Upper Thoracic Pedicle Screws Loss of Fixation Causing Spinal Cord Injury

OBJECT Almost all pediatric patients who incur a spinal cord injury (SCI) will develop scoliosis, and younger patients are at highest risk for curve progression requiring surgical intervention. Although the use of pedicle screws is increasing in popularity, their impact on SCI-related scoliosis has not been described. The authors retrospectively reviewed the radiographic outcomes of pedicle screw–only constructs in all patients who had undergone SCI-related scoliosis correction at a single institution. Methods Medical records and radiographs from Shriner's Hospital for Children–Philadelphia for the period between November 2004 and February 2011 were retrospectively reviewed. Results Thirty-seven patients, whose mean age at the index surgery was 14.91 ± 3.29 years, were identified. The cohort had a mean follow-up of 33.2 ± 22.8 months. The mean preoperative coronal Cobb angle was 65.5° ± 25.7°, which corrected to 20.3° ± 14.4°, translating into a 69% correction (p < 0.05). The preoperative coronal balance was 24.4 ± 22.6 mm, with a postoperative measurement of 21.6 ± 20.7 mm (p = 1.00). Preoperative pelvic obliquity was 12.7° ± 8.7°, which corrected to 4.1° ± 3.8°, translating into a 68% correction (p < 0.05). Preoperative shoulder balance, as measured by the clavicle angle, was 8.2° ± 8.4°, which corrected to 2.7° ± 3.1° (67% correction, p < 0.05). Preoperatively, thoracic kyphosis measured 44.2° ± 23.7° and was 33.8° ± 11.5° postoperatively. Thoracolumbar kyphosis was 18.7° ± 12.1° preoperatively, reduced to 8.1° ± 7.7° postoperatively, and measured 26.8° ± 20.2° at the last follow-up (p < 0.05). Preoperatively, lumbar lordosis was 35.3° ± 22.0°, which remained stable at 35.6° ± 15.0° postoperatively. Conclusions Pedicle screw constructs appear to provide better correction of coronal parameters than historically reported and provide significant improvement of sagittal kyphosis as well. Although pedicle screws appear to provide good radiographic results, correlation with clinical outcomes is necessary to determine the true impact of pedicle screw constructs on SCI-related scoliosis correction.

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Upper Thoracic Spinal Cord Injury Without Vertebral Bony Lesion: A Report of Two Cases

Spine ◽

10.1097/00007632-200211010-00020 ◽

2002 ◽

Vol 27 (21) ◽

pp. E467-E470 ◽

Cited By ~ 20

Author(s):

Munehisa Koizumi ◽

Yurito Ueda ◽

Jin Iida ◽

Etsuhiro Matsuyama ◽

Takafumi Yoshikawa ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Thoracic Spinal Cord ◽

Thoracic Spinal ◽

Cord Injury ◽

Bony Lesion ◽

Upper Thoracic

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Use of subtransverse process polyester bands in pediatric spine surgery: a case series of 4 patients with a minimum of 12 months’ follow-up

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.6.peds15255 ◽

2016 ◽

Vol 17 (2) ◽

pp. 208-214 ◽

Cited By ~ 5

Author(s):

Ben A. Strickland ◽

Christina Sayama ◽

Valentina Briceño ◽

Sandi K. Lam ◽

Thomas G. Luerssen ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Case Series ◽

Pedicle Screws ◽

Transverse Process ◽

Lessons Learned ◽

Minimal Risk ◽

Instrumented Fusion ◽

Cord Injury ◽

Posterior Instrumented Fusion

OBJECT In a previous study, the authors reported on their experience with the use of sublaminar polyester bands as part of segmental spinal constructs. However, the risk of neurological complications with sublaminar passage of instrumentation, such as spinal cord injury, limits the use of this technique. The present study reports the novel use of subtransverse process polyester bands in posterior instrumented spinal fusions of the thoracic and lumbar spines and sacrum or ilium in 4 patients. METHODS The authors retrospectively reviewed the demographic and procedural data of patients who had undergone posterior instrumented fusion using subtransverse process polyester bands. RESULTS Four patients, ranging in age from 11 to 22 years, underwent posterior instrumented fusion for neuromuscular scoliosis (3 patients) and thoracic hyperkyphosis (1 patient). There were 3 instances of transverse process fracture, with application and tensioning of the polyester band in 1 patient. Importantly, there was no instance of spinal cord injury with subtransverse process passage of the polyester band. The lessons learned from this technique are discussed. CONCLUSIONS This study has shown the “Eleghia” technique of passing subtransverse process bands to be a technically straightforward and neurologically safe method of spinal fixation. Pedicle screws, laminar/pedicle/transverse process hooks, and sublaminar metal wires/bands have been incorporated into posterior spinal constructs; they have been widely reported and used in the thoracic and lumbar spines and sacrum or ilium with varying success. This report demonstrates the promising results of hybrid posterior spinal constructs that include the Eleghia technique of passing subtransverse process polyester bands. This technique incorporates technical ease with minimal risk of neurological injury and biomechanical stability.

