Nonoperative versus operative management of type II odontoid fracture in older adults: a systematic review and meta-analysis.

OBJECTIVE: Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the inherently increased surgical risks in older patients. The objective of this study was to compare fusion rates and outcomes between operative and nonoperative treatments of type II odontoid fractures in the older population. METHODS: A systematic literature review was performed to identify studies reporting the management of type II odontoid fractures in patients older than 65 years from database inception to September 2022. A meta-analysis was performed to compare rates of fusion, stable and unstable nonunion, mortality, and complication. RESULTS: Forty-six articles were included in the final review. There were 2822 patients included in the different studies (48.9% female, 51.1% male), with a mean ± SD age of 81.5 ± 3.6 years. Patients in the operative group were significantly younger than patients in the nonoperative group (81.5 ± 3.5 vs 83.4 ± 2.5 years, p < 0.001). The overall (operative and nonoperative patients) fusion rate was 52.9% (720/1361). The fusion rate was higher in patients who underwent surgery (74.3%) than in those who underwent nonoperative management (40.3%) (OR 4.27, 95% CI 3.36-5.44). The likelihood of stable or unstable nonunion was lower in patients who underwent surgery (OR 0.37, 95% CI 0.28-0.49 vs OR 0.32, 95% CI 0.22-0.47). Overall, 4.8% (46/964) of nonoperatively managed patients subsequently required surgery due to treatment failure. Patient mortality across all studies was 16.6% (452/2721), lower in the operative cohort (13.2%) than the nonoperative cohort (19.0%) (OR 0.64, 95% CI 0.52-0.80). Complications were more likely in patients who underwent surgery (26.0% vs 18.5%) (OR 1.55, 95% CI 1.23-1.95). Length of stay was also higher with surgery (13.6 ± 3.8 vs 8.1 ± 1.9 days, p < 0.001). CONCLUSIONS: Patients older than 65 years of age with type II odontoid fractures had higher fusion rates when treated with surgery and higher stable nonunion rates when managed nonoperatively. Complications and length of stay were higher in the surgical cohort. Mortality rates were lower in patients managed with surgery, but this phenomenon could be related to surgical selection bias. Fewer than 5% of patients who underwent nonoperative treatment required revision surgery due to treatment failure, suggesting that stable nonunion is an acceptable treatment goal.

Utility of Magnetic Resonance Imaging for Ligamentous Injury in Cervical Spine Trauma: A 2-Year Consecutive Case Cohort.

BACKGROUND: Magnetic resonance imaging (MRI) is increasingly used as an adjunct to spinal soft tissue evaluation in cervical spine (C-spine) trauma; however, the utility of this information remains controversial. In this consecutive observational study, we reviewed the utility of MRI in patients with C-spine trauma. METHODS: We identified patients in real time over a 2-year period as they presented to our level 1 trauma center for C-spine computed tomography (CT) scan followed by MRI. MRI was obtained by the trauma team prior to the spine service consultation if (1) they were unable to clear the C-spine according to protocol or (2) if the on-call radiologist reported a concern for ligamentous integrity from the CT findings. RESULTS: Thirty-three patients, including 19 males (58%) and 14 females, with a mean age of 54 years, were referred to the spine service for concerns of ligamentous instability. The most common mechanisms of injury were motor vehicle accidents (n = 13) and falls (n = 11). MRI demonstrated ligamentous signal change identified by the radiologist as potentially unstable in all patients. Fifteen patients (45%) had multiple C-spine ligaments affected. The interspinous ligament was involved most frequently (28%), followed by the ligamentum flavum (21%) and supraspinous ligament (15%). All patients underwent dynamic upright C-spine X-rays that were interpreted by both the ordering surgeon and radiologist. There was no evidence of instability in any patient; concurrence between X-ray interpretation was 100%. The cervical collar was successfully removed in all cases. No patients required late surgical intervention, and there were no return visits to the emergency department of a spinal nature. CONCLUSIONS: MRI signal change within the ligaments of the C-spine should be interpreted with caution in the setting of trauma. To physicians less familiar with spinal biomechanics, MRI findings may be perceived in an inadvertently alarming manner. Bony alignment and, when indicated, dynamic upright X-rays remain the gold standard for evaluating the ligamentous integrity of the C-spine.

Consultations During COVID: Effects of a Pandemic on Neurosurgical Care.

