Validation of a New Tool to Detect and Characterize Spinal Cord Injury in the Acute Trauma Patient: The Montreal Acute Classification of Spinal Cord Injury.

STUDY DESIGN: Retrospective validation protocol. OBJECTIVE: The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive tool for classifying spinal cord injuries (SCI), but it is not adapted for the evaluation of trauma patients. The objective is to develop and validate a streamlined tool, the Montreal Acute Classification of Spinal Cord Injury (MAC-SCI) that can be integrated in the evaluation of trauma patients to detect and characterize traumatic SCI (tSCI). METHODS: The completion rate of the ISCNSCI during initial evaluation after tSCI was estimated at a Level-1 trauma center specialized in SCI care. Using a modified Delphi technique, we designed the MAC-SCI, a new tool to detect and characterize the severity grade and level of SCI in the polytrauma patient. A cohort consisting of 35 consecutive tSCI patients with complete ISNCSCI documentation was used to validate the MAC-SCI. The severity grade and neurological level of injury (NLI) were assessed using the MAC-SCI, and compared to those obtained with the ISNCSCI. RESULTS: Only 33% of 148 patients admitted after a tSCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI retains 53 of the 134 elements from the ISNCSCI. There was a 100% concordance in severity grade between the MAC-SCI and ISNCSCI. The NLI were within 2 levels between the MAC-SCI and ISNCSI for 100% of patients. CONCLUSION: The MAC-SCI is a streamlined tool that accurately detects and characterizes tSCI in the acute trauma setting. It could be implemented in trauma protocols to guide the management of SCI patients. LEVEL OF EVIDENCE: Level III Diagnostic criteria.

Generic versus disease-specific adverse event reporting: a comparison of the NSQIP and SAVES databases for the identification of acute care adverse events in adult spine surgery.

OBJECTIVE: The accurate identification and reporting of adverse events (AEs) is crucial for quality improvement. A myriad of AE systems are utilized. There is a lack of understanding of the differences between prospective versus retrospective, disease-specific versus generic, and point-of-care versus chart-abstracted systems. The objective of this study was to compare the benefits and limitations between the prospective, disease-specific, point-of-care Spine Adverse Events Severity System (SAVES) and the retrospective, generic, and chart-abstracted National Surgical Quality Improvement Program (NSQIP) for the identification and reporting of AEs in adult patients undergoing spinal surgery. METHODS: The authors conducted an observational ambidirectional cohort study of adult patients undergoing spine surgery other than for trauma between 2011 and 2019 in a quaternary spine center. Patients were identified using Current Procedural Terminology codes in the NSQIP database and matched using unique medical record numbers to their corresponding record in SAVES. The incidence of AEs and per-patient AEs as recorded in NSQIP and SAVES was the primary outcome of interest. Comparable AEs were identified by matching NSQIP AEs to equivalent ones in SAVES. Chi-square tests were used to test for significant differences in the incidence of overall and comparable AEs between the databases. RESULTS: There were 2198 patients identified in NSQIP, of whom 2033 also had complete records in SAVES. SAVES identified 5342 individual AEs in 1484 patients (73%) compared with 1291 individual AEs in 807 patients (39.7%) with the NSQIP database (p < 0.001). SAVES identified 250 intraoperative and 422 postoperative spine-specific AEs that NSQIP did not record. NSQIP captured a greater number of AEs beyond 30 days, including prolonged length of stay > 30 days, unplanned readmission, unplanned reoperation, and death later than 30 days after surgery compared with SAVES. CONCLUSIONS: SAVES captures a greater incidence of peri- and intraoperative spine-specific AEs than NSQIP, while NSQIP identifies a greater number of AEs beyond 30 days. While a prospective, disease-specific, point-of-care AE system such as SAVES is specific for guiding quality improvement in spine surgery, it incurs greater time and financial costs. Conversely, a retrospective, generic, and chart-abstracted system such as NSQIP provides equivocal cross-institutional comparability with reduced time and financial costs. Specific contextual and aim-specific needs should guide the choice and implementation of an AE system.

Does Older Age Affect the Likelihood to Achieve Normal Quality of Life After Traumatic Spinal Cord Injury? A Prospective Observational Cohort Study.

