This is a study to investigate the diagnostic and prognostic value of MRI in spinal cord injury.

We performed this prospective study on sixty two patients of acute spinal trauma. We evaluated the epidemiology of spinal trauma & various traumatic findings by MRI. MRI findings were correlated with clinical findings at admission & discharge according to ASIA impairment scale. Four types of MR signal patterns were seen in association with spinal cord injury-cord edema / non haemmorhagic cord contusion (CC), severe cord compression (SCC), cord hemorrhage (CH) and epidural heamatoma (EH). Isolated lesion of cord contusion was found in 40%. All other MR signal patterns were found to be in combination. In cord contusion we further subdivided the group into contusion of size < 3 cm and contusion of size > 3 cm to evaluate any significance of length of cord contusion. In cord heammorhage involving >1cm of the cord, focus was said to be sizable.

On bivariate analysis, there was a definitive correlation of cord contusion (CC) involving <3cm & > 3cm of cord with sensory outcome. In >3cm, chances of improvement was 5.75 times lesser than in patients with CC involving <3cm of cord (odds ratio = 5.75 (95% CI: 0.95, 36), Fisher's exact p = 0.0427 (p<.05). In severe cord compression (SCC) the risk of poor outcome was more (odds ratio 4.3 and p=0.149) however was not statistically significant. It was noted that the patients in which epidural hematoma (EH) was present, no improvement was seen, however, by statistical analysis it was not a risk factor and was not related with the outcome (odds ratio – 0.5 and p = 0.22). Presence of cord oedema / non haemorrhagic contusion was not associated with poor outcome (odds ratio 0.25 and p=0.178). On multiple logistic regression / multivariate analysis for estimating prognosis, sizable focus of haemorrhage was most consistently associated with poor outcome (odds ratio −6.73 and p= 0.32) however it was not statistically significant. The risk of retaining a complete cord injury at the time of follow up for patients who initially had significant haemorrhage in cord was more than 6 fold with patients without initial haemorrhage (odds ratio 6.97 and p= .0047).

Besides being helpful in diagnosis, MRI findings may serve as a prognostic indicator for clinical, neurological and functional outcome in acute spinal trauma patients.

Our knowledge regarding neurological recovery following spinal cord injury is like a tip of an iceberg. Spinal cord does not regenerate once damaged but nerve roots do so if an optimum environment is provided. Although distal neurological recovery is unlikely in ASIA Impairment Scale A (complete lesions), root recovery at the site of injury can occur. ASIA has recognized Zone of partial preservation & Zonal segmental recovery below the neurological level. Such a recovery in motor functions (Motor segmental recovery-MSR) of lumbar roots in paraplegia may make all the difference in final outcome of ambulation & functional status of the patient.

100 Thoracolumbar injuries in ASIA A underwent surgery. In 60, Posterior instrumentation alone (Gp1) and in 40 posterior instrumentation with laminectomy (Gp2) was done. Results of these were compared with randomly picked up 100 similar cases treated conservatively (Gp3).

Meritsofsurgery(Gp1& Gp2)overconservative(Gp3) were many in terms of reduction & stability, pain-function scores, total hospital stay, ambulation mode and time. At 1 year follow-up, functional distal neurological recovery (FDNR) was said to be significant when ASIA A improved up to ASIA D/E and MSR was said to be significant (MSR-Sig) when key muscle had a power > III. In Gp3, FDNR was (7/100) 7% and MSR-Sig was (40/100) 40%. In Gp1 FDNR was(7/60) 11.67% and MSR-Sig (41/60) 68.33%. When laminectomy was added with instrumentation (Gp2) FDNR was (5/40) 12.5% and MSR-Sig was found in (37/40) 92% cases. This was especially beneficial in thoracolumbar injuries where MSR-Sig of the L2 & L3 roots made all the difference between an ambulatory life (with braces) and an otherwise permanent wheel chair bound life. Motor segmental recovery becomes a blessing in disguise in complete cases of spinal cord injury where distal recovery of spinal cord is unlikely to occur.

The definition & etiology of spinal shock remain controversial. Time passed after trauma in initial recovery of any reflex is duration of spinal shock and this duration varies among patients. The factors influencing this duration and its clinical significance are not well studied.

116 patients in spinal shock following SCI were studied for duration of spinal shock with many variables & statistical analysis was done.

Mean duration of spinal shock (MD of SS) was shorter in children, shorter in malnourished, shorter in untrained/laborers, shorter in patients admitted early and shorter in patients without any complications. “MD of SS” was not influenced by sex of patient, associated injuries and by different modalities of treatment.

