Peter C. Wing

A global map for traumatic spinal cord injury epidemiology: towards a living data repository for injury prevention

Study design:Literature review.Objectives:To map traumatic spinal cord injury (TSCI) globally and provide a framework for an ongoing repository of data for prevention.Setting:An initiative of the ISCoS Prevention Committee.Methods:The results obtained from the search of Medline/Embase using search phrases: TSCI incidence, aetiology, prevalence and survival were analysed. Stratification of data into green/yellow/red quality ‘zones’ allowed comparison between data.Results:Reported global prevalence of TSCI is insufficient (236–1009 per million). Incidence data was comparable only for regions in North America (39 per million), Western Europe (15 per million) and Australia (16 per million). The major cause of TSCI in these regions involves four-wheeled motor vehicles, in contrast to South-east Asia where two-wheeled (and non-standard) road transport predominates. Southern Asia and Oceania have falls from rooftops and trees as the primary cause. High-fall rates are also seen in developed regions with aged populations (Japan/Western Europe). Violence/self-harm (mainly firearm-related) was higher in North America (15%) than either Western Europe (6%) or Australia (2%). Sub-Saharan Africa has the highest reported violence-related TSCI in the world (38%). Rates are also high in north Africa/Middle East (24%) and Latin America (22%). Developed countries have significantly improved TSCI survival compared with developing countries, particularly for tetraplegia. Developing countries have the highest 1-year mortality rates and in some countries in sub-Saharan Africa the occurrence of a spinal injury is likely to be a fatal condition within a year.Conclusion:Missing prevalence and insufficient incidence data is a recurrent feature of this review. The piecemeal approach to epidemiological reporting of TSCI, particularly failing to include sound regional denominators has exhausted its utility. Minimum data collection standards are required.

Impact of surgical intervention on quality of life in patients with spinal metastases.

Study Design. Prospective clinical study. Objective. To assess Health-Related Quality of Life outcomes in patients undergoing surgery for spinal metastases. Summary of Background Data. Increasing life expectancy of patients with spinal metastases has resulted in greater interest in overall quality of life, including pain and neurologic impairment. To assess the overall risks and benefits of surgical intervention, the overall impact of each on the overall health status must be assessed. Methods. All patients who presented to a single institution with bony spinal metastases requiring surgical intervention were eligible. Exclusion criteria: previous surgery for spinal metastases, primary tumors of the spine, and inability to fill out the questionnaires. Patients completed an EORTC QLQ-C30, the HUI-3, the EQ-5D, visual analog pain, and an ECOG functional assessment. at five points: before surgery and at 6 weeks, 3 months, 6 months, and 1 year post surgery. Results. Of 96 patients who presented to the hospital, 85 were enrolled in the study. Average age was 58.6 years (range, 20.3–80.7 years) with 47 male patients; 50% survival as 39.1 weeks. Maximal and average VAS pain levels showed a statistically significant (P < 0.00001) improvement from preoperative to all postoperative time points. Only the QLQ-C30 global health status showed a statistically significant improvement from preoperative to the 6-week (P = 0.017), 3-month (P = 0.039), and 6-month (P = 0.013) time points. There was a statistically significant correlation between baseline global health status and survival time (P = 0.041). Overall distribution of HUI-3 utility calculated Quality of Life Adjusted Years (QALY) during the 1-year postoperative period showed a bimodal distribution with peaks at 0.1 and 0.7 years. Conclusions. Surgery for patients with spinal metastases offers decreased pain and improved quality of life with low rates of surgical complications.

Factors predicting motor recovery and functional outcome after traumatic central cord syndrome: a long-term follow-up.

