Miyakoshi N, Suda K, Kudo D, Sakai H, Nakagawa Y, Mikami Y, Suzuki S, Tokioka T, Tokuhiro A, Takei H, Katoh S, Shimada Y.
A nationwide survey on the incidence and characteristics of traumatic spinal cord injury in Japan in 2018.
Spinal Cord. 2021 Jun;59(6):626-634. doi: 10.1038/s41393-020-00533-0. Epub 2020 Aug 11.
Abstract/Text
STUDY DESIGN: Retrospective epidemiological study.
OBJECTIVES: Since the causes and incidences of traumatic spinal cord injury (TSCI) in each country change over time, up-to-date epidemiological studies are required for countermeasures against TSCI. However, no nationwide survey in Japan has been conducted for about 30 years. The purpose of this study was therefore to investigate the recent incidence and characteristics of TSCI in Japan.
SETTING: Japan METHODS: Survey sheets were sent to all hospitals (emergency and acute care hospitals) that treated TSCI persons in Japan in 2018 and case notes were retrospectively reviewed. Frankel grade E cases were excluded from analysis.
RESULTS: The response rate was 74.4% (2804 of 3771 hospitals). The estimated annual incidence of TSCI excluding Frankel E was 49 per million, with a median age of 70.0 years and individuals in their 70s as the largest age group. Male-to-female ratio was 3:1. Cervical cord injuries occurred in 88.1%. Frankel D was the most frequent grade (46.3%), followed by Frankel C (33.0%). The most frequent cause was fall on level surface (38.6%), followed by traffic accident (20.1%). The proportion of fall on level surface increased with age. TSCI due to sports was the most frequent cause in teenagers (43.2%).
CONCLUSIONS: This nationwide survey in Japan showed that estimated incidence of TSCI, rate of cervical cord injury, and incomplete injury by falls appear to be increasing with the aging of the population.
Canale & Beaty: Campbell’s Operative Orthopaedics, 11th ed. Copyright © 2007 Mosby, An Imprint of Elsevier Fig. 35-33.
Canale & Beaty: Campbell’s Operative Orthopaedics, 11th ed. Copyright © 2007 Mosby, An Imprint of Elsevier Fig 35-26.
Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed. Table 146－1.
Allen BL Jr, Ferguson RL, Lehmann TR, O'Brien RP.
A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine.
Spine (Phila Pa 1976). 1982 Jan-Feb;7(1):1-27. doi: 10.1097/00007632-198200710-00001.
Abstract/Text
Closed, indirect fractures and dislocations of the lower cervical spine occur in families or groups within which there is a spectrum of anatomic damage to a cervical motion segment. This study of 165 cases demonstrates the various spectra of injury, called phylogenies, and develops a classification based on the mechanism of injury. The common groups are compressive flexion, vertical compression, distractive flexion, compressive extension, distractive extension, and lateral flexion. The probability of an associated neurologic lesion relates directly to the type and severity of cervical spine injury. With use of the classification, it is possible to formulate a rational treatment plan for injuries to the cervical spine.
Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S.
A comprehensive classification of thoracic and lumbar injuries.
Eur Spine J. 1994;3(4):184-201. doi: 10.1007/BF02221591.
Abstract/Text
In view of the current level of knowledge and the numerous treatment possibilities, none of the existing classification systems of thoracic and lumbar injuries is completely satisfactory. As a result of more than a decade of consideration of the subject matter and a review of 1445 consecutive thoracolumbar injuries, a comprehensive classification of thoracic and lumbar injuries is proposed. The classification is primarily based on pathomorphological criteria. Categories are established according to the main mechanism of injury, pathomorphological uniformity, and in consideration of prognostic aspects regarding healing potential. The classification reflects a progressive scale of morphological damage by which the degree of instability is determined. The severity of the injury in terms of instability is expressed by its ranking within the classification system. A simple grid, the 3-3-3 scheme of the AO fracture classification, was used in grouping the injuries. This grid consists of three types: A, B, and C. Every type has three groups, each of which contains three subgroups with specifications. The types have a fundamental injury pattern which is determined by the three most important mechanisms acting on the spine: compression, distraction, and axial torque. Type A (vertebral body compression) focuses on injury patterns of the vertebral body. Type B injuries (anterior and posterior element injuries with distraction) are characterized by transverse disruption either anteriorly or posteriorly. Type C lesions (anterior and posterior element injuries with rotation) describe injury patterns resulting from axial torque. The latter are most often superimposed on either type A or type B lesions. Morphological criteria are predominantly used for further subdivision of the injuries. Severity progresses from type A through type C as well as within the types, groups, and further subdivisions. The 1445 cases were analyzed with regard to the level of the main injury, the frequency of types and groups, and the incidence of neurological deficit. Most injuries occurred around the thoracolumbar junction. The upper and lower end of the thoracolumbar spine and the T10 level were most infrequently injured. Type A fractures were found in 66.1%, type B in 14.5%, and type C in 19.4% of the cases. Stable type A1 fractures accounted for 34.7% of the total. Some injury patterns are typical for certain sections of the thoracolumbar spine and others for age groups. The neurological deficit, ranging from complete paraplegia to a single root lesion, was evaluated in 1212 cases.(ABSTRACT TRUNCATED AT 400 WORDS)
Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Zeiller SC, Anderson DG, Bono CM, Stock GH, Brown AK, Kuklo T, Oner FC.
