A Randomized Controlled Trial of Early versus Late Surgical Decompression for Thoracic and Thoracolumbar Spinal Cord Injury in 73 Patients.
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ABSTRACT:
SUBMITTER: Haghnegahdar A
PROVIDER: S-EPMC8240887 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Intervertebral disc herniation is a common cause of spinal cord compression, especially for the thoracic and thoracolumbar spinal cord, which has limited buffer space in the spinal canal. Spinal cord compression usually causes decreased sensation and paralysis of limbs below the level of compression, urinary and fecal incontinence, and/or urinary retention, which brings great suffering to the patients and usually requires surgical intervention. Thoracotomy or abdominothoracic surgery is usually performed for the thoracolumbar cord compression caused by hard intervertebral disc herniation. However, there is high risk of trauma and complications with this surgery. To reduce the surgical trauma and obtain good visibility, we designed athoracic endoscopic-assisted mini-open surgery for thoracic and thoracolumbar disc herniation, and performed this procedure on 10 patients who suffered from hard thoracic or thoracolumbar spinal cord compression. During the procedure, the thoracic endoscopy provided clear vision of the surgical field with a good light source. The compression could be fully exposed and completely removed, and no nerve root injury or spinal cord damage occurred. All patients achieved obvious recovery of neurological function after this procedure. This technique possesses the merits of minimal trauma, increased safety, and good clinical results. The aim of this study is to introduce this thoracic endoscopic-assisted mini-open surgery technique, and we believe that this technique will be a good choice for the thoracic and thoracolumbar cord compression caused by hard intervertebral disc herniation.
| S-EPMC6584088 | biostudies-literature
Project description:BackgroundThe most frequent late complications in spinal cord injury result from arachnoiditis and consequent alterations in dynamics of cerebrospinal fluid flow. A surgical procedure carried out on patients with these alterations, resolved the various pathologies more efficiently in all cases.MethodsFrom October 2000 to March 2006, 23 patients were selected for surgery: three showed signs of syringomyelia, three presented with microcystic lesions, three presented with arachnoid cysts in different locations but always confluent to the scar area, and 14 showed evidence of tethered cords. The surgery consisted of laminectomy at four levels, followed by dural opening in order to remove all the arachnoiditis at the level of the scar and to remove the altered arachnoid and its cysts, at least at two levels above and below the lesion. The dentate ligaments were cut at all exposed levels.ResultsThe patients had no postoperative problems and not only retained all neurological functions but also showed neurological recovery. According to the motor and sensory scale of the American Spinal Injury Association, the recoveries were motor 20.6% (P < 0.001), touch 15.6% (P < 0.001) and pinprick 14.4% (P < 0.001). These patients showed no signs of relapse at 4-66 month follow-up.ConclusionThis alternative surgery resolved the pathologies provoking neurological deterioration by releasing the complete spinal cord at the level of the scar and the levels above and below it. It thus avoids myelotomies and the use of shunts and stents, which have a high long-term failure rate and consequent relapses. Nevertheless, this surgical procedure allows patients the chance to opt for any further treatment that may evolve in the future.
| S-EPMC1626077 | biostudies-literature
Project description:The clinical sign of ataxia is related to several neurological diseases and is seen in conjunction with paresis in dogs with spinal cord injury (SCI). Endeavours to objectify canine spinal ataxia in SCI remain limited. The aim of this clinical study was to determine and quantify differences between gait characteristics of ataxic dogs with thoracolumbar myelopathy and healthy control dogs using a computer-and treadmill-based gait analysis system. Five dogs with spinal ataxia and six healthy dogs underwent video-and computer-assisted gait analysis while walking on a four-ground reaction force plate treadmill system (maximum speed of 0.7 m/s). Spatio-temporal and kinetic gait characteristics regarding the dogs' locomotion were analysed with a focus on the individual coefficient of variation (CV), as a potential measure for quantification of the level of ataxia. Ataxic dogs with thoracolumbar SCI showed no effect on symmetry indices but higher variability in spatio-temporal and kinetic gait parameters mainly in the pelvic, but also in the thoracic limbs. Double support phase of the individual limb was prolonged in SCI dogs at the cost of the single support and swing phase. Reduced peaks of ground reaction forces (GRF) could potentially be explained by reduction of muscle strength, as a strategy of avoiding falling by taking enthusiastic steps, or by alteration of the rhythmogenic spinal circuits between the pelvic and thoracic limb pattern generators.
