An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies

1999 ◽  
Vol 91 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Michael G. Fehlings ◽  
Charles H. Tator
Keyword(s):  
Clinical Studies ◽  
Class Ii ◽  
Decompressive Surgery ◽  
Evidence Based ◽  
Class Iii ◽  
Content Type ◽  
Cord Injury ◽  
Limited Class ◽  
Fine Print

Object. The authors conducted an evidence-based review of the literature to evaluate critically the rationale and indications for and the timing of decompressive surgery for the treatment of acute, nonpenetrating spinal cord injury (SCI). Methods. The experimental and clinical literature concerning the role of, and the biological rationale for, surgical decompression for acute SCI was reviewed. Clinical studies of nonoperative management of SCI were also examined for comparative purposes. Evidence from clinical trials was categorized as Class I (well-conducted randomized prospective trials), Class II (well-designed comparative clinical studies), or Class III (retrospective studies). Examination of studies in which animal models of SCI were used consistently demonstrated a beneficial effect of early decompressive surgery, although it is difficult to apply these data directly to the clinical setting. The clinical studies provided suggestive (Class III and limited Class II) evidence that decompressive procedures improve neurological recovery after SCI. However, no clear consensus can be inferred from the literature as to the optimum timing for decompressive surgery. Many authors have advocated delayed treatment to avoid medical complications, although good evidence from recent Class II trials indicates that early decompressive surgery can be performed safely without causing added morbidity or mortality. Conclusions. There is biological evidence from experimental studies in animals that early decompressive surgery may improve neurological recovery after SCI, although the relevant interventional timing in humans remains unclear. To date, the role of surgical decompression in patients with SCI is only supported by Class III and limited Class II evidence. Accordingly, decompressive surgery for SCI can only be considered a practice option. Furthermore, analysis of the literature does not allow definite conclusions to be drawn regarding appropriate timing of intervention. Hence, there is a need to conduct well-designed experimental and clinical studies of the timing and neurological results of decompressive surgery for the treatment of acute SCI.

scholarly journals An evidence-based review of surgical decompression for acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies

1999 ◽  
Vol 6 (1) ◽  
pp. E3 ◽  
Author(s):  
Michael G. Fehlings ◽  
Charles H. Tator
Keyword(s):  
Spinal Cord ◽  
Clinical Studies ◽  
Class Ii ◽  
Surgical Decompression ◽  
Decompressive Surgery ◽  
Evidence Based ◽  
Class Iii ◽  
Cord Injury ◽  
Limited Class

The authors conducted an evidence-based review of the literature to evaluate critically the rationale and indications for and the timing of decompressive surgery for the treatment of acute, nonpenetrating spinal cord injury (SCI). The experimental and clinical literature concerning the role of, and the biological rationale for surgical decompression for acute SCI was reviewed. Clinical studies of nonoperative management of SCI were also examined for comparative purposes. Evidence from clinical trials was categorized as Class I (well-conducted randomized prospective trials), Class II (well-designed comparative clinical studies), or Class III (retrospective studies). Studies in which animal models of SCI were used consistently demonstrated a beneficial effect of early surgical decompression, although it is difficult to apply these data directly to the clinical setting. The clinical studies provided suggestive (Class III and limited Class II) evidence that decompressive procedures improve neurological recovery after SCI. However, no clear consensus can be inferred from the literature as to the optimum timing of decompressive surgery. Many authors have advocated delayed treatment to avoid medical complications, although there is good evidence from recent Class II trials that early decompressive surgery can be performed safely without added morbidity or mortality. There is biological evidence from experimental studies in animals that early surgical decompression may improve neurological recovery after SCI, although the relevant interventional timing in humans remains unclear. To date, the role of surgical decompression in patients with SCI is only supported by Class III and limited Class II evidence. Accordingly, decompressive surgery for SCI can only be considered a practice option. Furthermore, analysis of the literature does not allow definite conclusions to be drawn regarding appropriate timing of intervention. Hence, there is a need to conduct well-designed experimental and clinical studies of the timing and neurological results of surgical decompression for the treatment of acute SCI.

scholarly journals Evidence-based review of the role of reoperation in the management of malignant glioma

1998 ◽  
Vol 4 (6) ◽  
pp. E13 ◽  
Author(s):  
Clifford B. Soults ◽  
Greg S. Canute ◽  
Timothy C. Ryken
Keyword(s):  
Clinical Trials ◽  
Malignant Glioma ◽  
Randomized Clinical Trials ◽  
Case Series ◽  
Class Ii ◽  
Current Status ◽  
Evidence Based ◽  
Class Iii ◽  
Key Words Glioblastoma

