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Multimodal interventions to optimize spinal cord perfusion in patients with acute traumatic spinal cord injuries: a systematic review

Carly Weber-Levine, Brendan F. Judy, Andrew M. Hersh, Tolulope Awosika, Yohannes Tsehay, Timothy Kim, Alejandro Chara, and Nicholas Theodore

OBJECTIVE

The authors systematically reviewed current evidence for the utility of mean arterial pressure (MAP), intraspinal pressure (ISP), and spinal cord perfusion pressure (SCPP) as predictors of outcomes after traumatic spinal cord injury (SCI).

METHODS

PubMed, Cochrane Reviews Library, EMBASE, and Scopus databases were queried in December 2020. Two independent reviewers screened articles using Covidence software. Disagreements were resolved by a third reviewer. The inclusion criteria for articles were 1) available in English; 2) full text; 3) clinical studies on traumatic SCI interventions; 4) involved only human participants; and 5) focused on MAP, ISP, or SCPP. Exclusion criteria were 1) only available in non-English languages; 2) focused only on the brain; 3) described spinal diseases other than SCI; 4) interventions altering parameters other than MAP, ISP, or SCPP; and 5) animal studies. Studies were analyzed qualitatively and grouped into two categories: interventions increasing MAP or interventions decreasing ISP. The Scottish Intercollegiate Guidelines Network level of evidence was used to assess bias and the Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate confidence in the anticipated effects of each outcome.

RESULTS

A total of 2540 unique articles were identified, of which 72 proceeded to full-text review and 24 were included in analysis. One additional study was included retrospectively. Articles that went through full-text review were excluded if they were a review paper (n = 12), not a full article (n = 12), a duplicate paper (n = 9), not a human study (n = 3), not in English (n = 3), not pertaining to traumatic SCI (n = 3), an improper intervention (n = 3), without intervention (n = 2), and without analysis of intervention (n = 1). Although maintaining optimal MAP levels is the current recommendation for SCI management, the published literature supports maintenance of SCPP as a stronger indicator of favorable outcomes. Studies also suggest that laminectomy and durotomy may provide better outcomes than laminectomy alone, although higher-level studies are needed. Current evidence is inconclusive on the effectiveness of CSF drainage for reducing ISP.

CONCLUSIONS

This review demonstrates the importance of assessing how different interventions may vary in their ability to optimize SCPP.

Free access

Advancements in the treatment of traumatic spinal cord injury during military conflicts

Andrew M. Hersh, A. Daniel Davidar, Carly Weber-Levine, Divyaansh Raj, Safwan Alomari, Brendan F. Judy, and Nicholas Theodore

Significant advancements in the treatment of spinal cord injury (SCI) were developed in the setting of military conflicts, partly due to the large numbers of injuries sustained by service members. No effective SCI treatment options existed into the early 20th century, and soldiers who sustained these injuries were usually considered untreatable. Extensive progress was made in SCI treatment during and after World War II, as physical therapy was increasingly encouraged for patients with SCI, multidisciplinary teams oversaw care, pathophysiology was better understood, and strategies were devised to prevent wound infection and pressure sores. Recent conflicts in Iraq and Afghanistan have caused a substantial rise in the proportion of SCIs among causes of casualties and wounds, largely due to new forms of war and weapons, such as improvised explosive devices. Modern military SCIs resulting from blast mechanisms are substantively different from traumatic SCIs sustained by civilians. The treatment paradigms developed over the past 100 years have increased survival rates and outcomes of soldiers with SCI. In this paper, the authors review the role of military conflicts in the development of therapeutic interventions for SCI and discuss how these interventions have improved outcomes for soldiers and civilians alike.

Open access

Transpedicular Onyx embolization of a thoracic hemangioma with robotic assistance: illustrative case

Andrew M. Hersh, Yike Jin, Risheng Xu, A. Daniel Davidar, Carly Weber-Levine, L. Fernando Gonzalez, and Nicholas Theodore

BACKGROUND

Hemangiomas are common benign vascular lesions that rarely present with pain and neurological deficits. Symptomatic lesions are often treated with endovascular embolization. However, transarterial embolization can be technically challenging depending on the size and caliber of the vessels. Moreover, embolization can result in osteonecrosis and vertebral collapse.

