This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review

Aims. The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Methods. Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. Results. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Conclusion. Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research. Cite this article: Bone Joint J 2023;105-B(4):400–411

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Aims. Non-coding microRNA (miRNA) in extracellular vesicles (EVs) derived from mesenchymal stem cells (MSCs) may promote neuronal repair after spinal cord injury (SCI). In this paper we report on the effects of MSC-EV-microRNA-381 (miR-381) in a rodent model of SCI. Methods. In the current study, the luciferase assay confirmed a binding site of bromodomain-containing protein 4 (BRD4) and Wnt family member 5A (WNT5A). Then we detected expression of miR-381, BRD4, and WNT5A in dorsal root ganglia (DRG) cells treated with MSC-isolated EVs and measured neuron apoptosis in culture by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining. A rat model of SCI was established to detect the in vivo effect of miR-381 and MSC-EVs on SCI. Results. We confirmed an interaction between miR-381 and BRD4, and showed that miR-381 overexpression inhibited the expression of BRD4 in DRG cells as well as the apoptosis of DRG cells through WNT5A via activation of Ras homologous A (RhoA)/Rho-kinase activity. Moreover, treatment of MSC-EVs rescued neuron apoptosis and promoted the recovery of SCI through inhibition of the BRD4/WNT5A axis. Conclusion. Taken altogether, miR-381 derived from MSC-EVs can promote the recovery of SCI through BRD4/WNT5A axis, providing a new perspective on SCI treatment. Cite this article: Bone Joint Res 2021;10(5):328–339

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents. Cite this article: Bone Joint J 2023;105-B(4):347–355

Aim. The aim of the study was to define the peculiarities of bone remodeling and identify specific parameters to development to heterotopic ossification. Materials and methods. Markers of bone formation (Osteocalcin, serum type 1 procollagen (N-terminal) (tP1NP)) and bone resorption (serum collagen type 1 cross-linked C-telopeptide (β-CTx)) were determined by the electrochemiluminiscence immunoassay “ECLIA” for Elecsys user cobas immunoassay analyser. In the study were included 23 patients with spinal cord injury – first group (average age 26.8 ± 3.9, duration of spinal cord injury from 3 to 12 months) and 23 healthy people's appropriate age and gender (average age 30.6 ± 6.0, years). In the first group included 11 patients with spinal cord injury with the presence of heterotopic ossification – subgroup I and 12 patients with spinal cord injury without heterotopic ossification – subgroup II. Results. The results of examination showed that patients of first group had significantly higher bone markers than control group: P1NP (256.7±48.2 ng/ml vs 49.3±5.1 ng/ml, p<0.001), serum β-CTx (1.47±0.23 ng/ml vs 0.45±0.04 ng/ml, p<0.0001), osteocalcin (52.2±9.8 ng/ml vs 24.9±2.08 ng/ml, p<0.001). There were obtained that levels of bone remodeling markers in patients with HO were significantly higher in comparison with patients without HO: P1NP (404.9±84.9 ng/ml vs 133.2±15.7 ng/ml, p<0.001), serum β-CTx (1.75±0.23 ng/ml vs 0.28±0.14 ng/ml, p<0.0001), osteocalcin (87.1±18.9 ng/ml vs 29.4±3.7 ng/ml, p<0.001). Conclusion. The bone formation and bone resorption markers in patient of first group were significantly higher than in healthy individuals of appropriate age. The rate of bone turnover markers in patient with HO was considerably higher than in patient without HO and the process of formation dominated over the resorption in patient with HO

Despite advances in treating acute spinal cord injury (SCI), measures to mitigate permanent neurological deficits in affected patients are limited. Augmentation of mean arterial blood pressure (MAP) to promote blood flow and oxygen delivery to the injured cord is one of the only currently available treatment options to potentially improve neurological outcomes after acute spinal cord injury (SCI). However, to optimize such hemodynamic management, clinicians require a method to measure and monitor the physiological effects of these MAP alterations within the injured cord in real-time. To address this unmet clinical need, we developed a series of miniaturized optical sensors and a monitoring system based on multi-wavelength near-infrared spectroscopy (MW-NIRS) technique for direct transdural measurement and continuous monitoring of spinal cord hemodynamics and oxygenation in real-time. We conducted a feasibility study in a porcine model of acute SCI. We also completed two separate animal studies to examine the function of the sensor and validity of collected data in an acute experiment and a seven-day post-injury survival experiment. In our first animal experiment, nine Yorkshire pigs underwent a weight-drop T10 vertebral level contusion-compression injury and received episodes of ventilatory hypoxia and alterations in MAP. Spinal cord hemodynamics and oxygenation were monitored throughout by a transdural NIRS sensor prototype, as well as an invasive intraparenchymal (IP) sensor as a comparison. In a second experiment, we studied six Yucatan miniature pigs that underwent a T10 injury. Spinal cord oxygenation and hemodynamics parameters were continuously monitored by an improved NIRS sensor over a long period. Episodes of MAP alteration and hypoxia were performed acutely after injury and at two- and seven-days post-injury to simulate the types of hemodynamic changes patients experience after an acute SCI. All NIRS data were collected in real-time, recorded and analyzed in comparison with IP measures. Noninvasive NIRS parameters of tissue oxygenation were highly correlated with invasive IP measures of tissue oxygenation in both studies. In particular, during periods of hypoxia and MAP alterations, changes of NIRS-derived spinal cord tissue oxygenation percentage were significant and corresponded well with the changes in spinal cord oxygen partial pressures measured by the IP sensors (p < 0.05). Our studies indicate that a novel optical biosensor developed by our team can monitor real-time changes in spinal cord hemodynamics and oxygenation over the first seven days post-injury and can detect local tissue changes that are reflective of systemic hemodynamic changes. Our implantable spinal cord NIRS sensor is intended to help clinicians by providing real-time information about the effects of hemodynamic management on the injured spinal cord. Hence, our novel NIRS system has the near-term potential to impact clinical care and improve neurologic outcomes in acute SCI. To translate our studies from bench to bedside, we have developed an advanced clinical NIRS sensor that is ready to be implanted in the first cohort of acute SCI patients in 2022

Aim: To determine whether timing of intervention affects neurological outcome after spinal cord injury resulting from rugby cervical facet dislocations. Methods: An observational study on 57 rugby players who were admitted to a Spinal Cord Injuries Unit from 1988 to 2000 with cervical spine facet dislocations. Experienced medical officers, an orthopaedic specialist and physiotherapists determined the admission and discharge Frankel grades (A to E). The time was recorded from the actual injury to successful reduction in hours. The usual method of reduction was by Rapid Incremental Traction on an Awake Patient. Statistical analysis was performed using parametric and non-parametric tests (Mann Whitney). Results: 14 patients were treated within 4 hours of injury and 43 were treated after 4 hours. The median Frankel gain for patients reduced within 4 hours was 5 but only 2 for those reduced after 4 hours (p= 0.0002). Conclusion: Time from injury to intervention does significantly affect neurological outcome in a homogenous group of spinal cord injuries in fit young males as a result of low velocity trauma mechanisms. Spinal cord injuries secondary to cervical facet dislocations in these patients should be regarded as an absolute emergency

Objective: The purpose of this study was to assess whether the use of high dose methylprednisolone (MPS) given to trauma patients with acute spinal cord injury improves neurological and long term functional outcomes. Summary of Background Data: The National Acute Spinal Cord Injury Studies (NASCIS II and III) recommend the early administration of high dose MPS in the context of acute spinal cord injury. However, controversy exists surrounding its long term benefits. Methods: A retrospective data analysis was performed using the Helicopter Emergency Medical Service (HEMS) trauma registry, medical records, and rehabilitation notes of 263 trauma patients with acute spinal injury admitted over a 6-year period. All survivors over 16 years of age with documented spinal cord injuries were selected. Frankel grade, Injury Severity Score (ISS), and Functional Independence Measure (FIM) scores (minimum FIM of 18 implies total dependence, and a maximum of 126 implies no disability) as indicators of neurological and functional morbidity were recorded at initial presentation, hospital discharge, and intervals up to 12 months post injury. Details of the age, gender, mechanism of injury, nature of injury and associated injuries were also recorded. Results: There were 139 patients (107 males and 32 women) with documented acute spinal cord injuries, of which 74 patients had neurological deficits (Frankel A–D) at presentation. 49 patients were given high dose MPS within 8 hours of injury according to a standard protocol. The remaining 25 patients with documented neurological injury did not meet criteria or failed to receive the agent within the recommended time. The mean ISS scores were shown to be comparable in both groups. 59% (29/49) of patients who were given MPS showed an improvement of one or greater Frankel grade at the time of discharge whereas 52% (13/25) of patients who did not receive MPS showed a similar improvement in Frankel grades. We had long term functional outcome data (FIM scores) on 48% (67/139) of the total number of patients. At the time of discharge, the mean FIM scores for the MPS treated group and non MPS treated group were 68 and 90, respectively. Whereas at 12 months, there was no significant difference in the mean FIM scores between the two groups (both of which were > 100). Conclusions: The Frankel grade assesses the degree of neurological impairment while FIM scores are a basic measure of the severity of disability regardless of the underlying impairment. In our study, patients given high dose MPS in the context of acute spinal cord injury showed some early improvement in Frankel grades. However, we have shown, there is no short term or long term benefit in terms of functional outcome by using MPS in trauma patients with acute spinal cord injury

Summary Statement. In this study, we observed that MR16-1, an interleukin-6 inhibitor, recovered phosphatidylcholine containing docosahexaenoic acid at the injury site after spinal cord injury in mice model by using imaging mass spectrometry. Introduction. The current drugs for improving motor function of the limbs lost due to spinal cord injury (SCI) are ineffective. Development of new drugs for spinal cord injury is desired. MR16-1, an interleukin-6 inhibitor, is found to be effective in improving motor function after spinal cord injury in mice model. Thus, we examined the molecular mechanism in more detail. Therefore, the purpose of this study was to analyze the molecular changes in the spinal cord of the SCI mice treated with MR16-1 using imaging mass spectrometry. Methods. All experiments were performed according to the guidelines for animal experimentation and care and use of laboratory animals established by Hamamatsu University School of Medicine (Shizuoka, Japan). We used 36 adult female C57BL/6J mice for laminectomy and contusion injury of the spinal cord that were performed at the T10 level using the Infinite Horizon Impactor (IH Impactor, 60 kdyn; Muromachi, Tokyo, Japan). Immediately after SCI, mice were intraperitoneally injected with a single dose of MR16-1 (Chugai, Tokyo Japan) (100 µg/g body weight, MR16-1 group) or a single dose of phosphate-buffered saline (PBS) of the same volume (control group). Motor function of the hind limbs was evaluated using the Basso Mouse Scale (BMS), an open-field locomotor test in which the scores range from 0 points (scored for no ankle movement) to 9 points (scored for complete functional recovery). BMS scores were recorded at 1, 7, 14, 21, 28, 35, and 42 days after SCI. The spinal cord tissues were flash frozen and were sliced to a thickness of 8 µm using a cryostat (CM1950; Leica, Wetzler, Germany). Imaging mass spectrometry was used to visualise 12 molecular species of phosphatidylcholine (PC) from thin slices of the spinal cords obtained at 7 days post-SCI. Results. The contusive SCI immediately resulted in complete paralysis. The MR16-1–treated group showed a significant improvement in the BMS locomotor score compared with the control group at both 7 days and 42 days after SCI (1.4 vs 0.2 points and 4.0 vs 1.4 points, respectively). Phospholipids at 7 days after SCI showed unique distribution patterns. In particular, PCs containing docosahexaenoic acid (DHA) localised in the gray matter region was significantly higher in the MR16-1–treated group than in the control group, at 7 days post-SCI. Discussion. MR16-1 treatment showed to improve locomotor BMS score after 7 days of SCI compared with that observed in the control group. Spinal cord injury had induced inflammation; injury sites showed changes in the lipid content. We had previously reported that PC containing DHA mostly expressed in neuron cells decrease on injury sites. In this study, we observed that MR16-1 recovered PC containing DHA at the injury site. This may be associated with the recovery of motor function

Objective: Syrinx formation is estimated to occur in 20–25% patients after spinal cord injury. Aim of this study was to analyse the factors affecting the formation of post-traumatic syrinx. Design: Retrospective study of 295 patients with spinal cord injury treated in a spinal injury centre with a minimum follow-up of two years since injury. Patient notes, x-rays and scans were reviewed. Subjects: Two hundred and fifty-two men and 43 women were included in the study. The spinal injury was treated non-operatively in 172 (M 144, F28) patients and surgically in 123 (M 108, F 15) patients. Average age at the time of injury was 28.2 years. Mean follow-up was 6.4 years (2–34). There were 98 cervical, 134 thoracic and 73 lumbar and thoracolumbar injuries. Outcome Measures: The incidence of post-traumatic syrinx in both groups and its relationship with level and type of skeletal injury, severity of spinal cord injury, sagittal angle at the injury level were assessed. Results: In total 59 (20%) patients were identified with post-traumatic syrinx. Of the 123 patients managed operatively 15 (12.2%) had syrinx as did 44 (25.6%) of the 172 patients treated conservatively (p=0.001). Twenty-one (21.4%) cervical injuries, 29 (21.6%) thoracic injuries and nine (12.3%) lumbar injuries were found to have syrinx (p=0.023). Twenty-seven (46%) patients with syrinx had complete cord injury as did 130 (55%) patients who did not have syrinx (p=0.112). Fracture-dislocation was the injury most commonly associated with post-traumatic syrinx. Of the 40 `patients who had fracture dislocation as original injury, syrinx developed in 16 (40%). Eleven of the 18 patients with conservatively managed fracture dislocation, developed syrinx, compared to five of the 32 operatively treated fracture dislocations (p=0.0001). The mean sagittal angle at the level of injury was 25.2° in those syrinx formation, 20.4° in the conservatively treated patients without syrinx (p=0.1191) and 15.32° in the surgically treated patients without syrinx (p=0.016). Conclusions: In a series of 295 patients, post-traumatic syrinx formation was found in 20% cases. It was significantly more common in patients treated conservatively, especially if the original injury was fracture dislocation. Syrinx formation was also significantly more common in cervical and thoracic cord injuries, but had no association with the completeness of cord injury. In the sagittal plane there was significantly more kyphotic deformity in those with syrinx formation

Introduction: Complete spinal cord injury patients demonstrate an initial rapid lower limb bone mineral density loss. 1,. 2. ; Reports suggest an increase incidence of lower limb fractures in such patient. 3. Such injuries place an additional burden on patients undergoing rehabilitation. Aims: This prospective study was established to assess whether disuse osteopenia contributes to increased incidence of lower limb fractures in patients following complete spinal cord injury. We compare this cohort to patients who attained mobility after their spinal cord injury. Methods: We prospectively reviewed 128 patients (107 male; 21 female) treated in our unit, a Tertiary Referral Spinal Trauma Unit. All patients presented between January 1994 and July 2002. There were 66 patients 958 male; 8 female) who initially presented to this unit and subsequently attained mobility either while in hospital or during rehabilitation. Both groups were comparable in age and sex profiles. Results: The mean length of follow-up was 58 months for patients with complete neurology and 64 months for those who attained mobility. There were 4 lower limb fractures in the group of patient with complete neurology. Two patients sustained supracondylar femoral fractures with one requiring operative intervention, while 2 patients with mid-shaft tibia/fibula fractures were treated conservatively. Conclusions: Previous papers have shown that patients with complete neurology after spinal injury undergo disuse osteopenia. We report an increase incidence of lower limb fractures in patients with complete neurology compared to patients initially presenting with neurology but attaining full mobility. This difference is statistically significant, (p< 0.05)

Purpose: Prospective Observational Population Study to describe the incidence, demographics and pattern of spinal cord injury in British Columbia, Canada, for 10 years to 2004. Method: Systematic analysis of prospectively collected spine registry data (Vertebase) at Vancouver General Hospital, B.C., Canada from 1995–2004. Results: During the 10-year study period the 938 patients were admitted with a traumatic spinal cord injury. The Annual Population-Standardized Incidences ranged from 19.94 to 27.27 per million, with a median incidence of 23.34/million and with no significant change over the study period. The mean age was 39.7 years (34.73 in 1995 and 42.1 in 2004, p< 0.05) with a range of 16–92 years. 79.74 % were males. 48.2% of patients were AISA A on admission, of which 48% were quadraparetic. The most common levels of spinal cord injury were C5 (17.3%), C6 (10%), T1 (9.4%), T12 (5.8%). The Mean ASIA score was 50.22 with a range from 0–100. 19.8% of patients had a GCS£13. The mean ISS was 26.02, range of 0 – 75. Motor vehicle collisions and falls were responsible for 59% and 30% of admissions respectively. Mean length of in-hospital stay was 34 days, ranging from 1 – 275 days. In hospital mortality rate was 2.9%. ASIA Grade, Total Motor Score and anatomical level of injury all correlated directly with Length of stay (p< 0.0001). Conclusion: Acute Traumatic Spinal Cord Injury remains a major cause of significant morbidity among young males. The incidence appears to be increasing in the elderly. Modern multidisciplinary care has greatly reduced the associated acute mortality. Despite multiple prevention strategies the Annual Population-Standardized Incidence remained unchanged over the study period

