila Pa 1976). 2015 Sep 1;40(17):1371-1379. PubMed PMID: 26323025.
7)

Tee JW, Chan CH, Gruen RL, Fitzgerald MC, Liew SM, Cameron PA, Rosenfeld JV.Early predictors of health-related quality of life outcomes in polytrauma patients with spine injuries: a level 1 trauma center study. Global Spine J. 2014 Feb;4(1):21-32. doi: 10.1055/s-0033-1358617. Epub 2013 Nov 6. PubMed PMID: 24494178.

Update: Spinal cord injury treatment

Spinal cord injury treatment

Substantial heterogeneity in the patient population, their presentation and underlying pathophysiology has sparked debates along the care spectrum from initial assessment to definitive treatment.

In seeking a cure, these patients often undergo treatments that lack scientific and methodological rigor.

Ahuja et al. reviews spinal cord injury (SCI) management followed by a discussion of the salient controversies in the field. Current care practices modeled on the American Association of Neurological Surgeons/Congress of Neurological Surgeons joint section guidelines are highlighted including key recommendations regarding immobilization, avoidance of hypotension, early International Standards for Neurological Classification of SCI examination and intensive care unit treatment. From a diagnostic perspective, the evolving roles of CT, MRI, and leading-edge microstructural MRI techniques are discussed with descriptions of the relevant clinical literature for each. Controversies in management relevant to clinicians including the timing of surgical decompression, methylprednisolone administration, blood pressure augmentation, intraoperative electrophysiological monitoring, and the role of surgery in central cord syndrome and pediatric SCI are also covered in detail. Finally, the article concludes with a reflection on clinical trial design tailored to the heterogeneous population of individuals with SCI 1).

Cell therapy

Perfusion

Increased spinal cord perfusion and blood pressure goals have been recommended for spinal cord injury (SCI).

Treatment consists of restoration of CSF flow, typically via arachnoidolysis and syrinx decompression Research into treatments for spinal cord injuries includes controlled hypothermia and stem cells, though many treatments have not been studied thoroughly and very little new research has been implemented in standard care.

Treatment of spinal cord injuries starts with restraining the spine and controlling inflammation to prevent further damage. The actual treatment can vary widely depending on the location and extent of the injury.

Acute spinal cord injury (SCI) is commonly treated by elevating the mean arterial pressure (MAP). Other potential interventions include cerebrospinal fluid drainage (CSFD).

Both MAP elevation alone and CSFD alone led to only short-term improvement of SCBF. The combination of MAP elevation and CSFD significantly and sustainably improved SCBF and spinal cord perfusion pressure. Although laser Doppler flowmetry can provide flow measurements to a tissue depth of only 1.5 mm, these results may represent pattern of blood flow changes in the entire spinal cord after injury 2).

Lumbar cerebrospinal fluid drainage after spinal cord injury, as used in the pig study by Martirosyan et al would reduce intrathecal pressure at the injury site only if the spinal cord is not compressed against the surrounding dura. Unfortunately, in most patients with severe spinal cord injury, the spinal cord is compressed against the surrounding dura; therefore, drainage of cerebrospinal fluid from the lumbar region will not reduce intrathecal pressure at the injury site 3).

Unfortunately, no data correlate the severity of spinal cord injury, the degree of spinal cord swelling, and persistent CSF flow across an injured segment in the human spinal cord. The physiological observations in animals and humans alike indicate that CSF drainage and induced hypertension warrant further investigation as a potential treatment for acute spinal cord injury 4).

Rehabilitation

In many cases, spinal cord injuries require substantial physical therapy and rehabilitation, especially if the patient’s injury interferes with activities of daily life.

Pharmacological Therapy

Despite a degree of theoretical progress, there is a lack of effective drugs that are able to improve the motor function of patients following spinal cord injury (SCI) 5) 6) 7) 8).

see Methylprednisolone for Spinal cord injury.

