There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in ...patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥ 24 hours after injury) decompressive surgery after traumatic cervical SCI.
We performed a multicenter, international, prospective cohort study (Surgical Timing In Acute Spinal Cord Injury Study: STASCIS) in adults aged 16-80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up. Secondary outcomes included assessments of complications rates and mortality.
A total of 313 patients with acute cervical SCI were enrolled. Of these, 182 underwent early surgery, at a mean of 14.2(± 5.4) hours, with the remaining 131 having late surgery, at a mean of 48.3(± 29.3) hours. Of the 222 patients with follow-up available at 6 months post injury, 19.8% of patients undergoing early surgery showed a ≥ 2 grade improvement in AIS compared to 8.8% in the late decompression group (OR = 2.57, 95% CI:1.11,5.97). In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28). During the 30 day post injury period, there was 1 mortality in both of the surgical groups. Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).
Decompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up.
Although generally safe and effective, surgery for the treatment of cervical spondylotic myelopathy (CSM) is associated with complications in 11%-38% of patients. Several predictors of postoperative ...complications have been proposed but few are used to detect high-risk patients. A standard approach to identifying "at-risk" patients would improve surgeons' ability to prevent and manage these complications. The authors aimed to compare the complication rates between various surgical procedures used to treat CSM and to identify patient-specific, clinical, imaging, and surgical predictors of complications.
The authors conducted a systematic review of the literature and searched MEDLINE, MEDLINE in Process, EMBASE, and Cochrane Central Register of Controlled Trials from 1948 to September 2013. Cohort studies designed to evaluate predictors of complications and intervention studies conducted to compare different surgical approaches were included. Each article was critically appraised independently by 2 reviewers, and the evidence was synthesized according to the principles outlined by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) Working Group.
A total of 5472 citations were retrieved. Of those, 60 studies met the inclusion criteria and were included in the review. These studies included 36 prognostic cohort studies and 28 comparative intervention studies. High evidence suggests that older patients are at a greater risk of perioperative complications. Based on low evidence, other clinical factors such as body mass index, smoking status, duration of symptoms, and baseline severity score, are not predictive of complications. With respect to surgical factors, low to moderate evidence suggests that estimated blood loss, surgical approach, and number of levels do not affect rates of complications. A longer operative duration (moderate evidence), however, is predictive of perioperative complications and a 2-stage surgery is related to an increased risk of major complications (high evidence). In terms of surgical techniques, higher rates of neck pain were found in patients undergoing laminoplasty compared with anterior spinal fusion (moderate evidence). In addition, with respect to laminoplasty techniques, there was a lower incidence of C-5 palsy in laminoplasty with concurrent foraminotomy compared with nonforaminotomy (low evidence).
The current review suggests that older patients are at a higher risk of perioperative complications. A longer operative duration and a 2-stage surgery both reflect increased case complexity and can indirectly predict perioperative complications.
Purpose
One of the objectives of this review is to summarize the important features of a good scale. A second aim is to conduct a systematic review to identify scales that can detect the presence of ...cervical myelopathy and to determine their psychometric properties including validity, reliability and responsiveness.
Methods
A thorough literature search was performed using MEDLINE, MEDLINE in process, EMBASE, and Cochrane Central Register of Controlled Trials. Articles were included in this study if they compared scale measurements between a control and a myelopathic patient population or if they discussed any psychometric property of a scale.
Results
An ideal scale should be one that is quantifiable, valid, sensitive, responsive and easy to perform, has high inter/intra-rater reliability, internal consistency and a suitable distribution, and is one-dimensional and relevant. In the context of cervical spondylotic myelopathy, it is essential that the scale also addresses the pathophysiology, its key signs and symptoms as well as its natural history. For the systematic review, the search yielded 5,745 citations. Of these, 37 met inclusion criteria, 10 explored the ability of a scale to detect myelopathy, 23 examined validity by assessing correlation between scales, 10 reported reliability, 8 analyzed responsiveness, and 6 discussed internal consistency. The most frequently reported scale was short form-36 (
n
= 16) followed by Nurick grade (
n
= 14), Japanese Orthopaedic Association (
n
= 13), (modified) Japanese Orthopaedic Association (
n
= 7) and grip and release test (
n
= 6). Four studies each presented results on the Cooper, Harsh and 30-m walking test.