Using an evidence-based approach to available clinical studies, the authors examined the role of reoperation in the management of malignant glioma. A review of 1270 Medline-referenced articles spanning the period from 1966 through March 1998 was undertaken using the key words “glioblastoma” and “astrocytoma.” Using an evidence-based four-tiered grading system, the authors found only 14 articles that met their inclusion criteria. Of these, 11 were graded as Class III (retrospective case series) and three as Class II (prospective nonrandomized studies). There were no Class I reports (randomized clinical trials), and all Class IV reports (opinion reports) were excluded. The authors of 10 Class III and one Class II articles supported the role of reoperation in increasing survival time or quality of life in selected patients; however, the results of multivariate analysis in two Class II and one Class III article did not support prolonged survival. The authors conclude that there was insufficient evidence to support either a standard or a guideline for reoperation in malignant glioma given the current status of the literature. Selection bias was a major factor in these studies. With continued interest in clinical trials for recurrent malignant glioma, the role of reoperation needs to be addressed in case-controlled or randomized fashion to establish either standards or guidelines on this commonly debated issue.

Timing of surgical stabilization after cervical and thoracic trauma

2005 ◽  
Vol 3 (3) ◽  
pp. 182-190 ◽  
Author(s):  
Todd J. Albert ◽  
David H. Kim
Keyword(s):  
Thoracic Spine ◽  
Clinical Studies ◽  
Science Studies ◽  
Surgical Intervention ◽  
Medical Condition ◽  
Spine Trauma ◽  
Content Type ◽  
Thoracic Spinal ◽  
Cord Injury ◽  
Fine Print

✓ Appropriate timing for surgical intervention following destabilizing cervical or thoracic spine trauma remains controversial. Clinical investigators have failed to provide convincing evidence that the timing of surgery significantly affects neurological outcome in most situations. Nevertheless, early surgical stabilization of the injured spine has been shown to provide significant nonneurological benefits such as more rapid patient mobilization, facilitation of treating associated injuries, reduction in rates of pulmonary and pressure sore complications, reduction in duration of intensive care unit and hospital stays, and a decrease in overall medical costs. The findings of basic science studies have improved our understanding of the molecular and cellular events surrounding initial and secondary spinal cord injury (SCI), and analysis of these findings suggests that the early postinjury period may present a unique opportunity for meaningful intervention. This possibility has been supported by results obtained in animal studies that demonstrate the potential for improving functional outcome when surgical intervention is performed within a few hours following experimental SCI. Despite the absence of significant neurological recovery in most clinical studies, the results of most recent clinical studies strongly support the overall clinical benefits of early surgical intervention, particularly in the setting of unstable thoracic spinal column injury with associated SCI. Based on the best available scientific and clinical evidence, the authors report that it is therefore recommended that surgical stabilization be performed in as timely a fashion as possible, particularly for unstable thoracic spine trauma, within the constraints of the patient's overall medical condition and availability of appropriate resources.

Occipital plagiocephaly: a critical review of the literature

1998 ◽  
Vol 89 (1) ◽  
pp. 24-30 ◽  
Author(s):  
Harold L. Rekate
Keyword(s):  
Diagnostic Criteria ◽  
Treatment Options ◽  
Surgical Techniques ◽  
Class Ii ◽  
Population Based ◽  
Class I ◽  
Weight Of Evidence ◽  
Class Iii ◽  
Content Type ◽  
Fine Print

Object. The literature on occipital plagiocephaly (OP) was critically reviewed to determine the feasibility of establishing treatment recommendations. Methods. Using standard computerized search techniques, medical literature databases containing peer-review articles dating from 1966 were queried for key words related to OP. The titles of all articles were scanned for relevance, and copies of potentially relevant articles published in English were reviewed. Articles in which treatment was discussed were categorized according to their weight of evidence as Class I (prospective randomized controlled trials), Class II (clinical studies in which data are collected prospectively or retrospective analyses based on clearly reliable data), and Class III (most studies based on retrospectively collected data) to evaluate their contribution to developing a consensus on the treatment of OP. Of the 4308 articles identified, all but 89 were excluded. Based on the review of these articles, the actual incidence of OP is unknown, and no population-based studies of its incidence or prevalence exist. The reported incidence of lambdoid craniosynostosis ranges from 3 to 20% with differences in diagnostic criteria accounting for the variability. With the possible exception of a lambdoid suture that is replaced by a dense ridge of bone, no other diagnostic criteria have been agreed on. There were no Class I studies and only one Class II study provided comparisons of outcomes in more than one treatment group with outcomes in an untreated group. Recommended treatment options included observation only, mechanical interventions, and a variety of surgical techniques. Conclusions. Controlled clinical trials are needed before any form of intervention can be recommended for the treatment of OP. If surgery, which is expensive and potentially dangerous, is to continue to play a role in the management of this condition, efforts should be made to determine if patients with untreated OP have suffered from lack of treatment.

