Seminars in Spine Surgery最新文献

Medicolegal cases frequently arise within the realm of orthopaedic and neurological surgery, with a notable presence within the field of spine surgery. Despite new protocols and technological advancements created for the purpose of minimizing the risk of litigation, the rate of medicolegal cases still remains high in the United States. Understanding the basis of malpractice claims offers insight into strategies for surgeons to avoid litigation. Surgeons should emphasize these strategies in the perioperative care setting as this period represents the largest percentage of malpractice claims. Cases that directly involve surgical management, while less frequent, do tend to result in larger indemnity payments.

Acute cervical spinal cord injury (SCI) represents a significant challenge, with substantial implications for individual well-being and societal costs. In this chapter, we highlighted the importance of early surgical intervention within a critical time frame following injury to mitigate the risk of secondary damage and optimize neurological recovery. The chapter also delineated the dichotomy of primary and secondary injuries in traumatic cervical SCI, elucidating the pathophysiological mechanisms underlying each phase. Insights into the inflammatory cascade and cellular responses offer a nuanced understanding of injury progression, paving the way for targeted therapeutic interventions. Therefore, we delved into the current landscape of traumatic cervical SCI, addressing the advances in the medical and surgical care. Regarding surgical management, attention was directed towards established practices such as immobilization, respiratory support, and optimal timing of surgery, alongside emerging modalities including intraspinal pressure management, stem cell therapy, and nerve/tendon transfer. Similarly, the medical management section highlighted the importance of spinal cord perfusion, neurogenic shock management, and the role of steroids, while also exploring novel avenues such as genetic modification for spinal recovery. Overall, this chapter underscored the dynamic nature of SCI care, advocating for a holistic approach that integrates traditional and innovative treatment modalities.

Central Cord Syndrome (CCS) is a prevalent form of incomplete spinal cord injury (SCI) characterized by distinct motor and sensory deficits. This paper discusses the nuances of CCS, covering epidemiology, etiology, mechanisms, clinical presentation, diagnosis, predictive factors for outcomes, management strategies, and emerging therapeutic approaches. CCS accounts for a significant portion of SCIs, with trauma, particularly hyperextension injuries in individuals with preexisting spinal stenosis, being the primary cause. Patient demographics reveal skewed distributions in age, sex, and race, influencing outcomes and care approaches. Symptoms impact patients' quality of life extensively, ranging from motor dysfunction to neuropathic pain and bladder complications. Diagnosis involves a multifaceted approach utilizing clinical assessment tools, radiological imaging, and electrophysiological tests. Predictive factors for outcomes include age, time to presentation, and injury severity, guiding treatment decisions between conservative and surgical approaches. Initial management strategies focus on trauma assessment, neuroprotection, and preventing secondary injury. While established treatments have evolved, emerging therapies present promising avenues, including GM1 gangliosides, riluzole, minocycline, stem cell therapy, and transcutaneous electrical spinal stimulation. In conclusion, this paper sheds light on the multifaceted nature of CCS, exploring various aspects from epidemiology to emerging therapeutic approaches. It offers valuable insights for the advancement of care and outcomes in individuals affected by CCS.

High-income countries, including the United States, are confronting an evolving epidemiology of spinal trauma. This rise in geriatric spine trauma is marked by a growing occurrence of cervical spine trauma and incomplete spinal cord injuries. These trends are linked to the age-related prevalence of cervical spondylosis and higher fall risks. Cervical spine injuries in elderly patients require nuanced, patient-centered decision-making. This population is enriched for frailty, high comorbid burden, and poor bone health. This review discusses prevalent injury patterns in this group, evaluates surgical and non-surgical treatment options, and explores unique challenges in managing spine trauma among elderly patients.