Previous studies suggest that health-related quality of life (HRQoL) is impaired after a traumatic spinal cord injury (TSCI) and may be worse with older age. This study determines whether the expectations to achieve normal HRQoL in Canadians after a TSCI is indeed influenced by older age. A prospective observational study was conducted on adult patients admitted acutely at a single level-1 trauma center after a TSCI. We assessed HRQoL using the SF-36 physical and mental component summary (PCS and MCS) scores obtained one year post injury. Using Canadian normative HRQoL data matched for age and sex, we defined normal PCS and MCS as a score within 2 standard deviations with respect to the normative Canadian mean. We then conducted logistic regression models to determine the relationship between age at the time of injury and the likelihood of achieving normal PCS and MCS, while controlling for confounding variables. Overall, 39.3% of individuals displayed normal PCS, whereas 80.4% displayed normal MCS. When adjusted for confounders, older age remained significantly associated with increased likelihood of achieving normal PCS (Odds Ratio: 1.03; 95% Confidence Interval: 1.01-1.06; P = 0.002). We observed no association between age and achieving normal MCS. A significant proportion of individuals can achieve a normal HRQoL similar to their healthy peers following a TSCI, particularly for the mental component. When compared to younger individuals, older individuals are more likely to achieve normal PCS and present a similar likelihood for achieving normal MCS.

Does Wait Time During Acute Care for Transfer to Rehabilitation Admission Impact the Outcomes After a Traumatic Spinal Cord Injury?: A Retrospective Cohort Study.

BACKGROUND: The objective of this study was to determine the impact of wait time in acute care for inpatient functional rehabilitation admission on the inpatient functional rehabilitation length of stay and functional outcome after a traumatic spinal cord injury. METHODS: A retrospective cohort including 277 patients admitted to a single level 1 spinal cord injury acute care center was completed. Partial correlations were used between wait time (in days) for transfer to inpatient functional rehabilitation, the inpatient functional rehabilitation length of stay, and the Spinal Cord Independence Measure total score in the chronic period, adjusting for confounding variables. Stratified analyses were carried out based on the age group and severity of the injury. RESULTS: Patients had to wait a mean of 7.3 ± 6.4 days (median = 6 days, interquartile range = 2-10 days, max = 29 days) for inpatient functional rehabilitation admission after rehabilitation readiness, which was not associated with the outcomes when adjusted ( P > 0.05). However, individuals 65 yrs or older with a motor-complete injury showed a lower functional status when exposed to wait time for transfer ( r = -0.87, P = 0.02). CONCLUSIONS: Wait time up to 29 days may have no impact on the inpatient functional rehabilitation length of stay nor functional outcome after traumatic spinal cord injury. However, additional resources and/or prioritization should be considered for vulnerable subgroups.

Clinical judgment is a cornerstone for validating and using clinical prediction rules: a head-to-head study on ambulation outcomes for spinal cord injured patients.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: Clinical prediction rules (CPRs) are an effervescent topic in the medical literature. Recovering ambulation after a traumatic spinal cord injury (tSCI) is a priority for patients and multiple CPRs have been proposed for predicting ambulation outcomes. Our objective is to confront clinical judgment to an established CPR developed for patients with tSCI. SETTINGS: Level one trauma center specialized in tSCI and its affiliated rehabilitation center. METHOD: In this retrospective comparative study, six physicians had to predict the ambulation outcome of 68 patients after a tSCI based on information from the acute hospitalization. Ambulation was also predicted according to the CPR of van Middendorp (CPR-vM). The success rate of the CPR-vM and clinicians to predict ambulation was compared using criteria of 5% for defining clinical significance, and a level of statistical significance of 0.05 for bilateral McNemar tests. RESULTS: There was no statistical difference between the overall performance of physicians (success rate of 79%) and of the CPR-vM (81%) for predicting ambulation. The differences between the CPR-vM and physicians varied clinically and significantly with the level of experience, clinical setting, and field of expertise. CONCLUSION: Confronting CPRs with the judgment of a group of clinicians should be an integral part of the design and validation of CPRs. Head-to-head comparison of CPRs with clinicians is also a cornerstone for defining the optimal strategy for translation into the clinical practice, and for defining which clinician and specific clinical context would benefit from using the CPR.

An evaluation of the representativeness of a national spinal cord injury registry: a population-based cohort study.

