Spine Cryoablation: Pain Palliation and Local Tumor Control for Vertebral Metastases.

BACKGROUND AND PURPOSE: Percutaneous cryoablation has emerged as a minimally invasive technique for the management of osseous metastases. The purpose of this study was to assess the safety and effectiveness of percutaneous imaging-guided spine cryoablation for pain palliation and local tumor control for vertebral metastases. MATERIALS AND METHODS: Imaging-guided spine cryoablation was performed in 14 patients (31 tumors) with vertebral metastases refractory to conventional chemoradiation therapy or analgesics, to achieve pain palliation and local tumor control in this retrospective study. Spinal nerve and soft-tissue thermal protection techniques were implemented in all ablations. Patient response was evaluated by a pain numeric rating scale administered before the procedure and 1 week, 1 month, and 3 months after the procedure. Pre- and postprocedural analgesic requirements (expressed as morphine-equivalent dosages) were also analyzed at the same time points. Pre- and postprocedural cross-sectional imaging was evaluated in all patients to assess local control (no radiographic evidence of disease at the treated sites). Complications were monitored. Analysis of the primary end points was undertaken via paired-comparison procedures by using the Wilcoxon signed rank test. RESULTS: Thirty-one tumors were ablated in 14 patients (9 women and 5 men; 20-73 years of age; mean age, 53 years). The most common tumor location was in the lumbar spine (n = 14, 45%), followed by the thoracic spine (n = 8, 26%), sacrum (n = 6, 19%), coccyx (n = 2, 6%), and cervical spine (n = 1, 3%). There were statistically significant decreases in the median numeric rating scale score and analgesic usage at 1-week, 1-month, and 3-month time points (P < .001 for all). Local tumor control was achieved in 96.7% (30/31) of tumors (median follow-up, 10 months). Two patients had transient postprocedural unilateral lower extremity radiculopathy and weakness. CONCLUSIONS: Percutaneous imaging-guided spine cryoablation is a safe and effective treatment for pain palliation and local tumor control for vertebral metastases.

Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations.

STUDY DESIGN: A prospective clinical study using magnetic resonance imaging of the cervical spine in a consecutive series of patients with cervical spine dislocations. OBJECTIVES: To determine the incidence of intervertebral disc herniations and injury to the spinal ligaments before and after awake closed traction reduction of cervical spine dislocations. SUMMARY OF BACKGROUND DATA: Prior series in which the prereduction imaging of disc herniations in the dislocated cervical spine are described have been anecdotal and have involved small numbers of patients. In addition, no uniform clinical criteria to define the presence of an intervertebral disc herniation in the dislocated cervical spine has been described. The incidence of disc herniations in the unreduced dislocated cervical spine is unknown. METHODS: Eleven consecutive patients with cervical spine dislocations who met the clinical criteria for an awake closed traction reduction had prereduction and postreduction magnetic resonance imaging. Using strict clinical criteria for the definition of an intervertebral disc herniation, the presence or absence of disc herniation, spinal ligament injury, and cord injury was determined. Neurologic status before, during, and after the closed reduction maneuver was documented. RESULTS: Disc herniations were identified in 2 of 11 patients before reduction. Awake closed traction reduction was successful in 9 of the 11 patients. Of the nine patients with a successful closed reduction, two had disc herniations before reduction, and five had disc herniations after reduction. No patient had neurologic worsening after attempted awake closed traction reduction. CONCLUSIONS: The process of closed traction reduction appears to increase the incidence of intervertebral disc herniations. The relation of these findings, however, to the neurologic safety of awake closed traction reduction remain unclear.

The optimal radiologic method for assessing spinal canal compromise and cord compression in patients with cervical spinal cord injury. Part II: Results of a multicenter study.

