Vertebral augmentation in osteoporotic spine fractures: WFNS Spine Committee recommendations.

INTRODUCTION: The aim of this study was to formulate the WFNS Spine Committee guidelines on indications, outcomes, and complications of vertebral augmentation in osteoporotic spine fractures. EVIDENCE ACQUISITION: Computerized literature was searched from 2010 to 2021 using keywords "vertebral augmentation," "osteoporotic fracture," "technique," "surgery," "complication," and "outcome." PubMed yielded 92 articles whereas Google scholar resulted in 120 articles. 29 articles were studied in detail. The studies comprised of seventeen RCT's, two prospective non-randomized studies, three retrospective studies, and seven systematic reviews. The statements were produced to reach a consensus in two separate meetings of WFNS Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. EVIDENCE SYNTHESIS: Drafted statements on "Vertebral Augmentation in osteoporotic Spine Fractures" were voted upon by expert panelists in Virtual WFNS Spine Committee Consensus Meetings conducted on January 11, 2021, and February 13, 2021. Statements reaching positive consensus provided the basis for the WFNS guidelines regarding vertebral augmentation in osteoporotic spine fractures. CONCLUSIONS: WFNS Spine Committee recommendations on vertebral augmentation in osteoporotic spine fractures are summarized in this article. Vertebral augmentation is superior to conservative treatment for vertebral osteoporotic fractures but has conflicting results on comparison with placebo. Both vertebroplasty and kyphoplasty are equally effective. Most of the studies regarding the efficacy of vertebral augmentation procedures to reduce pain have been largely inconclusive. It is suggested that further high quality, better designed randomized controlled studies are required to establish the role of vertebral augmentation in spine osteoporotic compression fractures.

Epidemiology, natural course, and preventive measures of osteoporotic vertebral fractures: WFNS Spine Committee Recommendations.

INTRODUCTION: This review aims to search for up-to-date information on epidemiology, natural course, and preventive measures of osteoporotic spine fractures. EVIDENCE ACQUISITION: We reviewed the literature of the last ten years using keywords "natural course and osteoporotic vertebral fractures," "epidemiology and osteoporotic vertebral fractures" and "prevention and osteoporotic vertebral fractures." We then discussed the search results to reach an agreement in two consensus meetings on January and February 2021 of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Finally, we utilized the Delphi method to administer the questionnaire to preserve a high degree of validity. We summarized seven papers on the natural course, 15 articles on epidemiology, and 84 papers on preventing osteoporotic vertebral fractures. Finally, the consensus results after voting are presented. EVIDENCE SYNTHESIS: Natural course of acute osteoporotic vertebral fractures is benign; many patients may have sufficient pain relief during the first three months with conservative treatment. At the end of one year of conservative treatment, 40% may still have pain with VAS-scores ≥4. Since the populations are aging, the incidence of OVF continues to rise. Although the prevalence varies across the globe, the highest rates are from North America and some countries of Asia. Preventive treatment of OVF must involve an active lifestyle, adequate nutrition, prevention of immobilization with physical therapy, and pharmacological therapy. Oral calcium and vitamin D are first-line interventions to prevent the bone mass loss, especially in postmenopausal women. There are many pharmacological treatment options; the decision must be made by fracture risk assessment (clinical factors + BMD + BMI) alone or along with DXA (dual-energy X-ray absorptiometry) or history of previous fragility fractures. The indication of one respect to the others is based on patient preference, compliance, and risk of discontinuation related to adverse events and administration method. CONCLUSIONS: The incidence of osteoporotic vertebral fractures increases with age and other factors. The natural course shows that most patients benefit from conservative therapy without any surgical intervention during the first three months. Preventive measures must include active lifestyle, adequate nutrition, prevention of immobilization with physical therapy, oral calcium, and vitamin D intake, and pharmacological therapy after fracture risk assessment.

Osteoporotic vertebral fractures: radiologic diagnosis, clinical and radiologic factors affecting surgical decision making: WFNS spine committee recommendations.

INTRODUCTION: With the varied literature on osteoporotic vertebral fracture that may predispose to diagnostic and management dilemma, it is timely to evaluate and streamline the evidence. The aim of this review is to create recommendations on osteoporotic vertebral fractures regarding radiologic diagnosis, and clinical and radiological factors affecting surgical decision making. EVIDENCE ACQUISITION: A computerized literature search was done using PubMed, Google scholar and Cochrane Database of Systematic Reviews from 2010 to 2020. For radiologic diagnosis, the keywords "osteoporotic vertebral fractures" and "radiologic diagnosis" were used yielding 394 articles (19 relevant articles). For clinical and radiological factors affecting surgical decision making, the keywords "osteoporotic vertebral fractures," "radiologic diagnosis," and "surgery" were used yielding 568 articles (25 relevant articles). EVIDENCE SYNTHESIS: All pertinent data were reviewed, and consensus statements were obtained in two virtual separate consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine committee. The statements were voted and yielded positive or negative consensus using the Delphi method. CONCLUSIONS: This review summarizes the WFNS Spine Committee recommendations on the radiologic diagnosis, and clinical and radiological factors affecting surgical decision making of osteoporotic vertebral fractures.