Study Design. A prospectively maintained database-generated retrospective review and cross-sectional outcome analysis was performed at a single academic center. Objectives. To assess the improvement in ASIA motor score (AMS) and secondarily to assess generic health related quality of life (HRQoL) and functional status; correlating these with variables that may predict outcome. Summary of Background Data. Many variables are potential contributors to motor recovery, patient function, and outcome following cervical trauma. Studies often suffer from low power, short follow-up, heterogeneous cohorts, and use of outcome instruments that are neither valid nor psychometrically sound. Methods. AMS were collected within 72 hours of the time of injury and again at follow-up by trained examiners. The SF-36 and FIM were administered to all patients at follow-up. Results. AMS improved from a mean of 58.7 at injury to a mean of 92.3 at follow-up. Bowel and bladder continence was reported by 81% while independent ambulation was reported by 86%. Final AMS was positively correlated with the AMS at injury, formal education, and presence of spasticity at follow-up. Functional status (FIM) was positively correlated with higher AMS at injury, formal education, absence of comorbidities, absence of spasticity, and younger age. Generic HRQoL outcomes (SF-36) were improved in individuals with more formal education, fewer comorbidities, absence of spasticity, and anterior column fractures. Conclusions. Although the majority of patients improve to an AMS between 90 and 100, many have significant disability and are less functional than the general population. Significant predictive variables include the initial motor score, formal education, comorbidities, ageat injury, and development of spasticity. An assessment of more than just the motor score is required to obtain an appreciation of the function and outcomes in this population.

Effectiveness of titanium mesh cylindrical cages in anterior column reconstruction after thoracic and lumbar vertebral body resection.

Study Design. A retrospective cohort study with cross-sectional outcome analysis of patients who underwent anterior column reconstruction with a titanium mesh cage after single-level or multilevel thoracic or lumbar vertebrectomy. Objectives. To radiographically evaluate the ability of titanium mesh cages to maintain alignment and facilitate osseous fusion after thoracolumbar vertebrectomy. Secondary objectives assessed complications and patient outcome. Summary of Background Data. Titanium mesh cages with cancellous autograft bone for postvertebrectomy reconstruction of the thoracolumbar spine avoid some of the potential problems associated with the acquisition or use of structural autograft or allograft. There is little in the literature that describes the efficacy or outcomes of using cylindrical mesh titanium cages for postvertebrectomy reconstruction. Methods. The degree of kyphosis and the subsidence of the cage in relation to the vertebral endplates were measured in 43 of 57 (75%) patients available at a minimum of 2 years following titanium mesh cage reconstruction. Health-related quality of life and disability were assessed with various cross-sectional outcome measures. Results. The average kyphosis of 25.4° before surgery was reduced to 7.5° immediately after surgery, and at final follow-up was measured to be 10.4°. Cage subsidence averaged 0.28 and 0.20 cage fenestrations at the cephalad and caudal endplates, respectively. Osseous union (Grade 1 or 2) was identified in 93% of radiographs at the final follow-up. Thoracic reconstructions were significantly more likely to require surgical revision because of mechanical failure than thoracolumbar or lumbar reconstructions. Conclusion. The cylindrical mesh titanium cage is a successful adjunct in restoring and maintaining sagittal plane alignment after thoracolumbar vertebrectomy and, in this context, provides an effective method for anterior column reconstruction.

A prospective randomized controlled trial of anterior compared with posterior stabilization for unilateral facet injuries of the cervical spine.

OBJECT Unilateral facet injuries can be treated with either anterior or posterior fixation techniques with reportedly good outcomes. The two approaches have not been directly compared, however, and consensus is lacking as to which is the optimal method. The primary objective of this study was to determine whether acute postoperative morbidity differed between anteriorly and posteriorly treated patients with unilateral facet injuries. METHODS Forty-two patients were prospectively randomized to undergo either anterior cervical discectomy and fusion or posterior fixation. The primary outcome measure was the postoperative time required to achieve a predefined set of discharge criteria. Secondary outcome measures included postoperative pain, wound infections, radiographically demonstrated fusion and alignment, and patient-reported outcome measures. RESULTS The median time to achieve the discharge criteria was 2.75 and 3.5 days for anterior and posterior groups, respectively, a difference that did not reach statistical significance (p = 0.096). Compared with those treated using posterior fixation, anteriorly treated patients exhibited somewhat less postoperative pain, a lower rate of wound infection, a higher rate of radiographically demonstrated union, and better radiographically proven alignment. Nonetheless, the anterior approach was accompanied by a risk of swallowing difficulty in the early postoperative period. Patient-reported outcome measures did not reveal a difference between anterior and posterior fixation procedures. CONCLUSIONS This prospective randomized controlled trial provided level 1 evidence that both the anterior and posterior fixation approaches appear to be valid treatment options. Although statistical significance was not reached in the primary outcome measure, some secondary outcome measures favored anterior fixation and others favored posterior treatment for unilateral facet injuries.

