ORIGINAL RESEARCH ARTICLE |
https://doi.org/10.5005/jojs-10079-1135 |
A Study of Functional and Radiological Outcome in Anterior Cervical Discectomy and Fusion with Stabilization in Posttraumatic Acute Central Cord Syndrome
1–4Department of Orthopaedics, Spine Surgery Unit, Preethi Hospital, Madurai, Tamil Nadu, India
5Department of Orthopaedics, Preethi Hospital, Madurai, Tamil Nadu, India
Corresponding Author: Bharat K Ramalingam Jeyashankaran, Department of Orthopaedics, Spine Surgery Unit, Preethi Hospital, Madurai, Tamil Nadu, India, Phone: +91 9840746102, e-mail: bharatortho82@gmail.com
Received: 26 October 2023; Accepted: 08 December 2023; Published on: 12 January 2024
ABSTRACT
Background: Spinal injuries account for around 6% of overall trauma patients, of which cervical spine injuries contribute >50%. Central cord syndrome (CCS) is the most common subtype of incomplete spinal cord and accounts for around 15–25% of all cases. The aim of this study is to assess the functional and radiological outcomes of posttraumatic acute CCS treated with anterior cervical discectomy and fusion (ACDF) with stabilization.
Materials and methods: It is a prospective study done between October 2020 and September 2022 in the Department of Orthopaedics, Preethi Hospital. Our study consists of 23 patients with posttraumatic CCS treated with ACDF with stabilization. Neurological and functional outcomes were assessed using the modified Japanese Orthopedic Association (mJOA) scale, visual analog score (VAS), and American Spinal Injury Association (ASIA) score at regular intervals of 3 and 6 months and 1 and 2 years, respectively.
Results: Our study population comprised 19 males and four females with posttraumatic acute CCS. The average follow-up was 12–24 months. Out of 23 patients, 13 had single-level fusion, and 10 patients had double-level fusion surgery. In our study, preoperative (pre-op) mean VAS decreased from 7.6 ± 0.84 to 6.9 ± 1.6 postoperatively, and the mean mJOA score decreased from 8.2 ± 2.2 to 14.5 ± 2.0 postoperatively were statistically significant. On comparing pre-op and postoperative ASIA neurological grading, statistically significant improvement of ASIA grades. Radiological outcomes according to Bridwell’s fusion criteria in computer tomography (CT) were also excellent.
Conclusion: To conclude, we recommended surgical decompression with ACDF as the current mode of treatment with excellent functional and radiological outcomes with long-term results for posttraumatic CCS.
How to cite this article: Raju S, Velur Nagendra SK, Thangamani V, et al. A Study of Functional and Radiological Outcome in Anterior Cervical Discectomy and Fusion with Stabilization in Posttraumatic Acute Central Cord Syndrome. J Orth Joint Surg 2024;6(1):1–11.
Source of support: Nil
Conflict of interest: None
Keywords: Anterior cervical discectomy and fusion, American Spinal Injury Association score, Bridwell score, Central cord syndrome, Cervical spine injury, Modified Japanese Orthopedic Association score, Visual analog score
INTRODUCTION
Spinal injuries account for around 6% of overall trauma patients, of which cervical spine injuries contribute >50%.1 The most common subtype of incomplete spinal cord injury is central cord syndrome (CCS), which comprises 15–25% of all cases. Traumatic CCS typically results from hyperextension injury in the presence of preexisting cervical stenosis. It’s classically characterized as the predominant motor and sensory deficit of the upper extremities with emphasis on hand dysfunction and sparing or milder findings in the lower extremities.2,3 At present, magnetic resonance imaging (MRI) is the state-of-the-art clinical modality for the evaluation of traumatic spinal cord injury.4
Conservative medical treatment plays a major role in dealing with this specific hyperextension-related cervical cord injury. However, patients continue to suffer from persistent neurologic deficits of the upper extremities, with poor daily activity, for months or even years. More recent reports5–7 have emphasized the benefits of surgical management. Anterior cervical discectomy and fusion (ACDF) aims to establish complete neural decompression and provide segmental stability at the symptomatic cervical level. Spacer bone grafts are of different types, such as autograft bone (iliac crest bone graft), allograft bone (cadaver bone graft), and bone graft substitutes (cages—titanium or bioresorbable).
