Analysis of Neurosurgical Injuries and The Lessons Learned After the Catastrophic Double Earthquakes in Turkey.

AIM: To identify the patterns and types of neuorosurgical injuries sustained by victims of the double earthquakes affected ten cities with a population of 15 million in southern and central Türkiye. MATERIAL AND METHODS: In this descriptive observational study, we retrospectively analyzed the medical records of a university hospital located in one of the ten cities affected by the earthquake. RESULTS: A total of 1,612 patients with earthquake-related injuries were admitted during the study period, of which 139 (8.6%) had neurosurgical injuries. The mean age of the patients was 42.4 ± 21.1 years (median, 42 years), and 53.2% of them were female. Of the 139 patients with neurosurgical injuries, 41 (29.5%) had craniocerebral injuries, 95 (68.3%) had spinal injuries, and three (2.2%) had both craniocerebral and spinal injuries. A total of 31 surgeries were performed (22.3%) (five [3.6%] for craniocerebral injuries and 26 [18.7 %] for spinal injuries). Ninety-eight patients (70.5%) had concomitant systemic traumas. The overall mortality rate was 5.75%, with crush syndrome (n=4, 50%), being the leading cause of death, followed by neurosurgical pathologies (n=3, 37.5%) and pneumonia with septic shock (n=1, 12.5%). CONCLUSION: Neurosurgical injury is an important cause of post-earthquake mortality and morbidity. To ensure efficient medical rescue and judicious resource allocation, it is essential to recognize the characteristics of earthquake-related neurosurgical injuries. This study provides valuable information regarding the incidence, characteristics, and outcomes of neurosurgical injuries in earthquake-affected patients. Our findings highlight the need for prompt diagnosis and management of such injuries, particularly in those with concomitant systemic trauma.

Validation of the AO Spine CROST (Clinician Reported Outcome Spine Trauma) in the clinical setting.

PURPOSE: To evaluate feasibility, internal consistency, inter-rater reliability, and prospective validity of AO Spine CROST (Clinician Reported Outcome Spine Trauma) in the clinical setting. METHODS: Patients were included from four trauma centers. Two surgeons with substantial amount of experience in spine trauma care were included from each center. Two separate questionnaires were administered at baseline, 6-months and 1-year: one to surgeons (mainly CROST) and another to patients (AO Spine PROST-Patient Reported Outcome Spine Trauma). Descriptive statistics were used to analyze patient characteristics and feasibility, Cronbach's α for internal consistency. Inter-rater reliability through exact agreement, Kappa statistics and Intraclass Correlation Coefficient (ICC). Prospective analysis, and relationships between CROST and PROST were explored through descriptive statistics and Spearman correlations. RESULTS: In total, 92 patients were included. CROST showed excellent feasibility results. Internal consistency (α = 0.58-0.70) and reliability (ICC = 0.52 and 0.55) were moderate. Mean total scores between surgeons only differed 0.2-0.9 with exact agreement 48.9-57.6%. Exact agreement per CROST item showed good results (73.9-98.9%). Kappa statistics revealed moderate agreement for most CROST items. In the prospective analysis a trend was only seen when no concerns at all were expressed by the surgeon (CROST = 0), and moderate to strong positive Spearman correlations were found between CROST at baseline and the scores at follow-up (rs = 0.41-0.64). Comparing the CROST with PROST showed no specific association, nor any Spearman correlations (rs = -0.33-0.07). CONCLUSIONS: The AO Spine CROST showed moderate validity in a true clinical setting including patients from the daily clinical practice.

Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries.

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries. METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding. RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score. CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

Our experience with the surgical management of lower cervical spine fractures: fifty case series.