Motor Recovery, Functional Status, and Health-Related Quality of Life in Patients With Complete Spinal Cord Injuries

Study Design. A retrospective cohort with cross- sectional follow-up. Objectives. The primary objective was to determine motor recovery in patients with complete traumatic spinal cord injury (SCI). Secondary objectives included: 1) determining which factors predict local recovery, 2) assessing functional status using the Functional Independence Measure (FIM), and 3) assessing generic health-related quality of life using the Short Form-36 (SF-36). Summary of Background Data. Motor recovery following complete SCI has been documented in the literature; however, it has been difficult to interpret: 1) spinal shock is often not addressed; 2) the definition of complete SCI has changed over the last 10 years; and 3) few studies differentiate between local neurologic recovery in the zone of partial preservation and neurologic recovery caudal to the lesion. Methods. All patients admitted to Vancouver Hospital with a complete SCI between 1994 and 2001 were identified and included in the study if they remained complete following the resolution of spinal shock. Minimum 2-year follow-up consisted of an ASIA motor score, an FIM, and the SF-36. Results. Of 133 patients identified, 94 were eligible and 70 completed follow-up. For the tetraplegic patients, the average ASIA motor score was 11.9 ± 10.7 on admission and 20.1 ± 10.8 at follow-up, a change reflecting local recovery only. For the paraplegic patients, the average ASIA motor score was 49.3 ± 2.4 on admission and 50.6 ± 1.7 at follow-up. Conclusions. Motor recovery does not occur below the zone of injury for patients with complete SCI. Varying degrees of local recovery can be expected in tetraplegic individuals.

Comparison of outcomes for unstable lower cervical flexion teardrop fractures managed with halo thoracic vest versus anterior corpectomy and plating.

Study Design. A retrospective cohort study with cross-sectional outcome analysis was conducted. Objectives. To compare the outcome for two groups of patients with unstable cervical flexion teardrop fractures: those treated with halo thoracic vests and those treated with anterior corpectomy and plating. Summary of Background Data. With the evolution of safe and effective anterior cervical plates, the treatment of unstable cervical flexion teardrop fractures has shifted from halo immobilization to surgical stabilization. Although outcomes for these treatment alternatives have been reported, the literature reflects the inherent bias of retrospective studies without standardized health-related quality-of-life outcomes and without a control or comparative group. Furthermore, study populations have lacked homogeneity with respect to fracture patterns. Methods. For this study, 45 patients with cervical flexion teardrop fractures and at least 2 years of follow-up evaluation were identified. Of these patients, 24 were treated with a halo thoracic vest and 21 with anterior corpectomy and plating. Unstable cervical flexion teardrop fractures were defined as those exhibiting failure of the anterior spine under compression and the posterior spine in tension. The primary outcome was radiographic kyphosis at follow-up assessment. Secondary outcomes included the MOS 36-Item Short-Form Health Survey and the Cervical Spine Research Society Long-Term Follow-Up questionnaire. Results. The halo thoracic vest group and the anterior corpectomy and plating group were comparable for baseline demographic and clinical data, except for neurologic deficit (67% of the halo thoracic vest group and 96% of the anterior corpectomy and plating group had neurologic deficit). Most of the injuries occurred at C5. All 45 patients had radiographic follow-up evaluation, but only 17 of the 24 patients in the halo thoracic vest group and 13 of the 21 patients in the anterior corpectomy and plating group (30 of 45 in all) completed the health-related quality-of-life outcome instruments. The mean kyphosis was 11.4° in the halo thoracic vest group and 3.5° in the anterior corpectomy and plating group (P < 0.001). The difference remained significant, with control used for the baseline variables. The halo thoracic vest group had five failures, four of which were subsequently managed operatively. No major intra- or postoperative complications occurred in the anterior corpectomy and plating group. There were no significant differences in the MOS 36-Item Short-Form Health Survey mental component score and the Cervical Spine Research Society subscales even after adjustment for neurologic deficit. Conclusions. The results of this study indicate that anterior cervical plating is a safe and effective treatment for cervical teardrop fractures, and that it is superior to the halo thoracic vest for restoring and maintaining sagittal alignment and for minimizing treatment failures. There does not appear to be a relation between residual kyphosis and health-related quality-of-life outcomes. Although this raises questions about the relevance of restoring sagittal alignment in the treatment and outcome of cervical flexion teardrop fractures, the study was underpowered for secondary outcomes. Therefore, the secondary outcome results must be interpreted with caution.

