Object The objective of this study was to elucidate the relationship between admission demographic data, validated injury severity measures on imaging studies, and clinical indicators on the American Spinal Injury Association (ASIA) motor score, Functional Independence Measure (FIM), manual dexterity, and dysesthetic pain at least 12 months after surgery for acute traumatic central cord syndrome (ATCCS) due to spinal stenosis. Methods Over a 100-month period (January 2000 to April 2008), of 211 patients treated for ATCCS, 59 cases were due to spinal stenosis, and these patients underwent surgical decompression. Five of these patients died, 2 were lost to follow-up, 10 were not eligible for the study, and the remaining 42 were followed for at least 12 months. Results In the cohort of 42 patients, mean age was 58.3 years, 83% of the patients were men, and 52.4% of the accidents were due to falls. Mean admission ASIA motor score was 63.8 (upper extremities score, 25.8 and lower extremities score, 39.8), the spinal cord was most frequently compressed at skeletal segments C3–4 and C4–5 (71%), mean midsagittal diameter at the point of maximum compression was 5.6 mm, maximum canal compromise (MCC) was 50.5%, maximum spinal cord compression was 16.5%, and length of parenchymal damage on T2-weighted MR imaging was 29.4 mm. Time after injury until surgery was within 24 hours in 9 patients, 24–48 hours in 10 patients, and more than 48 hours in 23 patients. At the 1-year follow-up, the mean ASIA motor score was 94.1 (upper extremities score, 45.7 and lower extremities score, 47.6), FIM was 111.1, manual dexterity was 64.4% of baseline, and pain level was 3.5. Stepwise regression analysis of 10 independent variables indicated significant relationships between ASIA motor score at follow-up and admission ASIA motor score (p = 0.003), MCC (p = 0.02), and midsagittal diameter (p = 0.02); FIM and admission ASIA motor score (p = 0.03), MCC (p = 0.02), and age (p = 0.02); manual dexterity and admission ASIA motor score (p = 0.0002) and length of parenchymal damage on T2-weighted MR imaging (p = 0.002); and pain level and age (p = 0.02) and length of parenchymal lesion on T2-weighted MR imaging (p = 0.04). Conclusions The main indicators of long-term ASIA motor score, FIM, manual dexterity, and dysesthetic pain were admission ASIA motor score, midsagittal diameter, MCC, length of parenchymal damage on T2-weighted MR imaging, and age, but different domains of outcome were determined by different predictors.

Object This retrospective comparative cohort study was aimed at discovering the risk factors associated with subdural hygroma (SDG) following decompressive craniectomy (DC) to relieve intracranial hypertension in severe head injury. Methods Sixty-eight of 104 patients who had undergone DC during a 48-month period and survived > 30 days were eligible for this study. To assess the dynamics of subdural fluid collections, the authors compared CT scanning data from and the characteristics of 39 patients who had SDGs with the data in 29 patients who did not have hygromas. Variables significant in the appearance, evolution, and resolution of this complication were analyzed in a 36-week longitudinal study. Results The earliest imaging evidence of SDG was seen during the 1st week after DC. The SDG volume peaked between Weeks 3 and 4 post-DC and was gradually resolved by the 17th week. Among the mechanisms of injury, motor vehicle accidents were most often linked to the development of an SDG after DC (p < 0.0007), and falls were least often associated (p < 0.005). Moreover, patients with diffuse brain injury were more prone to this complication (p < 0.0299) than those with an evacuated mass (p < 0.0001). There were no statistically significant differences between patients with and without hygromas in terms of age, sex, Glasgow Coma Scale score, intraventricular and subarachnoid hemorrhage, levels of intracranial pressure and cerebral perfusion pressure, timing of decompression, and the need for CSF diversion. More than 90% of the SDGs were ipsilateral to the side of the craniectomy, and 3 (8%) of 39 SDGs showed evidence of internal bleeding at ~ 8 weeks postinjury. Surgical evacuation was needed in 4 patients with SDGs. Conclusions High dynamic accidents and patients with diffuse injury were more prone to SDGs. Close to 8% of SDGs converted themselves into subdural hematomas at ~ 2 months postinjury. Although SDGs developed in 39 (~ 60%) of 68 post-DC patients, surgical evacuation was needed in only 4.