| S-EPMC10442642 | biostudies-literature
Project description:ImportanceThe optimal clinical management of central cord syndrome (CCS) remains unclear; yet this is becoming an increasingly relevant public health problem in the face of an aging population.ObjectiveTo provide a head-to-head comparison of the neurologic and functional outcomes of early (<24 hours) vs late (≥24 hours) surgical decompression for CCS.Design, setting, and participantsPatients who underwent surgery for CCS (lower extremity motor score [LEMS] - upper extremity motor score [UEMS] ≥ 5) were included in this propensity score-matched cohort study. Data were collected from December 1991 to March 2017, and the analysis was performed from March 2020 to January 2021. This study identified patients with CCS from 3 international multicenter studies with data on the timing of surgical decompression in spinal cord injury. Participants were included if they had a documented baseline neurologic examination performed within 14 days of injury. Participants were eligible if they underwent surgical decompression for CCS.ExposuresEarly surgery was compared with late surgery.Main outcomes and measuresPropensity scores were calculated as the probability of undergoing early compared with late surgery using the logit method and adjusting for relevant confounders. Propensity score matching was performed in a 1:1 ratio by an optimal-matching technique. The primary end point was motor recovery (UEMS, LEMS, American Spinal Injury Association [ASIA] motor score [AMS]) at 1 year. Secondary end points were Functional Independence Measure (FIM) motor score and complete independence in each FIM motor domain at 1 year.ResultsThe final study cohort consisted of 186 patients with CCS. The early-surgery group included 93 patients (mean [SD] age, 47.8 [16.8] years; 66 male [71.0%]), and the late-surgery group included 93 patients (mean [SD] age, 48.0 [15.5] years; 75 male [80.6%]). Early surgical decompression resulted in significantly improved recovery in upper limb (mean difference [MD], 2.3; 95% CI, 0-4.5; P = .047), but not lower limb (MD, 1.1; 95% CI, -0.8 to 3.0; P = .30), motor function. In an a priori-planned subgroup analysis, outcomes were comparable with early or late decompressive surgery in patients with ASIA Impairment Scale (AIS) grade D injury. However, in patients with AIS grade C injury, early surgery resulted in significantly greater recovery in overall motor score (MD, 9.5; 95% CI, 0.5-18.4; P = .04), owing to gains in both upper and lower limb motor function.Conclusions and relevanceThis cohort study found early surgical decompression to be associated with improved recovery in upper limb motor function at 1 year in patients with CCS. Treatment paradigms for CCS should be redefined to encompass early surgical decompression as a neuroprotective therapy.
| S-EPMC9520438 | biostudies-literature
Project description:INTRODUCTION:The aim of this study is to evaluate whether early (<8 h) surgical decompression is better in improving neurologic outcomes than late (?8 h) surgical decompression for traumatic spinal cord injury (tSCI). METHODS:The various electronic databases were used to detect relevant articles published up until May 2016 that compared the outcomes of early versus late surgery for tSCI. Data searching, extraction, analysis, and quality assessment were performed according to Cochrane Collaboration guidelines. The results are presented as relative ratio (RR) for binary outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). RESULTS:Seven studies were finally included in this meta-analysis. There were significant differences between the 2 groups in neurologic improvement (MD = 0.54, 95% CI = -18.52 to -7.02, P < 0.0001) and length of hospital stay (MD = -12.77, 95% CI = 0.34-0.74, P < 0.00001). However, no significant differences were found between the 2 groups in perioperative complications (OR = 0.95, 95% CI = 0.35-2.61, P = 0.92). CONCLUSIONS:Early surgical decompression within 8 h after tSCI was beneficial in terms of neurologic improvement compared with late surgery. Early surgical decompression (within 8 h) is recommended for patients with tSCI. LEVEL OF EVIDENCE:Level III, therapeutic study.