Dexamethasone acetate (DA) produces neuroprotective effects by inhibiting lipid peroxidation and inflammation by reducing cytokine release and expression. However, its clinical application is limited by its hydrophobicity, low biocompatibility and numerous side effects when using large dosage. Therefore, improving DA’s water solubility, biocompatibility and reducing its side effects are important goals that will improve its clinical utility. The objective of this study is to use a biodegradable polymer as the delivery vehicle for DA to achieve the synergism between inhibiting lipid peroxidation and inflammation effects of the hydrophobic-loaded drugs and the amphipathic delivery vehicle. Wang et al., successfully prepared DA-loaded polymeric micelles (DA/MPEG-PCL micelles) with monodispersed and approximately 25 nm in diameter, and released DA over an extended period in vitro. Additionally, in the hemisection spinal cord injury (SCI) model, DA micelles were more effective in promoting hindlimb functional recover, reducing glial scar and cyst formation in injured site, decreasing neuron lose and promoting axon regeneration. Therefore, data suggest that DA/MPEG-PCL micelles have the potential to be applied clinically in SCI therapy 9).

Surgery

After traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP) or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression.

21 patients with acute, severe TSCI had realignment of the fracture and surgical fixation; 11 had laminectomy (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy + duroplasty group). Primary outcomes were MRI evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy + duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy + duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy + duroplasty group, ISP was lower, SCPP higher and sPRx lower, i.e. improved vascular pressure reactivity, compared with the laminectomy group. Duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved in five patients. We conclude that, after TSCI, laminectomy + duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy 10).

References

1)

Ahuja CS, Schroeder GD, Vaccaro AR, Fehlings MG. Spinal Cord Injury-What Are the Controversies? J Orthop Trauma. 2017 Sep;31 Suppl 4:S7-S13. doi: 10.1097/BOT.0000000000000943. PubMed PMID: 28816870.
2)

Martirosyan NL, Kalani MY, Bichard WD, Baaj AA, Gonzalez LF, Preul MC, Theodore N. Cerebrospinal fluid drainage and induced hypertension improve spinal cord perfusion after acute spinal cord injury in pigs. Neurosurgery. 2015 Apr;76(4):461-9. doi: 10.1227/NEU.0000000000000638. PubMed PMID: 25621979.
3)

Papadopoulos MC. Letter: Intrathecal Pressure After Spinal Cord Injury. Neurosurgery. 2015 Sep;77(3):E500. doi: 10.1227/NEU.0000000000000862. PubMed PMID: 26110999.
4)

Martirosyan NL, Kalani MY, Theodore N. In Reply: Intrathecal Pressure After Spinal Cord Injury. Neurosurgery. 2015 Sep;77(3):E500-1. doi: 10.1227/NEU.0000000000000857. PubMed PMID: 26111000.
5)

Hu R, Zhou J, Luo C, et al. Glial scar and neuroregeneration: Histological, functional, and magnetic resonance imaging analysis in chronic spinal cord injury. J Neurosurg Spine. 2010;13:169–180. doi: 10.3171/2010.3.SPINE09190.
6)

Macias CA, Rosengart MR, Puyana JC, et al. The effects of trauma center care, admission volume, and surgical volume on paralysis after traumatic spinal cord injury. Ann Surg. 2009;249:10–17. doi: 10.1097/SLA.0b013e31818a1505.
7)

Samantaray S, Sribnick EA, Das A, et al. Neuroprotective efficacy of estrogen in experimental spinal cord injury in rats. Ann NY Acad Sci. 2010;1199:90–94. doi: 10.1111/j.1749-6632.2009.05357.x.
8)

Fu ES, Tummala RP. Neuroprotection in brain and spinal cord trauma. Curr Opin Anaesthesiol. 2005;18:181–187. doi: 10.1097/01.aco.0000162838.56344.88.
9)

Wang Y, Wu M, Gu L, Li X, He J, Zhou L, Tong A, Shi J, Zhu H, Xu J, Guo G. Effective improvement of the neuroprotective activity after spinal cord injury by synergistic effect of glucocorticoid with biodegradable amphipathic nanomicelles. Drug Deliv. 2017 Nov;24(1):391-401. doi: 10.1080/10717544.2016.1256003. PubMed PMID: 28165815.
10)

Phang I, Werndle MC, Saadoun S, Varsos GV, Czosnyka M, Zoumprouli A, Papadopoulos MC. Expansion Duroplasty Improves Intraspinal Pressure, Spinal Cord Perfusion Pressure and Vascular Pressure Reactivity Index in Patients with Traumatic Spinal Cord Injury. J Neurotrauma. 2015 Feb 23. [Epub ahead of print] PubMed PMID: 25705999.

