Five-year mortality after traumatic central cord syndrome in Wales.

Aims: Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age. Methods: Patients aged ≥ 18 years with a traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and data about injury, management, and outcome were collected. Statistical analysis was performed to assess mortality and between-group differences. Results: A total of 65 patients were identified (66.2% male (n = 43), mean age 63.9 years (SD 15.9)). At a minimum of five years' follow-up, 32.3% of CCS patients (n = 21) had died, of whom six (9.2%) had died within 31 days of their injury. Overall, 69.2% of patients (n = 45) had been managed conservatively. There was no significant difference in age between conservatively and surgically managed patients (p = 0.062). Kaplan-Meier analysis revealed no significant difference in mortality between patients managed conservatively and those managed surgically (p = 0.819). However, there was a significant difference in mortality between the different age groups (< 50 years vs 50 to 70 years vs > 70 years; p = 0.001). At five years' follow-up, 55.6% of the patient group aged > 70 years at time of injury had died (n = 15). Respiratory failure was the most common cause of death (n = 9; 42.9%). Conclusion: Almost one-third of patients with a traumatic CCS in Wales had died within five years of their injury. The type of management did not significantly affect mortality but their age at the time of injury did. Further work to assess the long-term functional outcomes of surviving patients is needed to generate more reliable prognostic information.

Long-term outcome after surgical treatment of Scheuermann's Kyphosis (SK).

STUDY DESIGN: A retrospective observational cohort study with a minimum follow-up of 10 years of patients who underwent surgery for Scheurmann Kyphosis (SK). OBJECTIVE: Evaluate the long-term clinical and radiological outcome of patients with SK who either underwent combined anterior-posterior surgery or posterior instrumented fusion alone. There is paucity of literature for long-term outcome studies on SK. The current trend is towards only posterior (PSF) surgical correction for SK. The combined strategy of anterior release, fusion and posterior spinal fusion (AF/PSF) for kyphosis correction has become historic relic. Long-term outcome studies comparing the two procedures are lacking in literature. METHODS: 51 patients (30 M: 21F) who underwent surgery for SK at a single centre were reviewed. Nineteen had posterior instrumentation alone (PSF) (Group 1) and 32 underwent combined anterior release, fusion with posterior instrumentation (AF/PSF) (Group 2). The clinical data included age at surgery, gender, flexibility of spine, instrumented spinal levels, use of cages and morcellised rib grafts (in cases where anterior release was done), posterior osteotomies and instrumentation, complications and indications for revision surgery. Preoperative flexibility was determined by hyperextension radiographs. The radiological indices were evaluated in the pre-operative, 2-year post-operative and final follow-up [Thoracic Kyphosis (TK), Lumbar lordosis (LL), Voustinas index (VI), Sacral inclination (SI) and Sagittal vertical axis (SVA)]. The loss of correction and incidence of JK (Junctional Kyphosis) and its relation to fusion levels were assessed. Complications and difference in outcome between the two groups were analyzed. RESULTS: The mean age at surgery for 51 patients was 20.6 years who were followed up for a minimum of 10 years (mean: 14 years; range 10-16 years). The mean age was 18.5 ± 2.2 years and 21.9 ± 4.8 years in groups 1 and 2, respectively. The mean pre- and 2-year post-operative ODIs were 32.6 ± 12.8 and 8.4 ± 5.4, respectively, in group 1 (p < 0.0001) and 30.7 ± 11.7 and 6.4 ± 5.7, respectively, in group 2 (p < 0.0001). The final SRS-22 scores in group 1 and 2 were 4.1 ± 0.4 and 4.0 ± 0.35, respectively (p = 0.88). The preoperative flexibility index was 49.2 ± 4.2 and 43 ± 5.6 in groups 1 and 2, respectively (p < 0.0001). The mean TKs were 81.4° ± 3.8° and 86.1° ± 6.0° for groups 1 and 2, respectively, which corrected to 45.1° ± 2.6° and 47.3° ± 4.8°, respectively, at final follow-up (p < 0.0001). The mean pre-operative LL angle was 60.0° ± 5.0° and 62.4° ± 7.6° in groups 1 and 2, respectively, which at final follow-up was 45.1° ± 4.4° and 48.1° ± 4.8°, respectively (p < 0.0001). The mean pre-operative and final follow-up Voustinas index (VI) in group 1 were 22.9 ± 2.9 and 11.2 ± 1.2, respectively, and in group 2 was 25.9 ± 3.5 and 14.0 ± 2.3, respectively. The mean pre-operative and final follow-up SI angle were 43.6° ± 3.3° and 31.2° ± 2.5° in group 1, respectively, and 44.3° ± 3.5° and 32.1° ± 3.5° in group 2, respectively (p < 0.0001). The pre-operative and final follow-up SVA in group 1 were - 3.3 ± 1.0 cms and - 1.3 ± 0.5 cms, respectively, and in group 2 was - 4.0 ± 1.3cms and - 1.9 ± 1.1cms, respectively (p < 0.0001). Though the magnitude of curve correction in the groups 1 and 2 was significant 36° vs 39° (p = 0.05), there was no significant difference in correction between the two groups. Proximal JK was seen in seven and distal JK in five patients were observed in the whole cohort. CONCLUSION: The long-term clinical outcomes for both PSF and AF/PSF are comparable with reproducible results. No difference was noted in loss of correction and outcome scores between the two groups. The correction of thoracic kyphosis (TK) had a good correlation with ODI. AF/PSF had much higher complications than PSF group. The objective of correcting the sagittal profile and balancing the whole spinal segment on the pelvis can be achieved through single posterior approach with fewer complications.

