The Effect of Posterior Fossa Decompression Surgery on Brainstem and Cervical Spinal Cord Dimensions in Adults with Chiari Malformation Type 1.

OBJECTIVE: Posterior fossa decompression (PFD) surgery creates more space at the skull base, reduces the resistance to the cerebrospinal fluid motion, and alters craniocervical biomechanics. In this paper, we retrospectively examined the changes in neural tissue dimensions following PFD surgery on Chiari malformation type 1 adults. METHODS: Measurements were performed on T2-weighted brain magnetic resonance images acquired before and 4 months after surgery. Measurements were conducted for neural tissue volume and spinal cord/brainstem width at 4 different locations; 2 width measurements were made on the brainstem and 2 on the spinal cord in the midsagittal plane. Cerebellar tonsillar position (CTP) was also measured before and after surgery. RESULTS: Twenty-five adult patients, with a mean age of 38.9 ± 8.8 years, were included in the study. The cervical cord volume increased by an average of 2.3 ± 3.3% (P = 0.002). The width at the pontomedullary junction increased by 2.2 ± 3.5% (P < 0.01), while the width 10 mm caudal to this junction increased by 4.2 ± 3.9% (P < 0.0001). The spinal cord width at the base of second cervical vertebra and third cervical vertebra did not significantly change after surgery. The CTP decreased by 60 ± 37% (P < 0.0001) after surgery, but no correlation was found between CTP change and dimension change. CONCLUSIONS: The brainstem width and cervical cord volume showed a modest increase after PFD surgery, although standard deviations were large. A reduction in compression after PFD surgery may allow for an increase in neural tissue dimension. However, clinical relevance is unclear and should be assessed in future studies with high-resolution imaging.

In-hospital mortality rate in subaxial cervical spinal cord injury patients: a systematic review and meta-analysis.

PURPOSE: To determine existing trends concerning in-hospital mortality in patients with traumatic subaxial cervical spinal cord injury (SCI) over the last four decades. METHODS: We searched MEDLINE and EMBASE to assess the role of the following factors on in-hospital mortality over the last four decades: neurological deficit, age, surgical decompression, use of computed tomography (CT) and magnetic resonance imaging (MRI), use of methylprednisolone in the acute post-injury period, and study location (developing versus developed countries). RESULTS: Among 3333 papers after deduplication, 21 studies met the eligibility criteria. The mortality rate was 17.88% [95% confidence interval (CI): 12.9-22.87%]. No significant trend in mortality rate was observed over the 42-year period (meta-regression coefficient = 0.317; p = 0.372). Subgroup analysis revealed no significant association between acute subaxial cervical SCI-related mortality when stratified by use of surgery, administration of methylprednisolone, use of MRI and CT imaging, study design (prospective versus retrospective study), and study location. The mortality rate was significantly higher in complete SCI (20.66%, p = 0.002) and American Spinal Injury Association impairment scale (AIS) A (20.57%) and B (9.28%) (p = 0.028). CONCLUSION: A very low level of evidence showed that in-hospital mortality in patients with traumatic subaxial cervical SCI did not decrease over the last four decades despite diagnostic and therapeutic advancements. The overall acute mortality rate following subaxial cervical SCI is 17.88%. We recommend reporting a stratified mortality rate according to key factors such as treatment paradigms, age, and severity of injury in future studies.

Variability in Early Surgery for Acute Cervical Spinal Cord Injury Patients: An Opportunity for Enhanced Care Delivery.

