Spontaneous spinal cord infarction: a systematic review.

Background and objectives: Spontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes. Methods: The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords 'spontaneous', 'spinal cord', 'infarction' and 'ischaemic'. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed. Results: 440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids. Conclusion: The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research to establish diagnostic criteria and treatment guidelines.

Long-term outcomes after surgery for subaxial cervical spine injuries in octogenarians, a matched population-based cohort study.

PURPOSE: We aimed to investigate surgical outcomes in octogenarians with subaxial cervical spine injuries and determine the predictors of complications and mortality. METHODS: Eligible for inclusion were all patients surgically treated between 2006 and 2018, with either anterior or posterior fixation for subaxial spine injuries. A cohort of octogenarians was identified and matched 1:1 to a corresponding cohort of younger adults. Primary outcomes were perioperative complications and mortality. RESULTS: Fifty-four patients were included in each of the octogenarian and younger groups (median age: 84.0 vs. 38.5). While the risks for surgical complications, including dural tears and wound infections, were similar between groups, the risks of postoperative medical complications, including respiratory or urinary tract infections, were significantly higher among the elderly (p < 0.05). Additionally, there were no differences in operative time (p = 0.625) or estimated blood loss (p = 0.403) between groups. The 30 and 90-day mortality rates were significantly higher among the elderly (p = 0.004 and p < 0.001). These differences were due to comorbidities in the octogenarian cohort as they were revoked when propensity score matching was performed to account for the differences in American Society of Anesthesiology (ASA) grade. Multivariable logistic regression revealed age and ASA score to be independent predictors of complications and the 90-day mortality, respectively. CONCLUSIONS: Octogenarians with comorbidities were more susceptible to postoperative complications, explaining the increased short-term mortality in this group. However, octogenarians without comorbidities had similar outcomes compared to the younger patients, indicating that overall health, including comorbidities, rather than chronological age should be considered in surgical decision-making.

The Effect of Concomitant Spinal Cord Injury on Postoperative Health-related Quality of Life After Traumatic Subaxial Cervical Spine Injuries: A Nationwide Registry Study.

OBJECTIVE: To evaluate the effect of spinal cord injury (SCI) on the health-related quality of life (HRQoL) in patients surgically treated for traumatic subaxial cervical spine injuries and investigate the agreement between objective neurologic outcomes and patient reported outcome measures (PROMs) in that context. STUDY DESIGN: Observational study on prospectively collected multi-institutional registry data. SETTING: Sweden. PARTICIPANTS: Patients with traumatic subaxial spine injuries identified in the Swedish Spine Registry (Swespine) between 2006 and 2016. INTERVENTIONS: Anterior, posterior, or anteroposterior cervical fixation surgery. MAIN OUTCOMES: Patient-reported outcome measures (PROMs) consisting of EQ-5D-3Lindex and Neck Disability Index (NDI). RESULTS: Among the 418 identified patients, 93 (22%) had a concomitant SCI. In this group, 30 (32%) had a complete SCI (Frankel A), and the remainder had incomplete SCIs (17%) Frankel B; 25 (27%) Frankel C; 22 (24%) Frankel D. PROMs significantly correlated with the Frankel grade (P<.001). However, post hoc analysis revealed that the differences between adjacent Frankel grades failed to reach both statistical and clinical significance. On univariable linear regression, the Frankel grade was a significant predictor of a specific index derived from the EQ-5D-3L questionnaire (EQ-5D-3Lindex) at 1, 2, and 5 years postoperatively as well as the NDI at 1 and 2 years postoperatively (P<.001). Changes of PROMs over time from 1, to 2, and 5 years postoperatively did not reach statistical significance, regardless of the presence and degree of SCI (P>.05). CONCLUSION: Overall, the Frankel grade significantly correlated with the EQ-5D-3Lindex and NDI and was a significant predictor of PROMs at 1, 2, and 5 years. PROMs were stable beyond 1 year postoperatively regardless of the severity of the SCI.

Spontaneous spinal cord infarctions: a systematic review and pooled analysis protocol.