Transoral Gunshot Injury Resulting in Mechanical Block to Cervical Rotation: A Case Report.

CASE: We report a case of self-inflicted transoral gunshot injury in a 24-year-old man resulting in mechanical block to cervical rotation. Anterior surgical removal of the pellet was successful with the patient experiencing no early or long-term functional deficits. CONCLUSION: Given the rarity of a cervical spine injury from gunshot wound without long-term complications, this unique case supports the role of early operative management in such injuries.

Symptomatic Postoperative Spinal Subdural Extra-Arachnoid Hygromas: Resolution with Conservative Management: A Report of 2 Cases.

CASE: Two cases of postoperative spinal subdural extra-arachnoid hygromas were successfully treated with bed rest after patients developed symptoms 4 to 5 days following decompressive lumbar surgery. The development of the hygromas as well as the radiological findings are discussed. CONCLUSION: To the best of our knowledge, these comprise the first postoperative cases successfully treated without surgical re-exploration. This demonstrates conservative management may be a safe and effective management choice.

A Comparison of Magnetic Resonance Imaging Muscle Fat Content in the Lumbar Paraspinal Muscles with Patient-Reported Outcome Measures in Patients with Lumbar Degenerative Disk Disease and Focal Disk Prolapse.

Study Design Retrospective study. Objectives To assess the fatty atrophy of the lumbar paraspinal muscles (LPMs) as determined using magnetic resonance imaging in patients with lumbar degenerative disk disease (DDD) and focal disk herniation and to determine if fatty atrophy is associated with patient-reported outcome measures (PROMS). Methods One hundred sixty-five patients with lumbar DDD were identified from a PROMS database of >1,500 patients. These patients were divided into two study groups: DDD alone (n = 58) and DDD with disk herniation (n = 107). A grid was randomly applied to the axial scans at the L3-L4, L4-L5, and L5-S1 levels. The muscle-to-fat ratio of the LPMs was recorded and compared with PROMS data. Subcutaneous fat thickness at each level was also measured. Results This study found no difference in the muscle-to-fat ratio between the DDD and disk herniation groups. There was no association between the muscle-to-fat ratio and PROMS data in either group. There was significantly more subcutaneous fat at all levels in the DDD group as compared with the disk prolapse group. In DDD and disk prolapses, subcutaneous fat was thicker in women (p = 0.013 and 0.001). In patients with DDD, more subcutaneous fat was associated with disability (p < 0.001). Muscle content of erector spinae and multifidus negatively correlated with increasing age in both groups at the L3-L4 level. Conclusions Muscle fat content in the LPM does not appear to relate to PROMS. Muscle content decreases with age. Those with low back pain (DDD) have greater subcutaneous fat thickness.