In our study, patients with traumatic acute CCS underwent ACDF with stabilization in Preethi Hospital. Functional outcomes were assessed using a modified Japanese Orthopedic Association (mJOA) score/American Spinal Injury Association (ASIA) impairment scale and visual analog score (VAS) at intervals of 6, 12 months, and 2 years. Postoperatively, radiological outcome [X-rays/computer tomography (CT) scan bony fusion using Bridwell interbody fusion criteria/MRI T2-weighted images (T2w) intramedullary cord signal changes] was assessed at 2-year follow-up.
Materials and Methods
This prospective study was done in the Department of Orthopaedics, Preethi Hospital, Madurai, with a study period from October 2020 to September 2022. All demographic data was collected from patients presenting in the emergency and outpatient departments. Informed written consent was obtained, following which 23 patients with traumatic CCS underwent ACDF for CCS at our institution. Ethical committee clearance approval was obtained.
The inclusion criteria in this study were patients in the age-group of 20–70 (both genders), acute CCS due to traumatic injury presented within 48 hours, single and double spinal level involvement, people who accepted the consent and participated in the study for the whole length of follow up. The inclusion criteria in this study were translation spine injuries.
Multiple spinal level involvement of three or more levels, Pediatrics cervical spine injuries, patients <20 years of age, and patients with associated head injuries. A standardized protocol was followed for the assessment of patients after informed consent. Complete neurological examination of motor and sensory loss and loss/brisk reflexes using ASIA grading was used to evaluate the grade of spinal injury preoperatively (pre-op) and serially postoperatively till 2-year follow-up.
Functional outcomes were measured using mJOA and VAS scored pre-op and serially postoperative till the end the 2-year follow-up. All patients clinically suspected to be suffering from CCS were subjected to radiological imaging.
Plain radiograph (AP/lateral) study remained the primary diagnostic spine evaluation. Evidence of cervical spondylosis on digital X-ray imaging was assessed by the presence of anterior/posterior osteophytes, disk space narrowing with segmental kyphosis, loss of lordosis, and foraminal spurs.
Computed tomography (CT) of the cervical spine was done in patients to assess the canal dimensions and to document bony osteophyte compression. MRI is the investigation of choice. At the 2-year follow-up, X-rays and CT of the cervical spine were used, and fusion rates were assessed using the Bridwell fusion grading system (Table 1).
| Bridwell grade | Description |
|---|---|
| Grade 1 | Fused with remodeling and trabeculae present |
| Grade 2 | Graft intact, not fully remodeled and incorporated, no lucency |
| Grade 3 | Graft intact, potential lucency present at the top and bottom of the graft |
| Grade 4 | Fusion absent with collapse/resorption of the graft |
Magnetic resonance imaging (MRI) was done to assess the degree of cord compression, measure the spinal canal, cord hematomyelia changes, osteophyte protrusion into the canal, and intramedullary signal changes in T2w images, which was categorized according to Yuwaka et al. classification (Fig. 1 and Table 2).5
| Grade 0 | No ISI changes |
| Grade 1 | Light changes |
| Grade 2 | Bright changes |
Fig. 1: Yuwaka et al. classification grade 0: no ISIs; grade 1: light ISIs; grade 2: bright ISIs
Patient’s demographic data, duration of symptoms, pre-op neurological disability (ASIA), and functional disability (mJOA score and VAS score). Radiological parameters like bony osteophyte compression, number of levels of compression, and intramedullary hyperintense signal changes in T2 MRI were evaluated.
Postoperative follow-up duration surgery time was assessed.
Functional outcomes modified by the JOA and VAS was evaluated serially at 3-, 6-, 12-, and 24-month follow-up. The postoperative JOA score was determined at the 2-year follow-up.
The ASIA impairment scale (AIS) grades were evaluated serially at 3-, 6-, 12-, and 24-month follow-ups (grades A–E). The percentages of AIS improvement of one or more grades were also assessed.
Radiological outcomes were assessed by fusion rates according to the Bridwell interbody fusion grading system serially till the end of the 2-year follow-up.
Statistical Analysis
The sample size formula used is as follows:
Where
n = sample size, deff = design effect
d = desired absolute precision or absolute level of precision
Results from OpenEpi, version 3.