Posterior atlantoaxial facet screw fixation in rheumatoid arthritis

1998 ◽  
Vol 89 (1) ◽  
pp. 8-12 ◽  
Author(s):  
Mohammed Aly Eleraky ◽  
Roberto Masferrer ◽  
Volker K. H. Sonntag
Keyword(s):  
Screw Fixation ◽  
Class Ii ◽  
Atlantoaxial Instability ◽  
Rigid Fixation ◽  
Class Iii ◽  
Transarticular Screw ◽  
Content Type ◽  
Transarticular Screw Fixation ◽  
Fine Print

Object. This retrospective review was conducted to determine the efficacy of transarticular screw fixation in a group of patients who were treated for rheumatoid atlantoaxial instability. Methods. Thirty-six patients (mean age 63 years) with rheumatoid atlantoaxial instability were treated with posterior atlantoaxial transarticular screw fixation supplemented with an interspinous C1–2 strut graft—cable construct to provide immediate three-point fixation to facilitate bone fusion. Previous attempts at fusions by using bone grafting with wire fixation at other institutions had failed in six of these patients. Six patients underwent transoral odontoid resections for removal of large irreducible pannus as a first-stage procedure, which was followed within 2 to 3 days by the posterior procedure. Postoperatively, 33 patients were placed in hard cervical collars and three required halo vests because of severe osteoporosis. Of eight patients categorized as Ranawat Class II preoperatively, all eight returned to normal after surgery; of eight patients in Ranawat Class III-A preoperatively, four improved to Class II and four remained unchanged. All 20 patients classified as Ranawat Class I preoperatively recovered completely. Pain decreased or resolved in all patients, and there were no complications related to instrumentation. At follow-up review (mean 2 years), 33 patients (92%) had solid bone fusions, and three (8%) had stable fibrous unions. Conclusions. Posterior atlantoaxial transarticular screw fixation provides a good surgical alternative for the management of patients with rheumatoid atlantoaxial instability. This technique provides immediate three-point rigid fixation of the C1–2 region, thus obviating the need for halo vest immobilization in most cases.

The role of multiple hyperbaric oxygenation in expanding therapeutic windows after acute spinal cord injury in rats

2003 ◽  
Vol 99 (2) ◽  
pp. 198-205 ◽  
Author(s):  
Lixin Huang ◽  
Maheshkumar P. Mehta ◽  
Anil Nanda ◽  
John H. Zhang
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Hyperbaric Oxygenation ◽  
Rating Scale ◽  
Therapeutic Window ◽  
Content Type ◽  
Cord Injury ◽  
Weight Drop ◽  
Fine Print

Object. Hyperbaric oxygenation (HBO) therapy has been reported to improve neurological recovery after spinal cord injury (SCI). In the present study, the authors examined whether multiple HBO therapy can expand the therapeutic window after acute SCI. Methods. Seventy rats were randomly assigned to seven groups: sham surgery; SCI without treatment; single HBO treatment beginning at 30 minutes, 3 hours, and 6 hours after SCI; and multiple HBO treatments starting at 6 and 24 hours postinjury. Mild SCI was induced by adjusting the height of a weight drop (10 g) to 6.25 mm above the exposed spinal cord. A single HBO administration was performed at 2.82 ata for 1 hour. The multiple HBO treatment modality was performed once daily for 1 week. All rats underwent behavioral testing with the Basso-Beattie-Breshnahan locomotor rating scale twice a week. Rats were killed on Day 42 postinjury and specimens comprising the lesioned area were histopathologically examined. Those rats that received single HBO intervention beginning at 30 minutes and 3 hours and those that received multiple HBO treatment starting at 6 hours following injury made significantly greater neurological recoveries than those in the nontreatment SCI group. These rats also retained more sparing tissue than controls. Conclusions. The results of this study demonstrate that multiple HBO treatments can expand the therapeutic window for acute SCI to 6 hours after injury.

Pathological features including apoptosis in subacute posttraumatic ascending myelopathy

2005 ◽  
Vol 2 (5) ◽  
pp. 619-623 ◽  
Author(s):  
Mubarak Al-Ghatany ◽  
Mubarak Al-Shraim ◽  
Allan D. O. Levi ◽  
Rajiv Midha
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Rare Disorder ◽  
Pathological Features ◽  
Mechanical Instability ◽  
Content Type ◽  
Cord Injury ◽  
Fine Print

✓ Subacute posttraumatic ascending myelopathy (SPAM) is a rare disorder that may gradually emerge in the first 1 to 3 weeks after a spinal cord injury and is unrelated to syrinx formation or mechanical instability. In addition to several theories that have been put forth to explain the origin of this syndrome, the authors propose a possible role for apoptosis in the causation and the progression of SPAM. They discuss the various theories that have been proposed thus far, to place the role of apoptosis in perspective and use their case as an illustration.