PURPOSE: Trauma to the lower cervical spine is a serious lesion due to its neurological consequences which jeopardize the vital and functional prognosis. They constitute a public health problem due to their frequency and seriousness requiring rapid and adequate treatment. The aim of our study is to (1) describe the epidemiological, clinical, and radiological characteristics of lower cervical spine trauma patients; (2) support the therapeutic management of these patients and show our experience in surgery for lower cervical spine trauma; and (3) analyze the anatomical and functional results and discuss them with literature data. METHODS: This is a retrospective descriptive study of 50 patients with lower cervical spine trauma treated surgically over a period of five years from January 1, 2016, to December 2020. RESULTS: The average age of our patients was 34.5 years, with a sex ratio of 1.7. The etiologies are dominated by accidents on public roads (58%). They show neurological disorders such as spinal cord damage in 30% of cases and root damage in 20% of cases. The radiological assessment revealed eight tear drops, ten comminuted fractures, 12 severe sprains, 12 biarticular dislocations, six uniarticular dislocations, and two herniated discs. Treatment was surgical in all patients with an anterolateral approach and anterior arthrodesis. The evolution was favourable in 21 patients and stationary in 29 patients. CONCLUSION: Our study concluded that dislocations and fracture dislocations were the predominant type of injury in cases of AVP. Tetraplegia was mainly observed with uni- and biarticular dislocations. The variation in consolidation time was not correlated with trauma-to-surgery time. Better neurological recovery was observed with mild initial neurological damage than with initially severe damage. The appearance of an adjacent syndrome is less frequent with monosegmental arthrodesis than with multisegmental arthrodesis. Cage arthrodesis was an alternative to iliac harvesting with similar results.

How to Apply Intraoperative Ultrasound when Spinal Trauma Surgery Is Performed in the Lateral Decubitus Position?

OBJECTIVE: At present, intraoperative ultrasound was widely used in spinal surgery. But there have been no reports on the use of intraoperative ultrasound in lateral decubitus position spinal surgery. The authors' research objective was to describe the applications of intraoperative ultrasound in spinal trauma surgery when performed in the lateral decubitus position. METHODS: Six patients with polytrauma who underwent surgery for spinal trauma between June 2020 and March 2022 and could not be operated on using a posterior approach in the prone position. All six patients underwent surgery in the lateral decubitus position. During surgery, a capsular bag had been designed and surgical field can be filled with normal saline for acoustic coupling, and then ultrasound was used to observe and guide decompression, and assess injuries of the neural elements such as the spinal cord. The data of preoperative and postoperative (12 months) American Spinal Injury Association impairment scale (AIS), follow-up time, operation time, blood loss, ultrasound signal change of spinal cord, ultrasound guide decompression, internal fixation (12 months), and fracture healing(12 months) were collected. RESULTS: The study included four males and two females whose ages ranged from 19 to 56 years old (41.5 ± 13.06 years old). Follow-up times ranged from 12 to 20 months (14.33 ± 2.75 months). The operation times ranged from 195 to 248 mins (222.16 ± 16.86 mins). The estimated volume of blood loss ranged from 280 to 450 mL (383.33 ± 55.58 mL). The six cases' AIS (preoperative vs. postoperative) were A versus A, C versus D, A versus B, B versus B, B versus C, and B versus C. Intraoperative ultrasound was performed successfully in all patients using our designed method. Intraoperative ultrasound observation revealed varying degrees of changes in spinal cord echo in all patients. Intraoperative ultrasound provided excellent assistance in spinal cord decompression during surgery. The surgery was completed successfully with no surgery-related complications till the last follow-up. At the time of last follow-up (median time of 12 months) satisfactory fracture reduction and good internal fixation was confirmed on postoperative computed tomography scans and radiographs. CONCLUSIONS: The authors represented the technology of intraoperative ultrasound in spinal trauma surgery when performed in the lateral decubitus position. This technology solves how to apply intraoperative ultrasound in lateral decubitus position.

Diagnosis and treatment of cervical spine injuries in children.