Conclusion
This review summarizes outcome measures used to assess the presence and severity of cervical myelopathy. It includes several validation studies as well as those that have reported the responsiveness and reliability of various measures.
Design:
Systematic review.
Objective:
To conduct a systematic review to (1) summarize various classification systems used to describe cervical ossification of the posterior longitudinal ligament ...(OPLL) and (2) evaluate the diagnostic accuracy of various imaging modalities and the reliability of these classification systems.
Methods:
A search was performed to identify studies that used a classification system to categorize patients with OPLL. Furthermore, studies were included if they reported the diagnostic accuracy of various imaging modalities or the reliability of a classification system.
Results:
A total of 167 studies were deemed relevant. Five classification systems were developed based on X-ray: the 9-classification system (0.60%); continuous, segmental, mixed, localized or focal, circumscribed and others (92.81%); hook, staple, bridge, and total types (2.40%); distribution of OPLL (2.40%); and K-line classification (4.19%). Six methods were based on computed tomography scans: free-type, contiguous-type, and broken sign (0.60%); hill-, plateau-, square-, mushroom-, irregular-, or round-shaped (5.99%); rectangular, oval, triangular, or pedunculate (1.20%); centralized or laterally deviated (1.80%); plank-, spindle-, or rod-shaped (0.60%); and rule of nine (0.60%). Classification systems based on 3-dimensional computed tomography were bridging and nonbridging (1.20%) and flat, irregular, and localized (0.60%). A single classification system was based on magnetic resonance imaging: triangular, teardrop, or boomerang. Finally, a variation of methods was used to classify OPLL associated with the dura mater (4.19%).
Conclusions:
The most common method of classification was that proposed by the Japanese Ministry of Health, Labour and Welfare. Other important methods include K-line (+/−), signs of dural ossification, and patterns of distribution.
While the majority of existing reports focus on complications sustained during the chronic stages after traumatic spinal cord injury (SCI), the objective in the current study was to characterize and ...quantify acute inpatient complications. In addition, the authors sought to create a prediction model using clinical variables documented at hospital admission to predict acute complication development.
Analyses were based on data from the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) data registry, which contains prospective information on adult patients with cervical SCIs who were enrolled at 6 North American centers over a 7-year period. All patients who underwent a standardized American Spinal Injury Association (ASIA) neurological examination within 24 hours of injury and whose follow-up information was available at the acute hospital discharge were included in the study. For purposes of classification, complications were divided into 5 major categories: 1) cardiopulmonary, 2) surgical, 3) thrombotic, 4) infectious, and 5) decubitus ulcer development. Univariate statistical analyses were performed to determine the relationship between complication occurrence and individual demographic, injury, and treatment variables. Multivariate logistic regression was subsequently performed to create a complication prediction model. Model discrimination was judged according to the area under the receiver operating characteristic curve.
Complete complication information was available for 411 patients at the acute care discharge. One hundred sixty patients (38.9%) experienced 240 complications. The mean age among those who experienced at least one complication was 45.9 years, as compared with 43.5 years among those who did not have a complication (p = 0.18). In the univariate analysis, patients with complications were less likely to receive steroids at admission (p = 0.01), had a greater severity of neurological injury as indicated by the ASIA Impairment Scale (AIS) grade at presentation (p < 0.01), and a higher frequency of significant comorbidity (p = 0.04). In a multivariate logistic regression model, a severe initial AIS grade (p < 0.01), a high-energy injury mechanism (p = 0.07), an older age (p = 0.05), the absence of steroid administration (p = 0.02), and the presence of comorbid illness (p = 0.02) were associated with a greater likelihood of complication development during the period of acute hospitalization. The area under the curve value for the full model was 0.75, indicating acceptable predictive discrimination.
