Risk factors of AIS C incomplete cervical spinal cord injury for poor prognosis-The significance of anorectal evaluation.

BACKGROUND: Although the prognosis of incomplete cervical spinal cord injury (SCI) diagnosed as American Spinal Injury Association Impairment Scale grade C (AIS C) is generally favorable, some patients remain non-ambulatory. The present study explored the clinical factors associated with the non-ambulatory state of AIS C patients. METHODS: This study was a single-center retrospective observational study. Seventy-three participants with AIS C on admission were enrolled and divided into two groups according to ambulatory ability after one year. Prognostic factors of SCI were compared in ambulatory (A-group) and non-ambulatory participants (NA-group). Univariable and multivariable logistic regression analyses were performed on demographic information, medical history, mechanism of injury, presence of fracture, ASIA motor scores (MS) of the extremities, neurological findings, including an anorectal examination on admission, and imaging findings. RESULTS: Forty-one patients were included in the A-group and 32 in the NA-group. Univariable analysis revealed that the following factors were related to poor outcomes (p < 0.05): older age, history of cerebrovascular disorder, impairment/absence of S4-5 sensory score, deep anal pressure (DAP) (-), voluntary anal contraction (VAC) (-), anorectal tone (-), anal wink reflex (-), and low MS of the upper and lower extremities. In the multivariable analysis using age, presence or absence of sacral abnormality, and history of cerebrovascular disorders (adjusted for these three factors), older age and presence of sacral abnormality on admission were independent risk factors for a non-ambulatory state at the 1-year follow-up. CONCLUSIONS: Incomplete AIS C SCI individuals with older age and/or impairment of anorectal examination could remain non-ambulatory at 1-year follow-up.

Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis: A Randomized Clinical Trial.

Importance: The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. Objective: To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. Design, Setting, and Participants: This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. Interventions: Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. Main Outcomes and Measures: The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. Results: Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, -4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients). Conclusions and Relevance: These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation. Trial Registration: ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780.

Predictive factors for irreversible motor paralysis following cervical spinal cord injury.

STUDY DESIGN: A retrospective observational study. OBJECTIVES: To elucidate predictive clinical factors associated with irreversible complete motor paralysis following traumatic cervical spinal cord injury (CSCI). SETTING: Hokkaido Spinal Cord Injury Center, Japan. METHODS: A consecutive series of 447 traumatic CSCI persons were eligible for this study. Individuals with complete motor paralysis at admission were selected and divided into two groups according to the motor functional outcomes at discharge. Initial findings in magnetic resonance imaging (MRI) and other clinical factors that could affect functional outcomes were compared between two groups of participants: those with and those without motor recovery below the level of injury at the time of discharge. RESULTS: Of the 73 consecutive participants with total motor paralysis at initial examination, 28 showed some recovery of motor function, whereas 45 remained complete motor paralysis at discharge, respectively. Multivariate logistic regression analysis showed that the presence of intramedullary hemorrhage manifested as a confined low intensity changes in diffuse high-intensity area and more than 50% of cord compression on MRI were significant predictors of irreversible complete motor paralysis (odds ratio [OR]: 8.4; 95% confidence interval [CI]: 1.2-58.2 and OR: 14.4; 95% CI: 2.5-82.8, respectively). CONCLUSION: The presence of intramedullary hemorrhage and/or severe cord compression on initial MRI were closely associated with irreversible paralysis in persons with motor complete paralysis following CSCI. Conversely, subjects with a negligible potential for recovery could be identified by referring to these negative findings.

C1 posterior arch screw as an auxiliary anchor in posterior reconstruction for atlantoaxial dislocation associated with type II odontoid fracture: a case report and review of the literature.