Data supporting the benefits of early surgical intervention in acute spinal cord injury (SCI) is growing. For early surgery to be accomplished, understanding the causes of variabilities that effect the timing of surgery is needed to achieve this goal. The purpose of this analysis is to determine factors that affect the timing of surgery for acute cervical SCI within the North American Clinical Trials Network (NACTN) for SCI registry. Patients in the NACTN SCI registry from 2005 to 2019 with a cervical SCI, excluding acute traumatic central cord syndrome, were analyzed for time elapsed from injury to arrival to the hospital, and time to surgery. Two categories were defined: 1) Early Arrival with Early Surgery (EAES) commenced within 24 h of injury, and 2) Early Arrival but Delayed Surgery (EADS), with surgery occurring between 24 to 72 h post-injury. Patients' demographic features, initial clinical evaluation, medical comorbidities, neurological status, surgical intervention, complications, and outcome data were correlated with respect to the two arrival groups. Of the 222 acute cervical SCI patients undergoing surgery, 163 (73.4%) were EAES, and 59 (26.6%) were EADS. There was no statistical difference in arrival time between the EAES and EADS groups. There was a statistical difference in the median arrival time to surgery between the EAES group (9 h) compared with the EADS group (31 h; p < 0.05). There was no statistical difference in race, sex, age, mechanism of injury, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores, or medical comorbidities between the two groups, but the EAES group did present with a significantly lower systolic blood pressure (p < 0.05). EADS patients were more likely to present as an American Spinal Injury Association Impairment Scale (AIS) D than EAES (p < 0.05). Early surgery was statistically more likely to occur if the injury occurred over the weekend (p < 0.05). There were variations in the rates of early surgery between the eight NACTN sites within the study, ranging from 57 to 100%. Of the 114 patients with 6-month outcome data, there was no significant change between the two groups regarding AIS grade change and motor/pin prick/light touch score recovery. A trend towards improved motor scores with early surgery was not statistically significant (p = 0.21). Although there is data that surgery within 24 h of injury improves outcomes and can be performed safely, there remain variations in care outside of clinical trials. In the present study of cervical SCI, NACTN achieved its goal of early surgery in 73.4% of patients from 2005-2019 who arrived within 24 h of their injury. Variability in achieving this goal was related to severity of neurological injury, the day of the week, and the treating NACTN center. Evaluating variations within our network improves understanding of potential systemic limitations and our decision-making process to accomplish the goal of early surgery.

Quantifying Tenodesis Hand Function in Cervical Spinal Cord Injury: Implications for Function.

PURPOSE: Cervical spinal cord injury (SCI) has a profound effect on upper-extremity function. Individuals with stiffness and/or spasticity may have more, or less, useful tenodesis function. This study examined the variability present before any reconstructive surgery. METHODS: Tenodesis pinch and grasp were measured with the wrist in maximal active extension. Tenodesis pinch was the contact point of the thumb with the index finger proximal phalanx (T-IF:P1), middle phalanx (T-IF:P2), distal phalanx (T-IF:P3), or absent (T-IF:absent). Tenodesis grasp was the distance from the long finger to the distal palmar crease (LF-DPC). Activities of daily living function was assessed using the Spinal Cord Independence Measure (SCIM). RESULTS: The study included 27 individuals (4 females, 23 males; mean age 36 years, mean time since SCI 6.8 years). The mean International Classification for Surgery of the Hand in Tetraplegia (ICSHT) group classification was 3. In the dominant hand, individuals with a T-IF tenodesis pinch to P1 or P2 had significantly higher total SCIM scores (43.7 and 34.2, respectively) compared to those with absent T-IF tenodesis pinch (SCIM 17.8). Shorter LF-DPC distance with tenodesis grasp (improved finger closing) also correlated with improved SCIM mobility and total scores. No association was found between the ICSHT group and SCIM score or tenodesis measures. CONCLUSIONS: Quantifying tenodesis with pinch (T-IF) and grasp (LF-DPC) is a simple method to characterize hand movement in individuals with cervical SCI. Better tenodesis pinch and grasp were associated with improved activities of daily living performance. CLINICAL RELEVANCE: Differences in grasp function have implications for mobility, and differences in pinch function have implications for all functions, particularly self-care. These physical measurements could be used to assess movement changes after nonsurgical and surgical treatment in tetraplegia.

Early versus late surgical intervention for cervical spinal cord injury: A protocol for systematic review and meta-analysis.

