[Treatment of uncomplicated vertebral compression fractures]. / Lechenie neoslozhnennykh kompressionnykh perelomov pozvonochnika.

According to statistical studies in different countries, the annual incidence of spine and spinal cord injuries is 15-50 cases per 1 million people. In Russia, the incidence of this condition is 5% of the total number of all nonpenetrating traumatic injuries (Neurosurgery: Guidelines for Physicians, ed. by Prof. ON Dreval', 2013). According to the WHO reports, approximately 500,000 people annually experience spine injuries worldwide. Acute spine injuries make up 23.7% of all spinal traumas and include contusions (2.67%), injuries to the capsular ligamentous apparatus (3.88%), fractures and dislocations (7.63%), and muscle injury (9.52%). In males, the risk of experiencing a spine injury is the highest at the age of 20-29 and above 70 years, while in women this risk is the highest at an age of 15-19 and above 60 years. According to the studies, this risk is characterized by an at least 2:1 ratio between adult males and females. OBJECTIVE: To compare the outcomes of surgical (vertebroplasty) and conservative treatment in management of pain syndrome in patients with uncomplicated spine injury. MATERIAL AND METHODS: The study involved 60 patients with stable uncomplicated compression fractures of vertebral bodies in the thoracic and lumbosacral spine. These patients were subdivided into two groups. Group 1 consisted of 30 patients who had undergone unilateral transpedicular percutaneous vertebroplasty; Group 2 involved 30 patients who had undergone a course of conservative treatment. The medical records and the catamnestic follow-up data of patients treated at the Neurosurgery Department of the Research Clinical Center of JSC Russian Railways in 2015-2017 were analyzed for this purpose. RESULTS: No statistically significant differences in sex, age, and level of injury were revealed between the study groups. A comparative analysis of treatment outcomes demonstrated that pain intensity assessed using the VAS scale was significantly reduced after one-year follow-up in both groups as compared to the baseline. A statistically significant decrease in pain intensity in the group of patients who had undergone vertebroplasty was observed as early as one month after the injury. No significant intergroup differences were observed in the long-term follow-up period (3 and 6 months) for this parameter. In five out of 60 patients, examination 12 months after the injury revealed that vertebral body height decreased by up to 10%. No statistically significant correlation with the treatment method was observed. CONCLUSION: Vertebroplasty provides a statistically better pain relief during the first month after spine injury as compared to conservative treatment. For patients, this means earlier activization and quicker return to daily routines and work.

Properties and outcomes of spinal rehabilitation units in four countries.

OBJECTIVE: Compare rehabilitation after spinal cord lesions (SCL) in different countries. DESIGN: Multicenter comparative study. SETTING: Four spinal rehabilitation units, in Denmark, Russia, Lithuania and Israel. SUBJECTS: 199 SCL patients. INTERVENTIONS: Information was collected about unit properties, rehabilitation objectives, American Spinal Injury Association (ASIA) scale and spinal cord independence measure (SCIM) assessments, and patient data. chi (2)-test, t-test, ANOVA and ANCOVA were used for statistical analysis. MAIN OUTCOME MEASURES: Time from lesion onset to admission for rehabilitation (TAR), length of stay in rehabilitation (LOS), SCIM and spinal cord ability realization measurement index (SCI-ARMI) scores, SCIM gain, SCI-ARMI gain and rehabilitation efficiency (RE). RESULTS: Differences were found between the units in rehabilitation objectives, facilities and special equipment for rehabilitation. Staff/bed ratio was 1.7 in Lithuania and Denmark, 1.1 in Israel and 0.9 in Russia. Russian patients were the youngest and had the most severe lesions among participating units. Admission SCIM and SCI-ARMI were the lowest in Israel: 25.1+/-17.2 and 34.3+/-17.3. TAR was highest in Russia (12.4 month) and lowest in Israel (2 weeks; P<0.01). LOS was longest in Denmark (176.9 days; P<0.001). SCIM score at the end of rehabilitation was highest in Denmark (67.3+/-23). SCIM gain and SCI ARMI gain were highest in Israel (36.9+/-18.3 and 38.5+/-19.4, respectively) and lowest in Russia (P<0.001). RE was highest in Lithuania and lowest in Denmark (P<0.001). CONCLUSIONS: In the participating units, SCL rehabilitation outcomes depend on SCL severity and unit-specific properties. A moderately delayed rehabilitation with long LOS achieved high functioning, and early or slightly delayed rehabilitation combined with shorter LOS achieved high functional gain or efficiency.

[Clinical studies of transpedicular system using TiNi rod with functionally optimal rigidity].

