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Thread: Thoracic Spinal Cord Injury: Diagnosis & Treatment

  1. #41
    Quote Originally Posted by Schmeky
    bradsgirl,

    You need to turn on your private message topic. I am in West Monroe.
    Schmecky..thanks for the info, but ummmm i dont know how to do that..lmao.still looking to find out exactly what u are suggesting..lolthanks schmeky..oops my bad..lol..nevermind just found it ..it is done SCORE!!.
    Last edited by bradsgirl; 03-23-2006 at 12:23 AM.

  2. #42
    Quote Originally Posted by Wise Young
    Diagnosis and Treatment of Thoracic Spinal Cord Injury
    By Wise Young, Ph.D., M.D.
    ....
    Anatomy

    The thoracic spinal cord is situated in the T1-T9 thoracic spinal canal. The thoracic vertebral segments form the chest wall and have ribs.
    .....
    Treatment

    ....
    Because the injury does not involve the lumbar and sacral spinal cord, lumbosacral reflexes are usually preserved and spasticity is frequently present. Thus, people with thoracic spinal cord injuries are good candidates for regenerative therapies aimed regrowing descending motor axons from the injury site to the lumbosacral segments or ascending sensory axons from the injury site to the brain.
    ......
    Dear Dr Young,
    I just discover this interesting article of yours.
    You mention that an injury in considered as thoracic between T1 and T9 level and that patients with that level of injury have preserved reflexes and spaticity and are good candidates for regenerative therapies.
    My questions :
    - Do you then mean T1 to T9 neurological level or bone fracture level ?
    - I once saw that the selection criteria for a locomotor training trials was 'people with level up to T10' [I do also not know if they meant neurological or fracture level]. Is the assumption that locomotor training doesn't work under T9 or T10 level ?

    Remark : my understanding is that I am myself T12 bone fracture level and T10 neurological level.

    Thanks in advance for your reply

  3. #43
    Corinne, you need to look at the other topic on lower thoracic spinal cord injury.... http://carecure.org/forum/showthread.php?t=21893

    Wise.


    Quote Originally Posted by Corinne Jeanmaire
    Dear Dr Young,
    I just discover this interesting article of yours.
    You mention that an injury in considered as thoracic between T1 and T9 level and that patients with that level of injury have preserved reflexes and spaticity and are good candidates for regenerative therapies.
    My questions :
    - Do you then mean T1 to T9 neurological level or bone fracture level ?
    - I once saw that the selection criteria for a locomotor training trials was 'people with level up to T10' [I do also not know if they meant neurological or fracture level]. Is the assumption that locomotor training doesn't work under T9 or T10 level ?

    Remark : my understanding is that I am myself T12 bone fracture level and T10 neurological level.

    Thanks in advance for your reply

  4. #44

    harrington rods

    dr. young

    A little of your insight might help my problem. I’ve had Harrington rods in since 1985 after an auto accident where I had a compression fx of t-10 and broke the transverse processes off of t-8 thru t-11. My rod ends at t-12 there is a notable lump in that area. is it possabile that the hook is coming in contact with the spinal cord causing a reaction. In the past few years I’ve been experiencing what I can only explain as drop falls. During one of these episodes my back will lock up and I will fall to the ground. I know exactly what is happening during the event but I can't move to brace myself. Have you ever come a crossed something like this? I’ve been to my local dr. - I’ve been to Jefferson and U of P. i've had CT scans and an MRI but because of the rods it was unreadable in that area. In your opinion would you recommend to a patient of yours to have the rods removed.
    Last edited by FIREGUY; 04-11-2006 at 04:00 PM.

  5. #45
    I've only now happened upon this thread - I learned a lot. Thank you, Dr. Wise.
    It's just recently that I'm beginning to understand what happened to my wife: attempted correction of a 90 degree deformity to about 45 degrees was probably too much, causing ischemia at T5. It is very hopeful to know that there's still a chance of some return, though we haven't seen much of anything in the 10 months since. Still don't know why they didn't give her methylprednisolone.
    - Richard