A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status.
Spine (Phila Pa 1976). 2005 Oct 15;30(20):2325-33. doi: 10.1097/01.brs.0000182986.43345.cb.
Abstract/Text
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.
Vaccaro AR, Hulbert RJ, Patel AA, Fisher C, Dvorak M, Lehman RA Jr, Anderson P, Harrop J, Oner FC, Arnold P, Fehlings M, Hedlund R, Madrazo I, Rechtine G, Aarabi B, Shainline M; Spine Trauma Study Group.
The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex.
Spine (Phila Pa 1976). 2007 Oct 1;32(21):2365-74. doi: 10.1097/BRS.0b013e3181557b92.
Abstract/Text
STUDY DESIGN: The classification system was derived through a literature review and expert opinion of experienced spine surgeons. In addition, a multicenter reliability and validity study of the system was conducted on a collection of trauma cases.
OBJECTIVES: To define a novel classification system for subaxial cervical spine trauma that conveys information about injury pattern, severity, treatment considerations, and prognosis. To evaluate reliability and validity of this system.
SUMMARY OF BACKGROUND DATA: Classification of subaxial cervical spine injuries remains largely descriptive, lacking standardization and prognostic information.
METHODS: Clinical and radiographic variables encountered in subaxial cervical trauma were identified by a working section of the Spine Trauma Study Group. Significant limitations of existing systems were defined and addressed within the new system. This system, as well as the Harris and Ferguson & Allen systems, was applied by 20 spine surgeons to 11 cervical trauma cases. Six weeks later, the cases were randomly reordered and again scored. Interrater reliability, intrarater reliability, and validity were assessed.
RESULTS: Each of 3 main categories (injury morphology, disco-ligamentous complex, and neurologic status) identified as integrally important to injury classification was assigned a weighted score; the injury severity score was obtained by summing the scores from each category. Treatment options were assigned based on threshold values of the severity score. Interrater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.49, 0.57, and 0.87, respectively. Intrarater agreement as assessed by intraclass correlation coefficient of the DLC, morphology, and neurologic status scores was 0.66, 0.75, and 0.90, respectively. Raters agreed with treatment recommendations of the algorithm in 93.3% of cases, suggesting high construct validity. The reliability compared favorably to the Harris and Ferguson & Allen systems.
CONCLUSION: The Sub-axial Injury Classification and Severity Scale provides a comprehensive classification system for subaxial cervical trauma. Early validity and reliability data are encouraging.
Browner: Skeletal Trauma, 4th ed. Copyright © 2008 W. B. Saunders Company, FIGURE 30-21.
Browner: Skeletal Trauma, 4th ed. Fig25-6 Copyright © 2008 W. B. Saunders Company.
Bracken MB, Shepard MJ, Collins WF Jr, Holford TR, Baskin DS, Eisenberg HM, Flamm E, Leo-Summers L, Maroon JC, Marshall LF.
Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study.
J Neurosurg. 1992 Jan;76(1):23-31. doi: 10.3171/jns.1992.76.1.0023.
Abstract/Text
The 1-year follow-up data of a multicenter randomized controlled trial of methylprednisolone (30 mg/kg bolus and 5.4 mg/kg/hr for 23 hours) or naloxone (5.4 mg/kg bolus and 4.0 mg/kg/hr for 23 hours) treatment for acute spinal cord injury are reported and compared with placebo results. In patients treated with methylprednisolone within 8 hours of injury, increased recovery of neurological function was seen at 6 weeks and at 6 months and continued to be observed 1 year after injury. For motor function, this difference was statistically significant (p = 0.030), and was found in patients with total sensory and motor loss in the emergency room (p = 0.019) and in those with some preservation of motor and sensory function (p = 0.024). Naloxone-treated patients did not show significantly greater recovery. Patients treated after 8 hours of injury recovered less motor function if receiving methylprednisolone (p = 0.08) or naloxone (p = 0.10) as compared with those given placebo. Complication and mortality rates were similar in either group of treated patients as compared with the placebo group. The authors conclude that treatment with the study dose of methylprednisolone is indicated for acute spinal cord trauma, but only if it can be started within 8 hours of injury.