STUDY DESIGN: Population-based cohort study for the western part of Quebec. OBJECTIVES: To determine the impact of declining to participate in a national spinal cord injury (SCI) registry on patient outcomes and continuum of care. SETTING: Level-1 trauma center specialized in SCI care in Montreal, Canada. METHODS: This cohort study compared the outcomes of 444 patients who were enrolled in the Rick Hansen SCI registry and 140 patients who refused. Logistic regression analyses were performed to assess the association between voluntary participation and the outcomes, while adjusting for confounding factors. The main outcomes were: attendance to follow-up 6- to 12-month post injury, 1-year mortality, and the occurrence of pressure injury during acute care. RESULTS: Declining to be enrolled in the registry was a significant predictor of lower attendance to specialized follow-up (adjusted odds ratio [OR] 0.04, 95% confidence interval [CI] 0.02-0.08). It was also associated with a higher 1-year mortality rate (OR 12.50, CI 4.50-33.30) and higher occurrence of pressure injury (OR 2.56, CI 1.56-4.17). CONCLUSIONS: This study sheds invaluable insight on individuals that researchers and clinicians are usually blind to in SCI cohort studies. This study suggests that decline to participate in a registry during the care hospitalization may be associated with worsened health, poorer outcomes, and reduced follow-up to specialized care. Declining the enrollment to voluntary registry could represent a potential prognostic factor for future research.

Sarcopenia, but not frailty, predicts early mortality and adverse events after emergent surgery for metastatic disease of the spine.

BACKGROUND CONTEXT: Frailty and sarcopenia variably predict adverse events (AEs) in a number of surgical populations. PURPOSE: The aim of this study was to investigate the ability of frailty and sarcopenia to independently predict early mortality and AEs following urgent surgery for metastatic disease of the spine. STUDY DESIGN: A single institution, retrospective cohort study. PATIENT SAMPLE: One hundred eight patients undergoing urgent surgery for spinal metastases from 2009 to 2015. OUTCOME MEASURES: The incidence of AEs including 1- and 3-month mortality. METHODS: Sarcopenia was defined using the L3 Total Psoas Area/Vertebral body Area (L3-TPA/VB) technique on CT. The modified Frailty Index (mFI), Metastatic Frailty Index (MSTFI) and the Bollen prognostic scales were calculated for each patient. Additional data included demographics, tumor type and burden, neurological status, the extent of surgical treatment and the use of radiation-therapy. Spearman correlation test, logistic regression and Kaplan-Meier were used to study the relation between the outcomes measures and potential predictors (L3-TPA/VB, MSTFI, mFI, and the Bollen prognostic scales). RESULTS: Eighty-five percent of patients had at least one acute AE. Sarcopenia predicted the occurrence of at least one postop AE (L3-TPA/VB, 1.07±0.40 vs. 1.25±0.52; p=.031). Sarcopenia (L3-TPA/VB) and the degree of neurological impairment were predictive of postoperative AE but MFI or MSTFI were not. Sarcopenia predicted 3-month mortality, independent of primary tumor type (L3-TPA/VB: 0.86±0.27 vs. 1.12±0.41; p<.001). Kaplan-Meyer analysis showed L3-TPA/VB and the Bollen Scale to significantly discriminate patient survival. CONCLUSIONS: Sarcopenia, easily measured by the L3-TPA/VB on conventional CT, predicts both early postoperative mortality and adverse events in patients undergoing urgent surgery for spinal metastasis, thus providing a practical tool for timely therapeutic decision-making in this complex patient population.

Expectations for Postoperative Improvement in Health-Related Quality of Life in Young Patients With Lumbosacral Spondylolisthesis: A Prospective Cohort Study.