Cervical spine injuries in children are a common reason for emergency room visits, while bone, ligament or spinal cord cervical lesions are relatively rare (1-1.5% of severe trauma in children) and mainly involve the upper cervical spine. The main causes are sports injuries, accidents at home and traffic accidents. Clinical triage is needed to avoid unnecessary radiation exposure from imaging. We propose a protocol to optimize the diagnosis and treatment. In children, conservative treatment using rigid immobilization (cervical collar or halo-vest) is the preferred option in stable and/or minimally displaced injuries. Frequent clinical and radiological monitoring is required to ensure the patient's condition does not deteriorate due to inappropriate or poorly tolerated treatment. In these cases, surgical treatment can be proposed as second-line treatment. Internal fixation is indicated as the first-line treatment if the injury is unstable or a neurological deficit is present. The fixation methods must be adapted to the pediatric population by taking into account the vertebral volume and residual growth potential. Intraoperative CT scans or neuronavigation can make the surgical procedure safer and easier. Clinical, radiographic and CT scan monitoring should continue until the end of growth in a child who underwent surgical treatment to quickly detect any mechanical complications or sagittal imbalance due to poor craniocervical or cervicothoracic alignment. LEVEL OF EVIDENCE: IV.

Pediatric case of a penetrating lumbar spinal injury.

PURPOSE: Penetrating spinal injuries are generally extremely rare and are seldom encountered in pediatric patients. The non-compliance of pediatric patients with physical examination can sometimes delay diagnosis and treatment. Here, we present a case of a child who had a fall and suffered penetrating spinal trauma due to a small glass fragment. CASE REPORT: A penetrating foreign body was detected in the lumbar spinal region of a 2-year-old patient with complaints of increased restlessness on physical activity followed by difficulty in walking. The patient was operated on and followed up without any complications in the perioperative and late postoperative periods. CONCLUSION: A detailed physical examination is necessitated in the pediatric age group because of insufficient anamnesis. The high number of patients per physician, especially in societies having a low socioeconomic standard, prevents detailed examinations, and unnecessary examinations may cause delays in diagnosis. However, one must note that the skin findings of pediatric patients can be very helpful, especially in pediatric neurosurgery, and examination should not be neglected.

Is it true that treatment in patients with Subaxial Cervical Spine Injury Classification System (SLICS) 4 is the surgeon's choice?

BACKGROUND: The Subaxial Cervical Spine Injury Classification System (SLICS) is a commonly used algorithm for diagnosing and managing subaxial cervical spine trauma. A SLIC score 4 suggests either surgery or non-surgically treatment depending on the surgeon's experience and patient's conditions. OBJECTIVE: Prognosis and treatment results were analyzed in patients with SLIC score 4. METHODS: The patients with SLIC score 4 were retrospectively reviewed from 2012 to 2019. Forty-one patients were included and divided into two groups: non-surgically treated and surgically treated. Demographic data and radiographs were analyzed. Statistical analysis was performed to determine the difference between the two clinical groups. RESULTS: Twenty-two patients were non-surgically treated, and nineteen patients were surgically treated. There was no neurological deterioration in both groups. However, there was no statistically significant difference in the last follow-up AISA and Nurick grade (p> 0.05). There was no significant difference in the number of patients who showed improvement when comparing the initial and the last follow-up neurological status (p> 0.05). CONCLUSION: Regardless of the treatment method, the spinal cord injury patients with SLICS point 4 showed a relatively good prognosis. Patients with SLIC score 4 could be treated non-surgically or surgically based on the surgeon's experience and factors associated with the patient's acute health status and chronic comorbidities.

[Initial Medical Care for Spinal Injury].

Neurosurgeons who treat head traumas often encounter cervical spinal injuries. They should be aware of the neurological symptoms, the severity of the symptoms, and the imaging features of cervical injuries. When surgery is required, fixation is often performed.

Characteristics of work-related spine injury in the USA: a National Trauma Data Bank analysis.