The sample size for frequency in a population and its correlation with confidence interval was shown (Table 3).
| Sample size for frequency in a population | |
|---|---|
| Population size (N) | 25 |
| Proportion (p) | 50 ± 5% |
| Confidence limits % (d) | 5% |
| Design effect (DEFF) | 1 |
| Sample size (n) | |
| Confidence level (%) | Sample size |
| 95% | 21 |
RESULTS
In this study, a total of twenty-seven cases were diagnosed with posttraumatic CCS and underwent ACDF. Of this, 23 were followed up throughout the study. Four patients subsequently lost follow-up during the study period. Thus, it has a response rate of 85%.
In our study, it was observed that a total of 19 cases were male (83%) and four cases were females (17%). Thus indicating male predominance in our study (Table 4 and Fig. 2).
| Sex | Number of patients | Percentage |
|---|---|---|
| Male | 19 | 82.6 |
| Female | 4 | 17.4 |
Fig. 2: Gender distribution
Our entire study population (23 patients) was within the 20–70 age-group with a mean age of 46.6 ± 12.1.5 In our study, we noticed that 35% of the population belonged to the age-group 31–40 years of age, 31% in age-group 41–50, 17% in age-group 51–60, and 13% in age-group 61–70. This indicates that the majority of cases belong to the age-group of 31–50 years (Table 5 and Fig. 3).
| Age (years) | Number of patients | Percentage | Mean ± SD |
|---|---|---|---|
| 20–30 | 1 | 4.4 | 46.8 ± 12.1 |
| 31–40 | 8 | 34.8 | |
| 41–50 | 7 | 30.4 | |
| 51–60 | 4 | 17.4 | |
| 61–70 | 3 | 13.0 |
Fig. 3: Graphical presentation of age distribution
In our study, we noticed that the major mode of injury was road traffic accidents (61%), followed by falls from height/fall of heavy objects (22%)and trivial falls (17%) (Table 6 and Fig. 4).
| Mode of injury | Number of patients | Percentage |
|---|---|---|
| Fall from height/fall of heavy object | 5 | 21.7 |
| Trivial fall | 4 | 17.4 |
| Motor collision | 14 | 60.9 |
| Sports injuries | 0 | 0 |
Fig. 4: Graphical presentation of the mode of injury
In our study, six patients (26%) had diabetes mellitus, four patients (17%) were hypertensive, and three patients (13%) were both diabetic and hypertensive. One patient (4%) had an associated injury of clavicle fracture (Table 7 and Fig. 5).
| Comorbidities | Number of patients | Percentage |
|---|---|---|
| Diabetic | 6 | 26.1 |
| Hypertension | 4 | 17.4 |
| Diabetic and hypertension | 3 | 13.0 |
| Associated injuries clavicle | 1 | 4.4 |
| Nil | 9 | 39.1 |
Fig. 5: Graphical presentation of comorbidities
In our study, we noticed that 13 patients (56%) underwent single-level fusion surgery, and 10 patients underwent double-level fusion surgery (44%) (Table 8 and Fig. 6).
| Level | Number of patients | Percentage |
|---|---|---|
| Single level | 13 | 56.5 |
| Double level | 10 | 43.5 |
Fig. 6: Graphical presentation of single/double levels of fusion
In this study, we noticed eight patients (35%) underwent C5-C6 level ACDF, indicating that C5-C6 level is the most common level of injury in this study (Table 9 and Fig. 7).
| Levels of fusion | Number of patients | Percentage |
|---|---|---|
| C3-C4 | 2 | 8.7 |
| C3-C4/C4-C5 | 2 | 8.7 |
| C4-C5 | 2 | 8.7 |
| C4-C5/C5-C6 | 4 | 17.4 |
| C5-C6 | 8 | 34.8 |
| C5-C6/C6-C7 | 4 | 17.4 |
| C6-C7 | 1 | 4.4 |
Fig. 7: Graphical presentation of age distribution
In our study, we noticed pre-op ASIA neurological scale grading included ASIA A: eight patients (35%), ASIA B: four patients (17%), ASIA C: four patients (17%), and ASIA D: seven patients (30%), respectively (Table 10 and Fig. 8).