  6. #46
    Quote Originally Posted by FIREGUY
    dr. young

    A little of your insight might help my problem. I’ve had Harrington rods in since 1985 after an auto accident where I had a compression fx of t-10 and broke the transverse processes off of t-8 thru t-11. My rod ends at t-12 there is a notable lump in that area. is it possabile that the hook is coming in contact with the spinal cord causing a reaction. In the past few years I’ve been experiencing what I can only explain as drop falls. During one of these episodes my back will lock up and I will fall to the ground. I know exactly what is happening during the event but I can't move to brace myself. Have you ever come a crossed something like this? I’ve been to my local dr. - I’ve been to Jefferson and U of P. i've had CT scans and an MRI but because of the rods it was unreadable in that area. In your opinion would you recommend to a patient of yours to have the rods removed.
    Fireguy,

    I am not sure what is happening. Your spine should have fused completely and you do not need these rods any more. It is not trivial surgery to remove rods but it may be a good idea considering your symptoms. It would also allow imaging of your cord to find out what is going on.

    Wise.

  7. #47
    Quote Originally Posted by rfbdorf
    I've only now happened upon this thread - I learned a lot. Thank you, Dr. Wise.
    It's just recently that I'm beginning to understand what happened to my wife: attempted correction of a 90 degree deformity to about 45 degrees was probably too much, causing ischemia at T5. It is very hopeful to know that there's still a chance of some return, though we haven't seen much of anything in the 10 months since. Still don't know why they didn't give her methylprednisolone.
    - Richard
    Richard, you are welcome.

    Unfortunately, most orthopedic surgeons don't publish their experiences with spinal cord injury during scoliosis surgery and so there is not much published statistics concerning recovery from such situations. However, I tried to find all the studies on the subject that I can for you. Stocki, et al. (2005) reported two cases of anterior spinal artery syndrome after scoliosis surgery and both recovered. Tribus (2001) reported a case of transient paraparesis during surgery that reversed completely with removal of instrumentation. Mineiro & Weinstein (1997) reported a case report of delayed postoperative paraparesis in scoliosis surgery, with complete recovery. Nordeen, et al. (1997) described the spinal cord monitoring results for 99 patients operated on for neuromuscular scoliosis and reported only one case of "permanent" injury. All those with temporary paresis recovered completely. Nordeen, et al. (1994) also reported a case of a person with syringomyelia who got worse and then recovered when the distraction was reduced. Forbes, et al. (1991) reported 1168 cases of somatosensory evoked potential (SEP) monitoring and found that 119 cases of significant intraoperative SEP changes and only 32 had clinically detectable neurological changes. Savini, et al. (1990) reported two cases of late neurological complication associated with scoliosis correction and recovery. Van Dem, et al. (1987) described 91 cases of scoliosis and found only one case with neurological complications, a transient paraparesis that recovered.

    So, in the recent literature anyway, there is not much insight to be gained. Permanent neurological loss appears to be rare. On the other hand, it may be that doctors only publish cases that recover. I assume that your wife's doctor reduced or removed the distracting rods when they discovered the paralysis.

    Wise.


