James S. Harrop

A New Classification of Thoracolumbar Injuries: The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status

Study Design. A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management. Objective. To devise a practical, yet comprehensive, classification system for TL injuries that assists in clinical decision-making in terms of the need for operative versus nonoperative care and surgical treatment approach in unstable injury patterns. Summary of Background Data. The most appropriate classification of traumatic TL spine injuries remains controversial. Systems currently in use can be cumbersome and difficult to apply. None of the published classification schemata is constructed to aid with decisions in clinical management. Methods. Clinical spine trauma specialists from a variety of institutions around the world were canvassed with respect to information they deemed pivotal in the communication of TL spine trauma and the clinical decision-making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. An initial validation process to determine the reliability and validity of an earlier version of this system was also undertaken. Results. A new classification system called the Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based on three injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. A composite injury severity score was calculated from these characteristics stratifying patients into surgical and nonsurgical treatment groups. Finally, a methodology was developed to determine the optimum operative approach for surgical injury patterns. Conclusions. Although there will always be limitations to any cataloging system, the TLICS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurologic compromise. This classification system is intended to be easy to apply and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use. The TLICS may improve communication between spine trauma physicians and the education of residents and fellows. Further studies are underway to determine the reliability and validity of this tool.

Agreement between orthopedic surgeons and neurosurgeons regarding a new algorithm for the treatment of thoracolumbar injuries: a multicenter reliability study.

Introduction Considerable variability exists in the management of thoracolumbar (TL) spine injuries. Although there are many influences, one significant factor may be the treating surgeons specialty and training (ie, orthopedic surgery vs. neurosurgery). Our objective was to assess the agreement between spinal orthopedic and neurologic surgeons in rating the severity of TL spine injuries with a new treatment algorithm. This information could be important in establishing consensus-based protocols for managing these challenging injuries. Methods Twenty-eight spinal surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 TL injury case histories. Each case was classified and scored according to the TL injury severity score (TLISS). The case histories were reordered and the physicians repeated the exercise 3 months later. At both intervals the surgeons were asked if they agreed with the final treatment recommendation of the TLISS algorithm. The reliability and decision validity of the TLISS was compared. Results Between-group interrater reliability was similar to within group reliabilities. Intrarater reliability was also similar between groups. The between speciality interrater reliability of the TLISS management recommendation was moderate (74% agreement, κ=0.532). Orthopedic and neurosurgeons agreed with the TLISS management recommendation 91.4% and 94.4% of the time, respectively. Conclusions The TLISS demonstrated good reliability in terms of intraobserver and interobserver agreement on the algorithmic treatment recommendations. The recommendation for operation seems to be consistent between fellowship-trained orthopedic and neurosurgical spine surgeons. This type of classification system may reduce the existing variability and initial management decision for treatment of TL injuries.

Similarities and differences in the treatment of spine trauma between surgical specialties and location of practice.

Study Design. Questionnaires administered to practicing orthopedic and neurosurgical spine surgeons from various regions of the United States and abroad. Objectives. To determine similarities and differences in the treatment of spinal trauma. Summary of Background Data. Spinal trauma is generally referred to subspecialists of orthopedic or neurosurgical training. Prior studies have suggested that there is significant variability in the management of such injuries. Methods. Questionnaires based on eight clinical scenarios of commonly encountered cervical, thoracic, and lumbar injuries were administered to 35 experienced spinal surgeons. Surgeons completed profile information and answered approximately one dozen questions for each case. Data were analyzed with SPSS software to determine the levels of agreement and characteristics ofrespondents that might account for a lack of agreement on particular aspects of management. Results. Of the 35 surgeons completing the questionnaire, 63% were orthopedists, 37% were neurosurgeons, and 80% had been in practice for more than 5 years. Considerable agreement was found in the majority of clinical decisions, including whether or not to operate and the timing of surgery. Of the differences noted, neurosurgeons were more likely to obtain a MRI, and orthopedists were more likely to use autograft as a sole graft material. Physicians from abroad were, in general, more likely to operate and to use an anterior approach during surgery than physicians from the northeastern United States. Conclusions. More commonalities were identified in the management of spinal trauma than previously reported. When found, variability in opinion was related to professional and regional differences. Spine 2004;29:685–696

The Impact of Facet Dislocation on Clinical Outcomes after Cervical Spinal Cord Injury: Results of a Multicenter North American Prospective Cohort Study.