BACKGROUND: Acute traumatic cervical spinal cord injury (SCI) is a catastrophic event with substantial physical, emotional, and economic burdens to patients, families, and society. Spinal cord decompression is recommended for the treatment of acute SCI. However, the optimal surgical timing remains controversial. Therefore, we perform a protocol for systematic review and meta-analysis to compare the efficacy of early and late surgical intervention for acute SCI. METHODS: This systematic review and meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement, which have been registered in advance in the International prospective register of systematic reviews (registration number: CRD42023397592). We will search the following databases for randomized controlled trials: the Cochrane Skin Group Trials Register, MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, Chinese Medical Current Content, and China National Knowledge Infrastructure. The risk of bias of the included studies will be appraised using the Cochrane Collaboration tool for randomized controlled trials. Statistical analysis will be performed using IBM SPSS Statistics (Armonk, NY). RESULT: The results of this systematic review will be published in a peer-reviewed journal. CONCLUSION: This systematic review will provide evidence regarding the optimal timing for spinal cord decompression in patients with acute SCI.

Surgical Decompression of Traumatic Cervical Spinal Cord Injury: A Pilot Study Comparing Real-Time Intraoperative Ultrasound After Laminectomy With Postoperative MRI and CT Myelography.

BACKGROUND: Decompression of the injured spinal cord confers neuroprotection. Compared with timing of surgery, verification of surgical decompression is understudied. OBJECTIVE: To compare the judgment of cervical spinal cord decompression using real-time intraoperative ultrasound (IOUS) following laminectomy with postoperative MRI and CT myelography. METHODS: Fifty-one patients were retrospectively reviewed. Completeness of decompression was evaluated by real-time IOUS and compared with postoperative MRI (47 cases) and CT myelography (4 cases). RESULTS: Five cases (9.8%) underwent additional laminectomy after initial IOUS evaluation to yield a final judgment of adequate decompression using IOUS in all 51 cases (100%). Postoperative MRI/CT myelography showed adequate decompression in 43 cases (84.31%). Six cases had insufficient bony decompression, of which 3 (50%) had cerebrospinal fluid effacement at >1 level. Two cases had severe circumferential intradural swelling despite adequate bony decompression. Between groups with and without adequate decompression on postoperative MRI/CT myelography, there were significant differences for American Spinal Injury Association motor score, American Spinal Injury Association Impairment Scale grade, AO Spine injury morphology, and intramedullary lesion length (IMLL). Multivariate analysis using stepwise variable selection and logistic regression showed that preoperative IMLL was the most significant predictor of inadequate decompression on postoperative imaging (P = .024). CONCLUSION: Patients with severe clinical injury and large IMLL were more likely to have inadequate decompression on postoperative MRI/CT myelography. IOUS can serve as a supplement to postoperative MRI/CT myelography for the assessment of spinal cord decompression. However, further investigation, additional surgeon experience, and anticipation of prolonged swelling after surgery are required.

Predicting the Role of Preoperative Intramedullary Lesion Length and Early Decompressive Surgery in ASIA Impairment Scale Grade Improvement Following Subaxial Traumatic Cervical Spinal Cord Injury.