PURPOSE: Workplace injury is a commonplace occurrence in the USA. Spine injuries are especially devastating as they can cause chronic pain and limit mobility which prevents patients from returning to work. Gaining a better understanding of the patients, mechanisms, and treatments associated with these injuries can aid in improving outcomes. The purpose of this study is to characterize the nature of work-related spine injuries. METHODS: The National Trauma Data Bank was queried from 2017 to 2019 for all diagnoses involving the cervical, thoracic, lumbar, and sacral spine. Patient demographics, comorbidities, injury characteristics, spinal diagnoses, and procedures were identified for each occupation. Occupational industries, patient demographics, mechanisms of injury, diagnoses, and spinal procedures were characterized. RESULTS: A total of 100,842 work-related injuries were identified between 2017 and 2019. Of those, 19,002 (19%) were spine injuries, and subsequently, 3963 (21%) required spinal surgery. Eight thousand twenty-nine (42%) cases were seen among construction workers, which had the highest proportion of Hispanic patients (36%). Smoking was prevalent in labor-intensive occupations with high rates of spine injury such as building and grounds maintenance. The most common mechanism of injury was a fall from a roof. The most common injury diagnoses were L1, L2, and L3 fractures, and the most common procedures were T12-L1 fusion, multilevel thoracic fusion, and multilevel lumbar fusion. CONCLUSION: Spine injuries represent a significant portion of work-related injuries in the USA and a considerable portion require neurosurgical intervention. Initial efforts should focus on the prevention and management of lumbar spine injuries in the construction industry.

Closed cervical traction techniques: moving into the 21st century.

Closed cervical traction for reducing dislocating cervical injuries, deformity correction, or discectomy distraction has been implemented in its modern form since the 1930s. Cervical traction state of the art has not changed significantly since the 1960s, with most reductions performed by using Gardner-Wells tongs or halo traction; however, there are many limitations of traditional weight-pulley traction, including limited reduction efficacy and patient safety shortcomings. In this paper, the authors review the history of cervical traction in the 20th century and the limitations of current traction techniques and describe a novel traction device developed at the University of Utah with robotic actuator load or position control and real-time force-sensing capabilities. Preliminary biomechanical testing results using the novel device in an extension spring loading model, with intact cadavers, and in iatrogenic facet injury cadaveric models demonstrated preliminary safety and efficacy of the device. The authors believe this and future research efforts aimed toward improving the efficacy and safety of cervical traction will help advance the field into the 21st century.

Adverse events in spine surgery: a prospective analysis at a large tertiary center in Germany.

STUDY DESIGN: Prospective study OBJECTIVES: The occurrence of adverse events (AEs) during surgery is a major cause of increased economic costs, disability, or even death. This study aimed to prospectively identify and quantify AEs in patients undergoing spinal surgery at a neurosurgical tertiary care hospital. METHODS: Patients who underwent spinal surgery and were discharged between January 2019 and December 2022 were enrolled prospectively. Each patient underwent a peer-reviewed AE evaluation at discharge. An AE was defined as any event that occurred up to 30 days postoperatively and resulted in an undesirable outcome. Patients were allocated to four groups according to spinal pathology (degenerative, oncologic, traumatic, and infectious). RESULTS: During the study period, 1778 patients with a mean age of 55.4 ± 10.5 years underwent surgery. Elective surgery was performed in 90.8% (1615/1778) of patients, while emergency surgery was performed in 9.2% (163/1778). The overall rate of surgery-related AEs was relatively low (8.7%). Degenerative pathologies were the most frequent reasons for surgery (78.5%, 1396/1778). Wound infection was the most prevalent AE in patients with degenerative diseases (1.4%), of which 1.1% required revision surgery. Wound infection, dural leakage, and new neurological deficits had the same prevalence (2.1%) in patients with spinal tumors. Among patients with spinal trauma, two presented with postoperative epidural bleeding and underwent emergency surgery. Postoperative wound infection was the most prevalent AE in this group (9.5%), with 7.0% of affected patients requiring revision surgery. The overall rate of non-surgery-related AEs was 4.3%, and the overall mortality rate was low (0.4%). CONCLUSION: AEs in spinal surgery remained low, with a prevalence of 8.7%. Documentation of AEs as part of clinical routine may be a key tool for identifying the occurrence of surgery-related and non-surgery-related AEs.