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The Blood Pressure Pendulum following Spinal Cord Injury: Implications for Vascular Cognitive Impairment

International Journal of Molecular Sciences ◽

10.3390/ijms20102464 ◽

2019 ◽

Vol 20 (10) ◽

pp. 2464 ◽

Cited By ~ 9

Author(s):

Rahul Sachdeva ◽

Tom E. Nightingale ◽

Andrei V. Krassioukov

Keyword(s):

Blood Pressure ◽

Spinal Cord ◽

Spinal Cord Injury ◽

Cognitive Impairment ◽

Systemic Blood Pressure ◽

Vascular Cognitive Impairment ◽

Convincing Evidence ◽

Autonomic Dysreflexia ◽

Cord Injury ◽

Upper Thoracic

Cognitive impairment following spinal cord injury (SCI) has received considerable attention in recent years. Among the various systemic effects of SCI that contribute towards cognitive decline in this population, cardiovascular dysfunction is arguably one of the most significant. The majority of individuals with a cervical or upper-thoracic SCI commonly experience conditions called orthostatic hypotension and autonomic dysreflexia, which are characterized by dangerous fluctuations in systemic blood pressure (BP). Herein, we review the potential impact of extreme BP lability on vascular cognitive impairment (VCI) in individuals with SCI. Albeit preliminary in the SCI population, there is convincing evidence that chronic hypotension and hypertension in able-bodied individuals results in devastating impairments in cerebrovascular health, leading to VCI. We discuss the pertinent literature, and while drawing mechanistic comparisons between able-bodied cohorts and individuals with SCI, we emphasize the need for additional research to elucidate the mechanisms of cognitive impairment specific to the SCI population. Lastly, we highlight the current and potential future therapies to manage and treat BP instability, thereby possibly mitigating VCI in the SCI population.

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Reduced Reflex Autonomic Responses following Intradetrusor OnabotulinumtoxinA Injections: A pre/post study in Individuals with Cervical and Upper Thoracic Spinal Cord Injury

10.1101/2021.04.24.21256011 ◽

2021 ◽

Author(s):

Tristan W. Dorey ◽

Matthias Walter ◽

Andrei V. Krassioukov

Keyword(s):