STUDY DESIGN: A multicenter, retrospective study using computed tomographic and magnetic resonance imaging data to establish quantitative, reliable criteria of canal compromise and cord compression in patients with cervical spinal cord injury. OBJECTIVES: To develop and validate a radiologic assessment tool of spinal canal compromise and cord compression in cervical spinal cord injury for use in clinical trials. SUMMARY OF BACKGROUND DATA: There are few quantitative, reliable criteria for radiologic measurement of cervical spinal canal compromise or cord compression after acute spinal cord injury. METHODS: The study included 71 patients (55 men, 16 women; mean age, 39.7 +/- 18.7 years) with acute cervical spinal cord injury. Causes of spinal cord injury included motor vehicle accidents (n = 36), falls (n = 20), water-related injuries (n = 8), sports (n = 5), assault (n = 1), and farm accidents (n = 1). Canal compromise was measured on computed tomographic scan and T1- and T2-weighted magnetic resonance imaging, and cord compression at the level of maximum injury was measured on T1- and T2-weighted magnetic resonance imaging. All films were assessed by two independent observers. RESULTS: There was a strong correlation of canal compromise and/or cord compression measurements between axial and midsagittal computed tomography, and between axial and midsagittal T2-weighted magnetic resonance imaging. Spinal canal compromise assessed by computed tomography showed a significant although moderate correlation with spinal cord compression assessed by T1- and T2-weighted magnetic resonance imaging. Virtually all patients with canal compromise of 25% or more on computed tomographic scan had evidence of some degree of cord compression on magnetic resonance imaging, but a large number of patients with less than 25% canal compromise on computed tomographic scan also had evidence on magnetic resonance imaging of cord compression. CONCLUSIONS: In patients with cervical spinal cord injury, the midsagittal T1- and T2-weighted magnetic resonance imaging provides an objective, quantifiable, and reliable assessment of spinal cord compression that cannot be adequately assessed by computed tomography alone.

Surgical treatment for acute spinal cord injury study pilot study #2: evaluation of protocol for decompressive surgery within 8 hours of injury.

Acute spinal cord injury (SCI) is a major public health problem for which there is still only limited treatment available. The National Acute Spinal Cord Injury Study-2 (NASCIS-2) and -3 clinical trials demonstrated that the use of acute pharmacotherapy with methylprednisolone can attenuate the secondary injury cascade if administered within 8 hours of acute SCI. However, no trial has been performed to examine whether acute surgical decompressive procedures within this critical 8-hour time window can improve patients' neurological outcome. The purpose of the current prospective Surgical Treatment for Acute Spinal Cord Injury Study (STASCIS) pilot study was to determine the feasibility of obtaining a radiological diagnosis of spinal canal compromise of 25% or more and to perform spinal cord (C3-T1) decompressive procedures by 8 hours postinjury. One of the following three decompressive methods was used: 1) traction alone; 2) traction and surgery; or 3) surgery alone. Twenty-six patients from eight North American centers were entered into the study between 1996 and 1997. Significant difficulties were encountered in many centers in performing immediate magnetic resonance imaging examination in patients with acute SCI. Fewer than 10% of acute cervical SCI patients could be enrolled into this protocol mainly because the combination of the required time for rescue, resuscitation, transport, imaging study, and surgical preparation exceeded the 8-hour injury-to-decompressive surgery window. Eleven patients underwent decompressive procedures initially by being placed in traction at a mean time of 10.9 hours postinjury. Those patients not undergoing this procedure underwent decompressive surgery at a mean time of 40.1 hours. However, the surgical decompressive procedure was completed within 12 hours in seven patients. As a result of these findings, several major changes have been made to the STASCIS protocol for early decompressive therapy.

Neurologic outcome of early versus late surgery for cervical spinal cord injury.

STUDY DESIGN: A prospective analysis evaluating neurologic outcome after early versus late surgery for cervical spinal cord trauma. OBJECTIVES: The study was conducted to determine whether neurologic and functional outcome is improved in traumatic cervical spinal cord-injured patients (C3-T1, American Spinal Injury Association grades A-D) who had early surgery (<72 hours after spinal cord injury) compared with those patients who had late surgery (>5 days after spinal cord injury). SUMMARY OF BACKGROUND DATA: There is considerable controversy as to the appropriate timing of surgical decompression and stabilization for cervical spinal cord trauma. There have been numerous retrospective studies, but no prospective studies, to determine whether neurologic outcome is best after early versus late surgical treatment for cervical spinal cord injury. METHODS: Patients meeting appropriate inclusion criteria were randomized to an early (<72 hours after spinal cord injury) or late (>5 days after spinal cord injury) surgical treatment protocol. The neurologic and functional outcomes were recorded from the acute hospital admission to the most recent follow-up. RESULTS: Comparison of the two groups showed no significant difference in length of acute postoperative intensive care stay, length of inpatient rehabilitation, or improvement in American Spinal Injury Association grade or motor score between early (mean, 1.8 days) versus late (mean, 16.8 days) surgery. CONCLUSIONS: The results of this study reveal no significant neurologic benefit when cervical spinal cord decompression after trauma is performed less than 72 hours after injury (mean, 1.8 days) as opposed to waiting longer than 5 days (mean, 16.8 days).