[Endoscopic treatment of mine-explosive spine injuries: 3 clinical cases and literature review]. / Endoskopicheskoe lechenie minno-vzryvnykh ranenii pozvonochnika: 3 klinicheskikh nablyudeniya i obzor literatury.

Modern warfare is characterized by common mine-explosive injuries. The last ones are accompanied by multiple injuries, large area of damage and severe clinical status of victims. OBJECTIVE: To demonstrate treatment of mine-explosive spinal injuries using modern minimally invasive endoscopic techniques. MATERIAL AND METHODS: The authors present 3 victims with various mine-explosive injuries. Endoscopic removal of fragments from the lumbar and cervical spine was successful in all cases. DISCUSSION: Most of victims with injuries of the spine and spinal cord do not require urgent surgery and can underwent surgical treatment after clinical stabilization. At the same time, minimally invasive techniques provide surgical treatment with minimal risk and earlier rehabilitation, as well as reduce the risk of infectious complications associated with foreign bodies. CONCLUSION: Careful selection of patients for spinal video endoscopy will ensure positive outcomes. Minimization of iatrogenic postoperative injuries is especially important in patients with combined trauma. However, well-experienced surgeons should perform these procedures at the stage of specialized medical care.

[Surgical management of acute traumatic spinal cord injury : Stability vs. functionality]. / Chirurgische Therapie der akuten traumatischen Querschnittsverletzung : Stabilität vs. Funktionalität.

BACKGROUND: Traumatic spinal cord injuries represent a devastating condition in the lives of those affected, with physical, emotional, and economic burdens for the patients themselves, their social environment, and society as a whole. OBJECTIVE: Surgical approach and techniques in traumatic spinal cord injuries. RESULTS: Traumatic spinal cord injuries should be surgically treated as soon as possible, but at least within 24 h of injury. If accompanying dural injuries occur, suturing or applying a patch is the primary method of choice. Early surgical decompression is essential, particularly in cervical spinal cord injuries. Stabilization in terms of instrumentation or fusion is inevitable and should be carried out over short segments to maintain the functionality of the cervical spine. Long-distance dorsal instrumentation with prior reduction in thoracolumbar spinal cord injuries provides high stability and preserved functionality in patients. Injuries to the thoracolumbar junction often require a two-stage anterior treatment. CONCLUSION: Early surgical decompression, reduction, and stabilization of traumatic spinal cord injuries within 24 h are recommended. While short-segment stabilization is recommended in the cervical spine in addition to decompression, instrumentation should be over long segments in the thoracolumbar spine to provide the necessary stability while maintaining functionality.

A Novel Classification of Cervical Spine Trauma in Ankylosing Spondylitis and Corresponding Surgical Outcomes.