| Functional assessment: pre-op ASIA grading | Number of patients | Percentage |
|---|---|---|
| ASIA A | 8 | 34.8 |
| ASIA B | 4 | 17.4 |
| ASIA C | 4 | 17.4 |
| ASIA D | 7 | 30.4 |
Fig. 8: Graphical presentation of pre-op ASIA
At the 2-year follow-up, we noticed that postoperative ASIA neurological grading was ASIA A: two patients (8.7%), ASIA B: three patients (13%), ASIA C: five patients (22%), ASIA D: four patients (17%), and ASIA E: nine patients (39%), respectively (Table 11 and Fig. 9).
| Functional assessment: pre-op ASIA grading | Number of patients | Percentage |
|---|---|---|
| ASIA A | 5 | 21.7 |
| ASIA B | 3 | 13.0 |
| ASIA C | 4 | 17.4 |
| ASIA D | 3 | 13 |
| ASIA E | 8 | 34.8 |
Fig. 9: Graphical presentation of postoperative ASIA
In our study, pre-op ASIA grading included ASIA A: eight patients, ASIA B: four patients, ASIA C: four patients, and ASIA D: seven patients. All 23 patients underwent ACDF. On postoperative follow-up, it was found that three out of eight patients in ASIA grade A showed improvement in ASIA grades. Two patients improved from ASIA A to ASIA B, and one patient improved from ASIA A to ASIA C. Three patients from ASIA B improved to ASIA C. Out of the four patients in ASIA C pre-op, three patients improved to ASIA D, and one patient improved by two grades to ASIA E. All of seven patients in ASIA D improved to ASIA E. The postoperative grading was ASIA A: two patients, ASIA B: three patients, ASIA C: five patients, ASIA D: four patients, and ASIA E: nine patients. On comparing pre-op and postoperative ASIA neurological grading, improvement of ASIA grades was found to be statistically significant with a p-value of <0.001 (Table 12).
| Variable | ASIA score pre-op | Total | p-value | ||||
|---|---|---|---|---|---|---|---|
| ASIA A | ASIA B | ASIA C | ASIA D | ||||
| ASIA score, post | ASIA A | 2 | 0 | 0 | 0 | 2 | 0.001, significant |
| 8.7% | 0.0% | 0.0% | 0.0% | 8.7% | |||
| ASIA B | 3 | 0 | 0 | 0 | 3 | ||
| 13.0% | 0.0% | 0.0% | 0.0% | 13.0% | |||
| ASIA C | 3 | 1 | 1 | 0 | 5 | ||
| 13.0% | 4.3% | 4.3% | 0.0% | 21.7% | |||
| ASIA D | 0 | 3 | 1 | 0 | 4 | ||
| 0.0% | 13.0% | 4.3% | 0.0% | 17.4% | |||
| ASIA E | 0 | 0 | 2 | 7 | 9 | ||
| 0.0% | 0.0% | 8.7% | 30.4% | 39.1% | |||
| Total | 8 | 4 | 4 | 7 | 23 | ||
| 34.8% | 17.4% | 17.4% | 30.4% | 100.0% | |||
In our study, we noticed that the pre-op mean VAS was 7.6 ± 0.84 and decreased postoperatively to a mean VAS of 6.9 ± 1.6. This difference was found to be statistically significant with a p-value of <0.043 (Table 13 and Fig. 10).
| Variable | Mean | SD | p-value | |
|---|---|---|---|---|
| VAS score | Pre | 7.6 | 0.84 | 0.043, significant |
| Post | 6.9 | 1.6 | ||
Fig. 10: Graphical presentation of pre-op and postoperative VAS
In our study, we noticed that the pre-op mean mJOA score was 8.2 ± 2.2, decreased postoperatively as the mean VAS of 14.5 ± 2.0. This difference was found to be statistically significant with a p-value of <0.001 (Table 14 and Fig. 11).
| Variable | Mean | SD | p-value | |
|---|---|---|---|---|
| mJOA | Pre | 8.2 | 2.2 | 0.001, significant |
| Post | 14.5 | 2.0 | ||
Fig. 11: Graphical presentation of pre-op and postoperative mean mJOA score
In our study, we noticed that the pre-op classification of mJOA scoring consisted of mild grade: one patient, moderate grade: nine patients, and severe grade: six patients. Postoperative classification of mJOA scoring consisted of mild grade: 10 patients, moderate grade: seven patients, and severe grade: six patients. On comparing pre-op and postoperative modified Japanese association scores, improvement in grades was found be statistically significant with a p-value of <0.003 (Table 15).