Steroids and gunshot wounds to the spine.

OBJECTIVE: The second National Acute Spinal Cord Injury Study demonstrated that there were neurological benefits from "spinal cord injury" doses of methylprednisolone for blunt spinal cord injuries. In this review, we examined the relative risk/benefit ratio of intravenously treating spinal gunshot wound victims with steroids. METHODS: A retrospective review was conducted of 254 consecutive patients who were treated between 1979 and 1994 for gunshot wounds to the spine (C1-L1) and a spinal cord injury. Three subgroups were established based on the administration of the steroids methylprednisolone (National Acute Spinal Cord Injury Study 2 protocol), dexamethasone (initial dose, 10-100 mg), and no steroids. All patients who received steroids were initially treated at another hospital and then transferred. No patients received steroids at our institution. The data analyzed included neurological outcome and infectious and noninfectious complications. RESULTS: No statistically significant neurological benefits were demonstrable from the use of steroids (methylprednisolone, dexamethasone). Infectious complications were increased in both groups receiving steroids (not statistically significant). Gastrointestinal complications were significantly increased in the dexamethasone group (P = 0.021), and pancreatitis was significantly increased in the methylprednisolone group (P = 0.040). The mean duration of follow-up was 56.3 months. CONCLUSION: In this retrospective, nonrandomized review, no neurological benefits were detectable from intravenously administered steroids after a gunshot wound to the spine. Both infectious and noninfectious complication rates were higher in the groups receiving steroids. Patients who sustain a spinal cord injury secondary to a gunshot wound to the spine should not be treated with steroids until the efficacy of such treatment is proven in a controlled study.

Occurrence of infection in anterior cervical fusion for spinal cord injury after tracheostomy.

STUDY DESIGN: This study retrospectively reviewed the outcomes of 11 patients treated for a cervical spine injury with a tracheostomy placed before anterior cervical spine surgery. OBJECTIVES: The primary goal was to show that anterior cervical spine surgery in the setting of spinal cord injury is a viable option in patients with previous tracheostomy. SUMMARY OF BACKGROUND DATA: Respiratory failure after cervical cord injury commonly requires tracheostomy, possibly increasing the risk of soft tissue or bony infection in patients at high risk for morbidity after surgery. Although numerous studies have explored the risk of infection after tracheostomy or anterior cervical spine surgery, no study has been performed to explore the risk of infection in patients with previous tracheostomy at the time of anterior cervical spine surgery. METHODS: A retrospective review of the clinical data of 1800 spinal cord injury patients seen from 1979 to the present at the Regional Spinal Cord Injury Center of the Delaware Valley of Thomas Jefferson University with affiliated institutions of Thomas Jefferson University Hospital and Magee Rehabilitation Hospital was performed. Eleven patients were found who had existing tracheostomy at the time of anterior cervical spine surgery. Clinical follow-up period averaged 28 months with a range of 6-51 months, and radiographic analysis averaged 7 months with a range of 1-51 months. Autogenous iliac crest graft was used in all patients, consisting of an intervertebral graft after a discectomy or a strut graft after a complete corpectomy. Anterior instrumentation was used in more than 50% of the patients. RESULTS: After all patient interviews and review of all radiographs for evidence of infection, no patient was noted to have evidence of a cervical soft tissue or bony infection after surgery. The tracheostomy complications were minor and resolved quickly. CONCLUSIONS: The authors concluded that in patients with cervical cord damage resulting from nonpenetrating trauma, tracheostomy was not found to increase the risk of infection in subsequent anterior cervical surgery. Careful preparation of the skin and placement of the second surgical incision lateral to the tracheostomy site is recommended. Anterior cervical spine surgery remains a viable treatment option in this severely injured patient population.

Isolation and characterization of a type II JC virus from a brain biopsy of a patient with PML.