INTRODUCTION: Spinal cord infarction (SCInf) is a rare ischaemic event that manifests with acute neurological deficits. It is typically classified as either spontaneous, defined as SCInf without any inciting event, or periprocedural, which typically occur in conjunction with vascular surgery with aortic manipulations. While periprocedural SCInf has recently been the subject of intensified research, especially focusing on the primary prevention of this complication, spontaneous SCInf remains less studied. METHODS AND ANALYSIS: Electronic databases, including PubMed, Web of Science and Embase, will be searched using the keywords "spinal cord", "infarction", "ischemia" and "spontaneous". The search will be set to provide only English studies published from database inception. Editorials, letters and reviews will also be excluded. Reference lists of relevant records will also be searched. Identified studies will be screened for inclusion, by one reviewer in the first step and then three in the next step to decrease the risk of bias. The synthesis will address several topics of interest including epidemiology, presentation, diagnostics, treatment strategies, outcomes and predictors. The review aims to gather the body of evidence to summarise the current knowledge on SCInf. This will lead to a better understanding of the condition, its risk factors, diagnosis and management. Moreover, the review will also provide an understanding of the prognosis of patients with SCInf with respect to neurological function, quality of life and mortality. Finally, this overview of the literature will allow the identification of knowledge gaps to help guide future research efforts. ETHICS AND DISSEMINATION: Ethics approval was not required for our review as it is based on existing publications. The final manuscript will be submitted to a peer-reviewed journal.

Long-term Outcomes After Periprocedural and Spontaneous Spinal Cord Infarctions: A Population-Based Cohort Study.

BACKGROUND AND OBJECTIVES: Spinal cord infarction (SCInf) is a rare condition where consensus regarding diagnostic criteria is lacking, and misdiagnosis or delayed diagnosis can be detrimental. The aim of this study was to describe baseline findings and predictors of long-term functional outcome in a population-based cohort of patients with SCInf. METHODS: All adult patients (aged 18 years or older) treated at the spinal cord injury unit of the study center, between 2006 and 2019, and discharged with a G95 diagnosis (other and unspecified disease of the spinal cord) were screened for inclusion. The diagnostic criteria proposed by Zalewski et al. were retrospectively applied to evaluate the certainty of the SCInf diagnosis. RESULTS: A total of 270 patients were screened and 57 were included in the study, of whom 30 had a spontaneous SCInf and 27 had a periprocedural SCInf. The median American Spinal Cord Injury Association Impairment Scale (AIS) on admission was C, which at a median follow-up of 2.1 years had improved to D (p = 0.002). Compared with periprocedural cases, those with spontaneous SCInf showed significantly better admission AIS (median AIS D vs B, p < 0.001), fewer multilevel SCInf (27% vs 59%, p = 0.029), shorter hospital stay (median 22 vs 44 days, p < 0.001), and better AIS (median AIS D vs C, p < 0.001) and ambulatory status on long-term follow-up (66% vs 1%, p < 0.001). Regression analyses revealed that spontaneous SCInfs (odds ratio [OR] 5.91 [1.92-18.1], p = 0.002) and more favorable admission AIS (OR 33.6 [7.72-146], p < 0.001) were significant predictors of more favorable AIS at follow-up, with admission AIS demonstrating independent predictive ability (OR 35.9 [8.05-160], p < 0.001). DISCUSSION: SCInf is a rare neurologic emergency lacking specific management guidelines. While the presumptive diagnosis is based on the typical presentation and clinical findings, T2-weighted and diffusion-weighted MRI were the most useful diagnostic tools in establishing a definitive diagnosis. Our data show that spontaneous SCInf mostly affected a single spinal cord segment, whereas periprocedural cases were more extensive, had poorer AIS on admission, poorer ambulatory function, and longer hospital stays. Regardless of the etiology, significant neurologic improvements were seen at long-term follow-up, highlighting the importance of active rehabilitation.

Long-term outcome following surgical treatment of posttraumatic tethered cord syndrome: a retrospective population-based cohort study.