BACKGROUND: Traumatic cervical spinal cord injury (TCSCI) is a disabling condition with uncertain neurologic recovery. Clinical and preclinical studies have suggested early surgical decompression and other measures of neuroprotection improve neurologic outcome. We investigated the role of intramedullary lesion length (IMLL) on preoperative magnetic resonance imaging (MRI) and the effect of early cervical decompressive surgery on ASIA impairment scale (AIS) grade improvement following TCSCI. METHODS: In this retrospective study, we investigated 34 TCSCI patients who were admitted over a 12-year period, from January 1, 2008 to January 31, 2020. We studied the patient demographics, mode of injury, IMLL and timing of surgical decompression. The IMLL is defined as the total length of edema and contusion/hemorrhage within the cord. Short tau inversion recovery (STIR) sequences or T2-weighted MR imaging with fat saturation increases the clarity of edema and depicts abnormalities in the spinal cord. All patients included had confirmed adequate spinal cord decompression with cervical fixation and a follow-up of at least 6 months. RESULTS: Of the 34 patients, 16 patients were operated on within 24 hours (early surgery group) and 18 patients were operated on more than 24 hours after trauma (delayed surgery group). In the early surgery group, 13 (81.3%) patients had improvement of at least one AIS grade, whereas in the delayed surgery group, AIS grade improvement was seen in only in 8 (44.5%) patients (early vs. late surgery; odds ratio [OR] = 1.828; 95% confidence interval [CI]: 1.036-3.225). In multivariate regression analysis coefficients, the timing of surgery and intramedullary edema length on MRI were the most significant factors in improving the AIS grade following cervical SCI. Timing of surgery as a unique variance predicted AIS grade improvement significantly (p < 0.001). The mean IMLL was 41.47 mm (standard deviation [SD]: 18.35; range: 20-87 mm). IMLL was a predictor of AIS grade improvement on long-term outcome in bivariate analysis (p < 0.001). This study suggests that patients who had IMLL of less than 30 mm had a better chance of grade conversion irrespective of the timing of surgery. Patients with an IMLL of 31 to 60 mm had chances of better grade conversion after early surgery. A longer IMLL predicts lack of improvement (p < 0.05). If the IMLL is greater than 61 mm, the probability of nonconversion of AIS grade is higher, even if the patient is operated on within 24 hours of trauma. CONCLUSION: Surgical decompression within 24 hours of trauma and shorter preoperative IMLL are significantly associated with improved neurologic outcome, reflected by better AIS grade improvement at 6 months' follow-up. The IMLL on preoperative MRI can reliably predict outcome after 6 months. The present study suggests that patients have lesser chances of AIS grade improvement when the IMLL is ≥61 mm.

Tracheostomy in traumatic cervical spinal cord injury: Early versus late tracheostomy.

OBJECTIVE: The purpose of this study was to characterize the relationship between predictors and the time of tracheostomy after traumatic cervical spinal cord injury (TCSCI). METHODS: Five hundred twenty-six patients with TCSCI treated between January,2012 and December, 2021 were retrospectively reviewed. Patients were subdivided into two groups: early tracheostomy (≤7 days from initiation of endotracheal intubation) and late tracheostomy. Comparisons between early tracheostomy and late tracheostomy were statistically analyzed. Logistic regression analysis was applied to identify independent predictors of tracheostomy and calculate probability for different grades of combining predictors to predict tracheostomy. Spearman's correlation coefficient was used to evaluate the association between the grade of combining predictors and the time to tracheostomy. RESULTS: Among 526 eligible patients, 63(12.0%) had a tracheostomy performed. Compared with late tracheostomy group, patients in early tracheostomy group had higher ISS, more severe neurological status while fewer In-hospital LOS days and ICU LOS days. By Logistic regression analysis, severe American Spinal Injury Association Impairment Scale (AIS A), the neurological level of injury (NLI>C5), higher Injury Severity Score (ISS>16) and advanced age (over 50 years old) were identified as independent predictors for tracheostomy. Depending on the likelihood of tracheostomy, the combining predictors were graded into five categories. As the value of probability was higher than 50%, Grade I-III made optimistic predictions about tracheostomy. According to Spearman's correlation analysis, early tracheostomy had a strong association with Grade I, while late tracheostomy was closely correlated with Grade III. CONCLUSIONS: Factors related to the decision of tracheostomy were ASIA impairment scale, neurological level of injury, injury severity score and age. The grades of combining predictors could support indication for predicting the time of tracheostomy.

Efficacy of a machine learning-based approach in predicting neurological prognosis of cervical spinal cord injury patients following urgent surgery within 24 h after injury.

We aimed to develop a machine learning (ML) model for predicting the neurological outcomes of cervical spinal cord injury (CSCI). We retrospectively analyzed 135 patients with CSCI who underwent surgery within 24 h after injury. Patients were assessed with the American Spinal Injury Association Impairment Scale (AIS; grades A to E) 6 months after injury. A total of 34 features extracted from demographic variables, surgical factors, laboratory variables, neurological status, and radiological findings were analyzed. The ML model was created using Light GBM, XGBoost, and CatBoost. We evaluated Shapley Additive Explanations (SHAP) values to determine the variables that contributed most to the prediction models. We constructed multiclass prediction models for the five AIS grades and binary classification models to predict more than one-grade improvement in AIS 6 months after injury. Of the ML models used, CatBoost showed the highest accuracy (0.800) for the prediction of AIS grade and the highest AUC (0.90) for predicting improvement in AIS. AIS grade at admission, intramedullary hemorrhage, longitudinal extent of intramedullary T2 hyperintensity, and HbA1c were identified as important features for these prediction models. The ML models successfully predicted neurological outcomes 6 months after injury following urgent surgery in patients with CSCI.