Update: AOSpine subaxial cervical spine injury classification system

AOSpine subaxial cervical spine injury classification system

See: aospine_subaxial_cervical_spine_injury_classification_system.pdf

This project describes a morphology-based subaxial cervical spine injury classification system. Using the same approach as the AOSpine Thoracolumbar Classification System, the goal was to develop a comprehensive yet simple classification system with high intra- and interobserver reliability to be used for clinical and research purposes.

A subaxial cervical spine injury classification system was developed using a consensus process among clinical experts. All investigators were required to successfully grade 10 cases to demonstrate comprehension of the system before grading 30 additional cases on two occasions, 1 month apart. Kappa coefficients (κ) were calculated for intraobserver and interobserver reliability.

The classification system is based on three injury morphology types similar to the TL system: compression injuries (A), tension band injuries (B), and translational injuries (C), with additional descriptions for facet injuries, as well as patient-specific modifiers and neurologic status. Intraobserver and interobserver reliability was substantial for all injury subtypes (κ = 0.75 and 0.64, respectively).

The AOSpine subaxial cervical spine injury classification system demonstrated substantial reliability in this initial assessment, and could be a valuable tool for communication, patient care and for research purposes 1).


The AOSpine subaxial cervical spine injury classification system (using the four main injury types or at the sub-types level) allows a significantly better agreement than the Allen and Ferguson classification of subaxial cervical spine injury. The A&F scheme does not allow reliable communication between medical professionals 2).


see also Subaxial Injury Classification (SLIC).

Case series

2017

Aarabi et al. analyzed the relevant clinical, imaging, management, and American Spinal Injury Association (ASIA) impairment scale (AIS) grade conversion of 92 AIS grades A-C patients with cervical spine injury. We correlated morphology class with age, injury severity score (ISS), follow-up ASIA motor score (AMS), intramedullary lesion length (IMLL), and AIS grade conversion at 6 months after injury.

The mean age of patients was 39.3 years, 83 were men, and 69 were injured during an automobile accident or after a fall. The AOSpine class was A4 in 8, B2 in 5, B2A4 in 16, B3 in 19, and C in 44 patients. The mean ISS was 29.7 and AMS was 17.1. AIS grade was A in 48, B in 25, and C in 19 patients. Mean IMLL on postoperative magnetic resonance imaging was 72 mm: A4 = 68.1; B2A4 = 86.5; B2 = 59.3; B3 = 46.8; and C = 79.9. At a mean follow-up of 6 months, the mean AMS was 39.6. Compared to patients with class B3 injuries, those with class C injuries were significantly younger (P < 0.0001), had longer IMLL (P < 0.002), and were less likely to have AIS grade conversion to a better grade (P < 0.02).

The AOSpine subaxial cervical spine injury classification system successfully predicted injury severity (longer IMLL) and chances of neurologic recovery (AIS grade conversion) across different class subtypes 3).

2016

Silva et al., evaluated the new classification

Patients with subaxial cervical spine trauma (SCST) treated at the authors’ institution according to the Subaxial Cervical Spine Injury Classification system were included. Five different blinded researchers classified patients’ injuries according to the new AOSpine system using CT imaging at 2 different times (4-week interval between each assessment). Reliability was assessed using the kappa index (κ), while validity was inferred by comparing the classification obtained with the treatment performed.

Fifty-one patients were included: 31 underwent surgical treatment, and 20 were managed nonsurgically. Intraobserver agreement for subgroups ranged from 0.61 to 0.93, and interobserver agreement was 0.51 (first assessment) and 0.6 (second assessment). Intraobserver agreement for groups ranged from 0.66 to 0.95, and interobserver agreement was 0.52 (first assessment) and 0.63 (second assessment). The kappa index in all evaluations was 0.67 for Type A, 0.08 for Type B, and 0.68 for Type C injuries, and for the facet modifier it was 0.33 (F1), 0.4 (F2), 0.56 (F3), and 0.75 (F4). Complete agreement for all components was attained in 25 cases (49%) (19 Type A and 6 Type C), and for subgroups it was attained in 22 cases (43.1%) (16 Type A0 and 6 Type C). Type A0 injuries were treated conservatively or surgically according to their neurological status and ligamentous status. Type C injuries were treated surgically in almost all cases, except one.