Transpedicular metal systems are very widely applied in surgical treatment of spinal pathology. Recently TiNi constructions were introduced into practice. This material is characterized by shape memory, superior elasticity and cyclic durability. Adequacy of mechanical interactions of tissues and TiNi-based alloys allows to suggest that TiNi systems are more physiological and functional in comparison with steel and titanium alloys. This enabled development of transpedicular TiNi system with good safety and stability properties in combination with physiologic compatibility and high functional value of TiNi connections. We performed computer modeling of different spine lesions treated by transpedicular systems using ANSYS program kit. Statistic and cyclic tests of transpedicular systems were made using test machine 'Terotest' according to international standards. Results of studies allowed to formulate guidelines for application of transpedicular systems with different level of rigidity in treatment of injuries and degenerative lesions of the spine. The authors performed 53 operations in patients with lesions of lower-thoracic and lumbar spine using TiNi rod with functionally optimal rigidity and obtined good postoperative results.

[Correction of neurological complications after transpedicular stabilization of the spine].

Nowadays transpedicular fixation systems have gained great priority in stabilization of thoracic and lumbar spine. But implantation of the system may cause iatrogenic complications due to extrapedicular insertion (malposition) of screws. Present work is devoted to analysis of neurologic disturbances of screw malposition in the prospective study of 44 consecutive patients. Patients had complains which could be attributed to mistakes in implantation of TPF system. After detailed examination we created a group of 8 patients who had compression of spinal cord and radices due to inadequately implanted TPF system (5 male and 3 female patients, age range 27-63 (median 42)). According to malposition of screws we divided patients into 3 groups: medial malposition (3 patients); lateral (2 patients); and 2 patients with inferior-lateral malposition. 1 patient had both medial and lateral malposition of screws. On the basis of results of treatment we suggested management protocol for complications due to mistakes in implantation of TPF.

[The specific features of clinical manifestations and surgical treatment of spastic and pain syndromes after injury to the vertebral column and spinal cord].

The purpose of the investigation was to study the clinical manifestations of spastic syndrome after injury to the vertebral column and spinal cord and to devise its surgical treatment policy. The investigation included 21 patients with significant spasticity or pain syndrome after severe injury to the vertebral column and spinal cord without any potential of motor recovery. All the patients were observed to have severe inferior paraplegia, cacesthesia following the radicular and conduction with total hypo- or anesthesia. Pain was rated, by using the visual analogue scale and the McGill questionnaire, spasticity was estimated by the Ashworth scale. The patients' motor activity was also evaluated. Bilateral rhizomyeolotomy of the dorsal root entry zone (DREZ) was performed in 10 patients with pain syndrome; posterior partial rhizidiotomy was made in 8 patients with spastic syndrome; 3 patients underwent epidural spinal cord stimulation. Groups with a preponderance of pain (47%) and spastic (53%) syndromes were identified. A clinically equal combination of spastic and pain components occurred rarely. Pain was maximally pronounced, neuropathic, metamerically radicular, in dermatomes from the level of injury. Leg spasticity was more marked and concurrent with contracture. The efficiency of lateral rhizomyelotomy of DREZ in the treatment of pain was 89% in the early period and 63% in the late (as long as 4 years) one. That of bilateral posterior partial rhizodiotomy in the treatment of spasticity was 75 and 75% in the early and late (as long as 2.5 years), respectively. Rhizomyelotomy of DREZ is a pathogenetically grounded and effective procedure when there is a preponderance of neuropathic metamerically radicular pain from the level of injury. Bilateral posterior partial rhizidiotomy is the method of choice in treating significant spasticity.

Reinnervation of the neurogenic bladder in the late period of the spinal cord trauma.