Basal Cisternostomy - A Microsurgical Cerebro Spinal Fluid Let Out Procedure and Treatment Option in the Management of Traumatic Brain Injury. Analysis of 40 Consecutive Head Injury Patients Operated with and without Bone Flap Replacement Following Cisternostomy in a Tertiary Care Centre in India.

BACKGROUND: Decompressive craniectomy (DC) is considered the gold standard blanket surgical procedure for all medically intractable cerebral oedema in Traumatic Brain Injury (TBI). It's only proven fact is that it reduces Intra Cerebral Pressure (ICP) by providing space for the oedematous brain. Attempts are being made to find additional or alternative procedures to improve outcomes in TBI. Basal Cisternostomy is one such technique proposed to bring such a change in world literature. AIM: To analyse the validity of Basal Cisternostomy in TBI patients. MATERIALS AND METHODS: A total of 40 patients who underwent Basal Cisternostomy (BC) in TBI admitted in the senior author's unit between January 2016 and April 2019 were analysed retrospectively. All surgeries were performed by single surgeon with microsurgical expertise. Outcome was assessed according to Glasgow outcome scale (GOS). Results were analysed using SPSS software. RESULTS: In severe TBI, Basal Cisternostomy group showed 77.8% favourable outcome while Decompressive Craniectomy in addition to Basal Cisternostomy group showed 72.7% only. While favourable GOS was seen in 82% (33/40), the unfavourable outcome was noticed in 12.5% (5/40) and death in 5% (2/40) in this series. Hydrocephalus was seen in 12.5% (5/40). Patients operated earlier from the time of injury showed better results than those who got operated later irrespective of severity of neurological status. ICU stay and hospital stay duration and its validity could not be assessed. CONCLUSION: Basal Cisternostomy is an effective procedure in Traumatic Brain Injury patients that not only improves outcome but also reduces the need for Decompressive Craniectomy as a blanket procedure and thus avoiding its associated complications.

Subaxial Cervical Spine Injuries: WFNS Spine Committee Recommendations.

To formulate specific guidelines for the recommendation of subaxial cervical spine injuries concerning classification, management, posttraumatic locked facets and vertebral artery injury. Computerized literature was searched on PubMed and google scholar database from 2009 to 2020. For classification, keywords "Sub Axial Cervical Spine Classification," resulting in 22 articles related to subaxial cervical spine injury classification system (SLICS) system and 11 articles related to AO (Arbeitsgemeinschaft für Osteosynthesefragen, German for "Association for the Study of Internal Fixation") Spine system. The literature search yielded 210 and 78 articles on "management of subaxial cervical spine injuries" and the role of "SLICS" and "AO Spine" respectively. Keywords "management of traumatic facet locks" were searched and closed reduction, traction, approaches and techniques were studied. "Vertebral artery injury and cervical fracture" exhibited 2,328 references from the last 15 years. The objective was to identify the appropriate diagnostic tests and optimal treatment. Up-to-date information was reviewed, and statements were produced to reach a consensus in 2 separate consensus meetings of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Based on the most relevant literature, panelists in Moscow consensus meeting conducted in May 2019 drafted the statements, and after a preliminary voting session, the consensus was identified on various statements. Another meeting was conducted at Peshawar in November 2019, where in addition to previous statements, few other statements were discussed and voted. Specific recommendations were then formulated guiding classification, management, locked facets and vertebral artery injuries. This review summarizes the WFNS Spine Committee recommendations on subaxial cervical spine injuries.

Pharmacologic and Regenerative Cell Therapy for Spinal Cord Injury: WFNS Spine Committee Recommendations.

This is a review article examining the pharmacologic and regenerative cell therapy for spinal cord injury. A literature search during last 10 years were conducted using key words. Case reports, experimental (nonhuman) studies, papers other than English language were excluded. Up-to-date information on the pharmacologic and regenerative cell therapy for spinal cord injury was reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. Pharmacologic and regenerative cell therapy for spinal cord injury have long been an interest of many experimental and clinical researches. Clinical studies with methylpredinisolone have not shown clear cut benefit. Other drugs such as Rho inhibitor, minocycline, riluzole, granulocyte colony-stimulating factor have also been tried without significant benefits. Regenerative cell therapy using different types of stem cells, different inoculation techniques, and scaffolds have undergone many trials highlighting the efficacies of cells and their limitations. This review article summarizes the current knowledge on pharmacologic and regenerative cell therapy for spinal cord injury. Unfortunately, there is a need for further experimental and human trials to recommend effective pharmacologic and regenerative cell therapy.

