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.

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.

Early Impact of Postoperative Bracing on Pain and Quality of Life After Posterior Instrumented Fusion for Lumbar Degenerative Conditions: A Randomized Trial.

STUDY DESIGN: A randomized controlled trial. OBJECTIVE: To investigate whether bracing after posterior spinal instrumented fusion (PSIF) can improve pain relief and quality of life (QoL) 6 weeks and 3 months postoperatively. SUMMARY OF BACKGROUND DATA: Braces are commonly prescribed after PSIF in patients with lumbar degenerative conditions with the aim of improving pain relief and QoL. However, there is a lack of evidence on the indication for postoperative bracing, as surgeons use braces mainly based on their experience and training. METHODS: A randomized blinded and controlled trial of 43 patients with PSIF for lumbar degenerative conditions were recruited. The caregivers were blinded but not the orthotist in the present study. There were 25 patients in the brace group and 18 patients in the control group with similar baseline characteristics. All patients completed the Oswestry Disability Index (ODI), the short form (SF)-12v2 General Health Survey and Visual Analog Scale (VAS) for back pain preoperatively, at 6 weeks and 3 months follow-up. Wilcoxon-Mann-Whitney test and a level of significance of 0.05 were used for statistical analyses. RESULTS: Both groups had comparable demographic characteristics, and preoperative SF-12v2, ODI, and VAS scores. The ODI, SF-12v2, and VAS for back pain were improved in comparison to preoperative scores. The improvement was significant at 3 months follow-up regarding ODI and VAS for both groups and significant only for the control group regarding SF-12v2 scores. The improvement in ODI, SF-12v2, and VAS was significantly greater for control group at 3 months postoperatively. Moreover, larger proportion of patients in the control group reached minimum clinically important difference as compared to brace group at 6 weeks and 3 months. CONCLUSION: Postoperative bracing did not result in better improvement in QoL or pain relief up to 3 months after PSIF in patients with lumbar degenerative conditions. LEVEL OF EVIDENCE: 1.

Treatment of thoracolumbar burst fractures by means of anterior fusion and cage.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To evaluate the outcome of treating acute thoracolumbar burst fractures using anterior corpectomy and reconstruction with a mesh cage and instrumentation. SUMMARY OF BACKGROUND DATA: There is increasing interest in using an anterior mesh cage with instrumentation after corpectomy for burst fractures. However, there is only limited information on this technique in the literature. METHODS: Twenty-two patients (mean age 37.6 y old) that had sustained a thoracolumbar burst fracture were included in this study. On admission, 20 patients (90.9%) had an incomplete neurological deficit. An anterior thoracolumbar approach was used to perform anterior corpectomy and reconstruction with a mesh cage and lateral fixation with screws and dual rods. We studied the operation date and delayed the blood loss, and we used the American Spinal Injury Association grade to evaluate the neurological status before surgery and in the follow-up period. Local kyphosis measured by the Cobb method was compared before and after the surgery using Wilcoxon signed-rank test/2-tailed test for analysis. RESULTS: Ninety percent of patients were operated within 2 days after admission and all were followed for a minimum of 25 months. The mean follow-up period was 47.4 months (range, 25 to 71 mo). Blood loss averaged 1445 mL. Of the 20 patients with incomplete neurological lesions, there were 6 (30%) patients with an improvement of at least 1 American Spinal Injury Association grade. No neurological deterioration was observed in any case. The local kyphosis measured by the Cobb method was improved from a mean of 15 degrees preoperative to a mean of 9.6 degrees in early postoperative period (P=0.002). The mean after 2 years was 11.5 degrees (P=0.011). There was no instrumentation failure. CONCLUSIONS: Anterior thoracolumbar decompression and fusion secured with an anterior mesh cage and instrumentation in thoracolumbar burst fractures provided excellent immediate reduction of post-traumatic local kyphosis.

A phase I/IIa clinical trial of a recombinant Rho protein antagonist in acute spinal cord injury.