OBSERVATIONS

Here the authors report the first case of a T10 vertebral hemangioma treated with transpedicular Onyx embolization aided by a robotic platform that guided pedicle cannulation and Craig needle placement. An intravenous catheter was attached to the needle and dimethylsulfoxide was infused, followed by Onyx under real-time fluoroscopy. Repeat angiography demonstrated significantly reduced contrast opacification of the vertebral body without compromise of the segmental artery. A T9–11 pedicle screw fixation was performed to optimize long-term stability. The patient’s symptoms improved and was stable at the 6-month follow-up.

LESSONS

Transpedicular embolization of vertebral hemangiomas can be performed successfully under robotic navigation guidance, avoiding complications seen with the intra-arterial approach and allowing for simultaneous pedicle screw fixation to prevent collapse and delayed kyphotic deformity. During the same procedure, a biopsy specimen can be collected for pathology. This technique can help to alleviate patient symptoms while avoiding complications associated with transarterial embolization or open resection.

Free access

Automated prediction of the Thoracolumbar Injury Classification and Severity Score from CT using a novel deep learning algorithm

Sophia A. Doerr, Carly Weber-Levine, Andrew M. Hersh, Tolulope Awosika, Brendan Judy, Yike Jin, Divyaansh Raj, Ann Liu, Daniel Lubelski, Craig K. Jones, Haris I. Sair, and Nicholas Theodore

OBJECTIVE

Damage to the thoracolumbar spine can confer significant morbidity and mortality. The Thoracolumbar Injury Classification and Severity Score (TLICS) is used to categorize injuries and determine patients at risk of spinal instability for whom surgical intervention is warranted. However, calculating this score can constitute a bottleneck in triaging and treating patients, as it relies on multiple imaging studies and a neurological examination. Therefore, the authors sought to develop and validate a deep learning model that can automatically categorize vertebral morphology and determine posterior ligamentous complex (PLC) integrity, two critical features of TLICS, using only CT scans.

METHODS

All patients who underwent neurosurgical consultation for traumatic spine injury or degenerative pathology resulting in spine injury at a single tertiary center from January 2018 to December 2019 were retrospectively evaluated for inclusion. The morphology of injury and integrity of the PLC were categorized on CT scans. A state-of-the-art object detection region-based convolutional neural network (R-CNN), Faster R-CNN, was leveraged to predict both vertebral locations and the corresponding TLICS. The network was trained with patient CT scans, manually labeled vertebral bounding boxes, TLICS morphology, and PLC annotations, thus allowing the model to output the location of vertebrae, categorize their morphology, and determine the status of PLC integrity.

RESULTS

A total of 111 patients were included (mean ± SD age 62 ± 20 years) with a total of 129 separate injury classifications. Vertebral localization and PLC integrity classification achieved Dice scores of 0.92 and 0.88, respectively. Binary classification between noninjured and injured morphological scores demonstrated 95.1% accuracy. TLICS morphology accuracy, the true positive rate, and positive injury mismatch classification rate were 86.3%, 76.2%, and 22.7%, respectively. Classification accuracy between no injury and suspected PLC injury was 86.8%, while true positive, false negative, and false positive rates were 90.0%, 10.0%, and 21.8%, respectively.

CONCLUSIONS

In this study, the authors demonstrate a novel deep learning method to automatically predict injury morphology and PLC disruption with high accuracy. This model may streamline and improve diagnostic decision support for patients with thoracolumbar spinal trauma.

Open access

Robot-assisted screw fixation in a cadaver utilizing magnetic resonance imaging–based synthetic computed tomography: toward radiation-free spine surgery. Illustrative case

A. Daniel Davidar, Brendan F. Judy, Andrew M. Hersh, Carly Weber-Levine, Safwan Alomari, Arjun K. Menta, Kelly Jiang, Meghana Bhimreddy, Mir Hussain, Neil R. Crawford, Majid Khan, Gary Gong, and Nicholas Theodore

BACKGROUND

Synthetic computed tomography (sCT) can be created from magnetic resonance imaging (MRI) utilizing newer software. sCT is yet to be explored as a possible alternative to routine CT (rCT). In this study, rCT scans and MRI-derived sCT scans were obtained on a cadaver. Morphometric analysis was performed comparing the 2 scans. The ExcelsiusGPS robot was used to place lumbosacral screws with both rCT and sCT images.