While the general reliability of the newer AOSpine system for SCST was acceptable for group classification, significant limitations were identified for subgroups. Type B injuries were rarely diagnosed, and only mild (Type A0) and extreme severe (Type C) injuries had a high rate of interobserver agreement. Facet modifiers and intermediate injury patterns require better descriptions to improve their low agreement in cases of SCST 4).

References

1)

Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ, Kandziora F, Fehlings MG, Dvorak MF, Aarabi B, Rajasekaran S, Schroeder GD, Kepler CK, Vialle LR. AOSpine subaxial cervical spine injury classification system. Eur Spine J. 2016 Jul;25(7):2173-84. doi: 10.1007/s00586-015-3831-3. Epub 2015 Feb 26. PubMed PMID: 25716661.
2)

Urrutia J, Zamora T, Campos M, Yurac R, Palma J, Mobarec S, Prada C. A comparative agreement evaluation of two subaxial cervical spine injury classification systems: the AOSpine and the Allen and Ferguson schemes. Eur Spine J. 2016 Jul;25(7):2185-92. doi: 10.1007/s00586-016-4498-0. Epub 2016 Mar 5. PubMed PMID: 26945747.
3)

Aarabi B, Oner C, Vaccaro AR, Schroeder GD, Akhtar-Danesh N. Application of AOSpine Subaxial Cervical Spine Injury Classification in Simple and Complex Cases. J Orthop Trauma. 2017 Sep;31 Suppl 4:S24-S32. doi: 10.1097/BOT.0000000000000944. PubMed PMID: 28816872.
4)

Silva OT, Sabba MF, Lira HI, Ghizoni E, Tedeschi H, Patel AA, Joaquim AF. Evaluation of the reliability and validity of the newer AOSpine subaxial cervical injury classification (C-3 to C-7). J Neurosurg Spine. 2016 Sep;25(3):303-8. doi: 10.3171/2016.2.SPINE151039. Epub 2016 Apr 22. PubMed PMID: 27104288.

Book: Modern Thoraco-Lumbar Implants for Spinal Fusion

Modern Thoraco-Lumbar Implants for Spinal Fusion

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This book presents an updated perspective on spinal implants currently used in thoraco-lumbar spine surgery, leading to a rigid or dynamic spine fusion. The development of new surgical devices and techniques is mostly focused on a spinal fusion for lumbar instability due to trauma, tumours or degenerative or infectious diseases. Pedicle-screw fixation and fusion are currently considered to be the gold standard for most of the above-mentioned pathologies, and modern implants are designed to improve the accuracy of pedicle-screw placement and to allow the use of new surgical techniques and minimally invasive approaches. The content is relevant for surgeons, orthopaedic specialists, neurosurgeons, physiotherapists and osteopaths.


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  • Published on: 2017-08-08
  • Original language: English
  • Number of items: 1
  • Dimensions: 9.30″ h x .0″ w x 6.10″ l,
  • Binding: Hardcover
  • 190 pages

Editorial Reviews

About the Author

Prof. Roberto Delfini is a specialist in Neurosurgery at the Policlinico Umbreto I and chair of the University La Sapeinza of Rome as well as head of the School of Specialization in Neurosurgery. He is a Member of the Italian Society of Neurosurgery, where he held the position of Director, Treasurer, Secretary and President (currently past president). And he is also member of other national and international Societies of Neurosurgery and related disciplines as well as member of the World Academy of Neurosurgeons. In 2014 he was awarded the Prize Boniface VIII. He is author of over 300 scientific articles and book chapters on national laws and international neurosurgery. Prof. Delfini performed as first operator over 6,000 surgeries covering most of neurological diseases. His main fields of interest and activities are: the surgery of intracranial tumors in general and in particular tumors of the skull base; surgery of the brain and spinal vascular malformations; surgery of vertebrobasilar medullary cancer and degenerative and traumatic.