    References
    1. Stockl B, Wimmer C, Innerhofer P, Kofler M and Behensky H (2005). Delayed anterior spinal artery syndrome following posterior scoliosis correction. Eur Spine J 14: 906-9. The authors report two cases of delayed post-operative anterior spinal artery syndrome (ASAS) following posterior correction with Cotrel Dubousset (CD) instrumentation for adolescent idiopathic scoliosis. Sensory pathways were continuously monitored from skin incision to awakening. In both cases intraoperative SEPs were normal and the wake-up test revealed no neurological deficit. Both patients were presented with incomplete paraplegia (no sensory impairment) three and ten hours after surgery. Without delay, both patients underwent revision surgery, and the CD instrumentation was removed. Immediately after surgery, both patients' motor power in their lower extremities improved rapidly. In cases with delayed ASAS after posterior scoliosis correction, the removal of the instrumentation system was shown to be sufficient to regain full motor recovery caudal to the level of impairment. Department of Orthopaedics, Innsbruck Medical University, Austria. bernd.stoeckl@uibk.ac.at http://www.ncbi.nlm.nih.gov/entrez/q..._uids=15937672
    2. Tribus CB (2001). Transient paraparesis: a complication of the surgical management of Scheuermann's kyphosis secondary to thoracic stenosis. Spine 26: 1086-9. STUDY DESIGN: Transient paraparesis during the operative management of a 16-year-old patient with Scheuermann's kyphosis secondary to thoracic stenosis is reported. OBJECTIVE: To describe a treatable cause for paraparesis in a patient with Scheuermann's kyphosis undergoing surgical treatment. SUMMARY OF BACKGROUND DATA: Cord injury in the surgical treatment of Scheuermann's kyphosis is a rare event, yet it is felt to be more common in the surgical correction of kyphosis than in surgery for scoliosis. Suggested etiologies have included vascular insufficiency, hypotension, direct mechanical trauma, and neural element stretch. Concomitant thoracic spinal stenosis predisposing to neurologic injury during surgical manipulation has not been reported. METHODS: A 16-year-old boy with progressive Scheuermann's kyphosis measuring 80 degrees from T7 to T12 underwent an anteroposterior spinal fusion with somatosensory-evoked potential monitoring and wake-up tests. During the instrumentation posteriorly, somatosensory-evoked potential monitoring became markedly abnormal. This was followed by a wake-up test that demonstrated the patient's inability to move either of his lower extremities. All instrumentation was removed. The patient had recovered neurologic function by the time he reached the recovery room. A computed tomography myelogram was performed on the third postoperative day, which demonstrated severe thoracic stenosis from T8 to T10. The patient was returned to the operating room 1 week later to undergo a posterior laminectomy from T7 to T11 and instrumented fusion from T5 to L2. Somatosensory-evoked potential monitoring was stable throughout this procedure, and the wake-up test was normal. RESULTS: The patient's postoperative course and subsequent 2-year follow-up period were unremarkable. He progressed to clinical and radiographic union and maintained a normal lower extremity neurologic examination. CONCLUSIONS: A treatable cause for paraparesis secondary to the surgical treatment of Scheuermann's kyphosis is presented. The author currently obtains a thoracic magnetic resonance image (MRI) before the surgical correction of any patients with Scheuermann's kyphosis. University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA. tribus@surgery.wisc.edu http://www.ncbi.nlm.nih.gov/entrez/q..._uids=11337630
    3. Mineiro J and Weinstein SL (1997). Delayed postoperative paraparesis in scoliosis surgery. A case report. Spine 22: 1668-72. STUDY DESIGN: A case report is presented of an unusual complication of scoliosis surgery that, to the authors' knowledge, has never been reported in the literature. OBJECTIVE: Neurologic complications can occur after an uneventful posterior spinal instrumentation and fusion for scoliosis. Careful observation during the post-operative period is crucial for early detection of impending neurologic deficit. SUMMARY OF BACKGROUND DATA: Nerve compression of the cauda equina has been reported as a complication of different types of surgery in the lumbar spine, but an ascending paraparesis has never been described as a complication of scoliosis surgery. METHODS: A 12-year-old boy with a right thoracic scoliosis measuring 68 degrees and a 72 degrees left lumbar curve underwent Cotrel-Dubousset instrumentation and fusion from T5 to L4. Spinal cord monitoring with somatosensory evoked potentials and motor action potential were recorded and stable through out the entire procedure. Thirty hours later, a rapidly progressive ascending para-paresis developed that required urgent decompression. RESULTS: This patient underwent urgent decompression and removal of the Cotrel-Dubousset instrumentation. After surgery, the clinical picture improved gradually, and at 2-month follow-up he had regained normal strength in his lower limbs except for a grade 4 left extensor hallucis longus. By 4 months postdecompression, he had made a total recovery. CONCLUSIONS: Although clinical examination may be difficult to perform in patients who are unconscious, on large doses of narcotic drugs, or mentally retarded, careful observation during the postoperative period and awareness of this complication can allow early detection of impending reversible neurologic deficit and provision of appropriate treatment. Department of Orthopaedic Surgery, Hospital Santa Maria, Lisbon, Portugal. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=9253104
    4. Noordeen MH, Lee J, Gibbons CE, Taylor BA and Bentley G (1997). Spinal cord monitoring in operations for neuromuscular scoliosis. J Bone Joint Surg Br 79: 53-7. We reviewed retrospectively the role of monitoring of somatosensory spinal evoked potentials (SSEP) in 99 patients with neuromuscular scoliosis who had had operative correction with Luque-Galveston rods and sublaminar wiring. Our findings showed that SSEP monitoring was useful and that a 50% decrease in the amplitude of the trace optimised both sensitivity and specificity. The detection of true-positive results was higher than in cases of idiopathic scoliosis, but the method was less sensitive and specific and there were more false-negative results. In contrast with the findings in idiopathic scoliosis, recovery of the trace was associated with a 50% to 60% risk of neurological impairment. Only one permanent injury occurred during the use of this technique, and any temporary impairment resolved within two months. The Institute of Orthopaedics and the Royal National Orthopaedic Hospital Trust, Stanmore, London, UK. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=9020445