Brain tissue of a patient with multiple myeloma suffering from neurological disorders similar to those seen in progressive multifocal leukoencephalopathy (PML) patients was evaluated for the presence of the papovavirus, JCV. Results from polymerase chain reaction (PCR) revealed the presence of JCV with structural organization at the control region which is distinct from well-characterized isolates, ie Mad-1 and Mad-4. The control region of the new isolate, named JCVPhila-1' contains a 22 nucleotide insertion which separates the TATA box from the NF-1 regulatory motif. Only 18 nucleotides of the insert are duplicated in the second copy of the enhancer/promoter of the new isolate, which is 84 nucleotides in size. Results from a transcription assay indicate a modest elevated level of JCVPhila-1 early promoter activity compared to that of JCVMad-4 in glial cell lines. The basal and T-antigen-induced transcriptional activities of the JCVPhila-1 late promoter was lower with respect to Mad-4 late gene activity in glial cells. Of particular interest was the observation that in the cells producing the early protein, T-antigen, JCVPhila-1 DNA replicated more efficiently then the Mad-4 DNA. These results suggest that the alterations seen in the JCVPhila-1 control region may differentially influence early and late gene expression and facilitate amplification of the viral genome in cells derived from the CNS.

Factors associated with severe intracranial hypertension in candidates for emergency liver transplantation.

Cerebral edema is the leading cause of death in patients with fulminant hepatic failure (FHF). Emergency OLT is often a life-saving therapy for FHF but severe cerebral edema is a contraindication to transplantation. We attempted to identify clinical and biochemical factors associated with the development of severe intracranial hypertension in FHF. Fever, psychomotor agitation, and arterial hypertension were more frequently observed preceding episodes of severe intracranial hypertension, and more than 50% of FHF patients with uncontrolled intracranial hypertension sustained severe brain injury in our series. These observations suggest that vigorous treatment of fever, arterial hypertension, and agitation are important aspects of the intensive care management of FHF patients to maintain their OLT candidacy.

Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury.

Fifty-seven patients with acute cervical spine injuries and associated major neurological deficit were examined within 2 weeks of injury by magnetic resonance (MR) imaging. All patients had abnormal scans, indicating intramedullary lesions. This study was undertaken to determine if the early MR imaging pattern had a prognostic relationship to the eventual neurological outcome. Three different MR imaging patterns were observed in these patients: 21 patients had patterns characteristic of intramedullary hematoma (Group 1); 17 had intramedullary edema over more than one spinal segment, but no hemorrhage (Group 2); and 19 had restricted zones of intramedullary edema involving one spinal segment or less (Group 3). The neurological state was determined using standard motor index scores at admission and at follow-up examination. Characteristically, the patients in Group 1 had admission motor scores significantly lower than the other two groups. At follow-up examination, the median percent motor recovery was 9% for Group 1, 41% for Group 2, and 72% for Group 3. These studies suggest that the MR imaging pattern observed in the acutely injured human spinal cord has a prognostic significance in the final outcome of the motor system. It is only when an accurate prognosis can be given at the outset that useful treatment data might be collected for homogeneous injury groups, and accurately based long-term planning made for the best patient care.

Elevated intracranial pressure and computed tomography of the brain in fulminant hepatocellular failure.

Cerebral herniation is a leading cause of death in patients with fulminant hepatocellular failure. Classical signs of elevated intracranial pressure are often absent in these patients. A reliable noninvasive method by which the presence of cerebral edema could be determined is much needed. To assess the efficacy of computed tomography of the brain in this setting, we compared the radiographic findings to the intracranial pressure measured by an epidural monitor in patients with fulminant hepatic failure. Unfortunately, a considerable difference existed between the presence of cerebral edema diagnosed by computed tomography of the brain and elevation of the intracranial pressure. Our observations suggest that in patients with fulminant hepatic failure and advanced hepatic encephalopathy, computed tomography of the brain is of little value in detecting cerebral edema. Pressure monitoring is most important to establish the presence and guide the therapy of intracranial hypertension.

Cervical spinal canal plasticity in children as determined by the vertebral body ratio technique.