Spinal Cord ◽

Heart Rate ◽

Spinal Cord Injury ◽

Frequency Domain ◽

Mean Difference ◽

Detrusor Muscle ◽

Autonomic Responses ◽

Rr Interval ◽

Cord Injury ◽

Upper Thoracic

Importance: Urodynamic studies (UDS) can provoke autonomic dysreflexia (AD) in individuals with spinal cord injury (SCI) at and above the sixth thoracic (T6) spinal segment potentially leading to profound vagally mediated heart rate reductions. Intradetrusor onabotulinumtoxinA injections have been shown to reduce AD events during UDS in this cohort but evidence is lacking whether this treatment can improve reflex autonomic responses. Objective: To assess the effects of intradetrusor onabotulinumtoxinA injections on heart rate variability (HRV) responses to UDS in individuals, 18-65 years of age, with chronic (>1-year) SCI at or above T6 with confirmed neurogenic detrusor overactivity and AD during UDS. Design, Setting, and Participants: This cohort study used participants from our recent prospective phase IV clinical trial. Individuals were screened at an academic medical centre between November 2014 and December 2019. After enrollment, participants underwent UDS prior to (i.e., baseline) and one month after intradetrusor onabotulinumtoxinA injections (post-treatment). Interventions: OnabotulinumtoxinA (200 U) was injected into the detrusor muscle at 20 sites (10 U/site). Main Outcomes and Measures: Continuous electrocardiogram (ECG) and blood pressure (BP) recordings were used to assess RR-interval, time and frequency domain metrics of HRV (a surrogate marker of autonomic nervous system activity), and AD pre- and post-intervention. Results: A total of 19 participants with SCI (5 women; mean [SD] age 42 [8.3] years) with complete ECG and BP data sets were suitable for autonomic analysis. During baseline UDS, an increase in RR-interval (adjusted mean difference, -0.08; 95% CI, -0.14 to -0.03; P=0.002) as well as time and frequency domain metrics of HRV were detected. Vagally mediated increases in high frequency (HF) power during UDS were larger in participants with cervical SCI compared to upper thoracic SCI (adjusted mean difference, 20.3; 95% CI, 3.3 to 37.2; P=0.013). Intradetrusor onabotulinumtoxinA injections significantly reduced time domain metrics of HRV and HF power (adjusted mean difference, 9.1; 95% CI, 3.1 to 15.1, P<0.01) responses to UDS across all participants. Conclusions and Relevance: Changes in HRV during UDS could be a potential indicator of improved autonomic cardiovascular function following interventions such as intradetrusor onabotulinumtoxinA injections.

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Reduced Reflex Autonomic Responses Following Intradetrusor OnabotulinumtoxinA Injections: A Pre-/Post-study in Individuals With Cervical and Upper Thoracic Spinal Cord Injury

Frontiers in Physiology ◽

10.3389/fphys.2021.796277 ◽

2021 ◽

Vol 12 ◽

Author(s):

Tristan W. Dorey ◽

Matthias Walter ◽

Andrei V. Krassioukov

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Frequency Domain ◽

Surrogate Marker ◽

Post Treatment ◽

Thoracic Spinal Cord ◽

Rr Interval ◽

Thoracic Spinal ◽

Cord Injury ◽

Upper Thoracic

Urodynamic studies (UDS) can provoke autonomic dysreflexia (AD) in individuals with spinal cord injury (SCI) at and above the sixth thoracic spinal segment potentially leading to profound vagally mediated heart rate (HR) reductions. In this study,1 we test the hypothesis that intradetrusor onabotulinumtoxinA injections will improve HR and its variability (HRV) responses to UDS in individuals with cervical and thoracic SCI. A total of 19 participants with chronic SCI (5 women, mean age 42.5 ± 7.9 years) with confirmed neurogenic detrusor overactivity underwent UDS before (i.e., baseline) and 1 month after intradetrusor onabotulinumtoxinA (200 U) injections (post-treatment). Continuous electrocardiography and blood pressure (BP) recordings were used to assess RR-interval, time, and frequency domain metrics of HRV (a surrogate marker of autonomic nervous system activity), and AD pre- and post-treatment. UDS pre-treatment resulted in increased RR-interval as well as time and frequency domain metrics of HRV. Vagally mediated increases in high-frequency (HF) power during UDS were larger in participants with cervical compared to upper thoracic SCI. Post-treatment, UDS had no effect on RR-interval and significantly reduced instances of bradycardia. Furthermore, intradetrusor onabotulinumtoxinA injections significantly reduced time domain metrics of HRV and HF power responses to UDS across all participants. Changes in HRV during UDS could be a potential indicator of improved autonomic cardiovascular function following interventions such as intradetrusor onabotulinumtoxinA injections.

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Associations between left ventricular structure and function with cardiorespiratory fitness and body composition in individuals with cervical and upper thoracic spinal cord injury

Spinal Cord ◽

10.1038/s41393-020-00591-4 ◽

2020 ◽

Author(s):