STUDY DESIGN: Retrospective population-based cohort study. OBJECTIVE: To investigate the long-term outcome following surgery for posttraumatic spinal cord tethering (PSCT). SETTING: Publicly funded tertiary care center. METHODS: Patients surgically treated for PSCT between 2005-2020 were identified and included. No patients were excluded or lost to follow-up. Medical records and imaging data were retrospectively reviewed. RESULTS: Seventeen patients were included. Median age was 52 (23-69) years and 7 (41%) were female. PSCT was diagnosed at a median of 5.0 (0.6-27) years after the initial trauma. Motor deficit was the most common neurological manifestation (71%), followed by sensory deficit (53%), spasticity (53%), pain (41%) and gait disturbance (24%). Median follow-up time was 5.1 (0.7-13) years. Fifteen patients (88%) showed satisfactory results following untethering, defined as improvement or halted progression of one or more of the presenting symptoms. Treatment goals were met for motor symptoms in 92%, sensory loss in 100%, spasticity in 100%, gait disturbance in 100% and pain in 86%. Statistically, a significant improvement in motor deficit (p = 0.031) and syrinx decrease (p = 0.004) was also seen. A postoperative complication occurred in four patients: three cases of cerebrospinal fluid leakage and one postoperative hematoma. Two patients showed a negative surgical outcome: 1 with increased neck pain and 1 with left arm weakness following the postoperative hematoma. CONCLUSION: Surgical treatment of PSCT results in improved neurological function or halted neurological deterioration in the vast majority of patients.

[Spinal cord infarction - a rare condition and a diagnostic challenge]. / Ryggmärgsinfarkt ­ ett ovanligt och svårdiagnostiserat tillstånd.

Spinal cord infarction (SCI) causes acute spinal cord dysfunction with high morbidity. Without an inciting event such as a surgical procedure, a definitive diagnosis may be challenging. Thus, patients with a spontaneous (i e, non-traumatic, non-surgical) SCI are often misdiagnosed and the radiological distinction between SCI and other conditions with similar symptoms is more difficult than in cerebral infarction. Compared to cerebral infarction, SCI is rare and only accounts for approximately 1.2% of all strokes. SCI is usually localized to the anterior spinal artery area, causing the anterior spinal artery syndrome. Misdiagnosis may lead to unnecessary and possibly deleterious treatments as well as missed secondary stroke prevention. In this review, a typical case, an overview of the disease and newly proposed diagnostic criteria are presented.

Incidence, aetiology and injury characteristics of traumatic spinal cord injury in Stockholm, Sweden: A prospective, population-based update.

OBJECTIVES: To update the incidence rate, aetiology and injury characteristics of acutely-injured adults with traumatic spinal cord injury in Stockholm, Sweden, using international standards of reporting. STUDY DESIGN: Prospective, (regional) population-based observation. SUBJECTS: Forty-nine consecutively enrolled individuals. METHODS: A surveillance system of newly-injured adults with traumatic spinal cord injury was implemented for an 18-month period. The International Spinal Cord Injury Core Data Set was used to collect data on those who survived the first 7 days post-injury. RESULTS: After an 18-month period, 49 incident cases were registered, of whom 45 were included in this study. The crude incidence rate was 19.0 per million, consisting mainly of men (60%), and the mean age of the cohort was 55 years (median 58). Causes of injury were almost exclusively limited to falls and transport-related events, accounting for 58% and 40% of cases, respectively. The incidence has remained stable when compared with the previous study; however, significant differences exist for injury aetiology (p = 0.004) and impairment level (p = 0.01) in that more fall- and transport-related spinal cord injury occurred, and a larger proportion of persons was left with resultant tetraplegia, in the current study, compared with more sport-related injuries and those left with paraplegia in the previous study. CONCLUSION: The incidence rate appeared to remain stable in Stockholm, Sweden. However, significant changes in injury aetiology and impairment-level post injury were found, compared with the previous study. There remains a need for developing fall-related prevention strategies in rehabilitation settings as well as in population-based programmes.