| S-EPMC6136335 | biostudies-literature
Project description:ObjectivesThe burden of pain after spinal cord injury (SCI), which may occur above, at, or below injury level, is high worldwide. Spinal cord stimulation (SCS) is an important neuromodulation pain therapy, but its efficacy in SCI pain remains unclear. In SCI rats, we tested whether conventional SCS (50 Hz, 80% motor threshold [MoT]) and 1200 Hz, low-intensity SCS (40% MoT) inhibit hind paw mechanical hypersensitivity, and whether conventional SCS attenuates evoked responses of wide-dynamic range (WDR) neurons in lumbar spinal cord.Materials and methodsMale rats underwent a moderate contusive injury at the T9 vertebral level. Six to eight weeks later, SCS or sham stimulation (120 min, n = 10) was delivered through epidural miniature electrodes placed at upper-lumbar spinal cord, with using a crossover design. Mechanical hypersensitivity was examined in awake rats by measuring paw withdrawal threshold (PWT) to stimulation with von Frey filaments. WDR neurons were recorded with in vivo electrophysiologic methods in a separate study of anesthetized rats.ResultsBoth conventional SCS and 1200 Hz SCS increased PWTs from prestimulation level in SCI rats, but the effects were modest and short-lived. Sham SCS was not effective. Conventional SCS (10 min) at an intensity that evokes the peak Aα/β waveform of sciatic compound action potential did not inhibit WDR neuronal responses (n = 19) to graded or repeated electrical stimulation that induces windup.ConclusionsConventional SCS and 1200 Hz, low-intensity SCS modestly attenuated below-level mechanical hypersensitivity after SCI. Inhibition of WDR neurons was not associated with pain inhibition from conventional SCS.
| S-EPMC7855640 | biostudies-literature
Project description:The number of elderly patients with spinal cord injury without radiographic abnormalities (SCIWORA) has been increasing in recent years and common of most cervical spinal cord injuries. Basic research has shown the effectiveness of early decompression after spinal cord injury on the spinal cord without stenosis; no studies have reported the efficacy of decompression in models with spinal cord compressive lesions. The purpose of this study was to evaluate the effects of decompression surgery after acute spinal cord injury in rats with chronic spinal cord compressive lesions, mimicking SCIWORA. A water-absorbent polymer sheet (Aquaprene DX, Sanyo Chemical Industries) was inserted dorsally into the 4-5th cervical sublaminar space in 8-week-old Sprague Dawley rats to create a rat model with a chronic spinal compressive lesion. At the age of 16 weeks, 30 mildly myelopathic or asymptomatic rats with a Basso, Beattie, and Bresnahan score (BBB score) of 19 or higher were subjected to spinal cord compression injuries. The rats were divided into three groups: an immediate decompression group (decompress immediately after injury), a sub-acute decompression group (decompress 1 week after injury), and a non-decompression group. Behavioral and histological evaluations were performed 4 weeks after the injury. At 20 weeks of age, the BBB score and FLS (Forelimb Locomotor Scale) of both the immediate and the sub-acute decompression groups were significantly higher than those of the non-decompression group. There was no significant difference between the immediate decompression group and the sub-acute decompression group. TUNEL (transferase-mediated dUTP nick end labeling) staining showed significantly fewer positive cells in both decompression groups compared to the non-decompression group. LFB (Luxol fast blue) staining showed significantly more demyelination, and GAP-43 (growth associated protein-43) staining tended to show fewer positive cells in the non-decompression group. Decompression surgery in the acute or sub-acute phase of injury is effective after mild spinal cord injury in rats with chronic compressive lesions. There was no significant difference between the immediate decompression and sub-acute decompression groups.