BACKGROUND: COVID-19 has impacted neurosurgical care around the world. But reports describing patient admission trends during the pandemic have provided limited time frames and diagnoses. The purpose of this paper was to analyze the impact of COVID-19 on neurosurgical care provided to our emergency department during the outbreak. METHODS: Patient admission data were collected based on a list of 35 ICD-10 codes, which were placed into 1 of 4 categories: head and spine trauma ("Trauma"), head and spine infection ("Infection"), degenerative spine ("Degenerative"), and subarachnoid hemorrhage/brain tumor ("Control"). Emergency department (ED) consultations to the Neurosurgery Department were collected from March 2018 to March 2022, representing 2 years before COVID and 2 years of pandemic. We hypothesized that Control cases would remain stable throughout the 2 time periods while Trauma and Infection would decrease. Because of widespread clinic restrictions, we postulated Degenerative (spine) cases presenting to the ED would increase. RESULTS: During the first 2 years of the COVID pandemic, Neurosurgical Trauma and Degenerative ED patients decreased compared with prepandemic levels, while Cranial and Spinal infections increased and continued to do so during the pandemic period studied. Brain tumors and subarachnoid hemorrhages (Control cases) did not change in a significant way throughout the 4-year analysis. CONCLUSIONS: The COVID pandemic significantly altered the demographics of our Neurosurgical ED patient population and continues to do so.

Traumatic cervical spine subarachnoid hemorrhage with hematoma and cord compression presenting as Brown-Séqüard syndrome: illustrative case.

BACKGROUND: Spinal hematomas are a rare entity with broad etiologies, which stem from idiopathic, tumor-related, and vascular malformation etiologies. Less common causes include traumatic blunt nonpenetrating spinal hematomas with very few cases being reported. In the present manuscript presents a case report and review of the literature of a rare traumatic entity of a cervical subarachnoid hematoma in association with Brown-Séquard syndrome in a patient on anticoagulants. Searches were performed on PubMed and Embase for specific terms related. OBSERVATIONS: A well-documented case of an 83-year-old female taking anticoagulants with traumatic cervical subarachnoid hematoma presenting as Brown-Séquard syndrome was reported. Six similar cases were identified, scrutinized, and analyzed in the literature review. LESSONS: Traumatic blunt nonpenetrating cervical spine subarachnoid hematomas are a rare entity that can happen more specifically in anticoagulant users and in patients with arthritic changes and stenosis of the spinal canal. Rapid neurological deterioration and severe disability warrant early aggressive surgical treatment. This report has the intention to record this case in the medical literature for registry purposes.

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.

Complications in the Elderly Population Undergoing Spinal Deformity Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic Review and Meta-Analysis. OBJECTIVES: The elderly have an increased risk of perioperative complications for Adult Spinal Deformity (ASD) corrections. Stratification of these perioperative complications based on risk type and specific risk factors, however, remain unclear. This paper will systematically review perioperative risk factors in the elderly undergoing ASD correction stratified by type: medical, implant-related, proximal junctional kyphosis (PJK), and need for revision surgery. METHODS: A systematic review was performed using the PRISMA guidelines. A query of PubMed was performed to identify publications pertinent to ASD in the elderly. Publications included in this review focused on patients ≥65 years old who underwent operative management for ASD to assess for risk factors of perioperative complications. RESULTS: A total of 734 unique citations were screened resulting in ten included articles for this review. Pooled incidence of perioperative complications included medical complications (21%), implant-related complications (16%), PJK (29%), and revision surgery (13%). Meta-analysis calculated greater preoperative PT (WMD 2.66; 95% Cl .36-4.96; P = .02), greater preoperative SVA (WMD 2.24; 95% Cl .62-3.86; P = .01), and greater postoperative SVA (WMD .97; 95% Cl .03-1.90; P = .04) to significantly correlate with development of PJK with no evidence of publication bias or concerns in study heterogeneity. CONCLUSIONS: There is a paucity of literature describing perioperative complications in the elderly following ASD surgery. Appropriate understanding of modifiable risk factors for the development of medical and implant-related complications, proximal junctional kyphosis, and revision surgeries presents an opportunity to decrease morbidity and improve patient outcomes.

Injury of the Thoracolumbar Posterior Ligamentous Complex: A Bibliometric Literature Review.