Ito Y, Sugimoto Y, Tomioka M, Kai N, Tanaka M.
Does high dose methylprednisolone sodium succinate really improve neurological status in patient with acute cervical cord injury?: a prospective study about neurological recovery and early complications.
Spine (Phila Pa 1976). 2009 Sep 15;34(20):2121-4. doi: 10.1097/BRS.0b013e3181b613c7.
Abstract/Text
STUDY DESIGN: Consecutive cohort study.
OBJECTIVE: To reconsider effects of the Second National Acute Spinal Cord Injury Study.
SUMMARY OF BACKGROUND DATA: High dose methylprednisolone sodium succinate (MPSS) for the patients with acute spinal cord injury has been considered standard treatment in the several countries. However, many authors have criticized the effect of MPSS because of lack of evidence about neurologic improvement and the high incidence of complications.
METHODS: During 2-year, all patients with cervical cord injury were treated with MPSS within 8 hours of their injuries based on the Second National Acute Spinal Cord Injury Study protocol (MPSS group). During the next 2-year, all patients were treated without MPSS (non-MPSS group). There were 38 patients in the MPSS group and 41 in the non-MPSS. Early spinal decompression and stabilization was performed as soon after injury in both the groups.
RESULTS: According to The American Spinal Injury Association (ASIA) motor score, there was an average improvement by 3 months postinjury of 12.4 points in the MPSS group and 13.8 points in the non-MPSS group. In patients with complete motor loss, average ASIA motor score improved 9.0 points in the MPSS group and 12.6 points in the non-MPSS group. For patients with incomplete motor loss, average ASIA motor score improvement was 14.1 and 15.5 points in the MPSS and non-MPSS groups, respectively.In the MPSS group, 19 patients developed pneumonia, 13 developed urinary tract infections, and 5 developed wound infections. Incidence of pneumonia was significantly increased with the use of MPSS medication.
CONCLUSION: We found no evidence supporting the opinion that high-dose MPSS administration facilitates neurologic improvement in patients with spinal cord injury. We believe MPSS should be used under limited circumstances because of the high incidence of pulmonary complication.
Hurlbert RJ, Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, Rozzelle CJ, Ryken TC, Theodore N.
Pharmacological therapy for acute spinal cord injury.
Neurosurgery. 2013 Mar;72 Suppl 2:93-105. doi: 10.1227/NEU.0b013e31827765c6.
Abstract/Text
Yukawa Y. Posterior Pedicle Screw Fixation in Cervical Spine Reconstruction. Spine Trauma, Surgical Techniques. In : Patel VV, Burger E, Brown CW (eds.), Springer-Verlag Berlin Heidelberg, 2010, 1st ed, pp199-210.
Yukawa Y, Kato F, Yoshihara H, Yanase M, Ito K.
Cervical pedicle screw fixation in 100 cases of unstable cervical injuries: pedicle axis views obtained using fluoroscopy.
J Neurosurg Spine. 2006 Dec;5(6):488-93. doi: 10.3171/spi.2006.5.6.488.
Abstract/Text
OBJECT: The authors conducted a study to introduce the imaging technique in which pedicle axis views are obtained using fluoroscopy to match the screw entry point with pedicle orientation and to report the clinical results and safety of cervical pedicle screw fixation (PSF) in patients treated for unstable cervical injuries.
METHODS: One hundred consecutive patients with unstable cervical injuries underwent PSF in which the authors used fluoroscopic imaging to acquire pedicle axis views. There were 87 men and 13 women whose mean age was 42.5 years. The accuracy of PS placement was examined postoperatively using axial computed tomography (CT) and oblique radiography. Screw malpositioning was classified either as screw exposure (< 50% of the screw outside the pedicle) or pedicle perforation (> 50% of the screw outside the pedicle boundaries). The mean operative time was 97.6 minutes, and the mean estimated blood loss was 221 ml. Local vertebral alignment around the injured segment measured 6.0 degrees of kyphosis preoperatively and 6.7 degrees of lordosis postoperatively. Solid posterior bone fusion was achieved in all but three patients who died shortly after surgery. There was no secondary dislodgment of instrumentation in 95% of these 97 cases. Of the 419 cervical PSs, 43 (10.3%) were of the screw-exposure type and 17 (4.0%) of the pedicle-perforation type. There were two surgery-related complications: one penetration of a probe into the vertebral artery and one radiculopathy. There were six postoperative complications: two cases of instrumentation failure associated with loss of correction, three cases of correction loss (> 10 degrees), and one case of deep wound infection.
