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Thread: Dr. Young - decompression surgery 18 yrs post injury

  1. #1

    Dr. Young - decompression surgery 18 yrs post injury

    Dr. Young, I read your "risk benefit" account of decompression surgery. I am 42 and was injured in 1986 with incomplete C7 T1 injury and have used a wheelchair ever since. In 1990, I went to Barth Green of the Miami Project for an MRI. At the time he felt I "may" be a candidate for decomression surgery and the matter was not pursued.

    I have some motor function in that I can walk using parallel bars but that's about it. I also have complete proprioception and very good feeling (except temperature).

    Even though I am almost 18 years post injury, I am interested in the possibility of decompression surgery. I,m told that the MRI technology is considerably more advanced now than 13 years ago.I also work at a hospital and the radiologist would perform the MRI for less than market value.

    Is there any conclusive evidence that the benefits of decompression surgery would not warrant the risks? The research you cite ranges from months to 9 years post injury. Is there any reason the outer limit of the sample was 9 years?

    Your opinion and direction would be greatly appreciated.

    Thanks

  2. #2
    tucker, the studies (and common sense) also suggest that the longer one waits to decompress, the less likely one would get substantial functional recovery from the decompression. There have been relatively few or no studies of decompression that are more than 10 years after injury. This does not mean that decompression would be useless. The risk depends very much on the type of decompression, your health, and age.

    In the last few years, there has been a shift in thinking about compression of the cord. There is now increasing evidence that compression of the cord produces adhesive scarring between the spinal cord and the arachnoid/dura that surrounds the spinal cord. Occlusion of cerebrospinal fluid is known to produce syringomyelic cysts and we know that such cysts can produce neurological loss.

    As therapies, such as OEG transplants become available, the idea has emerged that would be important to decompress the spinal cord before transplantation. Dr. Huang thought that this was the case before he transplanted OEG cells into patients, insisting that all the patients be decompressed at least 6 months before he transplants. However, he recently changed his mind and is now trying to do decompression and transplantation in the same surgery, thinking that perhaps one surgery would be better than two. Obviously, however, he does not yet have much data to support the idea. By the way, Dr. Huang has operated on some patients that are more than 20 years after injury.

    In any case, it might all be a moot issue. If you have no evidence of current cord compression, there would be nothing to decompress. So, it is a good idea to get the MRI and see whether you have compression. By the way, it is recommended that people get annual MRI's of their spinal cord after injury.

    So, in summary, there is no conclusive evidence that decompression surgery would restore any neurological evidence. While the data encompasses patients that are up to 9 years after injury, I don't think that this would rule out people who are 18-20 years after injury. The risk of surgery depends on the procedure, health, and age.

    Wise.

  3. #3
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    Dr. Young

    Dr. Young, this probably sounds like a very stupid question. But why should a person with SCI have an MRI annually? When I read your post I called my husband and asked him was he aware of this. He said he was not, that he was not told this in rehab or by any other doctor since. He has been injured for over 14 years. He has spinal cord injuries T2-T10 and had a brain injury. Now, I feel very stupid. This is something he should have had all along, but has not, because he/we did not know. I'm glad I read your post. We are still planning on making an appointment with the neurosurgeon you recommended at UAB in Birmingham. Thank you so much! Carol

    Piglet sidled up to Pooh from behind. "Pooh!", he whispered. "Yes, Piglet?" "Nothing", said Piglet, taking Pooh's paw. "I just wanted to be sure of you."

  4. #4
    Senior Member alan's Avatar
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    Dr. Young,

    There are different types of MRI (i.e. contrast vs. no contrast.) What type should people with SCI get for best resolution?

    Alan

    "Was it over when the Germans bombed Pearl Harbor?"

  5. #5
    piglet, there are no formal guidelines for frequency of radiological examinations of people after spinal cord injury. At the present, most people get MRI's or other studies only when they have some kind of neurological change. I often hear from people who discover that they have neurological deterioration, get an MRI or CT scan, and find that they have an undetected and possibly preventable bony or spinal cord problem, such as a herniated disc, degeneration or curvature of the spinal cord, development of a syringomyelic cyst, or other problems.

    I personally think that all people with spinal cord injury should get either an MRI or a CT scan regularly. The frequency of the scans may not be the same for everybody and depend on the age and the health of the individual. My reasoning is as follows:

    1. Regular scans allow the detection of potentially correctable problems. In people with spinal cord injury, particularly if there is a problem that occurs in the spinal cord below the injury, symptoms of neurological loss or pain are often masked. The normal warning system that most people have are no longer in place. For example, somebody with a herniated disc below the injury site may not have clear symptoms except perhaps for changes in spasticity. By the time a problem is detected, the spinal cord may have sustained significant damage.