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

Objective: To assess the result of surgical stabilisation of spine in Spinal cord injured patients. Design: Retrospective review of patients managed and followed at a spinal injury centre. Subjects: Sixty-six patients with spinal cord injury, treated with surgical stabilisation of their spinal fracture and followed for a minimum of two years. Outcome Measures: Delay in starting ambulation from injury/surgery, sagittal balance, metalwork failure and surgical complications. Results: The mean age was 29.5 years (17–67), and five patients were female. The median follow up was 7.9 years (2–24). There were 19 cervical, 21 thoracic and 28 thoracolumbar and lumbar fractures. A total of 36 patients had over six weeks delay in starting ambulation. Of these 11 were due to inadequate fixation. Ten patients (50%) with cervical fracture and seven patients (25%) with lumbar fractures had normal lordosis. Significantly more patients with anterior cervical fixation had normal lordosis compared to those with posterior fixation. Nineteen with thoracic fracture had thoracic kyphosis within 40°. Nine patients had failure of metalwork. Surgical complications occurred in 21 (33%) patients. Conclusion: Early ambulation was not achieved in the majority. The maintenance of lordosis was successful in cervical but not in lumbar spine. Posterior fixation of thoracic spine was successful in maintaining normal sagittal balance

The NASCIS studies reported improved long-term neurological recovery when high dose methylprednisolone was administered following spinal cord injury. To determine if there is correct implementation of the NASCIS protocols. Prospective observational study. The admission Frankel grade and ASIA neurological classification were recorded. 100 patients with complete or incomplete spinal cord injuries were studied during a 24 month period. Outcome Measures: Correct administration of methyprednisolone. The mean ASIA score was 192 and median Frankel grade was C. Only 25% of the patients received methyl-prednisolone according to the NASCIS regime. “Evidence Based Medicine” is not being adopted

AO Spine Reference Centre & Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Australia. Traumatic spinal cord injury (SCI) is a devastating condition with no curative therapy. Pro-inflammatory therapy has been suggested recently to try and reduce the inhibitory glial scar and promote neural regeneration and healing. The aim of this study is to investigate the potential of sustained delivery of angiogenic/pro-inflammatory growth factors to reduce the secondary degeneration after spinal cord injury. Adult male Wistar Kyoto rats (200-300g; 12-16weeks old) were subjected to cord hemisections via a T10 laminectomy. Animals were randomised to treatment or control groups after the spinal cord injury had been induced. Treatment consisted of implantation of a mini-osmotic pump capable of delivering 5 micrograms vascular endothelial growth factor (VEGF) and 5 micrograms platelet-derived growth factor (PDGF), via a catheter, to the site of the lesion, over 7 days(n=6). Control animals were subjected to either cord lesion only (n=6) or lesion plus mini-pump delivering PBS (phosphate-buffered saline) solution (n=6). Rats were sacrificed at one month and the spinal cords were harvested and examined by immunohistology, using anti-neurofilament-200 and anti-Glial Acidic Fibrillary Acidic Protein (GFAP) antibodies. RESULTS: Active treatment spinal cords showed a higher level with aboration of the axonal filament through the defect and more dense neurofilament-200 staining at the lesion site compared to both control groups. The treatment also showed the elevated presence of activated microglia in the lesion, whilst distal to the lesion the microglia and astrocytes retained an unreactive phenotype. Pro-inflammatory therapy in the rat spinal cord-injury model showed favourable histological findings after sustained delivery of PDGF and VEGF

Silver nanoparticles (AgNPs) possess anti-inflammatory activities and have been widely deployed for promoting tissue repair. Here we explored the efficacy of AgNPs on functional recovery after spinal cord injury (SCI). Our data indicated that, in a SCI rat model, local AgNPs delivery could significantly recover locomotor function and exert neuroprotection through reducing of pro-inflammatory M1 survival. Furthermore, in comparison with Raw 264.7-derived M0 and M2, a higher level of AgNPs uptake and more pronounced cytotoxicity were detected in M1. RNA-seq analysis revealed the apoptotic genes in M1 were upregulated by AgNPs, whereas in M0 and M2, pro-apoptotic genes were downregulated and PI3k-Akt pathway signaling pathway was upregulated. Moreover, AgNPs treatment preferentially reduced cell viability of human monocyte-derived M1 comparing to M2, supporting its effect on M1 in human. Overall, our findings reveal AgNPs could suppress M1 activity and imply its therapeutic potential in promoting post-SCI motor recovery

Charcot spondyloarthropathy is one of the late complications of traumatic spinal cord injury that produces further disability. Purpose of this paper is to introduce 5 patients who developed Charcot spine after traumatic spinal cord injury treated surgically in our hospital (SIC) and discuss the result. Methods: 1) We experienced 7 pts who presented characteristic clinical and radiographic findings of Charcot spine treated in SIC for 20 years (an incidence < 1%). 2) 5 out of 7 pts underwent surgical fusion. They were 4 males, 1 female, aged: 39~66, previous injury comprises of: C6 Fracture-dislocation(Fx/Dx) in 1, T11 Fx/Dx in 2, T12 Fx/Dx in 2. respectively, 3) 4 pts had complete paraplegia, 0ne incomplete(Frankel B) and the Charcot spine occurred below fusion mass under the injured level. 4) Posterior spinal fusions combined with kyphosis correction were performed in 3, the same with posterior shortening osteotomy using TSRH instruments in 2. Fusions were extended to L4 in 1, L5 in 2, S1 in 2 respectively. Results: 1) 4 pts who had been followed-up over one year showed ultimate osseous union. Another one showed loosening of screws resulted in non-union at 5 months postoperatively. 2) Cobb angle of kyphosis were improved from 67.7 degrs. in av.(58~82) to 13.7 degrs in av. (15~36) by the operation. 3) All pts could have restored a good sitting balance tolerated a long time wheelchair sitting without any localized back pain. Conclusion: It is important for physicians who treat spinal cord injury patients to be aware of posttraumatic Charcot spine. As longevity of the people with paralysis is increasing, this phenomenon may occur more apparently. Special attention should be given to the spinal segments just below the fused level in patients with previous spinal fusion. For the unstable and symptomatic Charcot spine, a surgical correction and fusion should be considered. The correction of kyphosis is essential, but too much correction should be avoided, because it may worsen a sitting balance of the patient. We now recommend a posterior shortening osteotomy and rigid fusion using a solid pedicle screw instrumentation like TSRH

Introduction: Acute neurological damage from spinal cord injuries is believed to be localised, however it initiates a cascade of secondary events which usually leads to extensive and permanent neurological deficit. The secondary damage begins with the disruption of the blood-spinal cord barrier which unleashes a protracted inflammatory response. This prolonged inflammatory response is the catalyst for the secondary neurodegeneration and limited repair response that occurs in the chronic phase of a spinal cord injury. In this study it was proposed that the acute delivery of the angiogenic growth factors vascular endothelial growth factor (VEGF) and platelet derived growth factor (PDGF) would mediate inflammation and restore the blood spinal cord barrier. This would minimise the formation of glial scar and reduce the extent of secondary degeneration caudal and cranial to the lesion site. Methods: Adult male Wistar rats (400g) were anesthetised. Complete laminectomies were performed at T10 and the animals were subjected to T10 hemisection. Animals were randomised to a treatment group (Lesion Control (LC), Gel Control (GC) and Angiogenic Gel (AG)) after the spinal cord was cut. Each treatment group had 6 animals sacrificed 3 months post injury. Sections were stained with antibodies to neurofilament 200, glial fibrillary acidic protein, smooth muscle actin (SMA), and fluorescent secondary antibodies and mounted with DAPI. The lesion size was measured from horizontal histological sections of the midline from 5 animals in each group using Axiovision version 4.6.1.0 (Carl Zeiss Imaging Solutions, Germany). Results: The mean lesion size for the lesion control group was 2.09mm2, 1.97mm2 for the gel control group and 0.45mm2 for the active gel group. A t-test was used to confirm that the differences between the active gel and the two control groups were statistically significant (AG vs LC p= 0.021 AG vs GC p= 0.026). Histology showed a marked improvement of the morphology of the astrocytes in the treatment group over the control groups indicating that the treatment affected the population of reactive astrocytes. SMA staining showed an increased level of revascularisation in the treated lesions. Discussion: Spinal cords do not heal because of prolonged inflammation which leads to secondary necrotic events, scar formation and the inhibition of regeneration. In this study we present a method for regulating the post lesion inflammatory signals, significantly reducing post-lesion scar formation. We propose the delivery of VEGF/PDGF significantly increases the permeability of the blood spinal cord barrier to neutrophils and macrophages and promotes angiogenesis observed in the lesion site. This may have two major effects on the progression of the spinal cord injury. Firstly, by increasing the initial influx of inflammatory cells it enables the faster removal of damaged tissue and phagocytosis of apoptotic cells thereby restoring the balance in favour of regulated inflammation and results in a finite and reduced inflammation time. Secondly, combination of VEGF and PDGF provides a robust angiogenic response and reduces ischemia, the population of reactive astrocytes and the capacity to form glial scars. These growth factors appear to moderate the secondary degenerative changes that result from the prolonged inflammation and thus promote the inherent capacity for regeneration

Introduction The devastating and permanent effects of complete spinal cord injury are well documented. In animal models, olfactory ensheathing cells (OEC) transplanted into areas of complete spinal cord injury have promoted regeneration of the neural elements with reconnection of the descending motor pathways. This reproducible anatomical finding is associated with significant motor functional recovery. Accordingly, cellular transplantation therapies have been advocated for human spinal cord injury. In a single-blind, Phase I clinical trial, we aimed to test the feasibility and safety of transplantation of autologous olfactory ensheathing cells into the spinal cord of three humans with complete spinal cord injury. This paper describes the trial and the surgical procedures and presents twelve month safety data. Methods Six patients with paraplegia resulting from chronic (6 – 36 months post-injury) traumatic spinal cord injury (thoracic) were enrolled in the trial. Exclusion criteria included the presence of vertebral column instability, syringomyelia, an implanted spinal device or instrumentation and the presence of psychological instability. The patients were allocated to a treatment group and a control group. No intervention was undertaken to the control group. Olfactory ensheathing cells were harvested from each subject in the surgery group, grown and purified in vitro. After exposure via laminectomy, durotomy and adhesolysis, the cells were injected into the region of injured spinal cord. All patients are tested on enrollment and then at regular intervals up to three years by a group of assessors who are blinded to the treatment or control group status. These assessments include physical, radiological, neurophysiological and psychosocial parameters. Results All surgery patients exhibited continuity of presumed pia through the cystic region at the site of injury. The spinal cord adjacent to the cyst appeared macroscopically normal. There were no complications of surgery evident in the peri-operative period. At twelve months there was no evidence of tumour formation, syrinx development, clinical or psychosocial deterioration. Discussion The dictum, primum non nocere, is especially relevant to the emerging field of human spinal cord regeneration. Animal models promise such exciting potentials for therapy in this devastating condition, that the possibilities need to be fully explored. Anecdotal, non-trial based reports suggest that equivalent results may be able to be obtained in humans. However, science and care should guide the endeavours in this controversial field. This is the first reported trial of OEC’s in human spinal cord injury. Twelve-month data in a small cohort shows that there is no evidence of adverse events that would preclude completion of the current trial and the development of efficacy trials

Introduction: There are several complications associated with spinal cord injury. The authors propose to evaluate the complications developed during hospitalization of tetraplegic patients treated in our institution. Materials and Methods: The clinical and imaging records of 20 tetraplegic patients operated between 1995 and 2007 were evaluated (14 men and 6 women; mean age 31.5 years; 16 submitted to surgery using anterior cervical approach, 4 using posterior approach; 8 did steroids protocol during 24h and 12 during 48h; 9 patients were operated less than 48h after trauma and 11 patients after). Results: Mean hospitalization time was 47.4 days (men 48.9 d, women 23.4 d; anterior approach 50.25 d, posterior approach 39 d; corticosteroids during 24h 34.3 d, 55.3 d in those who did 48h; time until surgery < 48h 43.1 d, > 48h 54.5 d). 100% of patients developed respiratory tract infections. 56.3% of patients developed urinary tract infections (33% in patients doing corticosteroids during 24h, 70% in those who did 48h). Mean duration of mechanic ventilation was 20.3 days (anterior approach 19.3 d, posterior approach 19.8 d; steroids during 24h 16.7 d, steroids during 48h 21 d; time until surgery < 48h 13.6 d, > 48h 23 d). In 37.5% of patients a traqueostomy was performed (41.7% in patients submitted to anterior approach, 25% in posterior approach; 16.7% in patients doing steroids during 24h, 50% in those who did 48h; time until surgery < 48h 28.6%, > 48h 50%). Discussion: This patients are associated with long hospitalization and mechanic ventilation periods. Respiratory tract infection was the most frequent complication. The surgical approach had no influence on mechanic ventilation periods. Those submitted to anterior approach had longer hospitalization periods and higher incidence of traqueostomy. Patients who did corticosteroids during 48h had higher incidence of urinary tract infections and traqueostomy, and longer mechanic ventilation periods. Those operated less than 48h after trauma had shorter hospitalization and mechanic ventilation periods and traqueostomy procedure. Conclusion: Steroids longer than 24h, anterior cervical approach and time to surgery > 48h tend to be associated with higher complication rates

Purpose: Recent studies have examined the systemic inflammation that occurs following spinal cord injury (SCI) (Gris et al. 2008). It is believed that this systemic inflammation plays a role in the respiratory, renal and hepatic morbidity of SCI patients, ultimately contributing to mortality post-injury. Evidence of this inflammatory response has been shown as early as two hours post SCI (Gris et al. 2008) Intravital microscopy is a powerful tool for assessing inflammation acutely and in ‘real-time’ (Brock et al. 1999). This tool would be useful for demonstrating the acuteness of a systemic inflammatory response post-SCI, and for assessing the degree of inflammation to different severities of SCI. The liver has been shown to play a particularly important role in the initiation and progression of the early systemic inflammatory response to spinal cord injury (SCI), therefore the purpose was to evaluate hepatic inflammation immediately after SCI. We hypothesized that SCI would cause immediate leukocyte recruitment and that the magnitude of inflammation would increase with increasing severity of cord injury. Method: Male Wistar rats (200–225g) were randomly assigned to one of the following groups: uninjured, trauma-injured (laminectomy and no cord injury), cord compressed or cord transected. Spinal cord-injured rats were anesthetized by isoflurane, a dorsal laminectomy was performed, and the 4th thoracic spinal segment was injured by a moderately severe clip-compression injury or by a severe complete cord transection injury. Uninjured rats and trauma-injured rats served as controls. At 0.5 and 1.5 h after SCI rats had the left lobe of their livers externalized and visualized using intravital video microscopy. Results: At 0.5 hours the total number of leukocytes per post-sinusoidal venule was significantly increased after cord compression and cord transection compared to that in uninjured and trauma-injured rats (P< 0.05). Of these leukocytes significantly more were either adherent or rolling along venule walls compared to uninjured and trauma-injured rats (P< 0.05). Of the rolling leukocytes 2–fold more were observed after cord transection compared to cord compression. At 1.5 h the total number of leukocytes per post-sinusoidal venule and the number of adherent leukocytes was significantly increased only after cord transection. Conclusion: Injury to the spinal cord but not trauma alone causes immediate leukocyte recruitment to the liver within 0.5 h after injury. Also, leukocyte recruitment increases with increasing severity of injury. This is the first study to use intravital microscopy to visualize systemic inflammation in the liver following SCI

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

Primary spinal cord injury is followed by secondary, biochemical, immunological, cellular changes in the injured cord. A review article written by Brian Kwon looking critically at the use of hypothermia for SCI. It shows that it is neuroprotective in some settings (i.e. cardiac arrest). However, there are 25 animal studies with mixed results and only eight human SCI studies. Importantly, they are all case series of local, not systemic hypothermia. And the last one published was in 1984. Rho is a critical molecule in SCI. Rho ultimately inhibits axonal growth cone proliferation. Stopping RHO therefore will promote the growth cone. There are two drugs that ultimately targets rho. These are anti nogo antibodies and cethrin both of which ultimately inhibit rho. President Obama lifted the ban on federal funding of stem cell research. This was a monumental occasion and was right around the time that the FDA approved the first trial of hESC for SCI. The FDA trial of Geron is with Thoracic ASIA A SCI patients with transplantation of ESC directly into the cord at 7 to 14 days after injury. Geron has provided evidence to the FDA that there is no teratoma formation with transplantation of a human ESC to a rat or mouse. However, we do not know what will happen in a human to human transplant. In conclusion, use of steroids in setting of SCI is diminishing. There is no clinical evidence to support use of systemic hypothermia. Current clinical trials of pharmacologic therapy include Minocycline and RILUTEK(r) (riluzole) for neuroprotection, Anti-Nogo Antibodies and Cethrin(r) for axonal growth by ultimately inhibiting Rho. There is only one small study supporting safety, not efficacy of OEC transplantation