The Dose-Response Relationship Between Age and Tracheostomy in Patients with Traumatic Cervical Spinal Cord Injury: A Restricted Cubic Spline Function Analysis.

OBJECTIVE: To investigate the continuous relationship between age and tracheostomy in patients with traumatic cervical spinal cord injury (TCSCI). METHODS: This study comprised 689 TCSCI patients in total. The logistic regression and restricted cubic spline analysis was applied to analyze the possible dose-response relationship between age and tracheostomy. The subgroup analysis was performed for the American Spinal Injury Association (ASIA) grade and neurological level of injury. RESULTS: The proportion of patients with the age ≥60 was significantly higher in the tracheostomy group than in the non-tracheostomy group (42.2% vs. 19.6%; P < 0.001). Age ≥60 was independently associated with tracheostomy (total: odds ratio = 3.560, 95% confidence interval: 1.892-6.697; P < 0.001) after adjusting for gender, smoking history, dislocation, respiratory complications, ASIA grade, neurological level of injury, preexisting lung disease, brain injury, and thoracic injury. After the relationship was presented in the subgroup analysis, the restricted cubic spline revealed a nonlinear relationship between age and tracheostomy (P-overall < 0.001 and P-nonlinear = 0.021). CONCLUSIONS: Age and tracheostomy present a dose-response relationship in patients with TCSCI. This finding could help physicians bring assistance in the early identification of tracheostomy and rationalize the allocation of medical resources.

The Efficacy of Anterior Cervical Corpectomy and Fusion and Posterior Total Laminectomy on Cervical Spinal Cord Injury and Quality of Life.

This study is aimed at investigating the efficacy of anterior cervical corpectomy and fusion and posterior total laminectomy in the treatment of cervical spinal cord injury and assessing the impact of the two approaches on cervical spine function and patient quality of life. Retrospectively analyze the clinical data from 180 patients with cervical spinal cord injury who were admitted to the First Affiliated Hospital of Hebei North University from June 2019 to June 2021. The patients were divided into an anterior approach group (n = 89, treated with anterior cervical corpectomy and fusion) and a posterior approach group (n = 91, treated with posterior total laminectomy). The amount of blood loss in the posterior approach group was larger compared to the anterior approach group. Patients in the posterior approach group had higher wound diameters and operation times compared to the anterior approach group, as well as the operation cost. The visual analogue scale (VAS) scores of patients in the posterior approach group were significantly higher than in the anterior approach group one month after operation. The Japanese Orthopaedic Association (JOA), neck disability index (NDI), and American Spinal Injury Association (ASIA) scores of patients in both groups at 1, 6, and 9 months after surgery were higher compared to those before surgery, yet no significant differences were observed between the two groups. Also, no significant difference was observed in the incidence of complication and the quality of life between the two groups before and after treatment. Anterior cervical corpectomy and fusion and posterior total laminectomy can effectively restore the cervical nerve function in the treatment of cervical spinal cord injury. However, anterior subtotal vertebral resection is associated with improved perioperative indicators compared to posterior total laminectomy. Clinically, surgical methods can be selected according to imaging findings, the general condition of patients, and individual economic status.

Neurological Outcome of Early versus Late Surgery Following Cervical Spinal Cord Injury.