STUDY DESIGN: Prospective multicenter study of the changes in Scoliosis Research Society Outcome Questionaire 22 (SRS-22) scores for 78 patients younger than 25 years old surgically treated for lumbosacral spondylolisthesis OBJECTIVE.: Report the change of health-related quality of life (HRQOL) in patients younger than 25 years after surgical treatment of lumbosacral spondylolisthesis. SUMMARY OF BACKGROUND DATA: There is a paucity of data with regard to the influence of surgical treatment on the HRQOL of patients with lumbosacral spondylolisthesis. Large prospective studies are needed to clearly define the benefits of surgery in the young patient population. METHODS: A prospective multicenter cohort of 78 patients younger than 25 years (14.8 ±â€Š2.9, range: 7.9-23.6 yr) undergoing posterior fusion for lumbosacral spondylolisthesis were enrolled. There were 17 patients with low-grade (<50%) and 61 with high-grade (≥50%) slips. SRS-22 scores calculated before surgery and after 2 years of follow-up were compared for all patients using two-tailed paired t tests. Subanalyses for low- and high-grade patients were done using two-tailed Wilcoxon signed ranked and paired t tests, respectively. The level of significance was set at 0.05. RESULTS: HRQOL was significantly improved 2 years after surgery for all domains and for the total score of the SRS-22 questionnaire. The individual total score was improved in 66 patients (85%), and 52 patients (67%) improved by at least 0.5 point. All domains and the total score of the SRS-22 questionnaire were significantly improved for high-grade patients, whereas only pain, function, and total score were improved for low-grade patients. CONCLUSION: This is the largest study comparing the HRQOL before and after surgery in young patients with low- and high-grade lumbosacral spondylolisthesis. HRQOL significantly improves after surgery for the majority of patients, especially for high-grade patients. This study helps clinicians to better counsel patients with regard to the benefits of surgery for lumbosacral spondylolisthesis. LEVEL OF EVIDENCE: 2.

The impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature.

STUDY DESIGN: Systematic review. OBJECTIVES: To identify currently used measures of frailty and sarcopenia in the adult spine surgery literature. To assess their ability to predict postoperative outcomes including mortality, morbidity, in-hospital length of stay (LOS), and discharge disposition. To determine which is the best clinical measure of frailty and sarcopenia in predicting outcome after spine surgery. SUMMARY OF BACKGROUND DATA: Frailty and sarcopenia have been identified as predictors of mortality and adverse-events (AEs) in numerous nonsurgical and nonspine populations. This topic is an emerging area of interest and study in patients undergoing spinal surgery. METHODS: A systematic literature review using the PRISMA methodology of MEDLINE, PubMed, Ovid, EMBASE, and Cochrane databases was performed from January 1950 to August 2017. Included studies consisted of those that examined measures of frailty or sarcopenia in adult patients undergoing any spinal surgery. The literature was synthesized and recommendations are proposed based on the GRADE system. RESULTS: The initial search yielded 210 results, 11 of which met our complete inclusion criteria. Seven reported on measures of frailty and four reported on measures of sarcopenia. Frailty, assessed using a variety of measurement tools, was a consistent predictor of mortality, major and minor morbidity, prolonged in-hospital LOS, and discharge to a center of higher care for adult patients undergoing spinal surgery. The relationship between sarcopenia and postoperative outcomes was inconsistent due to the lack of consensus regarding the definition, measurement tools, and wide variability in sarcopenia measured in the spinal population. CONCLUSIONS: Frailty is predictive of AEs, mortality, in-hospital LOS, and discharge disposition in a number of distinct spinal surgery populations. The impact of sarcopenia on postoperative outcomes is equivocal given the current state of the literature. The relationship between spinal pathology, frailty, sarcopenia, and how they interact to yield outcome remains to be clarified. Frailty and sarcopenia are potentially useful tools for risk stratification of patients undergoing spinal surgery. This systematic review was registered with PROSPERO, registration number 85096.

Neurologic Recovery in Polytrauma Patients With Acute Spinal Cord Injury.

Traumatic spinal cord injury results in devastating and lifelong neurologic impairment in thousands of individuals each year. An understanding of the factors that influence neurologic outcome in polytrauma patients with a spinal cord injury allows for early treatment, which may improve neurologic recovery. Neurologic impairment in polytrauma patients with spinal cord injury is clinically classified based on the American Spinal Injury Association International Standards for Neurological Classification of Spinal Cord Injury. In general, neurologic recovery is worse in patients with more severe initial neurologic impairment, in patients with a higher level spinal cord injury (cervical versus thoracic), and in older patients. MRI features and neurochemical biomarkers in cerebrospinal fluid are used to objectively assess spinal cord injury severity and better predict patient outcomes. Well-accepted therapeutic interventions to improve neurologic recovery in polytrauma patients with a spinal cord injury include early surgical decompression/stabilization and maintenance of spinal cord perfusion by augmenting mean arterial pressure and avoiding hypotension. Early surgical decompression (within 24 hours postinjury) may be beneficial in polytrauma patients with acute spinal cord injury. The goal of mean arterial pressure augmentation is to improve spinal cord perfusion, and intrathecal pressure monitoring (to calculate spinal cord perfusion pressure) may improve the effectiveness of hemodynamic management, helping to avoid ischemic secondary spinal cord injury. Transfer of polytrauma patients with a spinal cord injury to a specialized medical center with expertise in the surgical and postoperative management of such injuries is necessary to ensure optimal neurologic and nonneurologic patient outcomes.