    5. Noordeen MH, Taylor BA and Edgar MA (1994). Syringomyelia. A potential risk factor in scoliosis surgery. Spine 19: 1406-9. STUDY DESIGN. An 18-year-old patient with "idiopathic" adolescent scoliosis is presented. A thoracic syrinx was detected as an incidental finding during magnetic resonance imaging of the spine. OBJECTIVES. Syringomyelia may be a risk factor for neurologic injury during correction of scoliosis, and in these cases, spinal cord monitoring may be of particular value. BACKGROUND DATA. Spinal distraction and instrumentation carry a risk of neurologic damage in patients with scoliosis and associated syringomyelia. Syringomyelia is a cause of scoliosis, and although neurologic problems are the usual symptom, scoliosis may be the only sign at initial examination. A higher risk of neurologic injury has been reported in corrective surgical treatment of patients with syringomyelia. The mechanism of cord damage is unclear. Monitoring of spinal cord function is recommended to detect intraoperative neurological injury, which may be reversed on removing distraction and implants. RESULTS. Intraoperative somatosensory-evoked potential (SSEP) spinal cord monitoring detected possible cord damage during outrigger distraction. Reduction of distraction led to a recovery of SSEPs and a satisfactory operative outcome. CONCLUSION. Syringomyelia may be a risk factor for neurologic injury during correction of scoliosis, and SSEP spinal cord monitoring may identify and prevent intraoperative spinal cord injury. Middlesex Hospital, London, United Kingdom. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=8066525
    6. Forbes HJ, Allen PW, Waller CS, Jones SJ, Edgar MA, Webb PJ and Ransford AO (1991). Spinal cord monitoring in scoliosis surgery. Experience with 1168 cases. J Bone Joint Surg Br 73: 487-91. Since 1981, during operations for spinal deformity, we have routinely used electrophysiological monitoring of the spinal cord by the epidural measurement of somatosensory evoked potentials (SEPs) in response to stimulation of the posterior tibial nerve. We present the results in 1168 consecutive cases. Decreases in SEP amplitude of more than 50% occurred in 119 patients, of whom 32 had clinically detectable neurological changes postoperatively. In 35 cases the SEP amplitude was rapidly restored, either spontaneously or by repositioning of the recording electrode; they had no postoperative neurological changes. One patient had delayed onset of postoperative symptoms referrable to nerve root lesions without evidence of spinal cord involvement, but there were no false negative cases of intra-operative spinal cord damage. In 52 patients persistent, significant, SEP changes were noted without clinically detectable neurological sequelae. None of the many cases which showed falls in SEP amplitude of less than 50% experienced neurological problems. Neuromuscular scoliosis, the use of sublaminar wires, the magnitude of SEP decrement, and a limited or absent intra-operative recovery of SEP amplitude were identified as factors which increased the risk of postoperative neurological deficit. Royal National Orthopaedic Hospital, London, England. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=1670455
    7. Savini R, Di Silvestre M and Gargiulo G (1990). Late paraparesis due to pseudarthrosis after posterior spinal fusion. J Spinal Disord 3: 427-32. The authors report three cases in which paraparesis related to a pseudarthrosis occurred several years after a posterior spinal fusion, but with a different mechanism (stretching of the spinal cord for progression of the deformity in kyphosis in two cases, and spinal cord compression for bone overgrowth within the canal in the site of pseudarthrosis in the third patient). Treatment was different. Partial correction of the deformity and stabilization of the spine by combined fusion (anterior and posterior) was sufficient in the first two cases for a complete neurological recovery. Posterior spinal cord decompression and stabilization of the spine by combined fusion was necessary for complete recovery in the third. Centro Scoliosi, Istituto Ortopedico Rizzoli, Bologna, Italy. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=2134461
    8. van Dam BE, Bradford DS, Lonstein JE, Moe JH, Ogilvie JW and Winter RB (1987). Adult idiopathic scoliosis treated by posterior spinal fusion and Harrington instrumentation. Spine 12: 32-6. Ninety-one patients with idiopathic scoliosis, who underwent posterior spinal fusion and instrumentation from January 1977 to December 1982, were reviewed. All patients were 20 years or older at the time of surgery and none had undergone a prior surgical procedure. Indications for surgery included pain, progressive deformity, and pulmonary symptoms. All patients had a posterior spinal fusion with Harrington instrumentation and autogenous iliac bone graft, with the addition of segmental wiring in only eight. No patient had an anterior fusion or fusion to the sacrum. Follow-up averaged 3.5 years (range: 2-7 years). The average correction at the time of surgery was 38%, and 32% at the time of last follow-up. Seventy-nine percent of the patients reported complete relief of the symptom(s) for which they had surgery. There were 34 complications in 30 (33%) patients. Pseudarthrosis occurred in 14 (15%), requiring 15 additional procedures to achieve a solid arthrodesis. Urinary tract infection occurred in 8 (9%) patients and Harrington hook dislodgement in 5 (5%). One patient sustained a partial paraparesis with recovery to a minimal deficit. No deaths occurred. Although largely successful, posterior fusion with Harrington instrumentation for adult scoliosis has a significant incidence of pseudarthrosis and instrumentation problems. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=3554557
    Last edited by Wise Young; 04-13-2006 at 01:34 AM.