Background There are numerous retrospective studies and a few prospective studies to determine the neurologic outcome after early versus late surgical treatment for cervical spinal cord injury. Objective To compare the neurological outcome between early (within 72 hours after injury) and delayed (≥ 72 hours after injury) surgery in patients with cervical spinal injury. Method This is a retrospective analysis of the neurological outcome of early versus late surgery following cervical spinal cord trauma. Patients meeting appropriate inclusion criteria were divided into an early or a late surgical treatment group. The neurologic outcomes and other complications were recorded up to six months of follow-up. Result Overall, there was a significant difference in neurological status at presentation and at follow-up (p < 0.001). However, there was no statistically significant difference between the early versus late surgery groups (p-value 0.261) in terms of neurological outcome. Complications were found to be higher among those undergoing posterior surgical approach (OR = 23.75; 95% CI 2.65, 212.98) than those with anterior or combined approach (p=0.005). However, multivariate analysis of these variables failed to show any statistically significant difference between the two groups. Conclusion The timing of surgery does not alter the neurological outcomes and the development of complications significantly. The American Spinal Cord Injury Association (ASIA) status at the time of presentation is found to be the single most important factor correlating with the neurological outcome.

Magnetic Resonance Imaging Scans of Cervical Spinal Cord Ependymoma with Changing Radiological Features over a Short Period of Time.

In a 30-year-old woman with cervical ependymoma, magnetic resonance imaging (MRI) features changed over a short period of time. A T2-weighted MRI scan obtained 1 month before surgery showed an intramedullary tumor with mixed intensity suggesting solid and cystic components at the C4-7 level. Gadolinium-enhanced MRI showed ring enhancement, including a cystic component at the C4-7 level. However, fluorodeoxyglucose positron emission tomography revealed uptake at the C5 level, and another gadolinium-enhanced MRI scan performed 24 days after the previous scan showed only enhanced lesions corresponding to the solid component at the C5-6 level. These images changed over a short time because the spontaneous hematoma, which was enhanced on the first MRI scan, had disappeared later. Fluorodeoxyglucose positron emission tomography or repeated gadolinium-enhanced MRI may be useful if the initial MRI scan suggests the presence of a hematoma in spinal ependymoma.

Guillain-Barré Syndrome with Respiratory Failure following Spine Surgery for Incomplete Cervical Cord Injury: A Case Report and Literature Review.

Guillain-Barré syndrome (GBS) often develops after a respiratory or gastrointestinal infection. A few cases have been reported on GBS following elective spinal surgery not preceded by an infectious disease. In patients with underlying upper motor neuron disease such as a spinal cord injury, concurrent development of lower motor neuron diseases, such as GBS, could be overlooked. Here, we present an uncommon case of an 87-year-old man with GBS that had developed after an operation for a traumatic cervical spinal cord injury. After surgery, he showed weakness over all four limbs with paresthesia, but he was able to hold a standing position with minimal assistance. Unfortunately, his muscle strength over his four limbs gradually weakened from two to four weeks later, and he became almost completely paralyzed. Cerebrospinal fluid (CSF) studies revealed albuminocytologic dissociation. A nerve conduction study (NCS) indicated an acute axonal polyneuropathy superimposed on chronic sensorimotor polyneuropathy. Thus, the patient was diagnosed with GBS. However, the patient's family declined immune-modulatory therapy due to personal reasons. The patient progressed into respiratory failure and remained ventilator-dependent before his death three years later. This case highlights the importance of taking GBS into account when postoperative weakness occurs in patients with spinal cord injury, and a worse prognosis if GBS is left untreated.

Spontaneous Motor Recovery after Cervical Spinal Cord Injury: Issues for Nerve Transfer Surgery Decision Making.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To quantify spontaneous upper extremity motor recovery between 6 and 12 months after spinal cord injury (SCI) to help guide timing of nerve transfer surgery to improve upper limb function in cervical SCI. SETTING: Nineteen European SCI rehabilitation centers. METHODS: Data was extracted from the European Multicenter Study of SCI database for individuals with mid-level cervical SCI (N = 268). Muscle function grades at 6 and 12 months post-SCI were categorized for analysis. RESULTS: From 6 to 12 months after SCI, spontaneous surgically-relevant recovery was limited. Of all limbs (N = 263) with grade 0-2 elbow extension at 6 months, 4% regained grade 4-5 and 11% regained grade 3 muscle function at 12 months. Of all limbs (N = 380) with grade 0-2 finger flexion at 6 months, 3% regained grade 4-5 and 5% regained grade 3 muscle function at 12 months. CONCLUSION: This information supports early (6 month) post-injury surgical consultation and evaluation. With this information, individuals with SCI can more fully engage in preference-based decision-making about surgical intervention versus continued rehabilitation and spontaneous recovery to gain elbow extension and/or hand opening and closing.