Predicting Injury Severity and Neurological Recovery after Acute Cervical Spinal Cord Injury: A Comparison of Cerebrospinal Fluid and Magnetic Resonance Imaging Biomarkers.

Biomarkers of acute human spinal cord injury (SCI) could provide a more objective measure of spinal cord damage and a better predictor of neurological outcome than current standardized neurological assessments. In SCI, there is growing interest in establishing biomarkers from cerebrospinal fluid (CSF) and from magnetic resonance imaging (MRI). Here, we compared the ability of CSF and MRI biomarkers to classify injury severity and predict neurological recovery in a cohort of acute cervical SCI patients. CSF samples and MRI scans from 36 acute cervical SCI patients were examined. From the CSF samples taken 24 h post-injury, the concentrations of inflammatory cytokines (interleukin [IL]-6, IL-8, monocyte chemotactic protein-1), and structural proteins (tau, glial fibrillary acidic protein, and S100ß) were measured. From the pre-operative MRI scans, we measured intramedullary lesion length, hematoma length, hematoma extent, CSF effacement, cord expansion, and maximal spinal cord compression. Baseline and 6-month post-injury assessments of American Spine Injury Association Impairment Scale (AIS) grade and motor score were conducted. Both MRI measures and CSF biomarker levels were found to correlate with baseline injury grade, and in combination they provided a stronger model for classifying baseline AIS grade than CSF or MRI biomarkers alone. For predicting neurological recovery, the inflammatory CSF biomarkers best predicted AIS grade conversion, whereas structural biomarker levels best predicted motor score improvement. A logistic regression model utilizing CSF biomarkers alone had a 91.2% accuracy at predicting AIS conversion, and was not strengthened by adding MRI features or even knowledge of the baseline AIS grade. In a direct comparison of MRI and CSF biomarkers, the CSF biomarkers discriminate better between different injury severities, and are stronger predictors of neurological recovery in terms of AIS grade and motor score improvement. These findings demonstrate the utility of measuring the acute biological responses to SCI as biomarkers of injury severity and neurological prognosis.

Costs and Length of Stay for the Acute Care of Patients with Motor-Complete Spinal Cord Injury Following Cervical Trauma: The Impact of Early Transfer to Specialized Acute SCI Center.

OBJECTIVE: Acute spinal cord injury (SCI) centers aim to optimize outcome following SCI. However, there is no timeframe to transfer patients from regional to SCI centers in order to promote cost-efficiency of acute care. Our objective was to compare costs and length of stay (LOS) following early and late transfer to the SCI center. DESIGN: A retrospective cohort study involving 116 individuals was conducted. Group 1 (n = 87) was managed in an SCI center promptly after the trauma, whereas group 2 (n = 29) was transferred to the SCI center only after surgery. Direct comparison and multivariate linear regression analyses were used to assess the relationship between costs, LOS, and timing to transfer to the SCI center. RESULTS: Length of stay was significantly longer for group 2 (median, 93.0 days) as compared with group 1 (median, 40.0 days; P < 10), and average costs were also higher (median, Canadian $17,920.0 vs. $10,521.6; P = 0.004) for group 2, despite similar characteristics. Late transfer to the SCI center was the main predictive factor of longer LOS and increased costs. CONCLUSIONS: Early admission to the SCI center was associated with shorter LOS and lower costs for patients sustaining tetraplegia. Early referral to an SCI center before surgery could lower the financial burden for the health care system. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Determine the optimal timing for transfer of individuals with cervical traumatic spinal cord injury (SCI) in order to decrease acute care resource utilization; (2) Determine benefits of a complete perioperative management in a specialized SCI center; and (3) Identify factors that may influence resource utilization for acute care following motor-complete tetraplegia. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Does the Acute Care Spinal Cord Injury Setting Predict the Occurrence of Pressure Ulcers at Arrival to Intensive Rehabilitation Centers?