Summary Statement. Collagen scaffolds modified with collagen-binding bFGF promotes the neural regeneration in the rat hemisected spinal cord injury model. Objective. To investigate the effects of the collagen scaffolds (CS) combined with collagen-binding basic fibroblast growth factor (CBD-bFGF) on the neural recovery after spinal cord injury (SCI). Methods. The left lateral 3 mm hemisection SCI of rat model (at T9 level) was made. A bundle of 2mm×2mm×3mm CS fused with CBD-bFGF (2μg/10μl/bundle, CS/bFGF) was implanted into hemi-transected gap. There were four groups in this experiment, the sham group without SCI, the control group with SCI, the CS-treated group with SCI and implanted CS, the CS/bFGF-treated group with SCI and implanted CS/bFGF. The 21-point Basso-Beattie-Bresnahan (BBB) scale was performed before the operation and at 1 week intervals after SCI for 8 weeks to assess the hindlimb locomotor function. 4 and 8 weeks after operation, footprint analysis was applied to evaluate the body weight support and limb coordination, respectively. H&E staining and immunohistochemistry for neurofilament (NF) and glial fibrillary acidic protein (GFAP) was administrated for histological evaluation at 4 and 8 weeks post injury, respectively. Results. 1). The survival curve showed that CS/bFGF-treated group had a significantly higher survival rate than that of the control group and CS-treated group, while the control group had the lowest one. 2). BBB score showed all the animals with SCI showed a gradual recovery in hindlimb locomotor function during the 8 weeks period. Moreover, the left hindlimb function in CS/bFGF-treated recovered faster and better than that of the control group and CS-treated group. Footprint analysis showed a significant improvement in interlimb coordination in the CS/bFGF-treated group contrast to the CS-treated and control groups at 4 and 8 weeks, respectively. The base of support was obviously reduced in CS/bFGF group and 8 weeks after SCI, the base of support of the CS/bFGF-treated group could closely approximate that of sham-operated group. Compared to the control and CS-treated groups, the CS/bFGF-treated group showed smaller angle of rotation. In addition, toe dragging was more serious in the control and CS-treated group than that in the CS/bFGF group. 3). At 4 and 8 weeks, spinal cord sections stained with H&E showed a significant increase in the density of linear fibrous tissues and cell infiltration in and around the scaffold of CS/bFGF-treated group compared to the control and CS-treated groups. The CS/bFGF-treated group showed highest NF-positive neural fiber density. Besides, the NF-positive neural fibers could extend into the scaffold and grow along with the direction of CS. GFAP. +. astrocytes were present around the hemi-transected site in all SCI rats. But the CS/bFGF-treated group showed lower number of GFAP. +. cells than that of the control and CS treated group at 4 and 8 weeks after the surgery, respectively, while in the control group the number of GFAP+ cells was highest. Conclusions. The data suggested that implantation of CS/bFGF into a semi-transected SCI rat model can guide axon growth at the injury site and promote obvious improvement in functional recovery. As a result, CS/bFGF combination could be a promising alternative system for the clinical application of SCI repair

Spinal cord injury following trauma is initially dealt with by acute hospitals. The early management including stabilization is usually performed by these centres. This is followed by onward referral to one of the Regional Spinal Injury Units. There is concern of both sides of the fence regarding mobilization following spinal cord injury. The acute hospitals want to avoid the problems of prolonged recumbency and the Regional Spinal Injury Units wish to avoid the problems of early aggressive mobilization. Therefore, we set out to discover if there was a standard approach to mobilising these patients following surgical stabilization, because of the oversubscribed resources of the spinal injury units and the wish to start mobilizing the injured as soon as possible. A comparative audit of the Regional Spinal Injury Units in the UK and North American Units. Regional Spinal Injury Units in United Kingdom and North America. Clear Management Plan. Mobilisation Schedule. We had replies from all Regional Spinal Injury Units in the UK and from seven in North America. The Regional Spinal Injury Units all had differing approaches. Only a few were able to convey a clear management plan and mobilization schedule. Whereas the North American Units provided a ‘mobilize as able’ plan in all cases. The North American Units had a ‘mobilize as able’ policy, whereas the UK units had a mixed approach. A coherent collaboration between the spinal surgeons stabilizing these injuries and the spinal injury units providing rehabilitation would improve patient management

Spinal cord damage was compared after an injury was inflicted by three clinically relevant mechanisms (contusion, dislocation, and distraction). A novel SCI multi-mechanism system has been developed. Central hemorrhage was common to all mechanisms. Increased membrane permeability was localized to the injury epicenter in contusion but spread further in distraction. Dislocation showed intermediate characteristics exhibiting both local neuronal losses at the epicenter and extended regions of membrane permeability. These preliminary observations suggest that distinct injury mechanisms result in differences in the primary damage of the spinal cord. This work compared primary damage after spinal cord injury (SCI) inflicted by three clinically relevant mechanisms. Different injury mechanisms result in regional differences in damage to the spinal cord. Differences in acute damage may help guide targeted therapies following SCI. At greater distances from the lesion, dextran was excluded from neuronal somata and in the white matter only distinct accumulation was seen at the Nodes of Ranvier. At the injury site, hemorrhage was common to all mechanisms although more diffuse in the distraction injuries. Increased membrane permeability was localized to the injury epicenter in contusion but spread further in distraction. Dislocation showed intermediate characteristics exhibiting both local neuronal losses at the epicenter and extended regions of permeability. A novel SCI multi-mechanism system was developed which uses an electromagnetic actuator to permit the modeling of injuries along any direction. Dextran was infused into the cisterna magna 1.5 to 2 hours prior to injury in order to visualize increases in membrane permeability. Stereotaxic clamps were designed to rigidly hold the lower cervical vertebrae of deeply anaesthetized rats permitting displacements at speeds of 100cm/s. A range of displacements was used in this pilot series: 0.9 to 1.1mm contusion, 2 to 6mm dislocation and 3 to 8mm axial distraction. Animals were sacrificed at five minutes in order to analyse the primary injury. These preliminary observations suggest that distinct injury mechanisms result in regional differences in the primary damage of spinal cord gray and white matter

Spinal cord injury (SCI) is a devastating disorder for which the identification of exacerbating factors is urgently needed. Although age, blood pressure and infection are each considered to be prognostic factors in patients with SCI, exacerbating factors that are amenable to treatment remain to be elucidated. Microglial cells, the resident immune cell in the CNS, form the first line of defense after being stimulated by exposure to invading pathogens or tissue injury. Immediately after SCI, activated microglia enhance and propagate the subsequent inflammatory response by expressing cytokines, such as TNF-α, IL-6 and IL-1β. Recently, we demonstrated that the activation of microglia is associated with the neuropathological outcomes of SCI. Although the precise mechanisms of microglial activation remain elusive, several basic research studies have reported that hyperglycemia is involved in the activation of resident monocytic cells, including microglia. Because microglial activation is associated with secondary injury after SCI, we hypothesized that hyperglycemia may also influence the pathophysiology of SCI by altering microglial responses. The mice were anesthetized with pentobarbital (75 mg/kg i.p.) and were subjected to a contusion injury (70 kdyn) at the 10th thoracic level using an Infinite Horizons Impactor (Precision Systems Instrumentation). For flow cytometry, the samples were stained with the antibodiesand analyzed using a FACS Aria II flow cytometer and the FACSDiva software program (BD Biosciences). We retrospectively identified 528 SCI patients admitted to the Department of Orthopaedic Surgery at the Spinal Injuries Center (Fukuoka, Japan) between June 2005 and May 2011. The patients' data were obtained from their charts. We demonstrate that transient hyperglycemia during acute SCI is a detrimental factor that impairs functional improvement in mice and human patients after acute SCI. Under hyperglycemic conditions, both in vivo and in vitro, inflammation was enhanced through promotion of the nuclear translocation of the nuclear factor kB (NF-kB) transcription factor in microglial cells. During acute SCI, hyperglycemic mice exhibited progressive neural damage, with more severe motor deficits than those observed in normoglycemic mice. Consistent with the animal study findings, a Pearson χ2 analysis of data for 528 patients with SCI indicated that hyperglycemia on admission (glucose concentration ≥126 mg/dl) was a significant risk predictor of poor functional outcome. Moreover, a multiple linear regression analysis showed hyperglycemia at admission to be a powerful independent risk factor for a poor motor outcome, even after excluding patients with diabetes mellitus with chronic hyperglycemia (regression coefficient, −1.37; 95% confidence interval, −2.65 to −0.10; P < 0.05). Manipulating blood glucose during acute SCI in hyperglycemic mice rescued the exacerbation of pathophysiology and improved motor functional outcomes. Our findings suggest that hyperglycemia during acute SCI may be a useful prognostic factor with a negative impact on motor function, highlighting the importance of achieving tight glycemic control after central nervous system injury

Summary of background data. The development of a spinal deformity, usually affecting the coronal and occasionally the sagittal balance of the spine is a recognised complication of paralysis following a spinal cord injury (SCI) occurring in childhood. Purpose of the study. The aim of the present study was to report our experience on the surgical treatment of patients who developed a paralytic spinal deformity secondary to SCIs occurring in childhood. Material-Methods. Our study cohort comprised 18 consecutive patients with a paralytic spinal deformity as a consequence of a SCI. The cause of paralysis in this group of patients included a traumatic incident in 10 patients, spinal cord tumour in 6 patients, vascular injury to the neural cord during cardiac surgery in one patient, and meningitis in one patient. Twelve patients presented with high- or mid-thoracic paraparesis, which was complete in all but two patients. Six patients developed tetraparesis, which was incomplete in 3 of these patients. Results. Fourteen patients underwent surgical correction of their spinal deformities; 11 patients had a scoliosis, 2 had a lordoscoliosis, and one had a kyphosis. The mean age at spinal arthrodesis was 13.4 years. Eleven patients underwent a posterior spinal fusion alone and 3 patients underwent a combined anterior and posterior spinal arthrodesis. Posterior spinal instrumentation with bilateral Luque rods and segmental fixation with sublaminar wires was used in all but one patient who was stabilised with the use of third generation spinal instrumentation. The spinal fusion extended to the sacrum in 10 of the 14 patients (71.4%) using the Galveston technique of intra-iliac pelvic fixation. None of the patients developed postoperative wound infections, either early or late. There were no major medical complications following surgery in this group of patients that would result in prolonged intensive care unit or hospital stay. Four of the 14 patients (28.6%) who had initially undergone a posterior spinal arthrodesis alone developed an asymptomatic pseudarthrosis with failure of the instrumentation. The non-union was treated successfully in 2 of these 4 patients with a combined anterior and posterior spinal fusion. The repair of the pseudarthrosis was performed through a repeat posterior spinal fusion in the remaining 2 patients and one of these patients necessitated a second revision procedure to address recurrence of the non-union. Conclusions. The high rate of pseudarthrosis (28.6%) recorded in the present series suggests that a combined anterior and posterior spinal arthrodesis could be considered as the initial treatment of choice for patients who are at a good general medical condition to tolerate anterior surgery and who have severe deformities. If pseudarthrosis develops following an isolated posterior spinal fusion, this can be treated more effectively by a combined anterior and posterior revision procedure with the use of instrumentation, which can increase the chances for a successful outcome

After spinal cord injury (SCI) rapid muscle atrophy and extensive bone loss occur in the paralysed limbs resulting in increased fracture incidence (mostly at the epiphyses in the distal and proximal tibia and distal femur). We investigated whether re-introducing mechanical loading of the lower-limb bones in chronic SCI through exercise could induce bone formation, in accordance with Wolff’s Law. We present cross-sectional data from the Scottish paraplegic population illustrating the time course of bone loss after SCI, and review case studies describing musculoskeletal changes following lower-limb exercise interventions in chronic SCI. Reference data were obtained from 47 subjects with SCI at neurological levels T2 to L2, ranging from 6 months to 40 years post-injury. We used peripheral Quantitative Computed Tomography (XCT3000, Stratec, Germany) to scan 4 sites in the tibia and 2 in the femur, and evaluated trabecular, cortical, and total bone data, and soft-tissue parameters. Here, we focus on trabecular bone mineral density (BMDtrab) at the epiphyses, which provides an indicator of bone integrity. The same scans were performed pre- and post-training in chronic paraplegics who undertook a period of lower-limb exercise training (body-weight-supported treadmill training (BWSTT) or electrically-stimulated leg cycle (FES-cycle) training); these results are reviewed. The temporal pattern of bone loss is characterised by exponential decline in BMDtrab, reaching steady-state at 100 mg/cm3 in the distal tibia after 7 years and at 130 mg/cm3 in the distal femur after 3 years. A subject with incomplete SCI (18 years post-injury) showed an increase in BMDtrab in the distal tibia following 5-months BWSTT. In a separate study, subjects with complete SCI had varying responses to FES-cycle training. Bone loss appears to plateau after 7 years post-SCI. The effectiveness of physical interventions aimed at reversing bone loss in chronic SCI seemingly depends on the details of the associated bone-loading patterns

Study Design & Setting: Prospective multi-center longitudinal cohort study within the ‘European Multicenter Study of Human Spinal Cord Injury’ (EM-SCI) consortium. Introduction: Determination between complete and incomplete spinal cord injury (SCI) is commonly applied in prognosticating patients’ functional recovery. Complete and incomplete injury is defined by absence or presence of at least 1 of 4 ASIA sacral sparing (SS) criteria. To date, however, the ASIA SS criteria have not been validated with respect to chronic phase functional outcomes. Objectives: To validate the prognostic value of the acute phase sacral sparing (SS) measurements regarding to chronic phase ambulation in traumatic SCI patients. Methods: In 251 patients, acute phase (0–15 days) ASIA Impairment Scale (AIS) grades, ASIA SS measurements and chronic phase (6 or 12 months) Timed Up & Go (TUG) outcome measurements were analyzed. Calculation of sensitivity, specificity, positive and negative predictive values (PPV/NPV), univariate and multivariate logistic regressions were performed in all 4 SS criteria. The area under the receiver-operating characteristic curve (AUC) ratios of all regression equations were calculated. Results: In completing the 1-year follow-up TUG test, presence of voluntary anal contraction (VAC) showed the best PPV (94.3%, p< 0.001, 95% CI: 80.8–99.3). Best NPV was reported in the S4–5 light touch (LT) score (96.9%, p< 0.001, 95% CI: 92.9–98.9). Presence of anal sensation in the traumatic SCI patients resulted in a PPV of 41% (p=0.124). Use of the combination VAC and S4–5 LT score (AUC: 0.917, p< 0.001, 95% CI: 0.868–0.966) showed significantly better (p< 0.001, 95% CI: 0.042–0.102) discriminating results in 1-year TUG test prognosis than with use of currently used distinction between complete and incomplete SCI (AUC: 0.845, p< 0.001, 95% CI: 0.790–0.901). Conclusion: Out of the 4 sacral sparing criteria, VAC and S4–5 LT scores are the only acute phase measurements contributing significantly to the prognosis of ambulation. With the combination of acute phase VAC and S4–5 LT scores, significantly better chronic phase ambulation prognosis can be predicted than with use of currently used distinction between complete and incomplete SCI. This study stresses the importance of further research on functional predictive algorithms in the acute setting of traumatic SCI care

Introduction. While there is a desperate need for effective treatments for acute spinal cord injury (SCI), the clinical validation of novel therapeutic interventions is severely hampered by the need to recruit relatively large numbers of patients into clinical trials for sufficient statistical power. While a centre might annually admit 100 acute SCI patients, only a fraction may satisfy the basic inclusion criteria for an acute clinical trial, which typically requires patients of a certain injury severity (eg ASIA A), within a specific time window (eg. 12 hours from injury), and without other major injuries or conditions that would cloud the baseline neurologic assessment. This study was conducted to define that “fraction” of SCI patients that would theoretically satisfy standard inclusion criteria of an acute clinical trial. Methods. Using a local database, we reviewed patients admitted to our Level 1 trauma center with a complete (ASIA A) or an incomplete (ASIA B, C and D) acute SCI involving bony spinal levels between C0 and sacrum. All patients admitted over the 4 year period from 2005 to 2009 were reviewed. Demographic information and data about the patients' SCI and other injuries were reviewed. We then determined how many of the total number of SCI patients would be eligible for enrolment into a hypothetical acute clinical trial that required a valid baseline assessment of neurologic impairment, and an enrolment window of either 12 hours, 24 hours, or 48 hours. Results. 408 acute traumatic SCI patients were admitted over the 4 year period. 253 of 408 (62%) patients presented within 12 hours of injury, 60 (15%) between 12–24 hours, and 28 (7%) between 24–48 hours. 42% of patients were ASIA A, 13% B, 18% C and 27% D. The number of patients who presented with injuries or other conditions that would exclude them from enrolment was relatively high: 4% had penetrating injuries, 12% had illicit drug use, and 20% had either alcohol intoxication or head injuries which precluded a valid baseline neurologic examination. Conclusions. Out of a total of 408 patients admitted over 4 years, the number who would have been optimistically eligible for an acute neuroprotective trial was disappointingly small. Given that acute clinical trials are increasingly interested in cervical ASIA A patients (in whom segmental motor recovery can be assessed), the number of such patients who would actually be eligible for an acute intervention was surprisingly low. Given that additional inclusion/exclusion criteria would also be applicable in a real clinical trial, the true number of “eligible” or “recruitable” patients is conservatively even lower. This study is the first to quantify this challenging aspects of conducting acute SCI clinical trials, and provides valuable information for those planning such initiative

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.

Purpose of study:

The question of prolonged bracing following injury in patients diagnosed with SCIWORA remains controversial. Proponents of the ‘Segmental Spinal Instability’ hypothesis claim that there is occult ligamentous injury leading to instability and a risk of recurrent injury. Published reports of recurrent SCIWORA involve patients with minor, transient neurological symptoms and normal MRI findings. The contradicting ‘differential stretch hypothesis’ is based on the premise that the spinal column will deform elastically, exceeding the elastic deforming potential of the more fragile spinal cord, but will return to its baseline stability. The purpose of this study is to evaluate the need for bracing in patients with SCIWORA based on MRI evidence of instability.