A Novel Method to Classify Cervical Incomplete Spinal Cord Injury Based on Potential for Recovery: A Group-Based Trajectory Analysis.

The outcomes of cervical incomplete spinal cord injury (SCI) are heterogeneous. This study sought to dissociate subgroups of cervical incomplete SCI patients with distinct longitudinal temporal profiles of recovery in upper limb motor function. Patients with cervical incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] B-D; C1-C8) were identified from four prospective, multi-center SCI datasets. A group-based trajectory model was fit to longitudinal upper extremity motor scores out to 1 year. Multi-variable multinomial logistic regression was performed to identify features that characterize each trajectory group. A classification system for predicting trajectory group at baseline was developed by recursive partitioning. In total, 801 patients were eligible. Four distinct trajectory groups were identified: 1) "Poor outcome": Severe injury, very minimal recovery; 2) "Moderate recovery": Moderate-to-severe injury, moderate recovery; most recovery occurs by 6 months, with mild, gradual recovery continuing thereafter; 3) "Good recovery": Moderate injury, good recovery; most recovery occurs by 3 months, with mild, gradual recovery continuing thereafter; and 4) "Excellent outcome": Mild injury, recovery to normal/near-normal by 3 months. On adjusted analyses, older age was associated with lower likelihood of "excellent outcome" (p = 0.020). AIS C and D injuries were associated with "moderate recovery," "good recovery," and "excellent outcome" (p < 0.001). Mid-cervical injuries occurred more frequently in "moderate recovery," "good recovery," and "excellent outcome" (p < 0.001) groups. Early surgical decompression (< 24 h) was associated with increased propensity for "good recovery" (p = 0.039) and "excellent outcome" (p = 0.048). A classification model based on recursive partitioning could predict trajectory group using age, AIS grade, and neurological level with an area under the curve of 0.81. Patients with cervical incomplete SCI demonstrate distinct temporal profiles of recovery in upper limb motor function. The trajectory a patient is likely to follow may be predicted at baseline with fair accuracy.

Postoperative spinal deformity and instability after cervical spinal cord tumor resection in adults: A systematic review and meta-analysis.

OBJECTIVE: To investigate the incidence of cervical spine deformity and instability after posterior cervical spinal cord tumor (CSCT) resection without fusion or fixation in adults and examine relevant risk factors by reviewing and summarizing previously reported studies. METHODS: We selected peer reviewed articles published between January 1990 and December 2020 from the MEDLINE and Cochrane Library databases using relevant key words. Articles in which the authors mainly described spinal cord tumor resection through posterior surgery without fusion or fixation in adults were selected for analysis. Patient's data including age, sex, extensive number of laminectomy levels, laminectomy at C2, C3, or C7, multilevel facetectomy, facet destruction, preoperative cervical kyphosis, and preoperative motor deficit were documented. Comparable factors were assessed using the odds ratio (OR) and weighted mean difference (WMD) of 95% confidence intervals (CI). RESULTS: Among 133 articles identified, 18 met selection criteria. Overall incidence of deformity and instability after CSCT surgery was 0%-41.7% and 0%-20.5%, respectively. Younger age (WMD, -5.5; 95% CI, -10.52 âˆ¼ -0.49; P = 0.03), C2 laminectomy (OR, 5.33; 95% CI, 2.39 âˆ¼ 11.91; P < 0.0001), more laminectomy level (WMD, 2.77; 95% CI, 1.78 âˆ¼ 3.76; P < 0.00001) were identified as risk factors for deformity and instability after CSCT surgery. CONCLUSION: Patients undergoing CSCT resection should receive careful follow-up for postoperative spinal deformity and instability. Younger age, C2 laminectomy, and more laminectomy level were significantly associated with occurrence of deformity and instability after CSCT surgery. Upfront spinal fixation at the time of resection should be considered in selected patients.