The sagittal cervical canal measurement from a plain spine radiography is easy to obtain and has a smaller range than the interpedicular distance. In an effort to standardize the sagittal measurement, a canal ratio, using the vertebral body diameter, has been formulated. If this method is to be used in the pediatric spine, the effect of the growing neuraxis must be considered. Lateral cervical spine radiographs of 301 normal children and adults were evaluated and grouped according to age. The canal ratio measurement demonstrated a consistent decrease through to the adult groups. Adjacent groups showed statistically significant decreases with age in all groups tested other than the oldest two groups. With the pediatric spinal canal vulnerable to various intracanalicular influences, the canal ratio may reflect early disease processes.

Acute cervical spine trauma: correlation of MR imaging findings with degree of neurologic deficit.

A retrospective analysis of magnetic resonance (MR) imaging studies of 78 patients with acute cervical spinal cord injuries was undertaken to determine which observations related directly to the neurologic injury. All MR imaging studies were performed on a 1.5-T unit and assessed with respect to 14 parameters related to the bony spine, ligaments, prevertebral soft tissues, intervertebral disks, and spinal cord. Forty-eight patients also underwent non-contrast material-enhanced thin-section computed tomography (CT) of the cervical spine. MR imaging was the definitive modality in the assessment of soft-tissue injury, especially in the evaluation of the spinal cord and intervertebral disks. All patients with a neurologic deficit had abnormal spinal cords at MR imaging. Intramedullary hemorrhage was predictive of a complete lesion. The degree of associated bone and soft-tissue injury had no bearing on the extent of spinal cord injury or neurologic deficit. Patients with residual cord compression following reduction demonstrated greater neurologic compromise than those without compression.

Magnetic resonance imaging of acute cervical spine trauma. Correlation with severity of neurologic injury.

Prior to the advent of computer-assisted imaging techniques, conventional radiographic studies did not accurately depict the severity of soft tissue injury (spinal cord and paravertebral tissue) attending severe spinal trauma. Computed tomography scanning is clearly superior to plain radiography in the demonstration of osseous fractures and impactions, but this modality does not clearly depict ligamentous or disc injuries and does not image the spinal cord directly. The authors' preliminary experience indicates that magnetic resonance imaging (MRI) more accurately defines the extent of soft tissue damage in the zone of injury. In this study, the authors correlate these objective imaging techniques with findings on neurologic exam. Seventy-eight patients with cervical spine injuries admitted to the Regional Spinal Cord Injury Center of the Delaware Valley between August 1987 and January 1989 were evaluated with surface-coil MRI on a 1.5-Tesla unit. Fifty-nine patients were studied within 7 days of injury. Image sequences consisting of T1-, proton density, and T2-weighted images were obtained in saggital views. Axial gradient recalled acquisitions in the steady state (GRASS) images were obtained from most patients. We learned that certain patterns of MRI signal were associated with severe neurologic deficit. These include: 1) intramedullary hematoma and 2) spinal cord contusion associated with edema encompassing more than one spinal segment. Magnetic resonance imaging findings also correlated with less severe injury and include 1) normal spinal cord signal and 2) small focal contusions associated with edema encompassing one spinal segment or less.

Obstructive emphysema due to mucus plugging in quadriplegia.

A quadriplegic patient with obstructive emphysema caused by mucus in the bronchi of the hyperinflated lung, demonstrated by chest radiograph and corrected by bronchoscopic aspiration of secretions from the hyperexpanded side, is reported. Subsequently, this phenomenon recurred in the opposite lung. This case is of particular interest, as it is the only documented report of obstructive emphysema due to mucus plugging in an adult with grossly normal airways. This case contrasts markedly with the usual picture of atelectasis and lobar or segmental collapse observed with large airway obstruction by mucus in this setting.

Dumbbell neuroblastoma presenting without spinal cord findings.

Patients with dumbbell neuroblastoma present with a wide variety of spinal cord problems. We recently treated an infant with a large dumbbell neuroblastoma who was neurologically intact. Because a CAT scan showed a retroperitoneal mass to be abutting the right vertebral body at T12-L1, a precautionary myelogram was performed, which revealed extensive intraspinal extension. We report this case to emphasize the need to have a high index of suspicion of spinal cord involvement in light of a normal neurologic examination since, any attempt at removing the extraspinal part, first, could cause serious neurologic sequelae. We also wish to emphasize avoiding radiation therapy when the tumor has been removed grossly to lessen the development of kyphoscoliatic deformity. The infant will be routinely followed with serial VMAs and ultrasound.