Early versus late enteral feeding in patients with acute cervical spinal cord injury: a pilot study.

Study Design. A prospective randomized clinical pilot study to compare early versus late enteral feeding in patients with acute cervical spinal cord injury. Objectives. To compare the incidence of infections in patients with acute cervical spinal cord injury who received early versus late enteral feeding. Secondary objectives included assessing nutritional status, feeding tolerance, the number of ventilator hours, and acute-care hospital length of stay. Summary of Background Data. Early nutritional support has been found to be beneficial in critically ill patients. However, the same benefits may not be realized in patients with acute cervical spinal cord injury because of their unique nutritional challenges. Methods. Eligible patients were randomized to early feeding (initiated before 72 hours after injury) and late (initiated more than 120 hours after injury). Patients were stratified on the basis of their neurologic level. Patients were assessed daily for the first 15 days. After that time, infections (according to Center for Disease Control criteria), ventilator hours, and length of acute-care hospital stay were tracked. Results. Twenty-three patients met the eligibility criteria, and 17 patients were included in the analysis. There were 7 patients in the early group and 10 in the late group. The early group had a mean of 2.4 ± 1.5 infections compared with the late group, which had a mean of 1.7 ± 1.1 infections. Secondary outcomes were not substantially different between the two groups. Conclusions. This pilot study failed to detect any differences in the incidence of infection, nutritional status, feeding complications, number of ventilator hours, or length of stay between patients receiving early versus late initiation of enteral feeding. These data will assist in the determination of an adequate sample size for future studies.

Percutaneous suction aspiration for osteomyelitis. Report of two cases

The nucieotome, a recently developed instrument for percutaneous disc excision, was used for suction aspiration to two eases of osteomyelitis of the spine. The technique obtained significant amounts of pus, serosan-guinous material, and tissue, which provided adequate samples for histotologic examination and culture. Both patients obtained immediate relief of pain after a significant amount of pus and infected material was removed. Appropriate antibiotics were used for subsequent control of the infections. The risk and morbidity of this technique are no greater than with conventional needle biopsy.

Diurnal changes in the profile shape and range of motion of the back

The diurnal height change reported to occur in young adults was investigated to characterize changes in the lumbar range of motion, spinal profile, and range of motion of the back. Twelve subjects aged 18–22 years were measured using stereophotography and standard clinical examinations in the evening and after a minimum of 8 hours of complete bed rest. The average increase in height was 20 mm. Forty percent of the height increase took place in the lumbar spine without change in the depth of the lordosis, and forty percent took place in the thoracic curve with a decrease in the kyphosis. The remaining 20% of the height increase was not located, but no measurements were taken of the cervical spine. Range of motion studies revealed that lumbar flexion, as measured using the lumber flexion increment was decreased in the morning, and straight leg rales was decreased when measured clinically but not when measured photographically. Extension, rotation, and femoral stretch test were not affected. The authors conclude that stereophotogrammetry offers an accurate, noninvasive way to study spinal profiles. Further work is needed to assess and quantify the relative motion of the skin and the underlying structures.