Study Design. A multicenter prospective cohort study. Objective. To define differences in baseline characteristics and long-term clinical outcomes in patients with cervical spinal cord injury (SCI) with and without facet dislocation (FD). Summary of Background Data. Reports of dramatic neurological improvement in patients with FD and cervical SCI, treated with rapid reduction have led to the hypothesis that this represents a subgroup of patients with significant recovery potential. However, without a large systematic comparative analysis, this hypothesis remains untested. Methods. Patients were classified into FD and non-FD groups based on imaging investigations at admission. The primary outcome was change in American Spinal Injury Association (ASIA) motor score (AMS) at 1-year follow-up. Secondary outcome measures included ASIA impairment scale (AIS) grade conversion and functional independence measure score at 1-year postinjury, as well as length of acute hospitalization. Baseline characteristics and long-term outcomes were also compared for patients with unilateral and bilateral FD. Results. Of 421 patients who enrolled, 135 (32.1%) had FD and 286 (67.9%) had no FD. Patients in the FD group presented with a significantly worse AIS grade and higher energy injury mechanisms (P < 0.01). Patients with bilateral FD had a greater severity of baseline neurological deficit compared with those with unilateral FD, measured by AIS grade and AMS. The mean length of acute hospitalization was 41.2 days among patients with FD and 30 days among patients without FD (P = 0.04). At 1-year follow-up, patients with FD experienced a mean AMS improvement of 18.0 points, whereas patients without FD experienced an improvement of 27.9 points (P < 0.01). In the adjusted analysis, patients with FD continued to demonstrate less AMS recovery compared with the patients without FD (P = 0.04). Conclusion. Compared with patients without FD, cervical SCI patients with FD tended to present with a more severe degree of initial injury and displayed less potential for motor recovery at 1-year follow-up.

Acute quadriplegia following closed traction reduction of a cervical facet dislocation in the setting of ossification of the posterior longitudinal ligament: case report.

Study Design. A case report of acute quadriplegia resulting from closed traction reduction of traumatic bilateral cervical facet dislocation in a 54-year-old male with concomitant ossification of the posterior longitudinal ligament (OPLL). Objectives. To report an unusual presentation of a spinal cord injury, examine the approach to reversal of the injury, and review the treatment and management controversies of acute cervical facet dislocations in specific patient subgroups. Summary of Background Data. The treatment of acute cervical facet dislocations is an area of ongoing controversy, especially regarding the question of the necessity of advanced imaging studies before closed traction reduction of the dislocated cervical spine. The safety of an immediate closed, traction reduction of the cervical spine in awake, alert, cooperative, and appropriately select patients has been reported in several studies. To date, there have been no permanent neurologic deficits resulting from awake, closed reduction reported in the literature. A case of temporary, acute quadriplegia with complete neurologic recovery following successful closed traction reduction of a bilateral cervical facet dislocation in the setting of OPLL is presented. Methods. The clinical neurologic examination, radiographic, and advanced imaging studies before and after closed, traction reduction of a cervical facet dislocation are evaluated and discussed. A review of the literature regarding the treatment of acute cervical facet dislocations is presented. Results. Radiographs showed approximately 50% subluxation of the fifth on the sixth cervical vertebrae, along with computerized tomography revealing extensive discontinuous OPLL. The cervical facet dislocation was successfully reduced with an awake, closed traction reduction, before magnetic resonance imaging (MRI) evaluation. The patient subsequently had acute quadriplegia develop, with the ensuing MRI study illustrating severe spinal stenosis at the C5, C6 level as a result of OPLL or a large extruded disc herniation. Following an immediate anterior decompression and a posterior stabilization procedure, the patient regained full motor and sensory function. Conclusions. This case report highlights the advantages and shows some safety concerns regarding immediate, closed traction reduction of cervical facet dislocation with real-time neural monitoring in an awake, alert, oriented, and appropriately select patient before MRI studies in the setting of preexisting central stenosis from OPLL.

Gastroesophageal reflux after anterior cervical surgery: a controlled, prospective analysis.

Study Design. Prospective controlled clinical study. Objective. To determine the incidence and severity of GERD in patients undergoing anterior cervical decompression and fusion (ACDF), using patients undergoing posterior lumbar decompression as a control group. Summary of Background Data. The incidence gastroesophageal reflux disease (GERD) after anterior cervical decompression and fusion (ACDF) has not previously been studied. Methods. Patients undergoing either 1- or 2-level ACDF (n = 38) or posterior lumbar decompression surgery (control group, n = 56) were prospectively enrolled. Baseline patient characteristics were recorded. Intraoperative and postoperative medical records were reviewed. A validated GERD measurement tool (GERD Impact Scale, GIS) and a dysphagia questionnaire (including a dysphagia numeric rating score, range, 0–10) were administered preoperatively, and during the 2-week, 6-week, and 12-week postoperative visits. Results. Cervical patients had a significantly higher incidence of GERD at 2 weeks than the lumbar patients (78.9% vs. 42.9%, P = 0.001). Cervical patients had a higher incidence of GERD at 6 and 12 weeks as well, but these differences were not statistically significant. The change in GIS score from baseline was significantly higher in the cervical group at all follow-up time periods. On average, cervical patients required 1.2 doses of antacid medication in the postoperative period, compared to an average of 0.5 doses required by lumbar patients (P = 0.006). There was a significant correlation between the severity of dysphagia and the GIS score at 2 weeks, but no correlation at 6 or 12 weeks. Operative time did not correlate with the GIS score at any of the follow-up time periods. The number of surgical levels (i.e., one vs. two) and level of surgery (i.e., above C5–C6 vs. at or below C5–C6) had no effect on the GIS score. Conclusion. Compared to the lumbar control group, patients in the cervical group had increased incidence, and severity of GERD-like symptoms in the early postoperative period.