Current use and timing of spinal surgery for management of acute spinal cord injury in North America: results of a retrospective multicenter study

1999 ◽  
Vol 91 (1) ◽  
pp. 12-18 ◽  
Author(s):  
Charles H. Tator ◽  
Michael Fehlings ◽  
Kevin Thorpe ◽  
Wayne Taylor
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Randomized Controlled Trial ◽  
Controlled Trial ◽  
Timing Of Surgery ◽  
Decompressive Surgery ◽  
Content Type ◽  
Randomized Controlled ◽  
Cord Injury ◽  
Fine Print

Object. A multicenter retrospective study was performed in 36 North American centers to examine the use and timing of surgery in patients who have sustained acute spinal cord injury (SCI). The study was performed to obtain information required for the planning of a randomized controlled trial in which early and late decompressive surgery are compared. Methods. The records of all patients aged 16 to 75 years with acute SCI admitted to 36 centers within 24 hours of injury over a 9-month period in 1994 and 1995 were examined to obtain data on admission variables, methods of diagnosis, use of traction, and surgical variables including type and timing of surgery. A total of 585 patients with acute SCI or cauda equina injury were admitted to participating centers, although approximately half were ultimately excluded because they did not meet inclusion criteria. Common causes for exclusion were late admission, age, gunshot wound, and absence of signs of compression on imaging studies. Thus, only approximately 50% of patients with acute SCI would be eligible for inclusion in a study of acute decompressive surgery. Although all patients underwent computerized tomography (CT) scanning, only 54% underwent magnetic resonance imaging, and CT myelography was performed in only 6%. Complete neurological injuries (American Spinal Injury Association Grade A) were present in 57.8%. Traction was applied in only 47% of patients who sustained cervical injury, in whom decompressive traction was successful in only 42% of cases. Neurological deterioration occurred in 8.1% of cases after traction. Surgery was performed in 65.4% of patients. The timing of surgery varied widely: less than 24 hours postinjury in 23.5%, between 25 and 48 hours postinjury in 15.8%, between 48 and 96 hours in 19%, and more than 5 days postinjury in 41.7% of patients. Conclusions. These data indicate that although surgery is commonly performed in patients with acute SCI, one third of cases are managed nonoperatively, and there is very little agreement on the optimum timing of surgical treatment. The results of this study confirm the need for a randomized controlled trial to assess the optimum timing of decompressive surgery in SCI.

Multiple subpial transections: outcome and complications in 20 patients who did not undergo resection

2002 ◽  
Vol 97 (1) ◽  
pp. 39-47 ◽  
Author(s):  
Johannes Schramm ◽  
Ales F. Aliashkevich ◽  
Thomas Grunwald
Keyword(s):  
Mr Imaging ◽  
Class Ii ◽  
Class I ◽  
Class Iii ◽  
Content Type ◽  
Surgical Methods ◽  
Over Time ◽  
Class Iv ◽  
Fine Print

Object. The authors describe patient characteristics, surgical methods, complications, and outcome over time in a cohort of patients who underwent multiple subpial transection (MST) without concomitant cortical resection. Methods. Twenty consecutive patients in whom drug-resistant epilepsy had been diagnosed a mean of 16 ± 9 years earlier (mean ± standard deviation [SD]) were treated with MST without cortical resection. The mean follow-up period was 49.3 ± 18.3 months (mean ± SD, median 58 months). At 12 months of follow up, two of the 20 patients were Engel Class I, one was Class II, six were Class III, and 11 were Class IV. At latest follow up, one patient was Engel Class I, one was Class II, seven were Class III, and 11 were Class IV. According to an alternative five-tiered classification system, two outcomes were excellent, seven were good, one was fair, nine were poor, and one was worse. Outcome was found to be better in patients with no lesions observed on magnetic resonance (MR) imaging, and worse in those with large MST areas. Outcome had a tendency to change (this occurred in 13 of 20 cases). Five patients (25%) improved and seven (35%) deteriorated in Engel outcome class, and in one (5%) both developments occurred over time. Most outcome class changes occurred before the end of the 2nd year (nine), and four were observed in the 5th year. There where seven transient neurological deficits and four surgical complications. There was no permanent significant morbidity, and there were no deaths. Conclusions. Forty-five percent of patients achieved a worthwhile improvement after pure MST, if Engel outcome Class III is deemed a worthwhile improvement. The alternative five-tiered classification resulted in 50% with worthwhile improvement (excellent, good, or fair outcome), 45% with poor, and 5% with worse outcome. Lesions that are detectable on MR imaging, and large MST areas are predictive of worse results. Significant intraoperative problems may arise, but this happens infrequently. There is a notable rate of transient morbidity but the rate of permanent morbidity is not significant.

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