Neurosurg Focus
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Ankylosing spondylitis can lead to severe cervical kyphosis, causing problems with forward vision, swallowing, hygiene, patient functionality, and social outlook. Evaluation of patients with cervical flexion deformity includes assessment of global sagittal balance and chin-brow angle. The primary treatment in extreme disabling cases is surgical correction involving a posterior cervical extension osteotomy, which is a technically demanding procedure with considerable risk of neurological injury. ⋯ These developments incorporate recent advances in anesthesia, neuromonitoring, and spinal instrumentation. Complications associated with the procedure include subluxation at the osteotomy level, spinal cord injury, radiculopathy, dysphagia, and pseudarthrosis. Although the risks of spinal correction are considerable, extension osteotomy remains an effective treatment modality for patients with disabling cervical flexion deformity.
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Cardiovascular complications in the acute stage following traumatic spinal cord injury (SCI) require prompt medical attention to avoid neurological compromise, morbidity, and death. In this review, the authors summarize the neural regulation of the cardiovascular system as well as the pathophysiology, diagnosis, and management of major cardiovascular complications that can occur following acute (up to 30 days) traumatic SCI. Hypotension (both supine and orthostatic), autonomic dysreflexia, and cardiac arrhythmias (including persistent bradycardia) are attributed to the loss of supraspinal control of the sympathetic nervous system that commonly occurs in patients with severe spinal cord lesions at T-6 or higher. ⋯ Although there is insufficient evidence to recommend (or refute) the use of screening tests for DVT in asymptomatic adults with acute SCI, this strategy may detect asymptomatic DVT in at least 9.4% of individuals who undergo thromboprophylaxis using lowmolecular- weight heparin. Indications and treatment of DVT and acute pulmonary embolism are well established and are summarized in this review. Recognition of cardiovascular complications after acute SCI is essential to minimize adverse outcomes and to optimize recovery.
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Traumatic central cord syndrome (TCCS), regardless of its biomechanics, is the most frequently encountered incomplete spinal cord injury. Patients with TCCS present with disproportionate weakness of the upper extremities, and variable sensory loss and bladder dysfunction. Fractures and/or subluxations, forced hyperextension, and herniated nucleus pulposus are the main pathogenetic mechanisms of TCCS. ⋯ More than one-half of these patients enjoy spontaneous recovery of motor weakness; however, as time goes on, lack of manual dexterity, neuropathic pain, spasticity, bladder dysfunction, and imbalance of gait render their activities of daily living nearly impossible. Based on the current level of evidence, there is no clear indication of the timing of decompression for relief of sustained spinal cord compression in hyperextension injuries. Future research, taking advantage of validated digital imaging data such as maximum canal compromise, maximum spinal cord compression, and lesion length on the CT and MR images, as well as more sensitive measures of bladder and hand function, spasticity, and neuropathic pain may help tailor surgery for a specific group of these patients.
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Comparative Study
Operative results and learning curve: microscope-assisted tubular microsurgery for 1- and 2-level discectomies and laminectomies.
The authors present their clinical results and the learning curve associated with the use of tubular retractors for 1- and 2-level lumbar microscope-assisted discectomies and laminectomies. ⋯ The use of tubular retractors for microsurgical decompression of degenerative spinal disease is a safe and effective treatment modality. As with other techniques, minimally invasive procedures are associated with a significant learning curve. As surgeons become more comfortable with the procedure, its applications can be expanded to include, for example, spinal instrumentation and deformity correction.
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The development of an acute traumatic spinal cord injury (SCI) inevitably leads to a complex cascade of ischemia and inflammation that results in significant scar tissue formation. The development of such scar tissue provides a severe impediment to neural regeneration and healing with restoration of function. ⋯ To achieve significant breakthroughs in outcomes, such approaches must combine both neuroprotective and neuroregenerative treatments. Novel techniques modulating endogenous stem cells demonstrate great promise in promoting neuroregeneration and restoring function.