OBSERVATIONS

In total, 14 screws were placed. All screws were grade A on the Gertzbein-Robbins scale. The mean surface distance difference between rCT and sCT on a reconstructed software model was –0.02 ± 0.05 mm, the mean absolute surface distance was 0.24 ± 0.05 mm, and the mean absolute error of radiodensity was 92.88 ± 10.53 HU. The overall mean tip distance for the sCT versus rCT was 1.74 ± 1.1 versus 2.36 ± 1.6 mm (p = 0.24); mean tail distance for the sCT versus rCT was 1.93 ± 0.88 versus 2.81 ± 1.03 mm (p = 0.07); and mean angular deviation for the sCT versus rCT was 3.2° ± 2.05° versus 4.04°± 2.71° (p = 0.53).

LESSONS

MRI-based sCT yielded results comparable to those of rCT in both morphometric analysis and robot-assisted lumbosacral screw placement in a cadaver study.

Restricted access

Spinal dysraphism in exstrophy: a single-center study of a 39-year prospective database

Brendan F. Judy, Joshua Materi, Ryan P. Lee, Jovanna A. Tracz, Jaimin Patel, Carly Weber-Levine, Chad Crigger, Preeya Mistry, John P. Gearhart, and Eric M. Jackson

OBJECTIVE

The two main objectives of this study were to explore the rate of spinal dysraphism within bladder and cloacal exstrophy and to analyze the relationship between spinal dysraphism surgery, including timing of spinal dysraphism surgery, with urological and neurological outcomes.

METHODS

A prospectively maintained IRB-approved database of pediatric exstrophy patients treated from 1982 to 2021 was retrospectively reviewed for patients with spinal dysraphism. Spinal dysraphism was categorized into the following 7 subtypes: lipoma-based closed defect, myelomeningocele, meningocele, diastematomyelia, myelocystocele, low-lying conus with tethered cord/fatty filum, and sacral bony defect. Other factors assessed included patient demographic characteristics, type of spinal dysraphism procedure, reoperation, complication, presence of other neurological problems (e.g., hydrocephalus, Chiari malformation), neurological status, and urological function.

RESULTS

Analysis revealed that 114/1401 patients had coexisting spinal dysraphism. Of these 114, sufficient records including type of dysraphism were available for 54. Spinal dysraphism was most common within cloacal exstrophy (83.3% [45/54 patients]), followed by cloacal exstrophy variants (9.3% [5/54]), classic bladder exstrophy (3.7% [2/54]), and classic bladder exstrophy variants (3.7% [2/54]). Within spinal dysraphism, lipoma-based closed defects (63.0% [34/54]) and low-lying conus with tethered cord/fatty filum (11.1% [6/54]) were most common. Hydrocephalus and Chiari malformation occurred in 24.1% (13/54) and 11.1% (6/54) of patients. All 13 patients with hydrocephalus underwent shunt placement. Among those who underwent neurosurgical intervention, the complication rate for spinal dysraphism was 14.6% (7/48). Motor function data were available for 41 patients and revealed that motor function declined for 2/41 (4.8%) patients and improved for 6/41 (14.6%) after neurosurgery. There was no statistical difference in lower-extremity motor outcome related to timing of neurosurgery and exstrophy closure.

CONCLUSIONS

The authors have reported the surgical management and outcomes of patients with exstrophy and coexisting spinal dysraphism (n = 54). In 54 patients, spinal dysraphism was most common in the subset of patients with cloacal exstrophy (83.3%). Lipoma-based closed defects (63.0%) and low-lying conus with tethered cord/fatty filum (11.1%) were the most common, and the rates of hydrocephalus and Chiari malformation were 24.1% and 11.1%, respectively. There was no difference in lower-extremity motor outcome related to timing of neurosurgery and exstrophy closure.