OBJECTIVE: To conduct a bibliometric review of literature on posterior ligamentous complex (PLC) injury in thoracolumbar trauma to guide future research. METHODS: A keyword-based search was conducted from January 2000 to September 2021 using the Scopus database. Relevant publications were analyzed for year of publication, authorship, publishing journal, institution and country of origin, subject matter, and article type. Content analysis of clinical articles was also performed, analyzed for sample size, retrospective versus prospective study design, single-center versus multicenter study, and level of evidence. RESULTS: The search yielded 262 publications published in 61 journals by 537 authors from 162 institutions and 29 countries. Thomas Jefferson University, University of Calgary, and University of Toronto had the largest number of publications related to posterior ligamentous complex injury. Authors from the United States, Canada, and China were the most frequent contributors in terms of the number of publications. Spine was the most prolific and top-cited journal, and A.R. Vaccaro was the most prolific author. The most cited publication was "A New Classification of Thoracolumbar Injuries: The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status" by Vaccaro et al. Most of the publications were case studies, with diagnostic accuracy being the most frequently discussed topic. The sample size for a large portion of the case series was <50. Most case series were retrospective studies conducted at a single center. CONCLUSIONS: Our review provides an extensive list of the most historically significant thoracolumbar PLC injury articles, acknowledging key contributions made to the advancement of this research area.

The Number of Organ System Injuries Is a Predictor of Intrahospital Mortality in Complete Cervical Spinal Cord Injury.

OBJECTIVE: We sought to determine the extent to which polytrauma significantly impacts intrahospital mortality among patients with complete cervical spinal cord injury (cSCI) and to assess whether an organ system-based approach would be appropriate as a mortality predictor as compared with conventional standards to help guide prognosis and management. METHODS: We retrospectively reviewed patient medical records and assessed the type of associated trauma at presentation. We then reviewed its correlation with mortality in patients who were admitted at our institution between 2012 and 2021. Types of associated trauma were classified under the following: traumatic brain injury, abdominal injury, thoracic injury, orthopedic injury, craniofacial injury, genitourinary injury, and vascular injury. RESULTS: Thirty patients with complete cSCIs were identified. Increased organ system-based polytrauma had a statistically significant increase in intrahospital mortality (P = 0.01). Using the logistic regression model, for each additional gain in organ system-based trauma, patients had a 2.455 odds ratio of mortality (P = 0.03, 95% confidence interval 1.171-6.348). Zero other organ system injuries in the setting of cSCI provided a predictive mortality probability of 6.6%. One organ system-based trauma provided a 14.8% intrahospital mortality probability, 2 traumas provided a 29.9% mortality probability, 3 traumas provided a 51.1% mortality probability, and 4 other organ-system traumas provided a 72.0% mortality probability. The predictive prognostic accuracy of using number of organ system-based trauma to predict mortality probability was quantified at area under the curve = 0.8264 (95% confidence interval 0.6729-0.9799, P = 0.01). CONCLUSIONS: Our research shows that an increased number of organ system injuries is associated with greater intrahospital mortality in polytrauma patients with complete cSCI.

The Central Cord Score: A Novel Classification and Scoring System Specific to Acute Traumatic Central Cord Syndrome.

BACKGROUND: Acute traumatic central cord syndrome (ATCCS) is the most common form of spinal cord injury in the United States. Treatment remains controversial, which is a consequence of ATCCS having an inherently different natural history from conventional spinal cord injury, thus requiring a separate classification system. We devised a novel Central Cord Score (CCscore), which both guides treatment and tracks improvement over time with symptoms specific to ATCCS. METHODS: Medical records of patients with a diagnosis of ATCCS were retrospectively reviewed at a single institution. The CCscore was devised based on signs, symptoms, and imaging findings we believed to be critical in assessing severity of ATCCS. Numeric values were assigned for distal upper extremity motor strength, upper extremity sensation, ambulatory status, magnetic resonance imaging cord signal, and urinary retention. RESULTS: We identified 51 patients with follow-up data; there were 17 cases of mild injury (CCscore 1-5), 23 moderate cases (CCscore 6-10), and 11 severe cases (CCscore 11-15). Patients treated surgically had significantly greater improvement in upper extremity motor scores and total CCscore only up to 3 months. In terms of timing of surgery, patients treated <24 hours after injury had significantly improved upper extremity motor scores and overall CCscores at last follow-up of ≥3 months. CONCLUSIONS: Based on these data and their alignment with past literature, the CCscore is able to objectively and specifically categorize the severity and outcome of ATCCS, which represents a step forward in the quest to determine the ultimate efficacy and timing of surgery for ATCCS.

Central Cord Syndrome Redefined.