Ossification of the posterior longitudinal ligament (OPLL) is a rare but potentially devastating cause of degenerative cervical myelopathy (DCM). Decompressive surgery is the standard of care for OPLL and can be achieved through anterior, posterior, or combined approaches to the cervical spine. Surgical correction of OPLL via any approach is associated with higher rates of complications and the presence of OPLL is considered a significant risk factor for perioperative complications in DCM surgeries. Potential complications include dural tear (DT) and subsequent cerebrospinal fluid leak, C5 palsy, hematoma, hardware failure, surgical site infections, and other neurological deficits. Anterior approaches are technically more demanding and associated with higher rates of DT but offer greater access to ventral OPLL pathology. Posterior approaches are associated with lower rates of complications but may allow for continued disease progression. Therefore, the decision to pursue either an anterior or posterior approach to surgical decompression may be critically influenced by complications associated with each procedure. The authors critically review anterior and posterior approaches to surgical decompression of OPLL with particular focus on the complications associated with each approach. We also review the recent work in developing new surgical treatments for OPLL that aim to reduce complication incidence.

Object One often overlooked aspect of spinal epidural abscesses (SEAs) is the timing of surgical management. Limited evidence is available correlating earlier intervention with outcomes. Spinal epidural abscesses, once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with one recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions with a mortality approaching 16%. One key issue of contention is the benefit of rapid surgical management of SEA to maximize outcomes. Timing of surgical management is definitely one overlooked aspect of care in spinal infections. Therefore, the authors performed a retrospective analysis in which they evaluated patients who underwent early (evacuation within 24 hours) versus delayed surgical intervention (> 24 hours) from the point of diagnosis, in an attempt to test the hypothesis that earlier surgery results in improved outcomes. Methods A retrospective review of a prospectively maintained adult neurosurgical database from 2009 to 2011 was conducted for patients with the diagnostic heading: epidural abscess, infection, osteomyelitis, osteodiscitis, spondylodiscitis, and abscess. The primary end point for each patient was neurological grade, measured as an American Spinal Injury Association Impairment Scale grade using hospital inpatient records on admission and discharge. Patients were divided into early surgical (< 24 hours) and delayed surgical cohorts. Results Eighty-seven consecutive patients were identified (25 females; mean age 55.5 years, age range 18–87 years). Fifty-four patients received surgery within 24 hours of admission (mean time from admission to incision, 11.2 hours), and 33 underwent surgery longer than 24 hours (mean 59 hours) after admission. Of the 54 patients undergoing early surgery 45 (85%) had a neurological deficit, whereas in the delayed surgical group 21 (64%) of 33 patients presented with a neurological deficit (p = 0.09). Patients in the delayed surgery cohort were significantly older by 10 years (59.6 vs 51.8 years, p = 0.01). With regard to history of prior revision, body mass index, intravenous drug abuse, tobacco use, prior radiation therapy, diabetes, chronic systemic infection, and prior osteomyelitis, there were no significant differences. There was no significant difference between early and delayed surgery groups in neurological grade on presentation, discharge, or location of epidural abscess. The most common organism isolated was Staphylococcus aureus (n = 51, 59.3%). The incidence of methicillin-resistant S. aureus was 21% (18 of 87). Conclusions Evacuation within 24 hours appeared to have a relative advantage over delayed surgery with regard to discharge neurological grade. However, due to a limited, variable sample size, a significant benefit could not be shown. Further subgroup analyses with larger populations are required.

Object The authors performed a study to determine if lesion expansion occurs in humans during the early hours after spinal cord injury (SCI), as has been established in rodent models of SCI, and to identify factors that might predict lesion expansion. Methods The authors studied 42 patients with acute cervical SCI and admission American Spinal Injury Association Impairment Scale Grades A (35 patients) and B (7 patients) in whom 2 consecutive MRI scans were obtained 3–134 hours after trauma. They recorded demographic data, clinical information, Injury Severity Score (ISS), admission MRI-documented spinal canal and cord characteristics, and management strategies. Results The characteristics of the cohort were as follows: male/female ratio 37:5; mean age, 34.6 years; and cause of injury, motor vehicle collision, falls, and sport injuries in 40 of 42 cases. The first MRI study was performed 6.8 ±2.7 hours (mean ± SD) after injury, and the second was performed 54.5 ± 32.3 hours after injury. The rostrocaudal intramedullary length of the lesion on the first MRI scan was 59.2 ± 16.1 mm, whereas its length on the second was 88.5 ± 31.9 mm. The principal factors associated with lesion length on the first MRI study were the time between injury and imaging (p = 0.05) and the time to decompression (p = 0.03). The lesion's rate of rostrocaudal intramedullary expansion in the interval between the first and second MRI was 0.9 ± 0.8 mm/hour. The principal factors associated with the rate of expansion were the maximum spinal cord compression (p = 0.03) and the mechanism of injury (p = 0.05). Conclusions Spinal cord injury in humans is characterized by lesion expansion during the hours following trauma. Lesion expansion has a positive relationship with spinal cord compression and may be mitigated by early surgical decompression. Lesion expansion may be a novel surrogate measure by which to assess therapeutic effects in surgical or drug trials.