We report a case of local compression-induced transient femoral nerve palsy in a 46-year-old man. He had previously undergone surgical release of the soft tissues anterior to both hip joints because of contractures following spinal injury. An MRI scan confirmed a synovial cyst originating from the left hip joint, lying adjacent to the femoral nerve. The cyst expanded on standing, causing a transient femoral nerve palsy. The symptoms resolved after excision of the cyst.

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?

From 1981 to 1986 we treated 413 patients for acute spinal-cord injuries. We reviewed 356 patients followed for a minimum of two years of whom 71 (20%) developed heterotopic ossification around one or more joints. Heterotopic ossification occurred more often in male patients (23%) than in female (10%), and was most frequent in the 20- to 30-year age group. It was also more common after injuries of the lower cervical or thoracic spine than after those of the lumbar spine. Patients with severe neurological deficits (Frankel grades A and B) showed significantly more heterotopic ossification but there was no correlation with the number or severity of associated head and limb injuries. Serum calcium levels did not change significantly in either group for 30 weeks after injury, but the erythrocyte sedimentation rate and the alkaline phosphatase level were significantly increased at six weeks in patients with heterotopic ossification.

Summary Statement. The mechanism of spinal cord injury varies across the human population and this may be important for the development of effective therapies. Therefore, detailed understanding of how variables such as impact velocity and depth affect cord tissue damage is important. Introduction. Studies have shown an independent effect of impact velocity and depth on injury severity, thereby suggesting importance of the interaction between the two for spinal cord injury. This work examines both the individual and interactive effects of impact velocity and impact depth on demyelination, tissue sparing, and behavioural outcomes in the rat cervical spinal cord. It also aims to understand the contribution of the energy applied during impact, not only the impact factors. Decoupling the effects of these two impact parameters will help to describe the injury mechanism. Maximum principal strain has also been shown to be useful as a predictor for neural tissue damage in vivo and in finite element (FE) models. A better understanding of this relationship with experimental results may help to elucidate the mechanics of spinal cord injury. Methods. In this study, 54 male Sprague-Dawley rats were given a contusion spinal cord injury at impact speeds of 8 mm/s, 80 mm/s, or 800 mm/s with depths of 0.9 mm or 1.5 mm. Animals recovered for 7 days followed by behavioural assessment and examination of the spinal cord tissue for demyelination and tissue sparing at 1 mm intervals, ±3 mm rostrocaudally to the epicentre. In parallel, a previously developed finite element model of the rat spinal cord was used to examine the resulting maximum principal strains in the spinal cord for correlations with histological and mechanical impact data. Results and discussion. Impact depth was a consistent factor in predicting axonal damage, tissue sparing, and the resulting behavioural deficit. Increased impact velocity resulted in significantly higher impact energies and measureable tissue damage at the 1.5 mm impact depth, but not at the 0.9 mm impact depth and is best displayed by the percentage of axon damage at the injury epicentre. Linear correlation analysis with FEA strain showed significant (p≪0.001) correlations with axonal damage in the ventral (R2=0.86) and lateral (R2=0.74) regions of the spinal cord and with white matter (R2=0.90) and grey matter (R2=0.76) sparing. Discussion and Conclusion. The difference in injury severity to velocity at different impact depths identifies the existence of threshold interactions between the two impact factors. Beyond this point incremental increases in either velocity or depth are more likely to result in significantly increased impact energy and thus tissue damage and functional impairment. The relationship between the impact depth and velocity of injury demonstrated a more rate sensitive response to spinal cord tissue damage at the deep (1.5 mm) impact depth than at the shallow (0.9 mm) impact depth. Impact velocity also became quickly less significant than impact depth in determining tissue damage further from the epicentre. Furthermore, the results shown by this work extend the research identifying significant correlations between maximum principal strain and neurological tissue damage

Purpose: Recent studies have shown differences in short term spinal cord pathology between spinal column injury mechanisms, such as contusion and fracture-dislocation. Such differences may exist at longer time points, and thus survival studies are needed in the dislocation models. A more in-depth characterization of the dislocation model is needed for development of a mild-moderate cervical spine dislocation model in a rat that is suitable for survival studies. Specifically, our objective in this study was to determine the dislocation displacement that produces initial spinal column failure in a Sprague-Dawley rat model and to validate a consistent injury at the desired dislocation in-vitro and in-vivo.

Method: For the dislocation model, the dorsal ligaments and facets at C4–C5 were removed to mimic the type of posterior element fracture and ligament injury commonly seen in a bilateral fracture-dislocation. C3 and C4 were clamped together and held stationary while the clamp holding C5 and C6 was connected to an electromagnetic actuator and displaced dorsally to produce the injury while force and displacement were recorded. Twenty-eight isolated cervical spine specimens of Sprague-Dawley rats were used to determine dislocation displacement at initial spinal column failure. The C4–C5 segment sustained dislocation (> 3mm) injury at 0.05mm/s (n=11), 100mm/s (n=4) and 1000mm/s (n=13). Initial spinal column failure was defined at with maximum force during the dislocation. A dislocation displacement of 1.4mm was applied to 7 isolated specimens and 4 anesthetized rats at 430mm/s. The spinal column failure was inspected up to 3 days after injury, as well as hemorrhage of spinal cord in-situ.

Results: The dislocation displacement at in-vitro spinal column failure was 0.95mm±0.32 and not significantly different among specimens at the three dislocation speeds. Under a dislocation displacement of 1.4mm, rupture of the C4–C5 disc occurred in all in-vitro (0.67mm±0.38) and in-vivo (0.65mm±0.17) cases. SCI hemorrhage at epicenter was observed in 3 of 4 cases.

Conclusion: The initial spinal column failure in an innovative SCI model occurs at displacement between 0.65mm and 0.95mm. Dislocation displacement of 1.4mm results in spinal column failure consistently and SCI hemorrhage, and may be suitable for survival studies.

Aim

Spinal infections with and without aSCI represent a severe disease with a high lethality rate of up to 17%. The current treatment recommendations include an antimicrobial therapy and if necessary in combination with operative procedures. Aims of this study are the analysis of risk factors and treatment concepts and to compare the outcome of patients suffering a spinal infection with and without an aSCI.

Neurogenic heterotopic ossification (NHO) is a disorder of aberrant bone formation affecting one in five patients sustaining a spinal cord injury or traumatic brain injury. Ectopic bone forms around joints in characteristic patterns, causing pain and limiting movement especially around the hip and elbow. Clinical sequelae of neurogenic heterotopic ossification include urinary tract infection, pressure injuries, pneumonia and poor hygiene, making early diagnosis and treatment clinically compelling. However, diagnosis remains difficult with more investigation needed. Our pathophysiological understanding stems from mechanisms of basic bone formation enhanced by evidence of systemic influences from circulating humor factors and perhaps neurological ones. This increasing understanding guides our implementation of current prophylaxis and treatment including the use of non-steroidal anti-inflammatory drugs, bisphosphonates, radiation therapy and surgery and, importantly, should direct future, more effective ones

The August 2024 Spine Roundup. 360. looks at: Laminectomy adjacent to instrumented fusion increases adjacent segment disease; Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: a retrospective multicentre study; Lumbar vertebral body tethering: single-centre outcomes and reoperations in a consecutive series of 106 patients; Machine-learning algorithms for predicting Cobb angle beyond 25° in female adolescent idiopathic scoliosis patients; Pain in adolescent idiopathic scoliosis; Teriparatide prevents surgery for osteoporotic vertebral compression fracture

Pressure ulcers are a common occurrence in individuals with spinal cord injuries, and are attributed to prolonged sitting and limited mobility. This therefore creates the need to better understand soft tissue composition, in the attempt to prevent and treat pressure ulcers. In this study, novel approaches to imaging the soft tissue of the buttocks were investigated in the loaded and unloaded position using ultrasound (US) and magnetic resonance imaging (MRI). Twenty-six able-bodied participants (n=26, 13 males and 13 females) were recruited for this study and 1 male with a spinal cord injury. Two visits using US were required, as well as one MRI visit to evaluate soft tissue thickness and composition. US Imaging for the loaded conditions was performed using an innovative chair which allowed image acquisition in the seated upright position and MRI was done in the lateral decubitus position and loading was applied to the buttocks using a newly developed MRI compatible loader. The unloaded condition was a lateral decubitus position. Soft tissue was measured between the peak of the ischial tuberosity (IT) and the proximal femur and skin. Tissue thickness reliability for US was excellent, ICC=0.934–0.981 with no significant differences between the scan days. US and MRI measures of tissue thickness were significantly correlated (r=0.68–0.91). US underestimated unloaded tissue thicknesses with a mean bias of 0.39 – 0.56 for total tissue and muscle + tendon thickness. When the buttocks were loaded, total tissue thickness was reduced by 64.2±9.1%. US assessment of soft tissue thicknesses was reliable in both positions. The unloaded measurements using US were validated with MRI with acceptable limits of agreement, albeit tended to underestimate tissue thickness. Tissue thickness, but not fatty infiltration of muscle played a role in how the soft tissue of the buttocks responded to loading

The identification of the extent of neural damage in patients with acute or chronic spinal cord injury is imperative for the accurate prediction of neurological recovery. The changes in signal intensity shown on routine MRI sequences are of limited value for predicting functional outcome. Diffusion tensor imaging (DTI) is a novel radiological imaging technique which has the potential to identify intact nerve fibre tracts, and has been used to image the brain for a variety of conditions. DTI imaging of the spinal cord is currently only a research tool, but preliminary studies have shown that it holds considerable promise in predicting the severity of spinal cord injury. . This paper briefly reviews our current knowledge of this technique

Spinal cord injury is an inevitable but rare occurrence in sports. Identifying trends and working to minimise risk is an integral part of sports management. All patients suffering a spinal cord injury in Scotland will be transferred to the Queen Elizabeth National Spinal Injuries Unit (QENSIU). Our records give an accurate account of trends in spinal cord injury. This study details the number of spinal cord injuries caused by sports and leisure pursuits in Scotland since 1992. 1451 patients have suffered a spinal cord injury in Scotland from 1992-2008. 142 (9.8%) arose from injuries during sport. The average age at injury was 32, and patients were predominantly male (91%). The commonest cause was diving (40, 28%) followed by cycling (29, 20%) climbing and hillwalking (15, 11%) and rugby union (12, 8%). Smaller numbers were seen in horse-riding (11), aerial sports (6), motor sports (6), snow sports (5), and football (5). Overall, there was evidence of an increasing trend in the number and severity of injuries in rugby and cycling. The number of spinal injuries, caused by diving, rugby and cycling remains disproportionally high and the increasing trends identified merit further investigation

Introduction The influence of timing of surgery on functional outcomes following spinal cord injury remains controversial. Animal studies suggest that the rate, degree, and duration of cord compression are the principal determinants of spinal cord injury (SCI) severity and prognosis for recovery. Delamarter et al, (J Bone Joint Surg Am 1995) have shown that when experimental cord compression in dogs is relieved within 1 hour, full motor recovery can be achieved. It is suggested by some clinically based research that definitive surgical treatment for unstable injuries results in fewer sequelae than prolonged immobilization and allows more rapid entry into rehabilitation. It is however the timing of this surgery which remains controversial. It has been suggested that early surgical management promotes neurological recovery by limiting secondary damage caused by inflammation, oedema, ischemia and instability. To date few studies have found a link between neurological recovery and timing of surgery (Fehlings, et al; Spine 2001). Methods Data was gathered retrospectively by chart review of patients referred to the Princess Alexandra hospital with spinal cord injury. Patients were age matched into high and low velocity groups. This data was studied to assess the effects of energy of injury and timing of surgical intervention on neurological outcome. Patients either had anterior, posterior, or combined surgery, external immobilization or traction depending on the preference of the treating surgeon. Results A cohort of 43 patients all of whom had spinal cord injury was retrospectively studied. Of these, 21 had a high energy injury (eg. MVA) and 21 had a low energy injury (eg. rugby). 28 had anterior stabilization 7 had traction, 4 had external immobilization 2 had a combined anterior / posterior fixation and 1 had posterior stabilization. The data suggest that the prognosis for recovery following a spinal cord injury is unrelated to the energy involved. The low energy group improved on average 0.6 ASIA grades (SEM 0.16) while the high energy improved 0.7 ASIA grades (SEM 0.17). The timing of definitive intervention for patients with incomplete cord lesions was shown to significantly (p=0.029) effect ultimate functional outcomes. Those with early (within 8hrs) intervention improved an average of 1.4 ASIA grades (SEM 0.21) and those with late intervention improved 0.6 ASIA grades (SEM 0.19). This effect was present in both high and low energy injury groups. Discussion The timing of definitive intervention for spinal cord injury is still controversial. However there is Class II evidence that early surgery can be done safely in a patient with spinal cord injury (Fehlings, et al; Spine 2001). The findings from this retrospective study suggest that early surgical intervention may improve neurological recovery

To prevent nosocomial transmission (NT) of multiresistent germs (MRG) the German Robert Koch Institute (RKI) recommends to isolate patients with MRG. At a so-called normal ward isolating patients is a challenging and stressful procedure for both patients and hospital staff. The present study proposes the hypothesis that, compared to normal wards, an isolation ward reduces the nosocomial infection rate. After an isolation ward with twelve beds has been established in 2005, patients with MRG on the wards of the department for spinal cord injury as well as on the isolation ward were monitored using a prospective screening and meeting the requirements of the RKI. Apart from detecting transmitter of MRG the NT of these bacteria was identified and registered between 2006 and 2013. The total length of a patients stay in the hospital, the number of isolation days and the rate of NTs were documented. The quotient of MRG load per ward and the number of NTs per ward were compared. In the investigation period of eight years 262175 patient days, 33416 isolation days and 33 transmissions were registered. On the spinal cord injury ward 223167 of the patient days, 1120 of the isolation days and 29 of the NTs were documented. On the isolation ward 39008 of the patient days and 32296 of the isolation days with four of the transmissions were registered. The mean load of MRG resulted from the quotient of the number of days with MRG per 100 patient days. The effective nosocomial frequency of transmission resulted from the quotient of the mean load of MRG to the number of transmissions. As a result, the frequency of transmission on the isolation ward was significantly lower (p=0,001) in comparison to the spinal cord injury ward. The presented results suggest that, despite multiple higher loads of MRG, constructional measures combined with contact isolation facilitate a reduction of NT rates of MRG. The reservation must be made, however, that in case of known MRG the screening was performed under isolation conditions, with unkown MRG without meeting requirements of isolation. The present comparison of NT rates on an isolation ward and a normal spinal cord injury ward emphasizes the importance and function of an isolation ward through constructional (physical) separation and pooling of professional competency for successful management of MRG in healthcare facilities

Purpose: Pressure ulcers at the ischial tuberosities are a significant cause of morbidity and mortality in persons with spinal cord injuries. Current prevention strategies are not fully adequate and surgical treatment is not always effective. In order to develop a novel method of ulcer prevention using magnetic repulsion, we needed to establish the relationship between pressure developed at the level of the ischial tuberosities while seated and the associated changes in blood flow in the sub-ischial tissues. Our hypothesis was that a threshold pressure or “pressure-prescription” would emerge as a target we could subsequently aim for with magnetic offloading. Method: We performed a physiologic study comparing incremental pressure applied at the ischial tuberosities with alterations in the local cutaneous perfusion. Persons with spinal cord injuries were compared to uninjured controls in order to detect any significant differences in the pressure-perfusion relationship between these two groups. Subjects were progressively lowered onto a seat where perfusion was measured with laser Doppler perfusion imaging and pressure was recorded with a pressure mapping system. The mean perfusion vs. pressure curve was determined from a zero loaded position to a maximally loaded position. Results: Healthy controls exhibited stable cutaneous ischial tissue perfusion up to sitting pressures of 150mm Hg followed by a 10% increase in blood flow at higher peak pressures. In contrast, subjects with spinal cord injuries underwent an early decrease in perfusion of 20% up to pressures of 150mm Hg, with a subsequent leveling off of their flow at higher pressures. The spinal cord injured also demonstrated lower reperfusion values indicative of a weaker reactive hyperemia in response to pressure. Conclusion: Compared to uninjured people, individuals with spinal cord injuries appear to have inherent blood flow regulation differences in response to pressure at the sub-ischial tissues, possibly due to dysfunction of an autonomic phenomenon termed pressure-induced vasodilation. Furthermore, a threshold pressure for maintaining optimal perfusion remains elusive for both healthy subjects and persons with spinal injuries. CLINICAL RELEVANCE: Targeting the altered blood flow response to pressure in patients with spinal cord injuries, pharmacologically or mechanically, may lead to a reduction in the incidence of decubital ulcers

Introduction The aim of this study was to assess trends in the circumstances of spinal cord injury in all codes of football played in Australia in 1997 to 2002, and to combine and contrast these findings with those of identical studies done covering earlier years (1960 to 1996). Methods A retrospective review of all spinal cord injuries occurring in all codes of football 1997 to 2002, combining and contrasting the results with identical studies done covering the years 1960 to 1985 and 1986 to 1996. Every football player with a documented spinal cord injury admitted to one of the spinal cord injury units across Australia was included. Data was recorded by way of record and radiograph review, and patient interview. Results Fifty-four footballers were admitted to the spinal injury units over the period. The average yearly frequency of injuries over the study period was higher than the period 1986 to 1996, and similar to the period 1977 to 1985. The annual incidence of injury was lower in every sport except soccer, although data still remains to be collected from Victoria which may affect the incidence pertaining to Australian Rules. Rugby League had the biggest decrease in incidence. Most notable was the absence of any scrum injuries in league, down from nine (24% of all league injuries) in the prior study. Scrums sustained at engagement remained a prevalent cause of injury in Union. They by far predominated over those in collapsed scrums, reversing the trend towards the latter noted in the prior study. One-third of scrum injuries were in adult front-rowers who had played between one and four games in the front-row in their careers. The incidence of schoolboy injuries overall decreased substantially. The tackle accounted for all League and 40% of Union injuries. Over 75% of known tackle injuries on the ball carrier involved two or more tacklers at once. A much smaller percentage of patients remain wheelchair dependent (30%) than in the last study, and nearly 15% returned to near normality. Conclusions Spinal cord injuries remain a significant concern in football, particularly the rugby codes. While the incidence overall may have slightly decreased, attention is needed to enforcing scrummaging laws, particularly in adult rugby, and focusing on the gang tackle as a cause of increased injuries in League and Union. An adequate compensation scheme and a national registry also need realisation