The influence of the energy of trauma, the timing of decompression, and the impact of grade of SCI on outcome.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To find out: (1) if the energy of trauma (high and low) influence the outcome after cervical spinal cord injury; (2) if time to decompression and degree of injury (complete and incomplete) influence the outcome after high- and low-energy cervical spinal cord injury. METHODS: Twenty-one consecutive patients with low-energy cervical spinal cord injury were identified from the spinal injuries unit database (eg, ball sports, diving, surfing, and falls). Twenty-one aged-matched patients with high-energy cervical spinal cord injury (eg, motor vehicle trauma) were then randomly selected and the groups were compared. All patients had formal American Spinal Injuries Association assessment on admission and at 6 months. RESULTS: At the 6-month follow-up, the energy of the initial trauma was not found to influence the neurological outcome (P = .76). Early definitive intervention (<8 hours) for patients with incomplete cord lesions was shown to significantly affect outcome (P = .049). As expected, patients with an incomplete spinal cord injury at presentation showed significantly greater neurological improvement at follow-up compared with those with complete injuries (P = .006). CONCLUSIONS: We were unable to find a correlation between the energy of the initial trauma causing a spinal cord injury and the neurological outcome. Early definitive decompression improved outcomes for patients with spinal cord injury, especially those with incomplete spinal cord injury. [Table: see text] The definiton of the different classes of evidence is available on page 55.

Two stage one component revision in infected total hip replacements - two case reports and literature review.

We present two cases of infected primary total hip replacements (THR) where only one of the two components exhibited loosening. Both were revised using a two stage, one component revision technique, replacing the loose component only. In the first case the acetabular component was revised leaving the original femoral stem in situ. In the second case, the femoral component was revised, leaving the original acetabular cup undisturbed. Both patients remained infection free at three and half and three years follow up respectively.

Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome.

STUDY DESIGN: Retrospective cohort study with prospective clinical follow-up. OBJECTIVE: To determine the factors that influence outcome after surgery for cauda equina syndrome (CES). SUMMARY OF BACKGROUND DATA: CES is a rare but serious consequence of lumbar disc prolapse and can have devastating long-lasting neurologic consequences. The timing of surgical decompression remains controversial. METHODS: Fifty-six patients with evidence of a sphincteric disturbance who underwent urgent surgery were identified and invited to follow-up. The outcome measures comprised history and examination and several validated self-assessment questionnaires. RESULTS: Forty-two patients (78%) attended with a mean follow-up of 60 months (range, 25-114 months). Mean age at onset was 41 years (range, 24-67 years) with 23 males and 19 females. Twenty-six patients were operated on within 48 hours of onset of sphincteric symptoms; 5 of these were within 24 hours. Acute onset of sphincteric symptoms and the time to operation did not influence the outcomes. Leg weakness at onset persisted in a significant number of patients at follow-up (P < 0.005). Urinary disturbance at presentation did not affect the outcomes. At follow-up, significantly more females had urinary incontinence (P < 0.005). Bowel dysfunction at presentation was associated with sexual problems at follow-up (P < 0.005). The 13 patients who failed their post operative trial without catheter had worse outcomes. The SF-36 scores at follow-up were reduced compared with age-matched controls in the population. The mean ODI was 29, Low Back Outcome Score 42, and VAS 4.5. The time elapsed from operation to follow-up was not found to influence the outcomes. CONCLUSIONS: In our series, the symptom duration before operation and the speed of onset do not affect the outcome more than 2 years after surgery. Based on the SF-36, ODI, and Low Back Outcome Scores, patients who have had CES do not return to a normal status.