OBJECTIVE: Currently, there are no reports on the specific classification of cervical spine trauma (CST) in ankylosing spondylitis (AS) based on the trauma mechanism. In this study, we aimed to describe a novel classification of CST in AS with more details, and put forward the corresponding surgical outcomes related to different types, hoping to provide a practical reference for clinical decision-making and academic communication. METHODS: From January 2008 to December 2021, AS patients who experienced CST were retrospectively reviewed and included. Clinical data including gender, age, reason of trauma, time interval between AS diagnosis and trauma were collected. The American Spinal Injury Association (ASIA) grade system was used to describe patients' neurological status. Based on the combination of surgical experience and follow-up observation, the lower cervical spine trauma in AS patients was divided into three main types, namely single level fracture-dislocation (type 1), spinal cord injury without fracture-dislocation (type 2), and Andersson lesion (type 3). Furthermore, we performed detailed subtypes according to whether cervical spine was completely fused and the location of injury. Meanwhile, according to different approaches, surgical methods mainly included Anterior Cervical Discectomy and Fusion (ACDF), Anterior Cervical Corpectomy and Fusion (ACCF), Posterior Expansive Open-door Cervical Laminoplasty (PEOLP), Posterior Cervical Laminectomy Decompression and Fusion (PCLDF), and their combination. Postoperative general and surgery-related complications were also recorded. RESULTS: A total of 102 patients were enrolled, including 91 males and 11 females, with an average age of 51.9 years. Their average interval time between AS diagnosis and injury was 27.8 years. Patients with high-energy and low-energy trauma were 54 and 48 respectively. There were 79 patients suffering spinal cord nerve impairment after trauma. With regard to the distribution of different types, the number of patients in type 1, type 2, and type 3 were 86, 14, and two, respectively. For different types, PCLDF was the most commonly used surgical method, accounting for 55.9%, while ACCF was only applied for one time. In type 1, the frequencies of ACDF, ACCF, PCLDF, and ACDF+PCLDF were 10.5%, 1.2%, 55.8%, and 32.5%. In type 2, the frequencies of ACDF, PCLDF, ACDF+PCLDF, and PEOLP were 7.1%, 50.0%, 7.1%, 35.8%. Postoperatively, 21 patients achieved neurological function improvement. The incidences of general and surgery-related complications were 19.6% and 5.9%, respectively. All patients achieved bone fusion and durable decompression at the last follow-up. CONCLUSIONS: Our novel classification could enrich the scope of CST in AS patients and provide valuable references to the corresponding clinical management. Besides, there are strict indications of different surgical methods, factors like patient's physical condition, trauma type, surgical purpose, and expected efficacy were all required to consider before making a clinical decision.

Emergency Posterior Decompression for Metastatic Spine Tumors in Octogenarians: Clinical Course and Prognostic Factors for Functional Outcomes.

BACKGROUND: This study aimed to describe the clinical outcome of metastatic epidural spinal cord compression in octogenarians with an acute onset of neurological illness who undergo laminectomy, further assess morbidity and mortality rates, and determine potential risk factors for a nonambulatory outcome. METHODS: This retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. RESULTS: Thirty-four patients aged 80 years and older who posterior decompression via laminectomy were enrolled in the present study. The mean Charlson Comorbidity Index was >6 (9.2 ± 2.1). The thoracic spine was the most common site of metastasis. A potentially unstable spine, determined using the Spinal Instability Neoplastic Score, was identified in 79.4% of the cases. Preoperatively, the neurological condition and functional status exhibited a notable decline (mean Motor Score of the American Spinal Injury Association grading system, 78.2 ± 16.4; mean Karnofsky Performance Index, 47.8 ± 19.5). The Motor Score of the American Spinal Injury Association grading system and Karnofsky Performance Index scores improved significantly after surgery. Motor weakness and comorbidities were unique risk factors for the loss of ambulation. CONCLUSIONS: Emergent decompressive laminectomy in patients with acute onset of neurological decline and potentially unstable spines improved functional outcome at discharge. Age should not be a determinant of whether to perform surgery; surgery should be performed in older patients when indicated.

Plastic Surgery Closure of Complex Spinal Wounds.

Wound breakdown and infection are common complications after complex spine surgery and may occur in up to 40% of high-risk patients. These are challenging scenarios which can result in a prolonged hospital stay, revision surgery, and elevated costs. Reconstructive specialists can do prophylactic closures for high-risk groups to potentially reduce the risk of developing a wound complication. These plastic surgery techniques often involve multilayered closure, with the addition of local muscle and/or fasciocutaneous flaps. The goal of this study was to review the literature for risks associated with wound complications, identification of high-risk patients, and the advantages of using plastic surgery techniques. In addition, we elaborate on the multilayered and flap closure technique for complex spine surgery which is done at our institution.