    2. In many cases, a person develops a neurological deficit, gets an MRI or CT scan for the first time in many years, and it is not clear whether the problem is a recent development or something that has been there for many years. Knowing the time course of the development of a spinal curvature, a syringomyelic cyst, spinal atrophy, etc. makes a big difference in the therapeutic decisions.

    3. The incidence of neurological deterioration and orthopedic deformity of the spinal column developing late after spinal cord injury, particularly in older people, is quite high. I can't find the papers that I posted earlier but as many as 40% of people develop some kind of neurological loss after spinal cord injury. A majority of people, particularly those who have spinal cord injury at a young age, develop progressive spinal deformities.

    For many years, doctors were cavalier about the spinal cord below the injury site, particularly in people who have "complete" spinal cord injury, based on their belief that people will not recover and that nothing should be done. Let me give an example, suppose a person has progressive degeneration of the intervertebral discs around and below the injury site, to the extent that the discs are compressing the spinal cord. The traditional thinking regarding such compression is to leave it alone if it is not causing significant pain, neurological deficits, autonomic dysreflexia.

    I believe that this situation is changing. As the prospects of therapy that can restore function improve, it behooves people to take care of their spinal cords below the injury site. I think that the care of the spinal cord and spinal column in people with spinal cord injury should not differ from the care of a person without spinal cord injury. Unfortunately, because spinal cord injury can mask neurological loss and eliminate some of the early warning signs that people have, one has to rely more on MRI or CT scans to detect deterioration, particularly in older patients.

    Because CT scans involve exposure to X-rays, it is probably not that advisable for people to get a CT scan every year. However, MRI scans do not involve X-rays. A common sense approach is perhaps for everybody to get an MRI scan yearly for the first three years after injury. If there are no problems, perhaps the frequency of MRI's can be reduced to perhaps every 2 years and then every 3 years. However, when people get older, the frequency of scans probably should be increased again. Of course, if problems are detected (such as a disc, syrinx, curvature), yearly scans would be advisable.

    I want to emphasize that the above is my personal opinion. Many doctors (and certainly insurance companies) may disagree with me. Perhaps I am influenced by the fact that I had a friend who died from compression of the spinal cord at over 10 years after injury. He was getting some symptoms but delayed in getting a scan. He had cervical spinal cord injury and died one day, sitting in front of his computer, probably while reading posts on spinewire (the predecessor of this site). He stopped breathing. If he had regulare MRI scans, it would have been possible to gauge the progressive nature of the compression, how long it has been there, and probably would have alerted his doctors to recommend corrective procedures.

    Wise.

  6. #6
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    Thank you Dr. Young!

    Thank you Dr. Young for explaining this, and in such wonderful detail. I am going to read this to my husband. I think he needs to have an MRI as soon as possible. I am so very sorry about your friend. Such a tragedy. Thank you for everything you do Dr. Young. I wish I had found you and this site years ago. I cannot describe what a help you and the others on this site are to us. Carol

    Piglet sidled up to Pooh from behind. "Pooh!", he whispered. "Yes, Piglet?" "Nothing", said Piglet, taking Pooh's paw. "I just wanted to be sure of you."

  7. #7
    Senior Member alan's Avatar
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    What's the treatment for disk problems? And which MRI scan best shows disks?

    Alan

    "Was it over when the Germans bombed Pearl Harbor?"

  8. #8
    Alan,

    Plain MRI's provide substantial information about the spinal cord. Contrast occasionally provides additional information but may not be necessary to determined compression. Contrast is most useful for visualizing vascular abnormalities.

    Treatment for interertebral discs is removal of the discs.

    Wise.

  9. #9
    Senior Member alan's Avatar
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    Originally posted by Wise Young:


    Treatment for interertebral discs is removal of the discs.

    Wise.
    Are there artificial replacements for disks?

    Alan

    "Was it over when the Germans bombed Pearl Harbor?"

  10. #10
    Yes, there are artificial discs although most artificial discs are not as good as real discs because they do not repair or replenish themselves with use. They wear down.

    I saw this presentation in china where an orthopedic surgeon used cadaver discs and showed that they are well-tolerated and still show reasonable thickness at 5 years after surgery.

    Most of the time, however, surgeons in the U.S. will fuse the vertebral bodies above and below the disc. If the vertebral body is damaged, they put in a titanium cage which will be infiltrated by bone cells from surrounding vertebral bodies and eventually fuse.

    Wise.

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