OBJECTIVE: The objective of this study was to evaluate the impact of acute care in specialized spinal cord injury (SCI) trauma centers on the prevalence of pressure ulcers (PU) upon arrival at a functional rehabilitation center after a traumatic SCI. DESIGN: This is a retrospective cohort study among 123 patients with traumatic SCI referred to intensive functional rehabilitation between January 1, 2009, and December 31, 2011. Group 1 (n = 90) was referred from a level 1 specialized SCI trauma center and group 2 (n = 33) was referred from seven trauma centers not specialized in SCI. RESULTS: The total prevalence of patients with PU at admission to functional rehabilitation was 33.3% (26.7% in group 1 and 51.5% in group 2, P = 0.017). There were also more patients with multiple PU in group 2 (24.2% vs. 2.2%, P = 0.0001). A binary logistic regression showed a significant relationship between the occurrence of PU and the type of acute care facility as well as the ASIA (American Spinal Injury Association) Impairment Scale grade. Receiving acute care at the specialized SCI trauma center was associated with a decrease in the number of patients developing one and multiple PU. CONCLUSIONS: These results highlight the importance of specialized SCI trauma centers in acute care of patients with traumatic SCI in reducing PU at their admission to functional rehabilitation settings.

Do Patients with Complete Spinal Cord Injury Benefit from Early Surgical Decompression? Analysis of Neurological Improvement in a Prospective Cohort Study.

The prognosis for patients with a complete traumatic spinal cord injury (SCI) is generally poor. It is unclear whether some subgroups of patients with a complete traumatic SCI could benefit from early surgical decompression of the spinal cord. The objectives of this study were: (1) to compare the effect of early and late surgical decompression on neurological recovery in complete traumatic SCI and (2) to assess whether the impact of surgical timing is different in patients with cervical or thoracolumbar SCI. A prospective cohort study was followed in a single Level 1 Trauma Center specializing in SCI care. All consecutive patients who sustained a traumatic SCI and were referred between 2010 and 2013 were screened for eligibility. Neurological status was assessed systematically using the American Spinal Injury Association impairment scale (AIS) at arrival to the trauma center and at rehabilitation discharge. Patients operated within 24 h of the trauma were compared with patients operated later than 24 h after the trauma. Potential confounders such as age, Injury Severity Score (ISS), smoking history, body mass index (BMI), Glasgow Coma Scale (GCS) score, and duration of follow-up were recorded. Fifty-three patients with complete SCI were included in the study: 33 thoracolumbar and 20 cervical SCIs. The 38 patients operated <24 h were generally younger than the 15 patients operated ≥ 24 h (p = 0.049). Overall, 28% (15/53) of complete SCI had improvement in AIS: 34% (13/38) who were operated <24 h and 13% (2/15) who were operated ≥ 24 h (p = 0.182). Sixty-four percent (9/14) of cervical complete SCI operated <24 h had improvement in AIS as opposed to none in the subgroup of six complete cervical SCI operated ≥ 24 h (p = 0.008). Surgical decompression within 24 h in complete SCI may optimize neurological recovery, especially in patients with cervical SCI.

Non-neurological outcomes after complete traumatic spinal cord injury: the impact of surgical timing.

It remains unclear whether the benefits of early surgical timing are significant in neurologically complete spinal cord injury (SCI). We wanted to compare the effects of early and late surgical timing on non-neurological outcomes in persons with traumatic complete SCI. All cases of traumatic complete SCI referred to a single institution between 2000 and 2011 were retrospectively reviewed. The occurrence of pneumonia, urinary tract infection (UTI), pressure ulcer (PU), and all other postoperative complications were recorded. Cost of acute hospitalization was calculated for each patient based on administrative data. Patients operated on within 24 h of the trauma were compared with patients operated on later than 24 h after the trauma. The effects of surgical timing on complication rate and cost of hospitalization were adjusted for potential confounding variables using multiple regression analyses. Fifty-five patients were operated on ≤ 24 h from injury and 142 were operated on >24 h from injury. Baseline demographic and clinical variables were comparable between the two groups. Pneumonia, UTI, and the presence of any complications were significantly higher in the group operated on >24 h post-trauma. Cost of hospitalization was higher among patients operated >24h post-trauma (≤ 24 h: 22,828$ vs. >24 h: 29,714$). Surgical timing >24 h was a predictor of pneumonia, UTI, total complications. and higher cost of hospitalization after controlling for other confounding variables. This study shows that surgical decompression and stabilization ≤ 24 h following a complete SCI may be a cost-effective strategy to reduce the postoperative complication rate.