| mJOA score | Post-mJOA | Total | p-value | |||
|---|---|---|---|---|---|---|
| Mild | Moderate | Severe | ||||
| Pre-mJOA | Mild | 1 | 0 | 0 | 1 | 0.003, significant |
| 4.3% | 0.0% | 0.0% | 4.3% | |||
| Moderate | 8 | 1 | 0 | 9 | ||
| 34.8% | 4.3% | 0.0% | 39.1% | |||
| Severe | 1 | 6 | 6 | 13 | ||
| 4.3% | 26.1% | 26.1% | 56.5% | |||
| Total | 10 | 7 | 6 | 23 | ||
| 43.5% | 30.4% | 26.1% | 100.0% | |||
At the 2-year follow-up, we noticed that postoperative, according to Bridwell’s fusion criteria in CT, 18 patients (78%) were in grade 1, and five patients (22%) were in grade 2 (Table 16 and Fig. 12).
| Radiological assessments Bridwell grading | Number of patients | Percentage |
|---|---|---|
| Grade 1 | 18 | 78.3 |
| Grade 2 | 5 | 21.7 |
| Grade 3 | 0 | 0 |
| Grade 4 | 0 | 0 |
Fig. 12: Graphical presentation of pre-op and postoperative Bridwell’s fusion grading
Case 1
A 45-year-old male had a road traffic accident and presented with CCS with ACDF with iliac crest bone graft and anterior cervical plate. Posttraumatic C4C5 disk protrusion with PLL rupture and CCS with ASIA C neurology. At the 2-year follow-up, neurology improved to ASIA E. VAS score improved. Radiologically, parameters like Bridwell’s fusion grade were one and marked improvement in intramedullary cord signal intensity changes (ISI) (Figs 131415).
Figs 13A and B: Case 1: (A) Pre-op radiographic image; (B) MRI showing grade 1 ISIs
Figs 14A and B: Case 1: (A) Postoperative radiographic image showing Bridwell’s fusion grade 1; (B) MRI showing grade 0 ISIs
Fig. 15: Case 1: Clinical images at the 2-year follow-up following an ACDF for CCS
Case 2
A 61-year-old male met with a road traffic accident and had a C5-C6 single-level ACDF with titanium cage/anterior osteophyte excision for a posttraumatic CCS with cord hematomyelia/C5-C6 discosteophytic leison hard (disk) with ASIA C neurology. At the 2-year follow-up, neurology improved to ASIA D. VAS score improved. Radiologically, parameters like Bridwell’s fusion grade were one and marked improvement in ISIs (Figs 161718).
Figs 16A and B: Case 2: (A) Pre-op radiographic image; (B) MRI showing grade 1 ISIs
Figs 17A and B: Case 1: (A) Postoperative radiographic image showing Bridwell’s fusion grade 1; (B) MRI showing grade 0 intramedullary signal
Fig. 18: Case 2: Clinical images at the 2-year follow-up following ACDF for CCS
DISCUSSION
In the 19th century, it was strongly believed that surgical treatment was contraindicated for traumatic spinal cord injury due to the risks in surgery and a higher rate of complications like neurologic deterioration, and the overall improvement in neurologic recovery was not favorable. Other authors also predominantly suggested nonoperative management was more favorable than surgery.9,10 However, the recent era with advanced techniques of surgical decompression and enhancements in the perioperative management of cervical spinal cord injuries and stabilization have almost reduced surgical risks in the treatment of CCS.11,12
In the early 2000s, a prospective multicentric study was compared to early vs late surgical decompression in acute traumatic central cord injury. Analysis of results indicated a significant difference in favor of the early decompression group, with a larger proportion of injured recovering at least two AIS grades at the 6-month follow-up. Respecting existing clinical evidence, a recently systematic review of the literature concluded that decompression within 24 hours of spinal cord injury provided better outcomes compared to delayed surgery (>24 hours) or CCS managed conservatively.13
Our study indicates satisfactory grades of neurological recovery in posttraumatic CCS patients managed surgically, and the overall surgical complications are not dramatically different from those found in the same age-group or comorbidity-matched patients having elective cervical decompression surgery for myelopathy. In this present study, 23 patients were diagnosed with posttraumatic CCS, of which 19 cases were male (83%) and four cases were female (17%). This is similar to the studies conducted by Chen et al.8 and Guest et al.,14 with 78.6 and 62% male prevalence, respectively. This indicates a male predominance, which may be attributed to more involvement of men in outdoor activities like heavy manual labor and riding motor vehicles in our population.