Abdullah A. Alrashidi ◽

Shane J. T. Balthazaar ◽

Katharine D. Currie ◽

Tom E. Nightingale ◽

Andrei V. Krassioukov

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Body Composition ◽

Cardiorespiratory Fitness ◽

Left Ventricular ◽

Structure And Function ◽

Bivariate Correlation ◽

Cord Injury ◽

Upper Thoracic ◽

And Function

Abstract Study design Cross-sectional. Objective It is known that left ventricular mass (LVM) and cardiorespiratory fitness (CRF) are associated to fat-free mass (FFM). It is unknown if these factors associated with left ventricular (LV) structure and function outcomes in individuals with spinal cord injury (SCI). Setting University-based laboratory.Vancouver, BC, Canada. Methods Thirty-two individuals (aged 40 ± 11 years) with chronic, motor-complete SCI between the fourth cervical and sixth thoracic levels were recruited. Echocardiographic LV parameters and body composition were assessed at rest, as per the recommended guidelines for each technique. CRF was assessed during an incremental arm-cycle exercise test until volitional fatigue. The appropriate bivariate correlation coefficients [i.e., Pearson’s (r) and Spearman’s rank (Rs)] tests were used for normal and non-normal distributed variables, respectively. Results LV structure and function parameters were not associated with the indexed peak oxygen consumption (V̇O2peak) [i.e., relative to body weight or FFM] (Rs values ranged from −0.168 to 0.134, all P values > 0.223). The association between peak oxygen pulse and the resting echocardiographic-obtained SV was medium sized (Rs = 0.331, P = 0.069). The LVM associations with FFM and fat mass (FM) were large and small (r = 0.614, P < 0.001 and r = 0.266, P = 0.141, respectively). Associations of absolute V̇O2peak were medium- positive with FFM (Rs = 0.414, P = 0.021) but negative with FM (Rs = −0.332, P = 0.068). Conclusion LV parameters measured at rest are not associated with V̇O2peak in individuals with cervical and upper-thoracic SCI. Given the observed associations between LVM and V̇O2peak with FFM, future studies may consider utilizing FFM for indexing cardiovascular measures following SCI.

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A scoping review on health economics in neurosurgery for acute spine trauma

Neurosurgical FOCUS ◽

10.3171/2018.2.focus17778 ◽

2018 ◽

Vol 44 (5) ◽

pp. E15 ◽

Cited By ~ 4

Author(s):

Brian C. F. Chan ◽

B. Catharine Craven ◽

Julio C. Furlan

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Surgical Treatment ◽

Literature Search ◽

Pedicle Screws ◽

Cost Benefit ◽

Direct Costs ◽

Cost Utility ◽

Spine Trauma ◽

Cord Injury

OBJECTIVEAcute spine trauma (AST) has a relatively low incidence, but it often results in substantial individual impairments and societal economic burden resulting from the associated disability. Given the key role of neurosurgeons in the decision-making regarding operative management of individuals with AST, the authors performed a systematic search with scoping synthesis of relevant literature to review current knowledge regarding the economic burden of AST.METHODSThis systematic review with scoping synthesis included original articles reporting cost-effectiveness, cost-utility, cost-benefit, cost-minimization, cost-comparison, and economic analyses related to surgical management of AST, whereby AST is defined as trauma to the spine that may result in spinal cord injury with motor, sensory, and/or autonomic impairment. The initial literature search was carried out using MEDLINE, EMBASE, CINAHL, CCTR, and PubMed. All original articles captured in the literature search and published from 1946 to September 27, 2017, were included. Search terms used were the following: (cost analysis, cost effectiveness, cost benefit, economic evaluation or economic impact) AND (spine or spinal cord) AND (surgery or surgical).RESULTSThe literature search captured 5770 titles, of which 11 original studies met the inclusion/exclusion criteria. These 11 studies included 4 cost-utility analyses, 5 cost analyses that compared the cost of intervention with a comparator, and 2 studies examining direct costs without a comparator. There are a few potentially cost-saving strategies in the neurosurgical management of individuals with AST, including 1) early surgical spinal cord decompression for acute traumatic cervical spinal cord injury (or traumatic thoracolumbar fractures, traumatic cervical fractures); 2) surgical treatment of the elderly with type-II odontoid fractures, which is more costly but more effective than the nonoperative approach among individuals with age at AST between 65 and 84 years; 3) surgical treatment of traumatic thoracolumbar spine fractures, which is implicated in greater direct costs but lower general-practitioner visit costs, private expenditures, and absenteeism costs than nonsurgical management; and 4) removal of pedicle screws 1–2 years after posterior instrumented fusion for individuals with thoracolumbar burst fractures, which is more cost-effective than retaining the pedicle screws.CONCLUSIONSThis scoping synthesis underscores a number of potentially cost-saving opportunities for neurosurgeons when managing patients with AST. There are significant knowledge gaps regarding the potential economic impact of therapeutic choices for AST that are commonly used by neurosurgeons.

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