Expansive Duraplasty - Simple Technique with Promising Results in Complete Cervical Spinal Cord Injury: A Preliminary Study.

Background: Complete cervical spinal cord injury is devastating with the currently available treatment modalities offering no hope for improvement. Intrathecal pressure is raised following spinal cord injury due to injured and edematous spinal cord. Due to constraints of the thecal sac, this sets up a vicious cascade leading to further spinal cord injury. Durotomy and expansile duraplasty could potentially prevent this secondary spinal cord injury. The aim of our study is to assess the advantage of durotomy and expansile duraplasty in addition to spinal bony decompression and fixation for traumatic cervical spine fracture. Methods: Two patients with posttraumatic complete cervical spinal cord injury (ASIA A) were managed with expansile duraplasty in addition to decompression and fixation. A thorough examination including perianal sensations and bulbocavernosus reflex was done to rule out the possibility of incomplete cord injury with spinal shock. Both the patients underwent posterior decompression and lax duraplasty. Standard protocols of spinal cord injury were followed like maintenance of MAP >85 mmHg. Results: Both the patients showed significant improvement in clinical status improving to ASIA D from ASIA A. Conclusion: Durotomy and duraplasty may be offered in all patients with complete spinal cord injury who are undergoing instrumentation.

Classification and regression tree (CART) model to assist clinical prediction for tracheostomy in patients with traumatic cervical spinal cord injury: a 7-year study of 340 patients.

OBJECTIVE: To develop a classification and regression tree (CART) model to predict the need of tracheostomy in patients with traumatic cervical spinal cord injury (TCSCI) and to quantify scores of risk factors to make individualized clinical assessments. METHODS: The clinical characteristics of patients with TCSCI admitted to our hospital from January 2014 to December 2020 were retrospectively analyzed. The demographic characteristics (gender, age, smoking history), mechanism of injury, injury characteristics (ASIA impairment grades, neurological level of impairment, injury severity score), preexisting lung disease and preexisting medical conditions were statistically analyzed. The risk factors of tracheostomy were analyzed by univariate logistic regression analysis (ULRA) and multiple logistic regression analysis (MLRA). The CART model was established to predict tracheostomy. RESULTS: Three hundred and forty patients with TCSCI met the inclusion criteria, in which 41 patients underwent the tracheostomy. ULRA and MLRA showed that age > 50, ISS > 16, NLI > C5 and AIS A were significantly associated with tracheostomy. The CART model showed that AIS A and NLI > C5 were at the first and second decision node, which had a significant influence on the decision of tracheostomy. The final scores for tracheostomy from CART algorithm, composed of age, ISS, NLI and AIS A with a sensitivity of 0.78 and a specificity of 0.96, could also predict tracheostomy. CONCLUSION: The establishment of CART model provided a certain clinical guidance for the prediction of tracheostomy in TCSCI. Quantifications of risk factors enable accurate prediction of individual patient risk of need for tracheostomy.

Stereotaxic Surgical Approach to Microinject the Caudal Brainstem and Upper Cervical Spinal Cord via the Cisterna Magna in Mice.

Stereotaxic surgery to target brain sites in mice is commonly guided by skull landmarks. Access is then obtained via burr holes drilled through the skull. This standard approach can be challenging for targets in the caudal brainstem and upper cervical cord due to specific anatomical challenges as these sites are remote from skull landmarks, leading to imprecision. Here we outline an alternative stereotaxic approach via the cisterna magna that has been used to target discrete regions of interest in the caudal brainstem and upper cervical cord. The cisterna magna extends from the occipital bone to the atlas (i.e., the second vertebral bone), is filled with cerebrospinal fluid, and is covered by dura mater. This approach provides a reproducible route of access to select central nervous system (CNS) structures that are otherwise hard to reach due to anatomical barriers. Furthermore, it allows for direct visualization of brainstem landmarks in close proximity to the target sites, increasing accuracy when delivering small injection volumes to restricted regions of interest in the caudal brainstem and upper cervical cord. Finally, this approach provides an opportunity to avoid the cerebellum, which can be important for motor and sensorimotor studies.