STUDY DESIGN: Intercostal nerve to spinal nerve root anastomosis in chronic spine-injured patients. OBJECTIVES: To analyze the effectiveness of neurogenic bladder reinnervation in spinal cord-injured patients through artificial creation of sprouting (intercostal nerve to spinal nerve root anastomosis). SETTING: Center of Neurosurgery, Moscow, Russia. Operations were performed by Professor A Livshits. (At present, Professor A Livshits is working at the Spinal Care Unit, Meir General Hospital, Kfar Saba, Israel.) METHODS: A total of 11 patients with spinal cord injury of the L1 level were operated on in the late (chronic) stage. The neurological status and urodynamics were investigated before and 12 months after operation. A laminectomy from T11 to L3 was performed. Next, a neurolysis of the 11th and 12th intercostal nerves was carried out, at a distance of 20-21 cm, and transferred to the vertebral canal. The S2-S3 roots were then cut in their proximal portion and anastomosed end-to-end to the intercostal nerves. The results of urodynamic studies were calculated by the Wilcoxon signed rank test for comparison before and 12 months after operation. RESULTS OF URODYNAMIC STUDIES: Bladder capacity (ml) before operation - 489+/-79, after operation - 350+/-39, urine volume (ml) before - 18.2+/-17, after - 306.4+/-39.8, residual urine (ml) before - 459+/-99.4, after - 50+/-11.8. Detrusor tone (rel. units) before - 0.6+/-1.5, after 1.2+/-0.2; voiding pressure (cmH(2)O) before - 4.4+/-5.2, after - 30.5+/-4.9. Force of detrusor contraction before - 5+/-5.8, after - 32.8+/-5.5. Sphincter resistance (cmH(2)O) before - 6.5+/-3.8, after - 21.1+/-4.2. Significant improvements in bladder function were observed during the 10th to 12th postoperative months. Restoration of reflex voiding occurred in all patients; in eight of the 11 paresthesic in the groin and scrotum and reappearance of the bulbocavernous, anal and cremasteric reflexes were noted. CONCLUSION: These results suggest that a restitutive process occurs in the bladder under novel conditions of its nerve supply provided by the intercostal nerve and by new connections established between it and the bladder nerves. Spinal cord lesions that might benefit from nerve crossover surgery would be located at the conus, so functional intercostal nerves could be connected to sacral roots to bypass the injury in an attempt to restore central connections to the bladder.

[Prognosis of the outcome of the surgical treatment of the acquired lumbar spinal stenosis]. / Prognozirovanie rezul'tatov khirurgicheskogo lecheniia priobretennogo stenoza pozvonochnogo kanala na urovne poiasnichnogo otdela.

Not clear-cut indications exist until now for surgical interventions in lumbar spinal stenosis. The satisfying surgical results range from 55% to 98%. The purpose of the present case study was to optimize the data related with the neurological status, magnetic-resonance tomography and with defining the factors having an influence on surgical results. A total of 77 patients were divided into 2 groups: group 1 comprised patients with the signs of intermittent claudication and group 2 comprised patients with pains in legs. The surgical treatment consisted in decompression of the spinal neural structures and, in cases of instability, in fixing the damaged spinal segments. The splendid surgical results were registered in 20 patients (66%) of group 1 and good results were obtained, in this group, in 10 patients (34%); the splendid results were obtained in 10 patients (21%) of group 2, good results--in 17 patients (37%), satisfactory results--in 11 patients (23%) and unsatisfactory--in 9 patients (19%) of group 2. The surgical treatment in neurogenic intermittent claudication with a scanty neurological symptomatology ensures good results. While, in case of pain in legs with definitely pronounced neurological symptomatology, the surgical treatment does not provide for a full-value regression of symptoms.

[Immunohistochemical study of apoptosis in the cells of experimental injured spinal cord]. / Immunogistokhimicheskoe izuchenie apoptoza kletok spinnogo mozga pri ego éksperimental'nom povrezhdenii.

We studied the temporal and spatial profile of apoptosis following acute spinal cord (SC) injury in rats and influence of chicken yolk transplantation on the programmed cell death. 18 female rats were subjected to complete SC transsection with removal of three millimeters of the SC at the level of the ninth thoracic vertebra. The gap was filled with denaturated chicken yolk in 9 animals. 9 control rats had no transplantation. Temporal and spatial course of apoptosis was estimated in longitudinal sections of the SC by TUNEL assay technique 4 hours, 3 days, 2 weeks, 40 days and 3 months after the injury. Apoptosis occurred through all posttraumatic period with its peak 40 days after the injury and decreased slowly to the minimal level by the third month. Apoptotic cells appeared near the site of the injury immediately after the trauma along the cord several hours later. Apoptosis involved only glial cells, neurons had no apoptotic signs. Suppression of apoptosis occurred in the yolk transplantation group and was accompanied by greater number of neuronal and glial survivals. Thus, apoptotic glial death after transsection of the SC in rats occurred mainly for the first eight weeks along the whole spinal cord.

[The surgical treatment of decubitus ulcers in patients with spinal cord trauma]. / Khirurgicheskoe lechenie prolezhnei u bol'nykh so spinnomozgovoi travmoi.

The paper summarizes experience in surgically treating decubitus in 429 patients with spinal cord injury. Main criteria for decubitus preparation for surgery, indications for various surgical interventions are defined. The outcomes of treatment are analyzed. The wound healed by first intention in 71% of patients and in 86% of patients within 3 months. Repeated surgery was required in 4.4% of patients. There is evidence that surgical intervention makes it possible to eliminate the existing decubituses in patients with spinal cord injury by score times more rapidly, to greatly improve the quality of their life and to increase survival.