These results will help clinicians to identify patients with cervical SCIs at greatest risk for complication development and thus allowing for the institution of aggressive complication prevention measures.
Spinal cord injury (SCI) is a devastating event causing lifelong disability that results in a significant decrease in quality of life and immense cost to the health care system, individuals and their ...families. Providing specialized and timely care can improve recovery and reduce costs, but to make this a reality requires understanding of the current care delivery processes and the care journey. The objective of this focus issue is to examine the current state of health care delivery and discover opportunities to improve access and timing to specialized care for individuals with tSCI. This issue provides an overview of care throughout the SCI continuum and its impact on individuals with tSCI using pan-Canadian data. The issue also presents findings from the RHI Access to Care and Timing (ACT) Project, a multi-center research study involving a multi-disciplinary team of Canadian researchers and clinicians. The initial articles describe the current state of the tSCI care journey including a comparison of environmental barriers, health status, and quality-of-life outcomes between patients living in rural and urban settings. The issue concludes with an article describing the national knowledge translation efforts of using the evidence from the articles published here to inform practice and policy change. Overall, this focus issue will be an excellent reference to guide and optimize evidence informed decision-making in the care of those with tSCI. The evidence can be transferred to care in non-traumatic SCI and other conditions that benefit from timely access to specialized care such as stroke and traumatic brain injury.
Clinical outcome study comparing the Short Form-36 (SF-36) and Short Form-12 (SF-12) assessment scales in patients with cervical spondylotic myelopathy (CSM).
To compare the validity, reliability, ...and sensitivity to change of the SF-12 and SF-36 scales in CSM patients undergoing decompressive surgery.
The SF-36 is a generic Health Related Quality of Life (HRQoL) questionnaire, consisting of 36 questions that can be reported as a Physical (PCS) and Mental Component Summary (MCS). Recently, an abbreviated version of SF-36, the SF-12, which uses only 12 questions drawn from the SF-36, has been described.
In this prospective study, patients with CSM undergoing decompressive surgery, self-completed the SF-36 questionnaire before surgery and at 6 months after surgery. SF-12 item responses were abstracted from the responses given to the SF-36 questionnaire. The validity, reliability, and sensitivity to change of the PCS and MCS components of SF-12 and SF-36 scales were compared.
Overall, 105 patients underwent anterior (N = 58) or posterior (N = 47) decompressive surgery. After surgery, there were improvements in the PCS components of both the SF-36 (40 +/- 2 to 54 +/- 2) and SF-12 (34 +/- 2 to 48 +/- 3), as well as in the MCS component of the SF-36 (48 +/- 2 to 63 +/- 2) and SF-12 (43 +/- 2 to 59 +/- 2) (P < 0.001). The sensitivity to change and absolute sensitivity for both SF-12 and SF-36 were comparable, but the reliability of SF-36 was marginally greater. There were close and linear correlations between the SF-36 and SF-12 scores for both the PCS and MCS components, before and after surgery (R = 0.86 to 0.93; P < 0.0001).
Both the SF-12 and SF-36 scales are valid and sensitive to changes in physical and mental health status in CSM patients, undergoing decompressive surgery. Despite its abbreviated nature, the SF-12 appears to be an adequate substitute for SF-36, and its brevity should increase its attractiveness to both clinicians and patients.
Retrospective case-control study.
To study the role of surgical decompression in cervical spondylotic myelopathy (CSM).
Fifty patients who received surgery, and 34 patients with myelopathy who were ...offered surgery but declined, or were not medically fit for surgery.
We studied the role of surgical decompression in CSM by using a validated 30-m walking test in a group of patients to assess severity before surgery and at regular intervals over the following 3 years after surgery. Such patients were compared with a matched group of control patients with myelopathy but who did not undergo surgery.