Introduction: Apoptosis, or secondary cell death, has been demonstrated in a number of neurological conditions, including Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis and brain ischaemia. It is well established from studies of acute spinal cord injury that apoptosis seems an important factor in secondary cell death and irreversible neurological deficit. It is only recently that studies have emerged analysing secondary cell death in chronic injury to the cord. In this study, the spatial and temporal expression of apoptotic cells was analysed in acute traumatic spinal cord injury (SCI) (n=6) and chronic myelopathies due to metastatic tumour (n=5), degenerative spondylosis (n=6) and syringomyelia (n=4). The study aimed to demonstrate apoptosis in compressive spinal cord injury and to analyse the spatial and temporal distribution of apoptosis in acute and chronic myelopathy. Method: Archival material from 21 spinal cords of patients with documented myelopathy during life and definitive evidence on post mortem examination were available for study. The spatial and temporal expression of apoptotic cells was analysed in acute traumatic spinal cord injury (SCI) (n=6) and chronic myelopathy due to metastatic tumour (n=5), degenerative spondylosis (n=6) and syringomyelia (n=4). Immunohistochemical analysis of each specimen was conducted using markers of apoptosis, as well as the biochemical apoptotic marker TUNEL. A total of 1800 histopathological slides were analysed. Specimens were also analysed using confocal microscopy to identify the immunopositive cell type. A combination of morphological, immunohistochemical and in situ end-labelling techniques were used to investigate the mechanism of cell death in this experiment. The analytical techniques employed were aimed at showing firstly the presence of apoptosis and secondly the size and position of the damaged regions. Results: Positivity for active Caspase-3, DNA-PKCS, PARP, TUNEL and active Caspase-9 was found in glia (oligodendrocytes and microglia) axons and neurons in both acute and chronic compression above, below and at the site of compression. In chronic compression, the severity of positivity for apoptotic immunological markers was positively correlated with the severity of white matter damage, as measured by APP immunostaining for axonal injury, and Wallerian degeneration. There was no correlation between the duration of chronic compression and immunopositivity for apoptotic markers. In acute SCI, axonal swellings were consistently positive for Caspases −9 and -3, suggesting mitochondrial activation of apoptotic pathways. Conclusion: Apoptosis occurs in both acute and chronic spinal cord injury. In acute compression, axonal injury is associated with apoptotic immunopositivity of glia and neurons. In chronic compression, apoptosis of oligodendrocytes and microglia correlates with demyelination of axons within the white matter

INTRODUCTION: Apoptosis, or secondary cell death, has been demonstrated in a number of neurological conditions, including Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis and brain ischaemia. It is well established from studies of acute spinal cord injury that apoptosis seems an important factor in secondary cell death and irreversible neurological deficit. It is only recently that studies have emerged analysing secondary cell death in chronic injury to the cord. In this study, the spatial and temporal expression of apoptotic cells was analysed in acute traumatic spinal cord injury (SCI) (n=6) and chronic myelopathies due to meta-static tumour (n=5), degenerative spondylosis (n=6) and syringomyelia (n=4). The study aimed to demonstrate apoptosis in compressive spinal cord injury and to analyse the spatial and temporal distribution of apoptosis in acute and chronic myelopathy. METHOD: Archival material from 21 spinal cords of patients with documented myelopathy during life and definitive evidence on post mortem examination were available for study. The spatial and temporal expression of apoptotic cells was analysed in acute traumatic spinal cord injury (SCI) (n=6) and chronic myelopathy due to metastatic tumour (n=5), degenerative spondylosis (n=6) and syringomyelia (n=4). Immunohistochemical analysis of each specimen was conducted using markers of apoptosis, as well as the biochemical apoptotic marker TUNEL. A total of 1800 histopathological slides were analysed. Specimens were also analysed using confocal microscopy to identify the immunopositive cell type. A combination of morphological, immunohistochemical and in situ end-labelling techniques were used to investigate the mechanism of cell death in this experiment. The analytical techniques employed were aimed at showing firstly the presence of apoptosis and secondly the size and position of the damaged regions. RESULTS: Positivity for active Caspase-3, DNA-PKCS, PARP, TUNEL and active Caspase-9 was found in glia (oligodendrocytes and microglia) axons and neurons in both acute and chronic compression above, below and at the site of compression. In chronic compression, the severity of positivity for apoptotic immunological markers was positively correlated with the severity of white matter damage, as measured by APP immunostaining for axonal injury, and Wallerian degeneration. There was no correlation between the duration of chronic compression and immunopositivity for apoptotic markers. In acute SCI, axonal swellings were consistently positive for Caspases −9 and -3, suggesting mitochon-drial activation of apoptotic pathways. CONCLUSION: Apoptosis occurs in both acute and chronic spinal cord injury. In acute compression, axonal injury is associated with apoptotic immunopositivity of glia and neurons. In chronic compression, apoptosis of oligodendrocytes and microglia correlates with demyelination of axons within the white matter

The inability to replace human muscle in surgical practice is a significant challenge. An artificial muscle controlled by the nervous system is considered a potential solution for this. We defined it as neuromuscular prosthesis. Muscle loss and dysfunction related to musculoskeletal oncological impairments, neuromuscular diseases, trauma or spinal cord injuries can be treated through artificial muscle implantation. At present, the use of dielectric elastomer actuators working as capacitors appears a promising option. Acrylic or silicone elastomers with carbon nanotubes functioning as the electrode achieve mechanical performances similar to human muscle in vitro. However, mechanical, electrical, and biological issues have prevented clinical application to date. In this study, materials and mechatronic solutions are presented which can tackle current clinical problems associated with implanting an artificial muscle controlled by the nervous system. Progress depends on the improvement of the actuation properties of the elastomer, seamless or wireless integration between the nervous system and the artificial muscle, and on reducing the foreign body response. It is believed that by combining the mechanical, electrical, and biological solutions proposed here, an artificial neuromuscular prosthesis may be a reality in surgical practice in the near future

To analyse the causes and factors associated with mortality in patients admitted to ASCI unit in a low- or middle-income country. The study was performed at a Tertiary Hospital at Groote Schuur Hospital, Cape Town South Africa. Data between 1996 –2022 were retrospectively collected from hospital records of patients admitted to the ASCI Unit. There was approximately 3223 admissions for the study period. 682 patients were confirmed dead 87% were male and 64% were unemployed. The mean age was 46 years (ranging from 14 – 87 years). A 1/3 of injuries were caused by a MVA, a ¼ by a fall (low energy and from a height), and 1/5 by a gunshot wound. Average length of stay was 47 days (SD = 52 days), ranging from as short as 1 day to 512 days for one patient. Majority (65%) were admitted for more than a week but less than 2 months 32% were ventilated, and 17% with a CPAP facemask. 10% of patients had a pre-existing ulcer prior to admission. 65% of patients had surgery via the posterior approach, 33% via the anterior approach. On average patients died within 5 years of being admitted to hospital, ranging from dying in the same year as the injury to 20 years later. 73% of the deaths were classified as natural deaths and 20% as unnatural. There is a high mortality in patients with acute spinal cord injury, causes are multifactorial, and in depth critical analyses is required to improve clinical outcomes and rationalise resource allocation

Abstract. Purpose. Intracanal rib head penetration is a well-known entity in dystrophic scoliotic curves in neurofibromatosis type 1. There is potential for spinal cord injury if this is not recognised and managed appropriately. No current CT-based classification system is currently in use to quantify rib head penetration. This study aims to propose and evaluate a novel CT-based classification for rib head penetration primarily for neurofibromatosis but which can also be utilised in other conditions of rib head penetration. Materials and methods. The grading was developed as four grades: normal rib head (RH) position—Grade 0, subluxed ext-racanal RH position—Grade 1, RH at pedicle—Grade 2, intracanal RH—Grade 3. Grade 3 was further classified depending on the head position in the canal divided into thirds. Rib head penetration into proximal third (from ipsilateral side)—Grade 3A, into the middle third—Grade 3B and into the distal third—Grade 3C. Seventy-five axial CT images of Neurofibromatosis Type 1 patients in the paediatric age group were reviewed by a radiologist and a spinal surgeon independently to assess interobserver and intraobserver agreement of the novel CT classification. Agreement analysis was performed using the weighted Kappa statistic. Results. There was substantial interobserver correlation with mean Kappa score (k = 0.8, 95% CI 0.7–0.9) and near perfect intraobserver Kappa of 1.0 (95% CI 0.9–1.0) and 0.9 (95% CI 0.9–1.0) for the two readers. Conclusion. The novel CT-based classification quantifies rib head penetration which aids in management planning

Introduction Approximately one quarter of spinal cord injury patients will develop post-traumatic syringomyelia. This condition can produce devastating neurological deficits, and treatment is often not successful. The pathogenesis is unknown, however it is likely that initial cyst formation plays an important role in subsequent syrinx development. An up-regulated inflammatory process observed following contusive and transective spinal cord injury has been proposed as a contributory factor in secondary spinal cord damage. Specifically, a depletion or suppression of macrophages following injury is shown to preserve neurons and myelinated axons. This study examines the role of inflammation following excitotoxic spinal cord injury, a potent precursor to syrinx formation. Methods Twenty-four male Sprague-Dawley rats were divided into six groups. Twenty rats received four 0.5 μL injections of 24 mg/ mL quisqualic acid and 1% Evans blue from the rostral C8 to the caudal T1 level. Ten microlitres of 250 mg/ mL kaolin were then injected into the subarachnoid space. Animals were sacrificed at 1, 5, 10, 20 or 50 days following the injections. There were four normal control animals. Spinal cord tissue was frozen and sectioned, and cytoplasmic antigen ED1 was detected immunohistochemically with anti-ED1 antibody. This antibody is specific to phagocytic macrophages and reactive microglia. The area and density of ED1 was semi-quantitated. Results Few ED1 positive cells were observed in normal controls in the subarachnoid space (SAS) and cord vessels. Day 1 animals displayed ED1 positive cells within 50% of the subarachnoid space. ED1 positive cells within cord vessels were also slightly increased (10%). Day 5 animals showed strong staining through 50% of grey matter, predominantly on the side of injury. This was also observed in cord above and below the level of Quisqualic Acid injection. Arachnoiditis was observed by day 10 combined with strong staining through grey and white matter. ED1 positive staining area was again increased by day 20, comprising 70% grey matter on the injured and non-injured sides of the cord, which was limited to the level Quisqualic Acid injection. By day 50 moderate staining was observed in the SAS and white matter. Discussion Cytoplasmic antigen ED1 cells were observed, reaching a peak at 20 days following excito-toxic spinal cord injury. Phagocytic macrophage proliferation might play a role in secondary spinal cord damage and initial cyst formation. The role of macrophages and the release of their inflammatory cytokines, reactive nitrogen and oxygen intermediates require further examination

Reduced cervical spine canal AP diameter is linked to the development of spinal cord injury and myelopathy. This is of particular interest to clinicians in New Zealand, given a unique socio-ethnic make-up and prevalent participation in collision sport. Our study builds upon previous unpublished evidence, by analysing normal cervical spine CT scans to explore morphological differences in the sub-axial cervical spine canal, between New Zealand European, Māori and Paciāca individuals. 670 sub-axial cervical vertebrae (C3-C7) were analysed radiographically using high resolution CT trauma scans, showing no acute pathology with respect to the cervical spine. All measurements were made uPlising mulP-planar reconstruction software to obtain slices parallel to the superior endplate at each vertebral level. Maximal canal diameter was measured in the AP and transverse planes. Statistical analysis was performed using analysis of variance (ANOVA). We included 250 Maori, 250 NZ European and 170 Paciāca vertebrae (455 male, 215 female). Statistically and clinically signiācant differences were found in sagittal canal diameter between all ethnicities, at all spinal levels. NZ European vertebrae demonstrated the largest AP diameter and Paciāca the smallest, at all levels. Transverse canal diameter showed no signiācant difference between ethnicities, however the raatio of AP:transverse diameter was signiācantly different at all spinal levels except C3. Subjective morphological differences in the shape of the vertebral canal were noted, with Māori and Paciāca patients tending towards a flatter, curved canal shape. A previous study of 166 patients (Coldham, G. et al. 2006) found cervical canal AP diameter to be narrower in Māori and Paciāca patients than in NZ Europeans. Our study, evaluating the normal population, conārms these differences are likely reflecPve of genuine variation between these ethniciPes. Future research is required to critically evaluate the morphologic differences noted during this study

To determine the current practice and to review the literature regarding administration of high dose Methylprednisolone for acute spinal cord injury (SCI). Administration of high dose Methylprednisolone for Acute Spinal Cord Injury has been widely practised following the publication of the three National Acute Spinal Cord Injury Studies (NASCIS). NASCIS recommends a bolus intravenous dose of 30mg/kg of Methylprednisolone in 15 minutes, followed by a 45 min pause and then followed by a maintenance dose of 5.4 mg / kg / hr for 23 hours. This regime has been recommended by the Advanced Trauma Life Support. The Cochrane reviews also extol the three NASCIS randomised controlled trials. The mechanism of neuroprotection by Methylprednisolone is based on its inhibition of lipid peroxidation. Three hundred questionnaires were sent to Consultants practising Spinal surgery, Neurosurgery and Accident & Emergency to determine the popular thought regarding the use of Methylprednisolone for Acute SCI. A thorough review of current medical literature was also performed. The literature search showed contradictory evidence regarding the use of high dose Methylprednisolone. The current popular thought, the diversity of responses between the three groups, the results of the 3 NASCIS trials and a recent review of literature is presented

Compartment Syndrome is a dreaded complication associated witha poor outcome if unrecognised in neurologically intact patients. This is also true in those with a spinal cord injury, but it is unclear from the current literature if this unique cohort of patients has different baseline vlaues for diastolic blood, compartment and perfusion pressures. This study was designed to test the Null Hypothesis that there is no difference between the values of these variables in intact “normal” patients and those with a spinal cord injury; in addition, comparisons were made between different ASIA groups and anatomical level of injury. The results revealed significant differences between complete (ASIA A) injuries and normal patients in diastoic blood and perfusion pressures (p=0.005, and 0.003 respectively). There was also a difference between complete and normal compartment pressure (p=0.009). Differences were found in cervical and thoracic diastolic blood pressures when compared to normal (p=0.07 and 0.09 resepectively), and between thoracic and lumbar diastolic pressures(p=0.06). In summary, those with spinal cord injuries tended to have lowered diastolic and perfusion pressures, and higher compartment pressures. These results demonstrate the importance of close surveillance of spinally injured patients with concomitant limb trauma. We would recommend routine compartment pressure monitoring in all such cases, especially as they are also relatively hypotensive and will not tolerate elevation of compartment pressure well

The October 2015 Spine Roundup360 looks at: Traumatic spinal cord injury under the spotlight; The odontoid peg nonunion; Driving and spinal surgery; Drains and antibiotics post-spinal surgery; Vertebroplasty and kyphoplasty equally effective; Who will benefit from steroid injections?; Back pain following lumbar discectomy

Spinal surgery deals with the treatment of different pathological conditions of the spine such as tumors, deformities, degenerative disease, infections and traumas. Research in the field of vertebral surgery can be divided into two main areas: 1) research lines transversal to the different branches; 2) specific research lines for the different branches. The transversal lines of research are represented by strategies for the reduction of complications, by the development of minimally invasive surgical techniques, by the development of surgical navigation systems and by the development of increasingly reliable systems for the control of intra-operative monitoring. Instead, specific lines of research are developed within the different branches. In the field of oncological pathology, the current research concerns the development of in vitro models for the study of metastases and research for the study of targeted treatment methods such as electrochemotherapy and mesenchymal stem cells for the treatment of aneurysmal bone cysts. Research in the field of spinal deformities is focused on the development of increasingly minimally invasive methods and systems which, combined with appropriate pharmacological treatments, help reduce trauma, stress and post-operative pain. Scaffolds based on blood clots are also being developed to promote vertebral fusion, a fundamental requirement for improving the outcome of vertebral arthrodesis performed for the treatment of degenerative disc disease. To improve the management and the medical and surgical treatment of vertebral infections, research has focused on the definition of multidisciplinary strategies aimed at identifying the best possible treatment path. Thus, flow-charts have been created which allow to manage the patient suffering from vertebral infection. In addition, dedicated silver-coated surgical instrumentation and bone substitutes have been developed that simultaneously guarantee mechanical stability and reduce the risk of further local infection. In the field of vertebral traumatology, the most recent research studies have focused on the development of methods for the biostimulation of the bone growth in order to obtain, when possible, healing without surgery. Methods have also been developed that allow the minimally invasive percutaneous treatment of fractures by means of vertebral augmentation with PMMA, or more recently with the use of silicone which from a biomechanical point of view has an elastic modulus more similar to that of bone. It is clear that scientific research has changed clinical practice both in terms of medical and surgical management of patients with spinal pathologies. The results obtained stimulate the basic research to achieve even more. For this reason, new lines of research have been undertaken which, in the oncology field, aim at developing increasingly specific therapies against target receptors. Research efforts are also being multiplied to achieve regeneration of the degenerated intervertebral disc and to develop implants with characteristics increasingly similar to those of bone in order to improve mechanical stability and durability over time. Photodynamic therapies are being developed for the treatment of infections in order to reduce the use of antibiotic therapies. Finally, innovative lines of research are being launched to treat and regenerate damaged nerve structures with the goal, still far from today, of making patients with spinal cord injuries to walk