  8. #48
    Again, thank you for all that information and for your time, Dr. Wise.

    Actually, the rods came later... Immediately after her first operation, in which he placed a cage between T4 and T6, the neurosurgeon told me she had a blockage at T5 and he thought perhaps he had overcorrected her kyphosis (from an amazingly sharp 90 degrees), so he went in again that day and reduced the correction somewhat, but that was unsuccessful in restoring the function of her cord. A week later, he went in again (as planned) and stabilized her spine by placing the 2 rods from T3 to T7. That had no effect on her paralysis, but did relieve the pain somewhat.
    The surgeon says he doesn't know for certain what caused the paralysis. At first he was thinking compression (and in fact he dug into her a fourth time, several days after placing the rods, because he thought just maybe the MRI showed an area of compression), but he now tends to think it is likely due to ischemia.
    - Richard

  9. #49
    Quote Originally Posted by rfbdorf
    Again, thank you for all that information and for your time, Dr. Wise.

    Actually, the rods came later... Immediately after her first operation, in which he placed a cage between T4 and T6, the neurosurgeon told me she had a blockage at T5 and he thought perhaps he had overcorrected her kyphosis (from an amazingly sharp 90 degrees), so he went in again that day and reduced the correction somewhat, but that was unsuccessful in restoring the function of her cord. A week later, he went in again (as planned) and stabilized her spine by placing the 2 rods from T3 to T7. That had no effect on her paralysis, but did relieve the pain somewhat.
    The surgeon says he doesn't know for certain what caused the paralysis. At first he was thinking compression (and in fact he dug into her a fourth time, several days after placing the rods, because he thought just maybe the MRI showed an area of compression), but he now tends to think it is likely due to ischemia.
    - Richard
    Richard,

    Oh, I understand now. She had a 90% kyphosis... that is very severe. How long was that kyphosis in place? In most kyphoscoliosis, the spinal cord is draped around the curvature and may have had significant loss of axons already and was probably close to the edge. The ischemia pushed it over the edge.

    He was a neurosurgeon and not an orthopedic surgeon?

    Wise.

  10. #50
    Quote Originally Posted by Wise Young
    Fireguy,

    I am not sure what is happening. Your spine should have fused completely and you do not need these rods any more. It is not trivial surgery to remove rods but it may be a good idea considering your symptoms. It would also allow imaging of your cord to find out what is going on.

    Wise.
    i thank you for your advice, i was wondering is it possable with the hooks at t-12 and with the bending and moving over the years there a chance the rods are pulling the vertebrae slightly out of alignment, but it won't show up during and exam because of being in the prone position there's no stress being put on the spine?? I haven't had a mylogram done yet is that something to due prior to any surgical procedure. i also have a slight to mod herniation of l-4 - l5 i don't know if that would be the cause of my back to seize up

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