The walking data indicated a lasting benefit from surgery for at least 3 years after surgery. Patients gained a significant recovery of function which was maintained. In contrast, unoperated patients continued to deteriorate. More benefit was surprisingly seen when surgery was performed in older patients or with worse myelopathy.
Surgical decompression is beneficial in the treatment of CSM. Improvements were generally seen by 6 months from operation. Older patients and greater degrees of myelopathy were not associated with a worse outcome, suggesting surgery should not necessarily be discouraged in such patients.
STUDY DESIGN.Review.
OBJECTIVE.To formally introduce “degenerative cervical myelopathy” (DCM) as the overarching term to describe the various degenerative conditions of the cervical spine that cause ...myelopathy. Herein, the epidemiology, pathogenesis, and genetics of conditions falling under this hypernym are carefully described.
SUMMARY OF BACKGROUND DATA.Nontraumatic, degenerative forms of cervical myelopathy represent the commonest cause of spinal cord impairment in adults and include cervical spondylotic myelopathy, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum, and degenerative disc disease. Unfortunately, there is neither a specific term nor a specific diagnostic International Classification of Diseases, Tenth Revision code to describe this collection of clinical entities. This has resulted in the inconsistent use of diagnostic terms when referring to patients with myelopathy due to degenerative disease of the cervical spine.
METHODS.Narrative review.
RESULTS.The incidence and prevalence of myelopathy due to degeneration of the spine are estimated at a minimum of 41 and 605 per million in North America, respectively. Incidence of cervical spondylotic myelopathy–related hospitalizations has been estimated at 4.04/100,000 person-years, and surgical rates seem to be rising. Pathophysiologically, myelopathy results from static compression, spinal malalignment leading to altered cord tension and vascular supply, and dynamic injury mechanisms. Occupational hazards, including transportation of goods by weight bearing on top of the head, and other risk factors may accelerate DCM development. Potential genetic factors include those related to MMP-2 and collagen IX for degenerative disc disease, and collagen VI and XI for ossification of the posterior longitudinal ligament. In addition, congenital anomalies including spinal stenosis, Down syndrome, and Klippel-Feil syndrome may predispose to the development of DCM.
CONCLUSION.Although DCMs can present as separate diagnostic entities, they are highly interrelated, frequently manifest concomitantly, present similarly from a clinical standpoint, and seem to be in part a response to compensate and improve stability due to progressive age and wear of the cervical spine. The use of the term “degenerative cervical myelopathy” is advocated.Level of Evidence5
Abstract
BACKGROUND:
Traumatic central cord syndrome (TCCS) is an incomplete spinal cord injury defined by greater weakness in upper versus lower extremities, variable sensory loss, and variable ...bladder, bowel, and sexual dysfunction. The optimal timing of surgery for TCCS remains controversial.
OBJECTIVE:
To determine whether timing of surgery for TCCS predicts neurological outcomes, length of stay, and complications.
METHODS:
Five databases were searched through March 2015. Articles were appraised independently by 2 reviewers, and the evidence synthesized according to Grading of Recommendation Assessment, Development and Evaluation principles.
RESULTS:
Nine studies (3 prognostic, 5 therapeutic, 1 both) satisfied inclusion criteria. Low level evidence suggests that patients operated on <24 hours after injury exhibit significantly greater improvements in postoperative American Spinal Injury Association motor scores and the functional independence measure at 1 year than those operated on >24 hours after injury. Moderate evidence suggests that patients operated on <2 weeks after injury have a higher postoperative Japanese Orthopaedic Association score and recovery rate than those operated on >2 weeks after injury. There is insufficient evidence that lengths of hospital or intensive care unit stay differ between patients who undergo early versus delayed surgery. Furthermore, there is insufficient evidence that timing between injury and surgery predicts mortality rates or serious or minor adverse events.
CONCLUSION:
Surgery for TCCS <24 hours after injury appears safe and effective. Although there is insufficient evidence to provide a clear recommendation for early surgery (<24 hours), it is preferable to operate during the first hospital admission and <2 weeks after injury.
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