Summary Statement. Spinal cord injury is characterised by an inflammatory cascade that leads to neuronal death by neurotoxicity. In a model of spinal cord damage we successfully preserved the number of ventral horn neurons by treatment with interleukin-1 receptor antagonist (IL1RA) and neurotrophin (NT)-3. Introduction. Secondary damage after spinal cord injury (SCI) is characterised by activation of microglial cells that release neurotoxic agents. This results in apoptotic death of neurons that survived the initial trauma. Interleukin (IL)-1 is one of the most prominent mediators of neurotoxicity. Organotypic spinal cord slice cultures (OSCSC) are a useful in vitro model of spinal cord injury. We have previously shown that OSCSC degenerate substantially during in vitro incubation under standard conditions. Our aim was to treat OSCSC with the putatively neuroprotective agents IL-1 receptor antagonist (IL1RA) and neurotrophin (NT)-3 and to evaluate neuronal and microglial populations as well as axonal preservation. We hypothesised that treatment with the above substances would enhance neuronal survival and suppress microglial activation. Materials & Methods. OSCSC were obtained from p9 (p=postnatal) mice and cultured in a 3-D collagen matrix for 0, 2, 4, 6 and 8 days in vitro (div). Neuroprotective substances were added to culture media, resulting in 4 treatment groups: IL1RA, NT3, IL1RA+NT3, and control (only medium). After fixation cultures were stained immunohistochemically for the neuronal marker NeuN and α-neurofilament (NF-L). Microglial cells were marked with isolectin B. 4. (IB. 4. ). Neurons in the ventral and dorsal horns were counted manually. The number of resting and activated microglial cells was calculated within the white and grey matter based on staining intensity and circularity index. Axonal preservation was evaluated qualitatively. Results. OSCSC under control conditions showed signs of early degeneration after 2 div with decreased number of neurons within both the ventral and dorsal horns. However, significant differences between the groups were noted after 8 div: In the ventral horns, the neurons in all treatment groups were significantly more numerous compared to the control group. In the IL1RA+NT3 group the number of neurons did not differ significantly when compared to directly fixed cultures (div 0), whereas that number was significantly decreased in the other groups. After 8 div the number of activated microglial cells was significantly increased in the control group compared to all treatment groups both in the white and grey matter. Qualitative analysis of axonal preservation after 6 and 8 div revealed axonal sprouting within the white matter in all groups. However, these sprouting axons seemed to expand into the collagen matrix only in the three treatment groups. Discussion/Conclusion. We demonstrate a neuroprotective effect of IL1RA and NT3 in OSCSC. OSCSC normally degenerate after in vitro incubation, however neurons in the ventral horns are sustained at initial levels in the IL1RA+NT3 group. At the same time microglial activation is suppressed in all treatment groups compared to controls. Finally, treatment of OSCSC with IL1RA and NT3 seem to be associated with axonal sprouting outside the cultures

The June 2015 Spine Roundup360 looks at: Less is more in pyogenic vertebral osteomyelitis; Paracetamol out of favour in spinal pain but effective for osteoarthritis; Local wound irrigation to reduce infection?; Lumbar facet joint effusion: a reliable prognostic sign?; SPORT for the octogenarian; Neurological deterioration following traumatic spinal cord injury; PROMS in spinal surgery

Introduction Charcot arthropathy is a well recognised complication in denervated synovial joints. This is a late complication of traumatic spinal cord injury that is rarely reported in the literature. Early recognition is important and can be difficult as the clinical presentation can vary from pain, deformity, autonomic dysreflexia and audible noises with motion. Methods We present 5 cases of Charcot’s arthropathy of the spine in patients with in patients with traumatic paraplegia. All patients had spinal surgery to stabilise the spine shortly after the acute injury. Results The average time from initial injury to presentation with Charcot’s arthropathy was 27 years (range 10–41). A combination of localised and neuropathic pain was the dominant symptom (4 patients) causing re-presentation, but other symptoms included deformity (1 patient). The level of the initial spinal cord injury was at the thoracolumbar junction patients. The Charcot joint level was usually 1 to 2 segments caudal to the spinal fusion. The features noted on plain radiology were destructive changes of the endplate in 4 patients and deformity in 1. With one exception, all patients went on to have MRI to exclude infection and subsequently all were surgically stabilised. All patients were treated surgically. One had an anterior approach, one had posterior approach and one had staged anterior and posterior approaches. The remaining two had anterior and posterior stabilisation through a lateral extra-cavitary approach. At an average follow-up of 36 months all patients reported good relief of their symptoms, and had returned to their best function post-injury. Discussion Surgical stabilisation in this series yielded very good results. We observed a wide variation in presenting symptoms and therefore would indicate that a high index of suspicion is required. We believe that MRI is mandatory to exclude infection and would advocate early stabilisation. The lateral extra-cavitary approach allows posterior and anterior stabilisation in a single procedure and in now the preferred method in our institution. As patients with spinal cord injuries live increasingly active lives, this problem will be seen more frequently

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status. Cite this article: Bone Joint J 2015;97-B:527–31

This basic science study attempts to explain why patients with spinal cord injuries have been seen to display increased healing of attendant fractures. For the main part, this has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear. This paper evaluates two group with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (24hrs, 120hrs, 10 days, 6 weeks and 12 weeks). The time period most closely related to the end of the acute inflammatory reaction and the laying down of callus was the 10-day post injury time period. Serum samples taken at this time period were analysed for IGF-1 and TGF-ß levels, both known to initiate osteoblastic activity, using ELISA kits. They were also exposed to an osteoblast cell culture line and cell proliferation was measured. Results show that the group with neurology has increased levels of IGF-1 compared to the other groups (p< 0.14, p< 0.18 respectively, Student’s t-test) but had lower TGF-ß (p< 0.05, p< 0.006) and osteoblast proliferation levels (p< 0.002, p< 0.0001). When the neurology group is subdivided into complete (n=5) and incomplete (n=5), it was shown that the complete group had higher levels of both IGF-1 and TGF-ß. This trend is reversed in the osteoblast proliferation assay. This work, for the first time in human subjects, identifies a factor which may be regulating this complication of acute spinal cord injuries, namely IGF-1. Furthermore, the observed trend in the two cytokines seen in the complete neurology group may suggest a role for TGF-ß. However, the results do show that a direct mediation of this unwanted side effect of spinal cord injuries is unlikely as seen in the proliferation assay. Further work remains to be done to fully understand the complexities of the excessive bone growth recognised in this patient group

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear. This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (24hrs, 120hrs, 10 days, 6 weeks and 12 weeks). The time period most closely related to the end of the acute inflammatory reaction and the laying down of callus was the 10-day post injury time period. Serum samples taken at this time period were analysed for IGF-1 and TGF-β levels, both known to initiate osteoblastic activity, using ELISA kits. They were also exposed to an osteoblast cell culture line and cell proliferation was measured. Results show that the group with neurology has increased levels of IGF-1 compared to the other groups (p< 0.14, p< 0.18 respectively, Student’s t-test) but had lower TGF- (p< 0.05, p< 0.006) and osteoblast proliferation levels (p< 0.002, p< 0.001), despite having a significantly higher cell proliferation than a control group (p< 0.0001). When the neurology group is subdivided into complete (n=5) and incomplete (n=5), it was shown that the complete group had higher levels of both IGF-1 and TGF-. This trend is reversed in the osteoblast proliferation assay. This work, for the first time in human subjects, identifies a factor which may be regulating this complication of acute spinal cord injuries, namely IGF-1. Furthermore, the observed trend in the two cytokines seen in the complete neurology group may suggest a role for TGF-β. However, the results do show that a direct mediation of this unwanted side effect of spinal cord injuries is unlikely as seen in the proliferation assay. Further work remains to be done to fully understand the complexities of the excessive bone growth recognised in this patient group

High-pressure injection injuries occur infrequently but are usually work-related and involve the non-dominant hand. The neck is a very rare site for such an injury. We describe the management of a 36-year-old man with a high-pressure grease-gun injection injury to his neck causing a cervical spinal cord injury. He developed severe motor and sensory changes which were relieved by surgical removal of the grease through anterior and posterior approaches

Aim of our study was the investigation and the cross-correlation of various neurologic scales to estimate, comparatively with the functional results of patients after damage of spinal cord injuries. Between 1989 – 2005, 115 patients were submitted in stabilization of Lower Cervical Spine that was judged unstable. The neurologic situation was certified with the scales: Frankel, ASIA motor score, NASCIS motor score, FIM scale, and MBI scale. In the protocol took part the 94 patients for that existed in neurologic details and long follow-up for at least two years. From the study of course of scores of all scales was not found statistically important difference between ASIA, NASCIS and other motor scales. However 12 patients with important improvement of mobility at ASIA motor score and NASCIS motor score they have not difference in Frankel scale, despite the make that the MRP (Motor Percentage Recovery) was improved: 21.5%. Also 8 patients with relatively big improvement in their total scores did not have corresponding functional improvement (FIM scale, and [MBI] scale). A lot of neurologic methods – scales were used and are used today. However for the essential and modern follow-up of patients with spinal cord injuries, it needs certification with a scale of classic team of (measurement of mobility) and a scale of functional faculties of the patient

The aim of this experimental study was to provide an in vitro model suitable for the investigation of the complex interactions of neurons with non-neuronal cells that take place throughout the degenerative and regenerative processes induced by spinal cord injury. Organotypic spinal cord slice cultures (OSCSC) were prepared from postnatal Wistar rats (p0–12), were sustained in vitro up to 12 days and characterized by immunohistochemistry by well-established markers such as NeuN, Calbindin, GFAP, IB4 and Nestin. Calbindin+ neurons, distributed across the entire gray matter, were visible also after longer culture periods. NeuN+ neurons were best preserved in the dorsal horn, whereas large NeuN+ and ChAT+ motoneurons in the ventral horn vanished after 3 days in vitro. GFAP+ astro-cytes, initially restricted to the white matter, invaded the gray matter of OSCSC early during the culture period. Microglial cells, stained by Griffonia simplicifolia isolectin B4, were rapidly activated in the dorsal tract and in the gray matter, but declined in number with time. Nestin-immunoreactivity was found in animals of all age groups, either in cells interspersed in the ependymal lining around the central canal, or in cells resembling protoplasmic astrocytes. OSCSC derived from p0 or p3 animals showed a better preservation of the cytoarchitecture than cultures derived from older animals. In summary, OSCSC contain defined neuronal populations, the cytoarchitecture is partially preserved, and the glial reaction is self-limited. Our model of OSCSC could prove useful in future experiments on the patho-physiology of spinal cord injury

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear. This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=15), and compares them with a control group with isolated long bone fractures (n=12). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days (12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-β using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration. Results show TGF-β levels of 142.79+/-29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p=0.009 vs. all other time points, ANOVA). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51+/-36.81 ng/ml) and long bone (102.28=/-47.58 ng/ml) groups at 84 days post-injury (p=0.009 and p=0.04 respectively, ANOVA). In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-β in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. While the benefits are obvious, this excessive bone growth also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear. This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=15), and compares them with a control group with isolated long bone fractures (n=12). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days(12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-.) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration. Results show TGF-.; levels of 142.79±29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (.0.009 vs. all other time points, ANOVA). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51±36.81 ng/ml) and long bone (102.28±47.58 ng/ml) groups at 84 days post injury (p=0.009 and p=0.04 respectively, ANOVA). In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-.; in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries

Aim:. To present the results of multi-modal IOM in 298 patients who underwent spinal deformity correction. Method:. We reviewed the notes, surgical and IOM charts of all patients who underwent spinal surgery with the use of cortical and cervical SSEPs, as well as upper/lower limb transcranial electrical MEPs under the senior author. We recorded IOM events which we categorised as true, transient true and false (+) or (−). We correlated the IOM events with surgical or anaesthetic incidents. Results:. Diagnosis included idiopathic scoliosis in 224, congenital in 12, syndromic in 14, scoliosis with intraspinal anomaly in 5, scoliosis with congenital cardiac disease in 4, spondylolisthesis in 2, spinal tumour in one, and Scheuermann's kyphosis in 36 patients. We identified 3 true (+) monitoring events occurring in 2 patients (1%), 6 transient true (+) (2%), and 11 transient false (+) events (3.7%). True (+) events occurred during deformity correction in one patient with severe AIS and during osteotomies in another with severe Scheuermann's. Transient true (+) events occurred during posterior osteotomies in 2 patients with Scheuermann's, during scoliosis correction (apical correction with sublaminar wires) in one and placement of concave apical pedicle screw in another patient, and 2 IOM changes during positioning (one during reduction of spondylolisthesis-one during positioning on the surgical table). Transient false (+) events were mainly related to low blood pressure (10 patients). There were no false (−) IOM events and none of our patients had postoperative neurological complications. Sensitivity of our IOM technique was 100% [all patients with impending spinal cord injury will have a (+) event] and specificity 96% (patients with normal IOM had 96% chance that the cord was safe). Positive predictive value was 65.3% (65.3% chance that an IOM event reflected a surgical-related cause of cord injury); negative predictive value 100% (100% chance that normal IOM corresponded to no cord injury). We found no difference between patients with AIS and Scheuermann's in terms of risk of true or transient true (+) IOM events (Fisher's exact test, p=0.12). Discussion:. Multimodal IOM is highly sensitive and specific for spinal cord injury. This technique is reliable to assess the condition of the spinal cord during high-risk major spinal deformity surgery. Conflict of interest statement: None

Purpose: The average age of people suffering spinal cord injuries in many countries is shifting toward an older population, with a disproportionate number occurring in the spondylotic cervical spine. These injuries are typically due to low energy impacts, such as a fall from standing height. Since a stenotic spinal canal (a common feature of a spondylotic cervical spine) can cause myelopathy when the spine is flexed or extended, traumatic flexion or extension likely causes the injury during the low energy impact. However, this injury mechanism has not been observed experimentally. Method: To better understand this injury mechanism an in-vitro study, using six whole cervical porcine spines, was conducted. The following techniques were combined to directly observe spinal cord compression in a stenotic spine during physiologic and super-physiologic motion:. A radio-opaque surrogate cord, with material properties matched to in-vivo specimens, replaced the real spinal cord. Sagittal plane X-rays imaged the surrogate cord in the spine during testing. Varying levels of canal stenosis were simulated by a M8 machine cap screw that entered the canal from the anterior by drilling through the C5 vertebral body. Pure moment loading and a compressive follower load were used to replicate physiologic and super-physiologic motion. Results: Initial results show that a stenotic occlusion that removes all extra space in the canal in the neutral posture, without compressing the cord, can lead to spinal cord compression within physiologic ranges of flexion and extension. The spinal cord can also be compressed during slightly super-physiologic flexion and extension with only 25% canal occlusion. Physiologic loads and motions in the same spines did not cause cord compression when canal occlusion was 0%. Conclusion: These results support the hypothesis that cervical spinal canal stenosis increases the risk of spinal cord injury because spinal cord compression was observed during motions and loads that would be safe for a non-stenotic spine. These results are limited primarily due to the use of a porcine spine. However, this new stenosis model and experimental technique will be applied to in-vitro human spine specimens in future work

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision. . A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings. At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system. We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful. . 3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision. Cite this article: Bone Joint J 2015; 97-B:899–904

Introduction: Post-traumatic syringomyelia produces a significant burden of pain and neurological deficits for patients with spinal cord injury. The mechanism of syrinx formation is unknown and treatment is often ineffective. Previous studies have demonstrated that fluid flow enters syrinxes from the subarachnoid space via perivascular spaces, however other pathways may be involved. It has been proposed that a damaged blood-spinal cord barrier (BSCB) provides another pathway for fluid to enter syrinxes. The purpose of this study was to investigate whether or not the integrity of the BSCB is compromised in an animal model of post-traumatic syringomyelia, and if so, whether this deficiency plays a role in the induction or subsequent enlargement of a syrinx. Methods: The excitotoxic amino acid and arachnoiditis model of syringomyelia was used to study the structural and functional integrity of the BSCB in 27 Sprague-Dawley rats. In this model, quisqualic acid is injected into the cord to create an initial cyst. The addition of subarachnoid kaolin to create arachnoiditis results in a reliable model of syringomyelia [1]. Structural integrity of the blood-spinal cord barrier was assessed using immunoreactivity to endothelial barrier antigen (EBA) and loss of functional integrity was assessed by extravasation of intravascular horseradish peroxidise (HRP). Animals were studied at 3 days, or 1, 3, 6, or 12 weeks after surgery. There were laminectomy-only and saline injection controls at each time point. Results: Syrinxes formed in 15 of 17 animals injected with excitotoxic amino acid. There was loss of structural and functional integrity of the BSCB in the syrinx animals at all time points. There was wide-spread disruption of the barrier at early time points, followed by recovery of the barrier except for vessels immediately adjacent to the syrinx. Discussion: This study has demonstrated a prolonged structural and functional disruption of the BSCB. Loss of functional integrity of the barrier, with fluid entering the interstitial space of the spinal cord, may contribute to initial cyst formation after spinal cord injury and subsequent enlargement of the cyst to form post-traumatic syringomyelia

Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes. Our objective was to determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day post-operative complication rates. This study was a multicenter retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. All anterior cervical or posterior lumbar fusion surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery and emergency surgery were excluded. Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay and 30 day post-operative complication rates. 1441 patients met the inclusion criteria: 1142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertile of predicted surgery duration, cervical or lumbar surgery, instrumentation, inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, lumbar fusion surgery and inpatient surgery. There were no significant differences reported for any other factors. After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates, length of hospital stay or surgical duration of more routine surgical cases. We found that resident involvement in surgical cases that were generally more complexed resulted in increased surgery time. Further study is required to determine the relationship between surgery complexity and the effect of resident involvement on surgery duration

Increased bone turnover and fracture healing is associated with acute spinal cord injuries. Experimental work to date has been confined to animal models. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. This paper evaluates two groups of patients with spinal column fractures – those with neurological compromise and those without, and compares them with a control group with isolated long bone fractures. Serum was taken from these patients at 10 days post injury and was analysed for the known osteogenic cytokines Insulin-like Growth Factor-1 (IGF-1) and Transforming Growth Factor-b1 (TGF-b1) as well as being added to an osteoblast cell culture line to analyse cell proliferation. The results for the IGF-1 show a higher level in the neurology group compared to the no neurology group (p=0.038). In the TGF-B1 assay, the neurology group has a lower level than the other two groups (p< 0.0001 and p=0.002 respectively). However, when this group is subdivided into patients with complete and incomplete neurology, it can be seen that the levels of the complete group are elevated, although not significantly so (p=0.228). All three groups stimulated markedly increased osteoblast cell proliferation versus a control group (p=0.086, p=0.005 and p=0.002 respectively). However, the neurology group is significantly lower than the other two groups (p=0.007 and p=0.001 respectively). Furthermore the complete group causes a lower proliferation rate than the incomplete group (p=0.539). In conclusion, at 10 days post injury when the acute inflammatory reaction is subsiding and new bone is being laid down, patients with acute spinal cord injuries have increased bone turnover. This increase is being indirectly mediated by IGF-1, and more elevated levels with more severe neurological compromise suggest a contributory role of TGF-b1. Direct stimulation of osteoblasts does not appear to have any role to play in this accelerated bone healing

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear. This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days(12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-b) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration. Results show TGF-b levels of 142.79+/−29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p< 0.001 vs. day 1, day 5 and day 10 and p=0.005 vs. 42 days, ANOVA univariate analysis). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51+/−36.81 ng/ml) and long bone (102.28=/−47.58 ng/ml) groups at 84 days post injury (p=0.011 and p=0.021 respectively, ANOVA univariate analysis). There was statistically significant difference in TGF-b levels seen between the clinically more severely injured patients i.e. complete neurological deficit and the less severely injured patients i.e. incomplete neurological deficit. In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-b in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear. This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days (12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-ß) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration. Results show TGF-ß levels of 142.79+/−29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p< 0.001 vs day 1, day 5 and day 10 and p=0.005 vs 42 days, ANOVA univariate analysis). Furthermore, this level is also higher than the levels recorded in the non neurology (103.51+/−36.81 ng/ml) and long bone (102.28=/−47.58 ng/ml) groups at 84 days post injury (p=0.011 and p=0.021 respectively, ANOVA univariate analysis). There was statistically significant difference in TGF-ß levels seen between the clinically more severely injured patients, ie complete neurological deficit and the less severely injured patients, ie incomplete neurological deficit. In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-ß in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries

Retrospective review of seventeen consecutive survivors of craniocervical dissociation (CCD). Thirteen patients had delay in diagnosis, with associated neurologic deterioration in five. Diagnosis of CCD was entertained after lateral C-spine x-ray in only two patients, and after screening C-spine CT in two others. At fifteen-month average follow-up, mean ASIA motor score improved from fifty preoperatively to seventy-nine postoperatively. One patient had temporary postoperative neurologic decline. There were no pseudarthroses. The diagnosis of CCD is often missed, with potentially severe neurologic consequences. Early diagnosis and stabilization are neuroprotective. A classification that identifies minimally displaced yet unstable injuries may improve diagnostic accuracy. To identify the timing and method of diagnosis, diagnostic reliability of screening lateral radiographs, effect of delayed diagnosis, complications of treatment, and neurologic outcome of this life-threatening condition. Diagnosis of craniocervical dissociation (CCD) was frequently delayed, increasing the risk of neurologic decline. Early diagnosis and stabilization protected against worsening spinal cord injury. This study highlights the importance of disciplined evaluation of the lateral cervical spine radiograph of poly-traumatized patients. Head-injured patients with cranio-facial trauma and asymmetric high cervical spinal cord injuries should heighten clinicians’ suspicion of CCD. CCD was identified or suspected on two of seventeen (12%) initial lateral cervical spine radiographs, and on screening CT scan in only two additional patients (12%), despite an abnormal dens-basion relationship in 16/17 (94%) patients. Of the thirteen patients with (two-day average) delay in diagnosis, 5/13 (38%) had profound neurologic deterioration. One patient worsened temporarily after fixation. There were no pseudarthroses at fifteen-month average follow-up. Mean ASIA motor score of fifty improved to seventy-nine, and the number of patients with useful motor function (ASIA D or E) increased from seven (41%) preoperatively to thirteen (76%) postoperatively. Four patients with severe craniocervical instability had < 3 mm displacement. We therefore adopted a classification based on provocative traction testing of minimally displaced injuries.(Table). Retrospective review of seventeen consecutive CCD survivors identified between 1994–2002 through institutional databases. Radiographic and clinical results were evaluated, emphasizing timing of diagnosis, effect of delayed diagnosis, clinical or radiographic warning signs, and response to treatment. Please contact author for tables and /or diagrams

Introduction: This is a report on results from the first three years of the British Spinal Registry. Background: The British Scoliosis Society supported a web based scoliosis registry in 2003. At the Britspine meeting in 2004 all four British spine societies (BSS, BASS, BCSS, SBPR) agreed to expand this to include all spinal surgical procedures in the United Kingdom. An extensive marketing and promotional campaign was targeted at all members of the four societies, and online and telephone support was provided. Aims: To report on the clinical results from the first three years registry activity. Methods: The British Spinal Registry is a web based out-come tool, collecting basic demographic and outcome data on spinal surgical procedures in the UK. Over three years from November 2004, 1410 patient data sets were entered. The activity analysis is party carried out using the online diagnostics that are part of the web based software tool, and partly with downloaded data. Results: 73 surgeons from 55 centres entered patient data on 1410 surgical episodes between November 2004 and December 2007. The number of patients entered per year has declined marginally, with 540 patients in the first year, 454 in the second and 416 in the third. The majority of cases entered have a low back diagnosis (842) of whom 106 were part of a BASS audit on discectomy. Of the low back cases 40% had disc herniation and 7.4% had previous surgery. The complications included dural tear (3.7%), nerve root injury (0.4%) and infection (1.1%). The BASS study showed that 70% of UK surgeons were not using intraoperative radiographic localisation of surgical level. There were 448 deformity cases, and of these 223 were idiopathic scoliosis, 49 neuromuscular and 20 congenital. 57% had posterior surgery, 20% anterior and 23% combined. There were no intraoperative deaths, no complete spinal cord injuries, 4 partial spinal cord injuries (0.9%), 6 deep infections (1.3%) and 14 implant revisions (3.1%). Conclusion: The initial clinical results from the British Spinal Registry support the hypothesis that such registries can produce useful audit data. There is no other record nationally of number and type of procedures in spinal surgery in the UK. The complication rates are similar to those reported elsewhere and provide an opportunity for benchmarking and for comparative personal and centre audit. The uptake and usage rates however are low and would not allow scientifically valid clinical results to be reported

Aim: To analyse the epidemiology of spinal injuries presented in our tertiary referral centre. Materials and Methods: 202 patients who sustained traumatic spinal column injury were admitted in our tertiary referral centre from 1999 to mid 2002. The case notes were looked at for epidemiological details. Results: Of 202 patients, 136 were male and the rest were females. Both in males and females, we found 2 peaks in the age incidence of spinal cord injuries. First peak was noted between the age group of 18–30 years and the second peak was noted above 60 years. We classified the spinal column injuries into upper cervical, lower cervical, thoracic, dorso-lumbar, lumber and sacral. Lower cervical and cervico-dorsal junction fractures constituted 48% of the spectrum of spinal column fractures. Significant soft tissue injury was noted in 12 patients. Multiple level spinal injuries were present in 16 patients (7.9%). Although road traffic accidents were responsible for 32% of the fractures, domestic falls also contributed to 30.6% of the fractures. 50%of these domestic falls occurred in patients above 60 years of age. We classified the falls into two categories; those from a height above 6 feet were classed as severe falls, which occurred in 65.6% of cases. Below this height the falls were classed as low falls. 71% of the patients who sustained low falls were above 60 years. Sporting accidents caused 19.8% of the spinal fractures. 27% of them are due to diving. Significantly self-harm was found to be a cause of spinal fracture in 3 patients. 67.8% (137) of the patients sustained neurological injury. Incomplete spinal cord injury was present in 86 patients and complete injury in 51 patients. Tetraplegia and tetraparesis was noted in 89 patients where as paraplegia and paraparesis was noted in 48 patients. 26 patients required ventilation at the time of admission. 63 patients sustained polytrauma of which chest injury was found in one third of the poly traumatised patients. Conclusion: From our observations, we find that there is an increasing trend of elderly population who are more susceptible for spinal trauma. Traditional high velocity trauma and high falls though still contribute a significant proportion of spinal injuries, equal proportions of spinal fractures are caused by low falls commonly seen in elderly patients. These epidemiological trends will have implications on treatment, rehabilitation and outcome of spinal injuries

In osteoporosis treatment, current interventions, including pharmaceutical treatments and exercise protocols, suffer from challenges of guaranteed efficacy for patients and poor patient compliance. Moreover, bone loss continues to be a complicating factor for conditions such as spinal cord injury, prescribed bed-rest, and space flight. A low-cost treatment modality could improve patient compliance. Electrical stimulation has been shown to improve bone mass in animal models of disuse, but there have been no studies of the effects of electrical stimulation on bone in the context of bone loss under hormone deficiency such as in post-menopausal osteoporosis. The purpose of this study was to explore the effects of electrical stimulation on changes in bone mass in the ovariectomized rat model of post-menopausal osteoporosis. All animal protocols were approved by the institutional Animal Research Ethics Board. We developed a custom electrical stimulation device capable of delivering a constant current, 15 Hz sinusoidal signal. We used 30 female Sprague Dawley rats (12–13 weeks old). Half (n=15) were ovariectomized (OVX), and half (n=15) underwent sham OVX surgery (SHAM). Three of each OVX and SHAM animals were sacrificed at baseline. The remaining 24 rats were separated into four equal groups (n=6 per group): OVX electrical stimulation (OVX-stim), OVX no stimulation (OVX-no stim), SHAM electrical stimulation (SHAM-stim), and SHAM no stimulation (SHAM-no stim). While anaesthetized, stimulation groups received transdermal electrical stimulation to the right knee through bilateral skin-mounted electrodes (10 × 10 mm) with electrode gel. The left knee served as a non-stimulated contralateral control. The no-stimulation groups had electrodes placed on the right knee, but not connected. Rats underwent the stim/no-stim procedure for one hour per day for six weeks. Rats were sacrificed (CO2) after six weeks. Femurs and tibias were scanned by microCT focussed on the proximal tibia and distal femur. MicroCT data were analyzed for trabecular bone measures of bone volume fraction (BV/TV), thickness (Tb.Th), and anisotropy, and cortical bone cross-sectional area and second moment of area. Femurs and tibias from OVX rats had significantly less trabecular bone than SHAM (femur BV/TV = −74.1%, tibia BV/TV = −77.6%). In the distal femur of OVX-stim rats, BV/TV was significantly greater in the stimulated right (11.4%, p < 0 .05) than the non-stimulated contralateral (left). BV/TV in the OVX-stim right femur also tended to be greater than that in the OVX-no-stim right femur, but the difference was not significant (17.7%, p=0.22). There were no differences between stim and no-stim groups for tibial trabecular measures, or cortical bone measures in either the femur or the tibia. This study presents novel findings that electrical stimulation can partially mitigate bone loss in the OVX rat femur, a model of human post-menopausal bone loss. Further work is needed to explore why there was a differential response of the tibial and femoral bone, and to better understand how bone cells respond to electrical stimulation. The long-term goal of this work is to determine if electrical stimulation could be used as a complementary modality for preventing post-menopausal bone loss

Study design: Retrospective, descriptive study. Objectives: To describe the characteristics and outcomes of patients with spinal canal stenosis who suffer significant spinal cord injury (SCI) due to hyperextension injury of the cervical spine. To compare their characteristics and outcomes with all patients suffering traumatic cervical SCI and with the total cohort of patients admitted to a Spinal Injuries Unit for rehabilitation. Setting: Spinal Injuries Unit (SIU), Princess Alexandra Hospital, Brisbane. Methods: Demographic, injury and outcome data were obtained from an existing database and by review of the medical records of 575 patients admitted to and discharged from the SIU between July 1st, 1995 and July 1st 2002. Main outcome measures were: change in American Spinal Injury Association (ASIA) scale category, change in ASIA motor score, discharge Functional Independence Measure (FIM) score and change in FIM score, length of stay (LOS), primary means of mobility at discharge and discharge destination. Standard statistical methods were used to compare groups. Results: A total of 18 (3%) of the 575 patients were found to have cervical canal stenosis and hyperextension injury (the CCS/HI group). This represents 8% of the total group suffering traumatic injury to the cervical spinal cord (the total cervical trauma: TCT group, n = 225). This CCS/HI group was found to have a mean age at injury of 55.1 years compared to 37.1 and 37.8 years respectively for the TCT and total groups. Ninety-four percent of patients were found to have a neurological level at admission at C1–3 or C4–5 compared to 75.6% of the TCT group and only 5.6% of patients had an ASIA Impairment Category A lesion at admission compared to 38.7% of the TCT group. Falls (55.6%) was the most common cause of injury in the CCS/HI group with motor vehicle accidents (33.8%) most common in the TCT group. The mean change in ASIA motor score between admission and discharge was 34.7 compared to 20.4 for the TCT group. Degree of impairment (measured by a change in ASIA Category) improved in 28% of patients and mean change in total FIM score was 41.3. There was no difference seen with the TCT group. LOS was shorter for these patients (111.1 days vs. 161.6 days). The primary means of mobility at discharge was “walking” for 50% of this group (compared to 28.4% for the TCT group) while the next most common means of mobility was “power wheelchair” at 28% (17% of TCT group). Most patients (55.4%) were discharged to their previous home following rehabilitation and 22.3% were discharged to another rehabilitation unit or acute hospital. Conclusions: Patients with cervical spinal canal stenosis who suffer hyperextension injury constitute a distinct subgroup with the total group of traumatic cervical spinal cord injuries. This study suggests that they are older at the time of injury, have more rostral cervical injuries, are more likely to have incomplete injuries and that falls is the most common cause of injury. They have greater improvement in motor function but this does not appear to result in greater function at discharge as measured by the FIM. There appears to be a dichotomy with results for mobility at discharge with patients either being able to walk or requiring a power wheelchair. LOS in the SIU is shorter but a higher percentage are discharged to another hospital or rehabilitation unit

STUDY DESIGN: Retrospective, descriptive study. OBJECTIVES: To describe the characteristics and outcomes of patients with spinal canal stenosis who suffer significant spinal cord injury (SCI) due to hyperextension injury of the cervical spine. To compare their characteristics and outcomes with all patients suffering traumatic cervical SCI and with the total cohort of patients admitted to a Spinal Injuries Unit for rehabilitation. SETTING: Spinal Injuries Unit (SIU), Princess Alexandra Hospital, Brisbane. METHODS: Demographic, injury and outcome data were obtained from an existing database and by review of the medical records of 575 patients admitted to and discharged from the SIU between July 1st, 1995 and July 1st 2002. Main outcome measures were: change in American Spinal Injury Association (ASIA) scale category, change in ASIA motor score, discharge Functional Independence Measure (FIM) score and change in FIM score, length of stay (LOS), primary means of mobility at discharge and discharge destination. Standard statistical methods were used to compare groups. RESULTS: A total of 18 (3%) of the 575 patients were found to have cervical canal stenosis and hyperextension injury (the CCS/HI group). This represents 8% of the total group suffering traumatic injury to the cervical spinal cord (the total cervical trauma: TCT group, n = 225). This CCS/HI group was found to have a mean age at injury of 55.1 years compared to 37.1 and 37.8 years respectively for the TCT and total groups. Ninety-four percent of patients were found to have a neurological level at admission at C1-3 or C4-5 compared to 75.6% of the TCT group and only 5.6% of patients had an ASIA Impairment Category A lesion at admission compared to 38.7% of the TCT group. Falls (55.6%) was the most common cause of injury in the CCS/HI group with motor vehicle accidents (33.8%) most common in the TCT group. The mean change in ASIA motor score between admission and discharge was 34.7 compared to 20.4 for the TCT group. Degree of impairment (measured by a change in ASIA Category) improved in 28% of patients and mean change in total FIM score was 41.3. There was no difference seen with the TCT group. LOS was shorter for these patients (111.1 days vs. 161.6 days). The primary means of mobility at discharge was “walking” for 50% of this group (compared to 28.4% for the TCT group) while the next most common means of mobility was “power wheelchair” at 28% (17% of TCT group). Most patients (55.4%) were discharged to their previous home following rehabilitation and 22.3% were discharged to another rehabilitation unit or acute hospital. CONCLUSIONS: Patients with cervical spinal canal stenosis who suffer hyperextension injury constitute a distinct subgroup with the total group of traumatic cervical spinal cord injuries. This study suggests that they are older at the time of injury, have more rostral cervical injuries, are more likely to have incomplete injuries and that falls is the most common cause of injury. They have greater improvement in motor function but this does not appear to result in greater function at discharge as measured by the FIM. There appears to be a dichotomy with results for mobility at discharge with patients either being able to walk or requiring a power wheelchair. LOS in the SIU is shorter but a higher percentage are discharged to another hospital or rehabilitation unit