Quality of life of patients with high-grade spondylolisthesis: minimum 2-year follow-up after surgical and nonsurgical treatments.

BACKGROUND CONTEXT: Surgical intervention is generally indicated in a pediatric high-grade spondylolisthesis to prevent the progression of deformity or neurologic deterioration and improve the quality of life. However, the outcome of the treatment on the health-related quality of life (HRQOL) of patients with high-grade spondylolisthesis remains largely unknown. PURPOSE: To describe the changes in the HRQOL of patients with pediatric high-grade spondylolisthesis after surgical and nonsurgical managements. STUDY DESIGN: Observational case series with a minimal of 2-year follow-up. PATIENT SAMPLE: Twenty-eight pediatric patients with high-grade spondylolisthesis from a single institution filled the inclusion criteria. Twenty-three patients were managed surgically and five were managed nonsurgically. OUTCOME MEASURES: Self-report measures: Scoliosis Research Society questionnaires (SRS-22). Neurologic examination, radiographic evaluation of slip grade. METHODS: The SRS-22 questionnaire was collected at the baseline (initial presentation for the nonsurgical group and preoperative visit for the surgical group) and at the last follow-up. Differences between baseline and last follow-up were evaluated in both groups. Correlation between the baseline score of SRS-22 score and improvement in the SRS-22 score was determined in surgical patients. RESULTS: In surgical patients, total SRS-22 scores were 3.31 ± 0.50 at the baseline and 4.26 ± 0.50 at the last follow-up. In nonsurgical patients, total SRS-22 scores were 4.12 ± 0.16 at the baseline and 4.14 ± 0.38 at the last follow-up. Therefore, variation in the SRS-22 total score was +0.94 ± 0.77 (p<.001) for surgical patients and +0.02 ± 0.35 (p=.854) for nonsurgical patients. Improvement of the SRS-22 score was correlated with a low baseline value of SRS-22 (R²=0.61; p<.001). There was no neurologic or slip deterioration during the follow-up for patients treated nonsurgically. CONCLUSIONS: The HRQOL improves after a surgical intervention for high-grade spondylolisthesis. Patients with lower baseline HRQOL scores are those who benefit the most from surgery. Close observation is a safe and feasible option in selected patients with a good baseline HRQOL and no neurologic impairment.

Complications in acute phase hospitalization of traumatic spinal cord injury: does surgical timing matter?

BACKGROUND: Optimal timing of surgery after a traumatic spinal cord injury (SCI) is one of the most controversial subjects in spine surgery. We assessed the relationship between surgical timing and the occurrence of nonneurologic postoperative complications during acute hospital stay for patients with a traumatic SCI. METHODS: A retrospective cohort study was performed in a single institution. Four hundred thirty-one cases of traumatic SCI were reviewed, and postoperative complications were recorded from the medical charts. Patients were compared using two different surgical timing cutoffs (24 hours and 72 hours). Logistic regression analyses were modeled for complication occurrence. The effect of surgical timing on complication rate was adjusted for potential confounding variables such as the level of injury, American Spinal Injury Association (ASIA) grade, Injury Severity Score (ISS), age, sex, Charlson Comorbidity Index, and Surgical Invasiveness Index. RESULTS: Patients operated on earlier were younger, had less comorbidity, had a higher ISS, and were more likely to have a cervical lesion and a complete injury (ASIA A). A reduction in the global rate of complications as well as in the rate of pneumonias and pressure ulcers were predicted by surgery performed earlier than 72 hours and 24 hours. Increasing age, more severe ASIA grade, and cervical lesion as well as increased Charlson Comorbidity Index, ISS, and SII were also statistically related to the occurrence of complications. CONCLUSION: This study showed that a shorter surgical delay after a traumatic SCI decreases the rate of complications during the acute phase hospitalization. We suggest that patients with traumatic SCI should be promptly operated on earlier than 24 hours following the injury to reduce complications while optimizing neurologic recovery. If medical or practical reasons preclude timing less than 24 hours, efforts should still be made to perform surgery earlier than 72 hours following the SCI. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic/care management study, level IV.

Does timing of surgery affect hospitalization costs and length of stay for acute care following a traumatic spinal cord injury?