On statistical analysis of duration of spinal shock with neurological level as a variable “MD of SS “was 1.7 days in cervical cord lesions, 8.2 days in upper thoracic, 15 days in lower thoracic and 17 days in lumbar cord lesions. Such an arithmetical progression was also found at each segmental level i.e. the duration of spinal shock progressively increased at every segmental level. “MD of SS” was 1.36days at C4, 1.60 at C5, 1.72 at C6, 8.1 at T6, 12.4 at T8, 13.1 at T10, 15.3 at T12 & 21.6 at L2.

Higher or proximal the SCI lesion, shorter is the spinal shock duration. Neurological level based segmental progression of spinal shock duration remains unanswered. Does the duration of spinal shock dependant on the cord length/neuronal mass involved/spared?

Recent advances in spinal cord injury(SCI) management have markedly reduced mortality & morbidity, but concern regarding final neurological outcome is still at large. Global search is for prognostic-factors to predict neurological recovery. We statistically analyzed different variables to review the established and determine newer predictors of neurological recovery in SCI.

During 1999–2000, 403 patients were admitted. 91 could be followed up for more than one year. Improvement in the motor score (ASIA) was taken as indicative of functional neurological recovery Prognostic factors were simplified into static(which do not change with time) and dynamic(which may change with time). Variables like age, sex, mode/mechanism of injury and skeletal level were static. These were recorded at admission and correlated for any association with neurological recovery at one year. Variables like neurological level, sacral sparing, duration of spinal shock, reflex recovery, sensory & motor scores and complications like bedsores, flexor spasms, UTI, URTI, & DVT were dynamic. These were recorded at admission, at weekly intervals till discharge and at 3 monthly intervals in follow-up.

Bivariant & Regressive analysis of static and dynamic factors was done.

No significant correlation of static variables was found with the neurological recovery.

On bivariant analysis Pin-prick sparing, intact bladder, spinal shock of < 24 hours and early appearance of deep tendon reflexes were good prognostic factors. Complete lesion, priapism, spinal shock for > 1 week, bedsore within 1 week and flexor spasms within 3 weeks were worst prognostic factor.

When regressive linear analysis was done speed of recovery in the initial three weeks was the most important prognostic factor irrespective of other variables studied against the final neurological recovery.

All variables affecting neurological recovery have an effect on the speed of recovery, which is the single most important prognostic factor influencing ultimate recovery.

The initial 3 weeks following injury were the critical period influencing final neurological & functional outcome.

Objective: The most dreaded and crippling complication of spinal tuberculosis is pott’s paraplegia.

The use of instrumentation in the presence of infection is usually deferred for the fear of formation of a focus, persistence bio material centered infection, preferential bacterial colonization and production of a bio-film (glycocalyx) which protects them from host defenses and chemotherapeutic agents. Fortunately, mycobacterium tuberculosis is less adhesive and produces less bio-film than other bacteria and the likelihood of persistence infection in the presence of implants is smaller.

Design: The present study is being conducted to study the positive and negative effects of decompression with instrumentation and to analyze and compare the results of conservative treatment, surgical decompression and decompression with instrumentation.

Participants/Methods: The study was conducted in 56 patients. All patients of Pott’s Paraplegia admitted during June,02 to June,03 were included. According to the treatment given the patients were divided into three groups:

Group I – Conservative treatment.

Group II – Surgical decompression only

Group III – Surgical decompression combined with instrumentation

Results: At different time intervals almost equal neurological recovery was found in group II and group III while slow recovery in group I.

The mean ambulatory time was almost equal in group I and group II while very low (less than a week) in group III.

Pain function score grade shifted towards excellency with time in all groups-- p=4.48 x 10-3 in group I, p=4.44 x 10-7 in group in II and p = 4.49 x 10-7 in group III.

The change from grade B to grade A is quick in group III. Excellent grade is maximum (77.8%) in group III and nil in group I (p value at 6 in = 1.22 x 10-3 which is statistically significant.

Introduction Management of cervical fracture-dislocation varies greatly. When using closed reducition it is not known what are the upper limits of skeletal-traction, the indications and approach of surgery. This study was done to evaluate a stepwise closed reduction protocol using vector principles and define the upper limit of weight tolerated by skeletal traction and manipulation under anaesthesia

Methods This study includes 47 patients of traumatic tetraplegia reporting within three weeks of injury. A sequential protocol was followed using the vector principle for closed reduction by skeletal traction. To begin with, three bricks (18.42 pounds) sustained traction was applied keeping the vector in flexion for five to six hours. This was followed by straightening of the spine and observing realignment. Check x-rays were taken. Acceptable reduction were maintained in extension. If reduciton was unacceptable, weights were added in one brick (6.14 pound) increments and sequential steps repeated. Vector angle in flexion, neutral and extension was easily maintained with bolsters, neck rolls and balancing bar. Manipulation under anaesthesia was tried when this protocol failed