Introduction: Reported standardized functional outcome assessment of flexion distraction injuries of the thoracolumbar spinal column seems to be lacking in the literature. The primary focus of this study was the long term functional outcome in this patient population in view of the management employed in a tertiary spine referral center. In an attempt to overcome the lack of pre-injury Health Related Quality of Life (HRQOL) data, patient recall of the pre-injury state was used. Secondary outcomes included the long-term disease-specific HRQOL in these patients, the correlation between radiographic alignment and functional outcome, comparison of HRQOL between operative and non-operative care, and identifying potential prognostic factors influencing functional HRQOL. Method: A database generated retrospective cohort study with a cross-sectional outcome analysis was carried out for patients with a thoracolumbar (T11-L2) flexion-distraction injury treated at a tertiary care referral center between 1995 and 2000. Inclusion criteria were age over sixteen, and referral to our center for a traumatic thoracolumbar flexion-distraction injury within two weeks of the injury. Exclusion criteria were an associated spinal cord injury, a previous spine injury or a multi-level spine injury, a significant associated other system injury with an ISS > 50, or patient refusal or inability to complete the outcome questionnaires. Patients were followed for a minimum of two years. Injury classification, healing, and alignment were determined by radiographic analysis. Standing lateral x-rays at final follow-up were used to determine the amount of residual kyphosis by two independent observers. Results: A total of 87 patients were identified by the research database, of which 83 met inclusion and exclusion criteria. Twenty-eight patients were lost to follow-up, leaving 55 eligible patients. Eight refused to participate. Of the 47 remaining patients, 40 completed questionnaires representing a response rate of 85%. There were 26 males and 14 females with a mean age of 27.4 years (range 16–48). Average follow-up was 3.3 years (range 2.5–7). Twenty-five patients (64.9%) were treated operatively and fifteen patients (35.1%) underwent non-operative management. Complications in the surgical group included one non-union, three cases of painful instrumentation, and one infection. In the non-surgical group, two patients developed non-unions requiring surgical intervention. Comparing the follow-up mean SF-36 PCS and MCS scores to the recalled baseline SF-36 pre-injury scores, demonstrated the patients did not return to baseline physical component and mental component scores (p < 0.001). The mental component (MCS) and NASS pain scores showed significant statistical difference between the two groups with a trend of non-surgical patients scoring higher. There was no statistically significant difference in the SF-36 PCS between the two groups. Linear and multiple regression models identified “associated other system injuries” as the only useful predictor of outcome influencing the SF-36 PCS. Patients with associated injuries are likely to have a poorer prognosis with lower scores. Radiographically, there was no association between degree of kyphosis at last follow-up and outcome. Discussion: Long term functional outcome assessment in this patient population and comparison between the surgical and non-surgical groups, revealed a trend in the non-surgical group towards reporting higher scores on both the generic and disease-specific questionnaires. There were also a higher number of complications associated with the surgical group, as well as potential residual back pain related to instrumentation. Limitations of the study were the retrospective nature of the study, as well as the inherent absence of real time pre-injury quality of life assessment. The study is, however, strengthened by a homogeneous cohort and the use of validated outcome measures. It also involves a cross-sectional analysis and so has a prospective component. Conclusion: The health related quality of life in patients treated for flexion-distraction injuries without spinal cord injury is favorable overall, but does not return to normal after an average of two years following injury, with a trend in the non-surgical group towards reporting higher scores on both the generic and disease-specific questionnaires. Radiographically, no association was found between degrees of focal kyphosis at last follow-up and functional outcome

Objective To assess the validity of Somatosensory Evoked Potential (SSEP) monitoring in identifying potential spinal cord vascular damage resulting from segmental artery ligation in anterior spinal deformity correction. Design SSEP monitoring was undertaken in patients deemed at risk of spinal cord vascular injury during corrective surgery. The segmental vessels of the vertebral bodies to be instrumented were identified. Baseline SSEPs were obtained prior to application of non-crushing microvascular clamps. After ten minutes of occlusion, further SSEP recordings were made. Surgery proceeded with either, vessel ligation and division allowing anterior instrumentation, or vessel sparing anterior release. Subjects 22 patients were included; 7 had Scheuermann’s hyperkyphosis and 15 had scoliosis (11 idiopathic, 3 syndromic, 1 neuromuscular). Perceived risk was defined by the presence of hyperkyphosis, abnormal neurological examination or radiologically identified spinal cord anomaly. Outcome Measures A drop of 30% from baseline reading was taken as significant. Post-operative neurological outcome was correlated with intra-operative signal change and alteration in planned surgery. Results There was no significant drop in post-clamping SSEPs in the hyperkyphotic patients. In 3 scoliosis patients anterior instrumentation was abandoned and a release was performed. Staged posterior instrumentation followed. In a further 2, anterior instrumentation proceeded but in a modified fashion. The remaining 10 patients had no significant drop and underwent the surgery as planned. No patient sustained a neurological injury. Conclusions SSEP monitoring is safe in assessing the apparent contribution of segmental vessel blood supply to the spinal cord in spinal deformity surgery. It has allowed timely alteration of planned surgical procedures that potentially may have caused vascular spinal cord injury

Aim. Posttraumatic pelvic-osteomyelitis is one of the most serious complications after pelvic-fractures. The necessary extensive surgical debridement as part of interdisciplinary treatment is complicated by the possible persistence of pelvic instability. The aim of this study was to determine the outcome and outline the course of treatment after early posttraumatic pelvic bone infections due to type-C pelvic ring injuries. Method. In a retrospective cohort study (2005–2015) all patients with pelvic-osteomyelitis within six weeks of surgical stabilization of a type-C pelvic-fracture were assessed. Microbiological results, risk factors, course of treatment and functional long-term outcome using the Orlando-Pelvic-Score were analyzed. Results. A total of 18 patients (age 43.7 years; Body-Mass-Index 27.9 kg/m2; ASA-physical-status 1.8; Injury-Severity-Score 38) developed a pelvic-osteomyelitis within an average of 27 days after internal surgical stabilization of a type-C pelvic injury (AO-type C1: 10, C2: 4, C3: 4). Os pubis was affected in 7 and Os ilium in 11 cases. In addition to the pelvic-fracture, major vascular injuries occurred in 8, nerve injuries in 9, and intestinal and/or bladder ruptures in 11 cases. In 14 cases a mass transfusion was necessary. In addition to clinical signs of inflammation, (10 × redness, 12 × wound secretion, 6 × fistula) elevated levels of c-reactive-protein (7.7 mg/dl) and white-blood-cells (10.5/nl) were found. Bacterial cultures harvested during the initial surgical revision demonstrated mixed cultures in 17/18 cases, with an average of 3 different organisms isolated per case (61% intestinal bacteria). During the scheduled repetitive debridement a reduction of the initial mixed cultures into a single organism was observed. Overall 6.8 surgical interventions, including implant removal, were necessary until osteomyelitis was eradicated. In no cases was re-osteosynthesis performed. In 6/18 cases recurrence of infection occurred after an average of 5 months, followed by an additional repetitive debridement. An average 3-year-follow-up after the initial osteomyelitis-diagnosis demonstrated eradication of infection in 17/18 cases combined with an Orlando-Pelvic-Score of 21.9 points (best possible function: 40 points). Despite significant pelvic malalignment the ability to walk was achieved in all patients, with one exception due to a spinal cord injury. Conclusions. Despite no new surgical stabilization of the initial unstable pelvic injury, the early removal of implants combined with extensive debridement and antibiotic therapy led to sufficient long-term outcomes in patients with early posttraumatic pelvic-osteomyelitis. In particular, due to the severity of the initial injury and the complex interdisciplinary approach, early diagnosis of the osteomyelitis is essential

Patients with neuromuscular disease and imbalance present a particularly challenging clinical situation for the orthopaedic hip surgeon. The cause of the neuromuscular imbalance may be intrinsic or extrinsic. Intrinsic disorders include those in which the hip is in development, such as cerebral palsy, polio, CVA, and other spinal cord injuries and disease. This can result in subluxation and dislocation of the hip in growing children, and subsequent pain, and difficulty in sitting and perineal care. Extrinsic factors involve previously stable hips and play a secondary role in the development of osteoarthritis and contractures in later life. Examples of extrinsic factors are Parkinson's disease, dyskinesis, athetosis, and multiple sclerosis. Goals of treatment in adults with pain and dysfunction in the setting of neuromuscular imbalance are to treat contractures and to perform salvage procedures to improve function and eliminate pain. Treatment of patients with neuromuscular imbalance may include resection arthroplasty (Girdlestone), arthrodesis, or total hip arthroplasty. Resection arthroplasty is typically reserved for patients that are non-ambulatory, or hips that are felt to be so unstable that arthroplasty would definitely fail due to instability. In modern times arthrodesis has limited use as it negatively impacts function and self-care in patients with neuromuscular disorders. Total hip arthroplasty has the ability to treat pain, relieve contractures, and provide improved function. Due to the increased risk of instability, special considerations must be made during primary total hip arthroplasty in this patient cohort. Risk of instability may be addressed by surgical approach, head size, or use of alternative bearing constructs. Posterior approach may have increased risk of posterior dislocation in this patient group, particularly if a posterior capsular repair is not possible due to the flexion contractures and sitting position in many patients. Surgeons familiar with the approaches may utilise the anterolateral or direct anterior approach judicially. Release of the adductors may be performed in conjunction with primary total hip arthroplasty to help with post-operative range of motion and to decrease risk of instability. In a standard bearing, the selected head size should be the largest that can be utilised for the particular cup size. Rigorous testing of intra-operative impingement, component rotation, and instability is required. If instability cannot be adequately addressed by a standard bearing, the next option is a dual mobility bearing. Multiple studies have shown improved stability with the use of these bearings, but they are also at risk for instability, intraprosthetic dislocation, and fretting and corrosion of the modular connections. Another option is a constrained liner. However, this results in reduced range of motion, and an increased risk for mechanical complications of the construct. The use of a constrained liner in a primary situation should be limited to the most severe instability cases, and the patient should be counseled with the associated risks. If total hip arthroplasty results in repeated instability, revision surgery or Girdlestone arthroplasty may be considered

Sciwora lesions are common in children but rare in adults. In adults, they are often associated with spondylosis, and minor trauma may result in paralysis of varying degrees. In our unit we conducted a retrospective analysis of adult patients with spinal cord injuries. Only two had Sciwora lesions. One lesion was in the thoracic spine and the other in the lumbar spine. The thoracic lesion led to complete paraplegia, with intrinsic cord damage. It was treated conservatively and the patient did not recover. The lumbar lesion was incomplete, with traumatic disc prolapse that recovered after discectomy. Management of Sciwora lesions of the thoracic and lumbar spine depends on MRI findings

Purpose. To assess the impact of implementing a joint Neurosurgical/Orthopaedic Spinal on-call rota on the referral patterns to the Neurosurgical Department at James Cook University Hospital, Middlesbrough. Methods. A joint spinal rota was implemented at James Cook University Hospital in April 2008, to provide 24-hour on-call availability of a Spinal specialist. Using the Neurosurgical Referral Database (Microsoft Access), the referrals received for the 12 months prior to, and subsequent to, the implementation were analysed. Results. There was a 13.4% increase in total spinal referrals in the 12 months post-implementation of the new spinal rota, compared with pre-implementation. Total admissions from these referrals increased by 11.7%. There was an increase of 5.5% in lumbar degenerative referrals (including cauda equina referrals), a 10.5% decrease in cervical degenerative referrals, and most significantly, a 42.9% increase in spinal injury referrals, including fractures, and spinal cord injuries. Conclusions. The implementation of a joint Neurosurgical and Spinal Orthopaedic on-call rota for Spinal Surgery has resulted in the availability of a Spinal Consultant on-call 24hrs a day, 7 days a week to cover Spinal emergencies. The resulting change in referrals to the Neurosurgical Department has seen an increase in both referrals and admissions, although it is uncertain whether this is a result of a general increase in referral rate, or a direct result of the change in service provision

C-type natriuretic peptide is the most abundant natriuretic peptide in the central nervous system. It has been implicated in neurogenesis and may have a significant role in spinal regeneration. We postulated that the spinal concentration of CNP would be reflected in the plasma concentrations of both CNP and the pro-hormone (NTproCNP) and this may be an indicator of repair potential in spinal injuries. Concurrent plasma and CSF concentrations of CNP forms were measured in 51 subjects undergoing spinal anaesthesia for elective total hip and knee replacement. Associations with CNP activity and metabolism in CSF were sought by measuring CSF levels of cGMP and neprilysin respectively. Elevated concentrations of NTproCNP (1045±359 pmol/L) were found in CSF and greatly exceeded those of CNP (7.9±3.2 pmol/L). The ratio of NTproCNP to CNP in CSF (145±55) was much higher than in plasma (31±27). A significant inverse relation was found between plasma and CSF CNP concentrations (r=−0.29, p<0.05). cGMP and neprilysin were unrelated to CNP levels in CSF. Despite markedly elevated levels of NTproCNP in CSF, it is unlikely that these contribute to systemic levels in healthy adults. Identifying NTproCNP as the dominant CNP form in CSF opens up the possibility of its use in future studies exploring CNP regulation within the CNS and possible applications in diagnosis and monitoring of healing in patients with spinal cord injury

Purpose of the study:. To describe the incidence, nature, and risk factors associated with upper limb injuries in athletes participating in the London 2012 Paralympic Games. Materials and methods:. This study formed a component of the large prospective cohort study conducted over the 14-day period of the London 2012 Paralympic Games, coordinated through the IPC Medical Committee. Daily injury data were collected by team physicians in 3 329 athletes (46 606 athlete days) participating in the study, and 258 upper limb injuries were recorded. The incidence proportion (IP=number of injuries per 100 athletes), and incidence (number of injuries per 1000 athlete days) of upper limb injuries was calculated. Results:. The overall IP (with 95% CI) of upper limb injuries was 7,2 (6,4–8,1), with an incidence of 5,2 (4,6–5,8). Shoulder injuries were encountered most frequently with an overall incidence of 2,2 (1,85–2,7) and caused the greatest amount of time lost from sport. The incidence of shoulder injuries by sport was 8,8 (5,4–13,5) in powerlifting, 5,0 (2,1–9,8) in Judo, 2,8 (1,2–5,6) in wheelchair basketball, and 2,7 (1,6–4,2) in swimming. The incidence of injuries of the wrist and hand was 3,9 (1,4–8,5) in goal ball, 3,2 (1,5–6,0) in wheelchair basketball, and 2,8 (1,3–5,4) in table tennis. The majority of upper limb injuries occurred in athletes with spinal cord injuries (38,3%) and athletes with amputation or limb deficiency (28,4%). Rotator cuff impingement syndrome and chronic rotator cuff injury were the most frequent specific diagnoses in the upper limb injuries. Conclusion:. To date, this is the largest study evaluating upper limb injuries at the Paralympic Games. The shoulder is the anatomical region most frequently injured and caused the greatest time lost from sport. Type of sport, older age group, and athlete disability category were identified as risk factors for upper limb injuries

Patients with spinal injuries are very vulnerable to early complications or secondary spinal cord injuries before and during transfer, which may delay their rehabilitation. We designed transfer guidelines following concerns raised in a pilot study of the transfer of 16 patients. We then examined the effectiveness of the guidelines in 100 consecutive patients and completed the cycle by re-auditing a further 254 consecutive admissions after incorporating changes from the initial audit. The transfer guidelines addressed ten areas of clinical concern. We recorded a 50% improvement in airway monitoring and management. There was also improvement in anti-ulcer therapy and thromboprophylaxis (from 50% to 96%). We saw a 50% improvement in the use of appropriate support staff during the transfer. The re-audit showed that initial improvements were maintained and further improvements were noted in the transfer of relevant documentation and investigations. Improvement was also noted in the use of a vacuum mattress for the transfer of spinal injury patients and subsequently reduced incidence of pressure sores by a statistically significant level, which helped in the early rehabilitation of these patients. The majority of transfers were safe. The transfer guidelines were easy to use and improved patient care by ensuring that common problems had been addressed before and during transfer. This system reduced the risk of preventable complications during inter-hospital transfer. There may be wider application of similar guidelines to other trauma patients who require inter-hospital transfer, where there is a possibility of preventable secondary injury