181 Guidelines for the Management of Patients With Spinal Cord Injury: The Optimal Timing of Decompression.

Abstract The objective of this study is to develop guidelines that outline the optimal timing of decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. A systematic review of the literature was conducted to address the following key questions: (1) What is the efficacy of early decompression (=24 hours) compared with late decompression (>24 hours) based on clinically important change in neurological status? (2) Does timing of decompression influence functional or administrative outcomes? (3) What is the safety profile of early decompression compared with late decompression? (4) What is the evidence that early decompression has differential efficacy or safety in subpopulations? (5) What is the comparative cost-effectiveness of early vs late decompression? A multidisciplinary guideline development group used this information, in combination with their clinical expertise, to develop recommendations for the optimal timing of SCI. The benefits and harms, financial impact, acceptability, feasibility, and patient preferences of each recommendation were carefully considered. The main conclusions from the systematic review included: (1) patients decompressed early were more likely to exhibit clinical improvement in neurological status at 6 months (cervical only) and at discharge from inpatient rehabilitation (all levels); (2) patients treated early for central cord syndrome achieved significantly greater improvements in neurological and functional status than those decompressed late; (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations included: We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome and We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level. These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by encouraging clinicians to make evidence-informed decisions.INTRODUCTIONnThe objective of this study is to develop guidelines that outline the optimal timing of decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome.nnnMETHODSnA systematic review of the literature was conducted to address the following key questions: (1) What is the efficacy of early decompression (=24 hours) compared with late decompression (>24 hours) based on clinically important change in neurological status? (2) Does timing of decompression influence functional or administrative outcomes? (3) What is the safety profile of early decompression compared with late decompression? (4) What is the evidence that early decompression has differential efficacy or safety in subpopulations? (5) What is the comparative cost-effectiveness of early vs late decompression? A multidisciplinary guideline development group used this information, in combination with their clinical expertise, to develop recommendations for the optimal timing of SCI. The benefits and harms, financial impact, acceptability, feasibility, and patient preferences of each recommendation were carefully considered.nnnRESULTSnThe main conclusions from the systematic review included: (1) patients decompressed early were more likely to exhibit clinical improvement in neurological status at 6 months (cervical only) and at discharge from inpatient rehabilitation (all levels); (2) patients treated early for central cord syndrome achieved significantly greater improvements in neurological and functional status than those decompressed late; (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations included: We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome and We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level.nnnCONCLUSIONnThese guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by encouraging clinicians to make evidence-informed decisions.

Occiput-Cervical Fixation

A 37-year-old male presents as an unrestrained passenger in a high speed motor vehicle accident. Cardiopulmonary resuscitation has been performed by fire rescue. He is resuscitated, immobilized,and transferred to the Emergency Department. The patient arrives intubated and immobilized on a long board.

Spinal disassociation masquerading as iatrogenic listhesis above a previous fusion.

Study Design. A case of remarkable instability adjacent to an L5–S1 fusion is reported. Objectives. The objective of this study was to review a case of marked instability adjacent to a prior fusion. Diagnostic workup and surgical management options are discussed. Summary of Background Data. Junctional degeneration above or below the levels of a spinal fusion may be associated with instability. We present an unusual case of instability whose severity was only apparent when the patient was under general anesthesia. Materials and Methods. A 52-year-old man with a history of prior L5–S1 fusion presented with severe back pain and lower extremity weakness. Workup including multiple imaging methods revealed junctional degeneration and a Grade I spondylolisthesis at L4–L5 with minimal translation on dynamic imaging. Operative intervention was planned. Results. Intraoperative imaging revealed marked distraction at the L4–L5 disc space not apparent on preoperative dynamic films. The surgical approach was modified accordingly. Conclusions. Adjacent segment degeneration next to a prior lumbar fusion may be associated with extreme instability. Treatment may require complex stabilization.