Multiple lines of evidence have validated the Rho pathway as important in controlling the neuronal response to growth inhibitory proteins after central nervous system (CNS) injury. A drug called BA-210 (trademarked as Cethrin(®)) blocks activation of Rho and has shown promise in pre-clinical animal studies in being used to treat spinal cord injury (SCI). This is a report of a Phase I/IIa clinical study designed to test the safety and tolerability of the drug, and the neurological status of patients following the administration of a single dose of BA-210 applied during surgery following acute SCI. Patients with thoracic (T2-T12) or cervical (C4-T1) SCI were sequentially recruited for this dose-ranging (0.3 mg to 9 mg Cethrin), multi-center study of 48 patients with complete American Spinal Injury Association assessment (ASIA) A. Vital signs; clinical laboratory tests; computed tomography (CT) scans of the spine, head, and abdomen; magnetic resonance imaging (MRI) of the spine, and ASIA assessment were performed in the pre-study period and in follow-up periods out to 1 year after treatment. The treatment-emergent adverse events that were reported were typical for a population of acute SCI patients, and no serious adverse events were attributed to the drug. The pharmacokinetic analysis showed low levels of systemic exposure to the drug, and there was high inter-patient variability. Changes in ASIA motor scores from baseline were low across all dose groups in thoracic patients (1.8±5.1) and larger in cervical patients (18.6±19.3). The largest change in motor score was observed in the cervical patients treated with 3 mg of Cethrin in whom a 27.3±13.3 point improvement in ASIA motor score at 12 months was observed. Approximately 6% of thoracic patients converted from ASIA A to ASIA C or D compared to 31% of cervical patients and 66% for the 3-mg cervical cohort. Although the patient numbers are small, the observed motor recovery in this open-label trial suggests that BA-210 may increase neurological recovery after complete SCI. Further clinical trials with Cethrin in SCI patients are planned, to establish evidence of efficacy.

Rare metastatic adenocarcinoma to the spine infiltrating three adjacent foramen in lumbar vertebrae.

An 83-year-old man presented with severe back pain and worsening neurodeficit. Lateral radiographs showed the presence of compression fractures of the L1 to L2 vertebral bodies. Computed tomography (CT) scan showed an intravertebral vacuum sign suggestive of ischemic fracture. Magnetic resonance imaging showed a large right retroperitoneal mass infiltrating the vertebral bodies and entering the spinal canal from L1 to L4 neural foramina. A fluid sign usually suggestive of acute compression fractures was seen near the superior end plate of the L1 vertebral body in our patient. Computed tomography-guided biopsy confirmed the diagnosis of metastatic adenocarcinoma. However, the primary site could not be found despite several investigations. It is usually thought that the primary tumor spreads to the spine through the valveless Batson's plexus or by direct arterial seeding into vertebral bodies. A paravertebral primary tumor such as a lymphoma, a primary tumor from the lungs, or a renal cell carcinoma can potentially infiltrate the vertebral bodies and enter the spinal canal through the neural foramen. But a large retroperitoneal metastatic mass from an unknown primary adenocarcinoma is a rare condition. No reports exist in the literature on a metastatic mass infiltrating vertebral bodies and then entering the epidural space through the 3 consecutive neural foramen. Thus, the pathogenesis of metastatic adenocarcinomas, particularly when the primary site is unknown, is not completely understood and can give a varied radiological presentation.

Posterior pedicle screw fixation with supplemental laminar hook fixation for the treatment of thoracolumbar burst fractures.

Surgical treatment of thoracolumbar burst fractures with posterior short-segment pedicle fixation usually provides excellent initial correction of kyphotic deformity, but a significant amount of correction can be lost afterwards. This study evaluates the clinical relevance of the short-segment pedicle fixation supplemented by laminar hooks (2HS-1SH) construct in the surgical treatment of thoracolumbar burst fractures. Twenty-five patients with a single-level thoracolumbar burst fracture were assessed in this retrospective study. All patients were followed for a minimum of 1 year (mean 2.9 [standard deviation {SD}] 1.5 y). Preoperative vertebral height loss and local kyphosis were 35% (SD 14%) and 19 degrees (SD 9 degrees ), respectively. Mean corrections of vertebral height and kyphosis were 10% (SD 16%) and 12 degrees (SD 9 degrees ), respectively. Mean loss of correction at last follow-up was 2% (SD 6%) and 4 degrees (SD 3 degrees ) for vertebral height and kyphosis, respectively. Loss of correction was significant for local kyphosis (p 0.001) but not for vertebral height (p = 0.20). Despite the significant loss of correction for local kyphosis, it remained improved at latest follow-up when compared with the preoperative value (p 0.001). For patients with more than 2 years of follow-up, most of the loss of correction in local kyphosis occurred during the first postoperative year. There was no evidence of instrumentation failure or pseudarthrosis in any patient. The 2HS-1SH construct provides significant correction of vertebral body height and local kyphosis. It also preserves the initial correction and minimizes the risk of instrumentation failure.