INTRODUCTION: Although pedicle or lateral mass screws are usually chosen to fix atlantoaxial (C1-C2) instability, there is an increased risk for vertebral artery (VA) injury when used in patients with bone or arterial anomalies or osteoporotic bone. Here we report the C1 posterior arch screw as a new technique for upper cervical fixation. CASE DESCRIPTION: A 90-year-old man complained of upper cervical pain after falling in his house. The initial computed tomography (CT) scan showed C1-C2 posterior dislocation with a type II odontoid fracture. The patient underwent C2 fracture reduction and posterior C1-C2 fixation. On the right side of C1, because lateral mass screw placement could cause injury to the dominant VA considering a risk in oldest-old osteoporotic patients, a posterior arch screw was chosen instead as an auxiliary anchor. An intralaminar screw was placed on the right side of C2 because a high-riding VA was observed. A lateral mass screw and a pars interarticularis screw were placed on the left side of C1 and C2, respectively. Ten months later, the odontoid fracture had healed, with normal anatomical alignment. Although the patient experienced slight weakness when spreading his bilateral fingers, his overall condition was good. DISCUSSION AND EVALUATION: We have presented a novel technique using C1 posterior arch screws for the fixation of a C1-C2 dislocation. Such a screw is an alternative to the C1 lateral mass screw in patients who are at risk for a VA injury because of anomalous bone and arterial structures or poor bone quality. CONCLUSIONS: Although there have been few comparable studies, and the long-term outcome is unknown, fixation with a posterior arch screw could be a beneficial choice for surgeries involving the upper cervical region.

The influence of Celecoxib on matrix synthesis by chondrocytes under mechanical stress in vitro.

To assess effects of Celecoxib, selective cyclo-oxygenase (COX)-2 inhibitor, on matrix synthesis by chondrocytes under mechanical stress in vitro. Chondrocytes from 7-day-old rat articular cartilage were cultured. Cyclic mechanical stress (0.5 Hz, 7% elongation) was loaded using a Flexercell strain unit in the presence of Celecoxib, Indomethacin, and Ketoprofen. Concentrations of chondroitin sulfate (CS) in culture media were measured by high-performance liquid chromatography. Nitric oxide (NO) formation was detected by measuring NO2-accumulation in culture supernatants during the Griess reaction, using sodium nitrite as a standard. Levels of mRNA for aggrecan (AGC), type II collagen (CII), COX-2, and membrane-associated prostaglandin E synthase-1 (mPGES-1) were measured using real time reverse transcriptase-polymerase chain reaction. Under mechanical stress, levels of AGC and CII mRNA were decreased, while COX-2 mRNA levels were increased. Of the three drugs tested, only Celecoxib prevented the decrease of AGC mRNA and inhibited the release of CS. In addition, Celecoxib suppresses the level of mPGES-1 mRNA. These findings show that excessive mechanical stress decreases synthesis of matrix components in chondrocytes through a NO-regulated pathway, and suggest that Celecoxib has a protective effect on matrix metabolism.

Interleukin-4 protects matrix synthesis in chondrocytes under excessive mechanical stress in vitro.

Abstract We examined the effect of interleukin-4 (IL-4) on matrix synthesis in chondrocytes under excessive mechanical stress in vitro. Chondrocytes from 7-day-old rat articular cartilage were incubated in the presence of rat IL-4 (0, 1, and 10 ng/ml) under a 5% CO2 atmosphere for 36 h. Cyclic mechanical stress (0.5 Hz, 7% elongation) was loaded using a Flexercell strain unit for 12, 16, and 24 h. Levels of messenger RNA (mRNA) for aggrecan (AGG), type II collagen (CII), fibronectin (FN), and integrin-ß1 (INTb1) were measured by real-time reverse transcriptase polymerase chain reaction (RT-PCR) using GAPDH as the internal control. Mechanical stress for 16 h significantly decreased levels of mRNA for both AGG and CII (P < 0.01), but with rat IL-4 at doses of 1 or 10 ng/ml these levels recovered (P < 0.05). In addition, mRNA levels of FN and INTb1 were increased by IL-4 in chondrocytes under mechanical stress (P < 0.05). IL-4 protects chondrocytes loaded with excessive mechanical stress against degradation.