This article reviews the historical origins of central cord syndrome (CCS), the mechanism of injury, pathophysiology, and clinical implications. CCS is the most common form of incomplete spinal cord injury. CCS involves a spectrum of neurologic deficits preferentially affecting the hands and arms. Evidence suggests that in the twenty-first century CCS has become the most common form of spinal cord injury overall. In an era of big data and the need to standardize this particular diagnosis to unite outcome data, we propose redefining CCS as any adult cervical spinal cord injury in the absence of fracture/dislocation.

Penetrating Spinal Cord Injury in civilians: analysis of a national database.

BACKGROUND: Spinal trauma is common in polytrauma; spinal cord injury (SCI) is present in a subset of these patients. Penetrating SCI has been studied in the military; however, civilian SCI is less studied. Civilian injury pathophysiology varies given the generally lower velocity of the projectiles. We sought to investigate civilian penetrating SCI in the United States. METHODS: We queried the National Inpatient Sample for data regarding penetrating spinal cord injury from the past 10 years (2006-2015). The National Inpatient Sample includes data of 20% of discharged patients from U.S. hospitals. We analyzed trends of penetrating SCI regarding its diagnosis, demographics, surgical management, length of stay, and hospital costs. RESULTS: In the past 10 years the incidence of penetrating SCI in all SCI patients has remained stable with a mean of 5.5% (range 4.3%-6.6%). Of the patients with penetrating SCI, only 17% of them underwent a surgical procedure, compared with 55% for nonpenetrating SCI. Patients with penetrating SCI had a longer length of stay (average 23 days) compared with nonpenetrating SCI (15 days). Hospital charges were higher for penetrating SCI: $230,186 compared with $192,022 for closed SCI. Males patients were more affected by penetrating SCI, as well as black and Hispanic populations compared with whites. CONCLUSIONS: Penetrating SCI represents 5.5% of all SCI patients. Men, blacks, and Hispanics are disproportionally more affected by penetrating SCI. Patients with penetrating SCI have fewer surgical interventions, but their overall length of stay and hospital costs are greater compared with nonpenetrating SCI.

Heterotopic ossification and radiographic adjacent-segment disease after cervical disc arthroplasty.

OBJECTIVE: Cervical disc arthroplasty (CDA) is an accepted motion-sparing technique associated with favorable patient outcomes. However, heterotopic ossification (HO) and adjacent-segment degeneration are poorly understood adverse events that can be observed after CDA. The purpose of this study was to retrospectively examine 1) the effect of the residual exposed endplate (REE) on HO, and 2) identify risk factors predicting radiographic adjacent-segment disease (rASD) in a consecutive cohort of CDA patients. METHODS: A retrospective cohort study was performed on consecutive adult patients (≥ 18 years) who underwent 1- or 2-level CDA at the University of Calgary between 2002 and 2015 with > 1-year follow-up. REE was calculated by subtracting the anteroposterior (AP) diameter of the arthroplasty device from the native AP endplate diameter measured on lateral radiographs. HO was graded using the McAfee classification (low grade, 0-2; high grade, 3 and 4). Change in AP endplate diameter over time was measured at the index and adjacent levels to indicate progressive rASD. RESULTS: Forty-five patients (58 levels) underwent CDA during the study period. The mean age was 46 years (SD 10 years). Twenty-six patients (58%) were male. The median follow-up was 29 months (IQR 42 months). Thirty-three patients (73%) underwent 1-level CDA. High-grade HO developed at 19 levels (33%). The mean REE was 2.4 mm in the high-grade HO group and 1.6 mm in the low-grade HO group (p = 0.02). On multivariable analysis, patients with REE > 2 mm had a 4.5-times-higher odds of developing high-grade HO (p = 0.02) than patients with REE ≤ 2 mm. No significant relationship was observed between the type of artificial disc and the development of high-grade HO (p = 0.1). RASD was more likely to develop in the lower cervical spine (p = 0.001) and increased with time (p < 0.001). The presence of an artificial disc was highly protective against degenerative changes at the index level of operation (p < 0.001) but did not influence degeneration in the adjacent segments. CONCLUSIONS: In patients undergoing CDA, high-grade HO was predicted by REE. Therefore, maximizing the implant-endplate interface may help to reduce high-grade HO and preserve motion. RASD increases in an obligatory manner following CDA and is highly linked to specific levels (e.g., C6-7) rather than the presence or absence of an adjacent arthroplasty device. The presence of an artificial disc is, however, protective against further degenerative change at the index level of operation.

Neurotrauma From Border Wall Jumping: 6 Years at the Mexican-American Border Wall.