Subaxial cervical spine fractures pose significant challenges for spine surgeons due to their varied nature and potential for neurological compromise. Despite C2 being the most frequently fractured level, subaxial fractures, especially at C7, constitute a substantial portion of cervical spine injuries. Incidence rates are rising, with up to 40 % involving multiple levels. Various classification systems, including AO Spine, SLIC, and CSISS, aid in treatment decisions, with SLIC showing high reliability among experienced surgeons. Surgical intervention is warranted for fractures causing persistent neurological deficits or instability. Treatment goals encompass neurologic preservation, biomechanical stability, and deformity correction, with considerations for prior surgery, degenerative stenosis, and osteoporosis. Fracture types, such as vertebral body, facet, flexion-distraction, and extension-distraction injuries, demand tailored surgical approaches. Special considerations, including comorbidities, pre-existing conditions, and vascular injuries, influence treatment strategies. A methodical approach considering neurology, stability, deformity, and patient-specific factors guides surgical planning. Despite the absence of a universal algorithm, a comprehensive understanding and individualized approach are essential for optimal management of subaxial cervical spine fractures.

Fracture-dislocations of the subaxial cervical spine are rare yet potentially devastating injuries often associated with high-energy trauma. These inherently unstable injuries frequently lead to neurologic compromise, necessitating urgent operative intervention. This review provides a comprehensive overview of subaxial cervical spine fracture-dislocations, addressing their epidemiology, anatomy, and classification systems. Classification schemes including Allen and Ferguson, Cervical Spine Injury Severity Score (CSISS), Subaxial Cervical Spine Injury Classification System (SLIC), and AO Spine Subaxial Cervical Spine Injury Classification System are discussed. Prompt recognition and management of these injuries is critical in optimizing long-term functional and neurologic outcomes. Rates of neurologic injury can exceed 50 %, with distractive flexion injuries and bilateral facet injuries often presenting with higher ASIA grades and lower neurologic recovery potential. Minimizing time to reduction is the most important factor in optimizing neurologic outcomes in these injury patterns. We discuss both closed and open reduction methods, timing considerations, technical pearls, and potential complications associated with each strategy. We also discuss the diagnosis and management of concurrent acute disk herniations, the role of advanced imaging, and the debated utility of pre-reduction MRI. Many subaxial cervical fracture-dislocations necessitate surgical intervention, which can be approached from an anterior, posterior, or combined approach. Although no standard surgical treatment algorithm exists, we discuss surgical options and situations where a preferred approach may exist. Selection of the approach depends on injury characteristics and surgeon preference, and there are no clearly defined surgical recommendations based on injury pattern.

Objective Provide background in cervical spinal cord injury and updates in rehabilitation for patients with cervical spinal cord injury.

Findings Cervical Spinal Cord injury is a catastrophic event that can be life-altering. The introduction of physiatrists, along with the rehabilitation team, early after cervical spinal cord injury has been shown to help decrease acute care length of stay and medical complications and provide education to patients and families facing life with spinal cord injury.

Conclusion There are newer technologies and modalities in spinal cord rehabilitation, including but not limited to functional electrical stimulation, epidural stimulation, and robot-assist gait training that are opening up the prospect of prolonged recovery after spinal cord injury and are an area of future potential and innovation.

The craniocervical junction (CCJ) protects critical neurovascular structures while allowing for a significant amount of head and neck motion.^1,2 Traumatic injuries at the CCJ are not uncommon, mainly occurring secondary to high-energy mechanisms in the young or low-energy mechanisms in the elderly.³ Unlike the subaxial spine, neurological deficits are less common with CCJ trauma, however neurological injuries in this area can be devastating.⁴ Given the complex bony, neurologic, and vascular anatomy at the CCJ, it is imperative that spine surgeons understand the diagnosis and management of C1 and C2 fractures.

Craniocervical dissociation (CCD) is a potentially devastating injury resulting from osseoligamentous injury to the craniovertebral junction and is associated with significant neurologic morbidity and mortality. CCD may be difficult to diagnose due to subtle imaging findings, and delayed diagnosis can lead to further neurologic decline. CCD is a surgical emergency and should be securely stabilized until definitive surgical rigid internal fixation can be performed. The current article will provide a framework for the management of CCD, with a particular emphasis on the critical first step of diagnosis.

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