Outcomes of Spinal Cord Injury: WFNS Spine Committee Recommendations.

This comprehensive review article aims to provide some definitive statements on the factors like clinical syndromes, radiological findings, and decompressive surgery, that may influence the outcomes in cervical spinal cord injury management. Literature search on these factors published in the last decade were analyzed and definite statements prepared and voted for consensus opinion by the WFNS Spine Committee members and experts in this field at a meeting in Moscow in June 2019 using Delphi method. This was re-evaluated in a meeting in Pakistan in November 2019. Finally, the consensus statements were brought out as recommendations by the committee to the world literature. Traumatic Spinal Cord Syndromes have good prognosis except in elderly and when the presenting neurological deficit was very poor. Though conservative management provides satisfactory results, results can be improved with surgery when instability and progressive compression was present. Locked facet with spinal cord injury denotes poor prognosis. Magnetic resonance imaging T2 imaging is the essential prognostic indicator that apart from sagittal grade, length of injury, maximum canal compromise, maximum spinal cord compression, axial grading (BASIC) score. Diffusion tensor imaging is the next promising predictor in the pipeline. Decompressive surgery when done earlier especially within 24 hours of injury provides better result and there is no clear evidence to show medical management is better or equivalent to delayed surgical management. Clinical syndromes, radiological syndromes, and surgical decompression have strong impact on the out comes in the management of cervical spinal cord injury. Our comprehensive review and final recommendations on this subject will be of great importance in understanding the complex treatment methods in use.

Cisternostomy: A Timely Intervention in Moderate to Severe Traumatic Brain Injuries: Rationale, Indications, and Prospects.

Traumatic brain injury (TBI) represents a major public health concern worldwide, with no significant change in its epidemiology over the last 30 years. After TBI, the primary injury induces irreversible brain damage, which is untreatable. The subsequent secondary injury plays a critical role in the clinical prognosis because without effective treatment it will provide additional tissue damage. The resulting scenario is the rise in intracranial pressure (ICP) with the development of progressive neurological deficits. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies among which is decompressive hemicraniectomy. With the advent of technology, research in the glymphatic pathways, and advances in microscopic surgery, a novel surgical technique-the cisternostomy-has emerged that holds promise in managing rising ICP in TBI-affected patients. In this article we describe the rationale for cisternostomy, an emerging microneurosurgical approach for the management of moderate to severe TBI.

Value of Surgery and Nonsurgical Approaches for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

Cervical spondylotic myelopathy (CSM) is a common cause of adult spinal cord dysfunction. Although the therapeutic options for moderate to severe CSM patients have been established well, the existing guidelines for therapeutic decisions in mild cases of CSM are unclear. We present a review of literature on conservative treatment and surgery for CSM and suggest general recommendations applicable in various clinical presentations and in different geographic locations across the globe, with due considerations to available resources and locally prevalent practices.

Anterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

OBJECTIVE: This study was performed to review the literature and to present the most up-to-date information and recommendations on the indications, complications, and success rate of anterior surgical techniques for cervical spondylotic myelopathy (CSM). The commonly performed anterior surgical procedures are multiple-level anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion and its variants (skip corpectomy and hybrid surgery), and oblique corpectomy without fusion. METHODS: A comprehensive literature search and analysis were performed using MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and the Web of Science for peer-reviewed articles published in English during the last 10 years. RESULTS: Corpectomy is mandated for ventral compression of fewer than 3 vertebral segments where single-level disc and osteophyte excision is inadequate to decompress the cord. Endoscopic or oblique partial corpectomy improves the sagittal canal diameter by 67% and obviates the need for an additional bone graft procedure. CONCLUSION: The indications of anterior surgery in patients with CSM include a straightened or kyphotic spine with a compression level lower than 3. With an appropriate choice of implants and meticulous surgical technique, surgical complications can be seen only rarely. Improvements after anterior surgery for CSM have been reported in 70% to 80% of patients.

Posterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

OBJECTIVE: This study was conducted to determine and recommend the most up-to-date information on the indications, complications, and outcomes of posterior surgical treatments for cervical spondylotic myelopathy (CSM) on the basis of a literature review. METHODS: A comprehensive literature search was performed, using the MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and Web of Science databases, for peer-reviewed articles published in English during the last 10 years. RESULTS: Posterior techniques, which include laminectomy alone, laminectomy with fusion, and laminoplasty, are often used in patients with involvement of 3 or more levels. Posterior decompression for CSM is effective for improving patients' neurological function. Complications resulting from posterior cervical spine surgery include injury to the spinal cord and nerve roots, complications related to posterior screw fixation or instrumentation, C5 palsy, spring-back closure of lamina, and postlaminectomy kyphosis. CONCLUSION: It is necessary to consider multiple factors when deciding on the appropriate operation for a particular patient. Surgeons need to tailor preoperative discussions to ensure that patients are aware of these facts. Further research is needed on the cost-to-benefit analysis of various surgical approaches, the comparative efficacy of surgical approaches using various techniques, and long-term outcomes, as current knowledge is deficient in this regard.

Cervical Spondylotic Myelopathy: Natural Course and the Value of Diagnostic Techniques -WFNS Spine Committee Recommendations.

OBJECTIVE: This study presents the results of a systematic literature review conducted to determine most up-to-date information on the natural outcome of cervical spondylotic myelopathy (CSM) and the most reliable diagnostic techniques. METHODS: A literature search was performed for articles published during the last 10 years. RESULTS: The natural course of patients with cervical stenosis and signs of myelopathy is quite variable. In patients with no symptoms, but significant stenosis, the risk of developing myelopathy with cervical stenosis is approximately 3% per year. Myelopathic signs are useful for the clinical diagnosis of CSM. However, they are not highly sensitive and may be absent in approximately one-fifth of patients with myelopathy. The electrophysiological tests to be used in CSM patients are motor evoked potential (MEP), spinal cord evoked potential, somatosensory evoked potential, and electromyography (EMG). The differential diagnosis of CSM from other neurological conditions can be accomplished by those tests. MEP and EMG monitoring are useful to reduce C5 root palsy during CSM surgery. Notable spinal cord T2 hyperintensity on cervical magnetic resonance imaging (MRI) is correlated with a worse outcome, whereas lighter signal changes may predict better outcomes. T1 hypointensity should be considered a sign of more advanced disease. CONCLUSION: The natural course of CSM is quite variable. Signal changes on MRI and some electrophysiological tests are valuable adjuncts to diagnosis.

Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick's grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski's sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.

The known-unknowns in spinal cord injury, with emphasis on cell-based therapies - a review with suggestive arenas for research.

INTRODUCTION: In spite of extensive research, the progress toward a cure in spinal cord injury (SCI) is still elusive, which holds good for the cell- and stem cell-based therapies. We have critically analyzed seven known gray areas in SCI, indicating the specific arenas for research to improvise the outcome of cell-based therapies in SCI. AREAS COVERED: The seven, specific known gray areas in SCI analyzed are: i) the gap between animal models and human victims; ii) uncertainty about the time, route and dosage of cells applied; iii) source of the most efficacious cells for therapy; iv) inability to address the vascular compromise during SCI; v) lack of non-invasive methodologies to track the transplanted cells; vi) need for scaffolds to retain the cells at the site of injury; and vii) physical and chemical stimuli that might be required for synapses formation yielding functional neurons. EXPERT OPINION: Further research on scaffolds for retaining the transplanted cells at the lesion, chemical and physical stimuli that may help neurons become functional, a meta-analysis of timing of the cell therapy, mode of application and larger clinical studies are essential to improve the outcome.

Index of CD34+ Cells and Mononuclear Cells in the Bone Marrow of Spinal Cord Injury Patients of Different Age Groups: A Comparative Analysis.

Introduction. Recent evidence of safety and efficacy of Bone Marrow Mononuclear Cells (BMMNC) in spinal cord injury makes the Bone Marrow (BM) CD34+ percentage and the BMMNC count gain significance. The indices of BM that change with body mass index and aging in general population have been reported but seldom in Spinal Cord Injury (SCI) victims, whose parameters of relevance differ from general population. Herein, we report the indices of BMMNC in SCI victims. Materials and Methods. BMMNCs of 332 SCI patients were isolated under GMP protocols. Cell count by Trypan blue method and CD34+ cells by flow cytometry were documented and analysed across ages and gender. Results. The average BMMNC per ml in the age groups 0-20, 21-40, 41-60, and 61-80 years were 4.71, 4.03, 3.67, and 3.02 million and the CD34+ were 1.05%, 1.04%, 0.94%, and 0.93% respectively. The decline in CD34+ was sharp between 20-40 and 40-60 age groups. Females of reproductive age group had lesser CD34+. Conclusion. The BMMNC and CD34+ percentages decline with aging in SCI victims. Their lower values in females during reproductive age should be analysed for relevance to hormonal influence. This study offers reference values of BMMNC and CD34+ of SCI victims for successful clinical application.