Although there is a trend toward performing early surgery for traumatic spinal cord injury (SCI), it remains unclear whether this tendency leads to decreased costs and length of stay (LOS) for acute care. This study determined the impact of surgical timing on costs and LOS after a traumatic SCI. A total of 477 consecutive patients sustaining an acute traumatic SCI and receiving surgery at a level I trauma center were included. A general linear model was used to assess the relationship among costs, LOS, and surgical delay, while accounting for various sociodemographic and clinical covariables. The analysis was also repeated with surgical delay dichotomized within 24 h or later after the trauma. Mean costs and LOS for all patients were respectively 24,156 ± 17,244 $CAD and 35.0 ± 39.4 days. The costs of acute care hospitalization were related to the surgical delay between the trauma and the surgery, in addition to age, injury severity score (ISS), American Spinal Injury Association (ASIA) grade, and neurological level. LOS was associated with the surgical delay dichotomized into two groups (<24 vs. ≥24 h), as well as with age, ISS, ASIA grade, and neurological level. This study suggests that resource utilization in terms of costs and LOS for the acute hospitalization is decreased with early surgery after an acute traumatic SCI, particularly if the procedure is performed within 24 h following the trauma. Performing the surgery as early as possible when the patient is cleared for surgery could lower the financial burden on the healthcare system, while optimizing the neurological recovery.

Radiological and clinical outcome of non surgical management for pediatric high grade spondylolisthesis.

OBJECTIVE: To describe and compare the quality of life of patients with pediatric high-grade spondylolisthesis managed non-operatively and operatively. SUMMARY OF BACKGROUND DATA: Some authors consider pediatric high-grade spondylolisthesis as an absolute indication for surgery, regardless of symptoms while others sometimes recommend observation in asymptomatic patients. Very little is known about the indications and outcome of non-operatively managed high-grade spondylolisthesis. METHODS: A prospective database comprising all the spondylolisthesis cases from a single pediatric institution was reviewed in order to identify all cases of high grade spondylolisthesis. Quality of life data from Short form (SF)-12 and Scoliosis Research Society (SRS)-22 questionnaires were collected. Non-operatively treated patients were identified and compared to surgically treated patients at baseline and at last follow-up. RESULTS: 34 spondylolisthesis were identified as high grade and 5 of them were non-operatively treated. Quality of life questionnaires showed less impairment in the non-operative group when compared to the surgical group preoperatively. Moreover at last follow-up, quality of life questionnaires were similar between the two groups. There was no worsening of quality of life observed in non-operative patients during follow-up. CONCLUSION: The quality of life after surgical treatment of high grade spondylolisthesis is similar to that of patients with high grade spondylolisthesis and mild symptoms undergoing non-operative treatment.

Redefining the technique for the radiologic measurement of slip in spondylolisthesis.

STUDY DESIGN: Comparison of 2 radiographic measurement techniques of slip severity in spondylolisthesis. OBJECTIVE: To analyze the differences between 2 radiologic measurement techniques of slip severity in L5-S1 developmental spondylolisthesis. SUMMARY OF BACKGROUND DATA: Different techniques for the assessment of slip in spondylolisthesis have been described in the literature, resulting in 2 different methods to report the position of the L5 vertebra on the S1 superior endplate. The clinical impact of these differences in slip measurement is unknown. METHODS: Radiographs of 130 subjects with developmental spondylolisthesis were reviewed. Two different techniques were used to assess the grade and percentage of slip. The technique 1 uses a line drawn from the L5 vertebra postero-inferior corner that is perpendicular to the S1 vertebra endplate. The technique 2 uses a line tangential to the L5 vertebra posterior wall that intersects the S1 vertebra endplate. The lumbosacral angle (LSA) was also measured to assess the orientation of L5 over S1. The slip percentage and grade obtained from the 2 techniques were compared. The influence of the LSA on the measurement of slip severity was also assessed. RESULTS: A significant difference (P < 10(-5)) was found between technique 1 (mean = 34.2% +/- 32.6%) and technique 2 (mean = 42.5% +/- 25.8%) with respect to the slip percentage. Eight subjects were found to switch classification from a low to a high-grade slip (or inversely) depending on the technique used. There was a significant relationship between the LSA and the difference in the measurement of slip percentage using either technique 1 or technique 2. CONCLUSION: The 2 measurement techniques can have a significant impact on the interpretation of slip severity in spondylolisthesis. The differences between the measurement techniques are influenced by the orientation of L5 over S1 and could potentially affect the clinical decision making. It is important to standardize and specify the technique used to plan and assess interventions in L5-S1 developmental spondylolisthesis.