[Apoptosis during spinal cord trauma: prospects for pharmacological correction]. / Apoptoz pri travmaticheskom povrezhdenii spinnogo mozga: perspektivy farmakologicheskoi korrektsii.

Spinal trauma is a serious problem of modern medicine. The morphological studies illustrate the presence of two alternative pathways of cell destruction in the injured spinal cord: immediate necrotic damage and delayed apoptotic destruction of cells. The apoptosis continues for about 14 days after trauma, and it involves both neurons and glia on a significant distance from the traumatic zone. In this review, the basic stages of apoptosis in spinal cord, biochemical regulation of this process, and methods for its detection are considered. The fact, that apoptosis is a normal cell death process, and that it has reversible stages allows to consider a possibility of pharmacological correction of apoptosis. The special attention is paid to anti-apoptotic therapy with the use of antisense oligodeoxynucleotides and to the perspectives of gene therapy.

[New possibilities in the surgical treatment of lower thoracic and lumbar spinal injuries]. / Novye vozmozhnosti khirurgicheskogo lecheniia povrezhdenii nizhnegrudnogo i poiasnichnogo otdelov pozvonochnika.

The paper presents new current approaches to surgically treating the lower thoracic and lumbar spinal injuries. By using new procedures for spinal stabilization, the authors propose algorithms for surgical treatment of spinal injuries in relation to the neurological symptomatology and the severity of fracture and its pattern. The study was performed in the clinical setting. Seventy patients with lower thoracic and lumbar spinal injuries were operated on. The outcomes of their surgical treatment are analyzed. Indications for nerve structural decompression, for approaches to vertebral bodies are defined.

[Changes in the somatosensory evoked potentials of patients with complicated spinal trauma after an omentomyelopexy operation]. / Izmenenie somatosensornykh vyzvannykh potentsialov u bol'nykh s oslozhnennoi spinal'noi travmoi posle operatsii omentomielopeksii.

The purpose of the study was to record somatosensory evoked potentials (SSEP) to objectify the results omentomyelopexy in late spinal cord injury. SSEP were recorded in 25 patients in leads of three levels of the somatosensory tract (from the popliteal fossa, from the lumbar enlargement of the spinal cord, and from the surface of the skull in the region of projection of leg presentation in cerebral hemispherical cortex) before and after surgery. The study indicated that there were no pre- or postoperative records of cortical evoked potentials. At the same time there was improvement in the magnitude of SSEP at the level of the lumbar enlargement (36%). In 4 (16%) and 5 (20%) cases of them SSEP changes were clear and unclear, respectively. The assessment of SSEP changes requires consideration of cases with unclear SSEP. Comparison of the results with clinical findings shows a correlation mainly with urological and urodynamic evidence. Thus, there are minor positive changes in the magnitude of SSEP after omentomyelopexy in the lumbar enlargement lead with unclearly pronounced evoked potentials.

[The results of omentomyelopexy in the late period of traumatic spinal cord disease]. / Rezul'taty omentomielopeksii v pozdnem periode tramaticheskoi bolezni spinnogo mozga.

The results of omental transplantation to the site of spinal cord lesion in 40 patients in late injury are given. Neurological deficit was alleviated in 17.5% of patients. Improvement of segmentary functions was observed in most cases and was recorded within 1 week to 3 months postoperatively. There was no neurological improvement after 6 months postoperatively. Patients with mild spinal cord injuries (D10-L1) had the best outcomes. Comparative analysis of the outcomes of omentomyelopexy with those of treatment in 115 patients undergone meningomyeloradicolysis did not demonstrate any significant difference. Thus, it is not justifiable to use omental transposition in late spinal cord injury.

[The late-period results of surgical treatment for trauma to the cervical spine and spinal cord]. / Rezul'taty operativnogo lecheniia travmy sheinogo otdela pozvonochnika i spinnogo mozga v pozdnem periode.

Seven patients with late-stage spinal cord injury (SCI) at the cervical level were operated on 2 to 11 months following the accident. To assess the preoperative status and the results of surgical treatment, the ASIA motor scoring system was utilized. In 6 cases anterior decompression was combined with a strut graft fusion, one patient was managed via posterior approach, i.e. C7 laminectomy, followed by myelotomy and drainage of the intramedullary cyst. Segmental motor improvement was noted in 3 patients. In one patient minor sensory improvement in the sacral area was documented. We believe even minor (i.e. segmental) neurological improvement can significantly alter the functional outcome. Our sense is that an evidence of the spinal cord compression even in late-stage SCI should be considered to be an indication for surgery. In patients with complete SCI, the goal of surgical treatment is segmental motor improvement. If muscular strength in the upper extremities is preserved, surgery is thought to be optional.