Results Reduction was achieved in 41 of 47 (87.22%) within 24 hours. Maximum weight needed was six bricks (36.84 pounds). All irreducible dislocations showed symptoms of cord stretching when higher weights were applied in terms of pain, dizziness, nausea and hypotension with neurological deterioration in two. Maximum weight that could be tolerated was only up to 28% of body weight. MUA was associated with high risk because of compromised cardio-pulmonary status in majority. It was tried only when this protocol failed in four of six unacceptable reductions. In all four reduction could not be achieved by MUA and they required open reduction. Two patients did not give consent for MUA and for surgery and remained unreduced. Distal neurological recovery was seen in 23.33% of complete and 88.23% of incomplete cases. Rapid root recovery at the site of cord injury was seen in all 47 patients suggesting zonal segmental recovery. Pain function score as per Porlo’s scale was satisfactory in 43 of 47 patients. Loosening and infection at pin site was observed in four. Two patients who deteriorated neurologically on increasing the weights of skeletal traction recovered to initial level within a week when weights were brought back to tolerance limits.

Conclusions Cervical fracture-dislocations can easily be reduced without the need of heavy traction if traction is applied on vector principles. Manipulation under anesthesia with associated risks seem to have no advantage over reduction by this protocol.

Introduction We have undertaken a retrospective study to identify prognostic factors predictive of neurological recovery after spinal cord injury (SCI).

Methods During the year 1999 to 2000, 403 patients with SCI were admitted and 91 patients could be followed-up for more than one year. Improvement in the motor score (ASIA) were taken as indicative of functional neurological recovery. Prognostic factors were simplified into static (which do not change with time) and dynamic (which may change with time). Variables like age, sex, mode of injury, mechanism of injury and skeletal level were static. Neurological level, sacral sparing, duration of spinal shock, reflex recovery, sensory & motor scores and complications like bedsores, flexor spasms, UTI, URTI, & DVT were dynamic. These were recorded at admission, at weekly intervals until discharge and at three monthly intervals in follow-up. They were correlated for any association with neurological recovery at one year. Regressive analysis of static and dynamic factors was done.

Results No significant correlation of static variables with the neurological recovery was found. First aid and transportation, duration of spinal shock, sacral sparing, rate of reflex recovery, flexor spasms and bedsores had a significant correlation with neurological recovery. Pin-prick sparing, spinal shock of < 24 hours and early appearance of deep tendon reflexes were good prognostic factors. Complete lesion, spinal shock for > 1 week, flexor spasms within three weeks and bedsore within one week were worst prognostic factor. Initial three weeks following injury was the critical period influencing final neurological and functional outcome.

Introduction Management of bedsores in traumatic paraplegia has been a challenge since time immemorial. Conventional serial debridement and dressings require prolong hospitalization, imply posible complications and are an economic burden. Modalities like hyperbaricoxygen, electrical stimulation, altered cultured keratinocytes are cumbersome, expensive, and not readily available. Negative pressure to promote wound healing is under evolution. This study evaluates the effect of negative pressure in bedsore management.

Methods The Negative Pressure Device (NPD) included sterilized foam, a low power continuous suction apparatus (Romovac) and a transparent polyurethane adhesive dressing. NPD was exclusively a bedside procedure. The perforated end of a drainage tube was placed on the wound surface and other end exited 10 cms away from wound margin, connected to Romovac. Sterilized foam was trimmed to size and geometry of wound as cover. Opsite closed the wound with an airtight seal. The bellow of Romovac was charged to attain negative pressure. Recharging was done after five to six hours. The wound inspected and dressings changed every five to seven days.

Results NPD converted an open wound into a close controlled wound. By drawing away fluid from the wound it prevented collection of secretions and decreased purulence. Negative pressure increased vascularity, enhanced granulation tissue and rapidly reduced the size and depth of wound. Airtight sealing prevented soiling and odor enabling universal acceptance. In controlled based study, NPD: Reduced the frequency of dressing from once daily to once in five to seven days (cost effective). Reduced bacterial contamination and substantially increased granulation tissue. Serial microbial assessment of wound revealed efficacy in controlling bacterial growth and achieving a sterile culture within 10 days. Prooved itself to be an efficient and painless method of serial debridement. Reduced wound size and depth to one third of the original within three weeks. Was well tolerated by patients. The drawbacks of NPD were: Failure in low sacral bedsores close to the natal cleft. Difficulty in getting an airtight seal using Opsite. The tendency of the sterile foam to disintegrate, making the secretions viscous and clogging the drain. Tendency to increase bleeding, during changes of dressings, from the exuberant granulation tissue which formed.

Conclusions NPD is a bedside procedure, easy to apply, with minimal side effects. It reduces the frequency of dressings and duration of hospitalization. By converting an open wound into a close-controlled wound it decreases purulence, hastens recovery and prevents soiling and the characteristic odor. The NPD apparatus suggested is innovative, cost-effective.