In our study, we observed the majority of patients that, 82.7% of the population, belong to the age-group of 31–60 years of age whose mode of injury is due to high-velocity road traffic accidents, 13% were >60 years predominately due to slip and fall. This indicates that the majority of cases belong to the age-group 31–50.
In our study, we noticed that the major mode of injury was road traffic accidents (61%), followed by Falls from height/fall of heavy objects (21.7%) and trivial falls (17.4%); Guest et al. reported cause of injury was motor vehicle accidents in 22 patients (44%), trivial falls in 19 (38%), and sports-related accidents in nine (18%).14 Guest et al. said that the predominantly affected age-group was adults (age range 26–64 years (62%) due to motor vehicle accidents. Injuries in elderly patients [age 65 years (24%)] tended to be trivial falls.14
In our study, we noticed that 13 patients (56%) underwent single-level fusion surgery, and 10 patients (44%) underwent double-level fusion surgery. Our study indicated that 10 patients had two levels of spinal injury. In this study, we noticed eight patients (35%) underwent C5-C6 level ACDF, indicating that C5-C6 level was the most common level of spinal injury. Similar studies conducted by Dvorak et al. reported that the majority of their cases included C5 level spinal injury, accounting for 34 cases, 48% of their sample size, and three patients had more than one level of injury.6
Several literature reviews showed that surgically managed CCS patients showed better levels of neurological improvements.
Uribe et al. reported most (71%) improved by one ASIA grade at 3 months in 29 patients of CCS treated with expansile laminoplasty.15 Stevens et al., in a 21-year retrospective review, reported that statistical significance of gain of at least one grade in the Frankel score compared nonsurgical management in 126 patients of CCS, with a mean follow-up of 32 months.5 Guest et al. reported a series of 50 patients with CCS underwent surgery. All patients improved by at least 30 points from baseline over a mean follow-up of 3 years. Pre-op AIS grades of their study were ASIA C (28 patients, 40.6%) and ASIA D (41 patients, 59.4%). Of these 28 patients ASIA C patients, six patients (21.4%) were still ASIA-C at follow-up, 19 patients (67.9%) improved to ASIA D, and three patients (10.7%) to ASIA E. Of the ASIA D, 41 patients, 12 patients (29.3%) remained in ASIA D, and 29 patients (70.7%) improved to ASIA E. In their study, 74% of the patients improved one or more AIS grades.14
In Chen et al.’s study, 33 out of 49 patients showed improvement in at least 20 points in their ASIA motor scores following surgery. Predominately, recovery was noted within 6 months following surgery, with a mean follow-up of 56 months.8 In 2005, Song et al. reported a series of 22 patients with CCS without fractures or dislocations following surgical intervention. All patients progressed by an increase in at least one Frankel grade, whereas four patients (18%) improved by two grades.16 In a recent study reported by Jia et al., which compared the ”effectiveness of different surgical methods in the treatment of acute CCS without fractures and dislocations of the cervical spine.” Study groups were divided into group I, treated by ACDF, and group I, which underwent posterior cervical laminectomy. Group I included 84 patients who were pre-op graded as ASIA A: 14 patients, ASIA B: 22 patients, ASIA C: 35 patients, and ASIA D: 13 patients. Group II included 84 patients who were pre-op graded as ASIA A: 13 patients, ASIA B: 24 patients, ASIA C: 34 patients, and ASIA D: 12 patients. Postoperatively, at 1-year follow-up, ASIA grades in group I were ASIA A: zero patients, ASIA B: one patient, ASIA C: seven patients, ASIA D: 28 patients, and ASIA E: 48 patients. Group II included 84 patients who were postoperatively graded as ASIA A: 0 patients, ASIA B: one patient, ASIA C: six patients, ASIA D: 31 patients, and ASIA E: 46 patients.7
In our study, pre-op ASIA grading included ASIA A–8 patients, ASIA B- 4 patients, ASIA C: four patients, and ASIA D: seven patients. On postoperative follow-up, it was found that three out of eight patients in ASIA grade A showed improvement in ASIA grades. Two patients improved from ASIA A to ASIA B, and one patient improved from ASIA A to ASIA C. Three patients from ASIA B improved to ASIA C. Out of the four patients in ASIA C pre-op, three patients improved to ASIA D, and one patient improved by two grades to ASIA E. All of seven patients in ASIA D improved to ASIA E. The postoperative grading was ASIA A: five patients, ASIA B: three patients, ASIA C: four patients, ASIA D: three patients, and ASIA E: eight patients. On comparison of pre-op and postoperative ASIA graded improvement of grades was found be statistically significant with a p-value of <0.001.