| S-EPMC9402533 | biostudies-literature
Project description:The role of decompressing the intradural space through a durotomy as a treatment option for acute traumatic cervical spinal cord injury has not been explored in an animal model, to our knowledge. We sought to determine the role of durotomy and duraplasty in the treatment of acute cervical spinal cord injury and its effects on inflammation, scar formation, and functional recovery.Seventy-two adult female Sprague-Dawley rats were assigned to three groups: contusion injury alone, contusion injury with a decompressive durotomy, and contusion injury with a decompressive durotomy followed by placement of a dural allograft. A mild (200-kdyn [2-N]) contusive injury was delivered to the exposed spinal cord at C5. The injured segment was reexposed four hours after injury, and a durotomy with decompression was performed. When a dural allograft was used it was affixed to the surrounding intact dura with use of a fibrin sealant. The Grip Strength Meter was used to assess forelimb function. Animals were killed at two and four weeks, and immunohistochemical analysis was performed to assess scar formation, inflammatory cell infiltration, and lesional volume.Immunohistochemical analysis revealed increased scar formation, cavitation, and inflammatory response in the animals treated only with a decompressive durotomy. Relative to the group with a contusion injury alone, the animals treated with a durotomy followed by a dural allograft had decreased cavitation and scar formation. Lesional volume measurements showed a significantly increased cavitation size at four weeks in both the contusion-only (mean and standard deviation, 12.6 +/- 0.5 mm(3)) and durotomy-only (15.1 +/- 1 mm(3)) groups relative to the animals that had received a dural allograft following durotomy (6.8 +/- 1.4 mm(3)).Functional recovery after acute cervical spinal cord injury was better in animals treated with decompression of the intradural space and placement of a dural allograft than it was in animals treated with decompression alone. These functional data correlated directly with histological evidence of a decrease in spinal cord cavitation, inflammation, and scar formation.
| S-EPMC2859904 | biostudies-other
Project description:Acute thoracolumbar spinal cord injury (SCI) is common in dogs frequently secondary to intervertebral disc herniation. Following severe injury, some dogs never regain sensory function to the pelvic limbs or tail and are designated chronically "deep pain negative." Despite this, a subset of these dogs develop spontaneous motor recovery over time including some that recover sufficient function in their pelvic limbs to walk independently without assistance or weight support. This type of ambulation is commonly known as "spinal walking" and can take up to a year or more to develop. This review provides a comparative overview of locomotion and explores the physiology of locomotor recovery after severe SCI in dogs. We discuss the mechanisms by which post-injury plasticity and coordination between circuitry contained within the spinal cord, peripheral sensory feedback, and residual or recovered supraspinal connections might combine to underpin spinal walking. The clinical characteristics of spinal walking are outlined including what is known about the role of patient or injury features such as lesion location, timeframe post-injury, body size, and spasticity. The relationship between the emergence of spinal walking and electrodiagnostic and magnetic resonance imaging findings are also discussed. Finally, we review possible ways to predict or facilitate recovery of walking in chronically deep pain negative dogs. Improved understanding of the mechanisms of gait generation and plasticity of the surviving tissue after injury might pave the way for further treatment options and enhanced outcomes in severely injured dogs.
| S-EPMC7479830 | biostudies-literature
Project description:BackgroundMetastatic spinal cord compression (MSCC) treatment depends on life expectancies. Data regarding palliative decompression outcomes is scarce. We demonstrate that surgical timing has a significant impact on survival in MSCC patients treated with palliative decompression.MethodsEighty-nine consecutive MSCC patients at a tertiary referral medical center were enrolled between January 2012 and February 2016. Wide laminectomy was performed for tumors invading the vertebral body. Debulking surgery was done for tumors damaging the posterior column of the spine. Patient records were retrospectively analyzed.ResultsBetter survival was observed in patients with preoperative intact motor function (Group A, n = 37) than in those with motor deficit (Group B, n = 52, p = 0.0031). In Group B, survival was better in those who underwent surgery within 7 days of motor deficit onset than in those who underwent surgery 7 days after onset (p = 0.0444) and in postoperative ambulant patients than in nonambulant patients (p = 0.0120). In Group B, Frankel grade improved in patients who underwent surgery within 48 h than in those who underwent surgery after 48 h (p = 0.0992). Group A patients had a shorter hospital stay and higher revised Tokuhashi score than Group B patients. Overall survival was better in patients with a lower Tomita score (?5, p = 0.0012), higher revised Tokuhashi score (?9, p = 0.0009), better preoperative Frankel grade (p < 0.0001), and younger age (?55 years, p = 0.0179). There were no significant differences in age, sex, tumor type, involved vertebrae level, Tomita score, intraoperative blood loss, operation time, incidence of infection, and postoperative complications between groups.ConclusionWe can improve the survival of MSCC patients with palliative decompression before motor deficits occur. After motor deficit onset, survival can still be improved with surgery within 7 days. Overall survival was better in patients aged ?55 years.
| S-EPMC5747484 | biostudies-literature