BACKGROUND: The border between the United States (US) and Mexico is an international boundary spanning 3000 km, where unauthorized crossings occur regularly. We examine patterns of neurotrauma, health care utilization, and financial costs at our level 1 trauma center incurred by patients from wall-jumping into the US. OBJECTIVE: To determine the clinical and socioeconomic consequences from neurotrauma as a result of jumping over the US-Mexico border wall. METHODS: Medical records of patients at (Banner University of Arizona Medical Center - Tucson) were retrospectively reviewed from January 2012 through December 2017. Demographics, clinical status, radiographic findings, treatment, length of stay, and financial data were analyzed for all patients suffering neurotrauma during that time. RESULTS: Over 6 yr, 64 patients sustained cranial or spinal injuries directly from jumping or falling onto US soil from the border wall. Fifty (78%) suffered spinal injuries, 15 (23%) experienced cranial injury, and 1 patient had both. Total medical charges were available in 36 patients and summed $3.6 M, of which 22% was reimbursed, an amount significantly lower than expected from more conventional trauma. Neurotrauma steadily declined over the 6-yr observation period, dropping in 2017 to 6% of rates observed in 2012. CONCLUSION: In the Southern US, neurotrauma from unauthorized border crossings occurs commonly as a result of wall-jumping. These injuries represent a clinical and costly extreme of border-related trauma, and future efforts from both sides of the border wall are needed to decrease the detrimental impacts felt both by immigrants and surrounding health care systems.

The role of diffusion tensor imaging in the diagnosis, prognosis, and assessment of recovery and treatment of spinal cord injury: a systematic review.

OBJECTIVEDiffusion tensor imaging (DTI) is an MRI tool that provides an objective, noninvasive, in vivo assessment of spinal cord injury (SCI). DTI is significantly better at visualizing microstructures than standard MRI sequences. In this imaging modality, the direction and amplitude of the diffusion of water molecules inside tissues is measured, and this diffusion can be measured using a variety of parameters. As a result, the potential clinical application of DTI has been studied in several spinal cord pathologies, including SCI. The aim of this study was to describe the current state of the potential clinical utility of DTI in patients with SCI and the challenges to its use as a tool in clinical practice.METHODSA search in the PubMed database was conducted for articles relating to the use of DTI in SCI. The citations of relevant articles were also searched for additional articles.RESULTSAmong the most common DTI metrics are fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity. Changes in these metrics reflect changes in tissue integrity. Several DTI metrics and combinations thereof have demonstrated significant correlations with clinical function both in model species and in humans. Its applications encompass the full spectrum of the clinical assessment of SCI including diagnosis, prognosis, recovery, and efficacy of treatments in both the spinal cord and potentially the brain.CONCLUSIONSDTI and its metrics have great potential to become a powerful clinical tool in SCI. However, the current limitations of DTI preclude its use beyond research and into clinical practice. Further studies are needed to significantly improve and resolve these limitations as well as to determine reliable time-specific changes in multiple DTI metrics for this tool to be used accurately and reliably in the clinical setting.

Outcomes in different age groups with primary Ewing sarcoma of the spine: a systematic review of the literature.

OBJECTIVEEwing sarcoma (ES) is among the most prevalent of bone sarcomas in young people. Less often, it presents as a primary lesion of the spine (5%-15% of patients with ES).METHODSA systematic literature search was performed, querying several scientific databases per PRISMA guidelines. Inclusion criteria specified all studies of patients with surgically treated ES located in the spine. Patient age was categorized into three groups: 0-13 years (age group 1), 14-20 years (age group 2), and > 21 (age group 3).RESULTSEighteen studies were included, yielding 28 patients with ES of the spine. Sixty-seven percent of patients experienced a favorable outcome, with laminectomies representing the most common (46%) of surgical interventions. One-, 2-, and 5-year survival rates were 82% (n = 23), 75% (n = 21), and 57% (n = 16), respectively. Patients in age group 2 experienced the greatest mortality rate (75%) compared to age group 1 (9%) and age group 3 (22%). The calculated relative risk score indicated patients in age group 2 were 7.5 times more likely to die than other age groups combined (p = 0.02).CONCLUSIONSPrimary ES of the spine is a rare, debilitating disease in which the role of surgery and its impact on one's quality of life and independence status has not been well described. This study found the majority of patients experienced a favorable outcome with respect to independence status following surgery and adjunctive treatment. An increased risk of recurrence and death was also present among the adolescent age group (14-20 years).