Stevenson et al. studied 27 patients with traumatic CCS patients, neurological and functional outcomes in five patients managed conservatively and 22 patients with surgery. Results of this study showed that the mean Rotterdam scores in the 3-year follow-up were 83% standard deviation (SD) ± 23 in the surgical group (n = 15) vs 70% SD ± 21 in the conservative group (n = 4). This difference was statistically significant (p = 0.05).17 Dvorak et al.’s prospective study included 70 patients who reported improvements in motor scores from a mean of 58.7 (27.5) pre-op to 92.3 (11.6) at the mean follow-up of 70 months. Greater motor improvements correlated with higher initial AMS, level of formal education, and absence of spasticity.6 In a recent study reported by Yongli Jia et al., they compared the ”effectiveness of different surgical methods in the treatment of acute CCS without fractures and dislocations of the cervical spine.”Study groups were divided into group I, treated by ACDF, and group II, which underwent posterior cervical laminectomy. The pre-op JOA scores, postoperative JOA score, and improvement rate in JOA score were 7.1 ± 1.7, 14.6 ± 1.3, 56%, and 6.8 ± 2.1, 13.2 ± 2.1, 57% in groups I and II, respectively.7
In our study, similar to patients in group I who underwent ACDF. The pre-op mJOA scores, postoperative mJOA score, and improvement rate in mJOA score were 8.2 ± 2.2, 14.5 ± 2, 54%.On evaluation, the mJOA score was statistically significant with a p-value of <0.043.
Kim et al. reported that the VAS in single-level ACDF was pre-op 8.31 ± 0.9 and 6.2 ± 0.8 postoperatively.18
In our study, the VAS pre-op and postoperatively was 7.6 ± 0.84 and 6.9 ± 1.6, respectively. On evaluation, the VAS score was statistically significant with a p-value of <0.043 VAS.
In MRI, ISI were classified according to Yuwaka et al. as grades 0–3, 1–10, and 2–10 patients.5 At the 2-year follow-up, only five patients were able to review with MRI, which showed changes in ISI. All patients showed a decrease in ISI; four patients decreased from grade 1 to 0, and one patient decreased from grade 2 to 1.
Complications and Limitations
In our study, out of these 27 patients with posttraumatic CCS, three patients (15%) lost follow-up postoperatively. One patient developed aspiration pneumonitis, which progressed into severe acute respiratory distress syndrome and type 1 respiratory failure, leading to mortality. In the remaining 23 patients, four patients (14%) were reported with preexisting diabetes mellitus and had a complication of superficial wound infection, which subsequently settled with antibiotics. Three patients (11%) postoperatively complained of minimal dysphagia, which settled on with time. Recurrent laryngeal nerve injuries were reported in two patients (7%), which eventually recovered overtime during the follow-up period. The limitation of this study was the requirement for a larger sample size. Long-term follow-up was required.
CONCLUSION
Surgical decompression with ACDF is the current mode of treatment with excellent functional and radiological outcomes with long-term results for posttraumatic CCS.
In our study, in which all patients underwent ACDF for posttraumatic acute CCS, functional outcome assessment showed statistically significant improvement among all grades of ASIA grade, including ASIA A and B grade. Other functional parameters like the modified Japanese Association score and VAS score showed statistically significant improvement in long-term follow-up.
Radiological outcomes assessed according to Bridwell interbody fusion criteria showed excellent outcomes.
Improvements in functional outcome scores also showed concomitant improvement in intramedullary cord signal intensity (ISI) in MRI in long-term follow-up.
To conclude, we recommended ACDF for posttraumatic acute CCS patients.
ORCID
Vinoth Thangamani https://orcid.org/0000-0002-7172-8045
Bharat K Ramalingam Jeyashankaran https://orcid.org/0009-0003-3100-8443
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