CONCLUSIONS: Solid posterior fusion without secondary dislodgment of hardware was demonstrated in 95% of the cases. The incidence of complications associated with cervical PSF was not high. Postoperative CT scanning showed that 17 (4.0%) of 419 screws perforated the pedicle. It appears that fluoroscopy performed using pedicle axis views improves the accuracy and safety of cervical PS insertion.
Yukawa Y, Kato F, Ito K, Horie Y, Hida T, Nakashima H, Machino M.
Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope.
Eur Spine J. 2009 Sep;18(9):1293-9. doi: 10.1007/s00586-009-1032-7. Epub 2009 Jun 2.
Abstract/Text
Cervical pedicle screw fixation is an effective procedure for stabilising an unstable motion segment; however, it has generally been considered too risky due to the potential for injury to neurovascular structures, such as the spinal cord, nerve roots or vertebral arteries. Since 1995, we have treated 144 unstable cervical injury patients with pedicle screws using a fluoroscopy-assisted pedicle axis view technique. The purpose of this study was to investigate the efficacy of this technique in accurately placing pedicle screws to treat unstable cervical injuries, and the ensuing clinical outcomes and complications. The accuracy of pedicle screw placement was postoperatively examined by axial computed tomography scans and oblique radiographs. Solid posterior bony fusion without secondary dislodgement was accomplished in 96% of all cases. Of the 620 cervical pedicle screws inserted, 57 (9.2%) demonstrated screw exposure (<50% of the screw outside the pedicle) and 24 (3.9%) demonstrated pedicle perforation (>50% of the screw outside the pedicle). There was one case in which a probe penetrated a vertebral artery without further complication and one case with transient radiculopathy. Pre- and postoperative tracheotomy was required in 20 (13.9%) of the 144 patients. However, the tracheotomies were easily performed, because those patients underwent posterior surgery alone without postoperative external fixation. The placement of cervical pedicle screws using a fluoroscopy-assisted pedicle axis view technique provided good clinical results and a few complications for unstable cervical injuries, but a careful surgical procedure was needed to safely insert the screws and more improvement in imaging and navigation system is expected.
湯川泰紹 頸椎椎弓根スクリュー固定（pedicel screw fixation in cervical spine） 脳神経外科 エキスパート 「脊椎・脊髄 ステップアップ編」 高安正和 編、中外医学社、p83-92, 2009.
湯川泰紹：頚椎後方インストゥルメンテーション 整形外科 治療と手術の合併症 冨士武史編：金原出版， 2011；150-155．.
Yukawa Y. Anterior and Posterior Surgery and Fixation for Burst Fractures Spine Trauma, Surgical Techniques. In : Patel VV, Burger E, Brown CW (eds.), Springer-Verlag Berlin. Heidelberg, 2010, 1st ed, pp299-309.
Machino M, Yukawa Y, Ito K, Nakashima H, Kato F.
Posterior/anterior combined surgery for thoracolumbar burst fractures--posterior instrumentation with pedicle screws and laminar hooks, anterior decompression and strut grafting.
Spinal Cord. 2011 Apr;49(4):573-9. doi: 10.1038/sc.2010.159. Epub 2010 Nov 16.
Abstract/Text
STUDY DESIGN: A prospective clinical study.
OBJECTIVE: The purpose of this study was to evaluate prospectively a large group of patients with thoracolumbar burst fractures who were treated with a posterior/anterior combined procedure and to report on the surgical outcomes, complications and radiographic results.
METHODS: A total of 100 consecutive patients were surgically managed with posterior instrumentation, anterior decompression and anterior strut grafting. There were 71 males and 29 females; the mean age was 36 years. Patients with osteoporotic delayed vertebral body collapse were excluded. The mean follow-up period was 30 months. Surgical outcomes such as operative time, blood loss and sagittal alignment were investigated. A neurological assessment was performed by a rating system based on the American Spine Injury Association impairment scale. An interbody fusion was judged using plain X-ray and computed tomographic scans.
RESULTS: The mean operative time was 256 min and the mean operative bleeding was 985 ml. Most of the patients were ambulatory within 3 days after surgery. Of the 76 patients with neurological injury, 54 (71.1%) recovered function following surgery. The mean local kyphosis angle was 12.2° kyphotic preoperatively and 0.8° lordotic at the final observation. The mean correction angle was 15.7° and correction loss was 2.6°. No instrumentation failure was observed and the postoperative fusion rate was 99%.
CONCLUSIONS: Posterior/anterior combined surgery with posterior pedicle screws and hooks fixation, and reconstruction by simultaneous strut grafting and anterior decompression, achieved short segment fixation and can be a useful option for surgically treating thoracolumbar burst fractures.
