Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA.
R. Adams Cowley Shock Trauma Center, and Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA.
J Neurotrauma. 2022 Dec;39(23-24):1716-1726. doi: 10.1089/neu.2022.0218. Epub 2022 Aug 9.
Expansion duraplasty to reopen effaced subarachnoid space and improve spinal cord perfusion, autoregulation, and spinal pressure reactivity index (sPRX) has been advocated in patients with traumatic cervical spinal cord injury (tCSCI). We designed this study to identify candidates for expansion duraplasty, based on the absence of cerebrospinal fluid (CSF) interface around the spinal cord on magnetic resonance imaging (MRI), in the setting of otherwise adequate bony decompression. Over a 61-month period, 104 consecutive American Spinal Injury Association Impairment Scale (AIS) grades A-C patients with tCSCI had post-operative MRI to assess the adequacy of surgical decompression. Their mean age was 53.4 years, and 89% were male. Sixty-one patients had falls, 31 motor vehicle collisions, 11 sport injuries, and one an assault. The AIS grade was A in 56, B in 18, and C in 30 patients. Fifty-four patients had fracture dislocations; there was no evidence of skeletal injury in 50 patients. Mean intramedullary lesion length (IMLL) was 46.9 (standard deviation = 19.4) mm. Median time from injury to decompression was 17 h (interquartile range 15.2 h). After surgery, 94 patients had adequate decompression as judged by the presence of CSF anterior and posterior to the spinal cord, whereas 10 patients had effacement of the subarachnoid space at the injury epicenter. In two patients whose decompression was not definitive and post-operative MRI indicated inadequate decompression, expansion duraplasty was performed. Candidates for expansion duraplasty (i.e., those with inadequate decompression) were significantly younger ( < 0.0001), were AIS grade A ( < 0.0016), had either sport injuries (six patients) or motor vehicle collisions (three patients) ( < 0.0001), had fracture dislocation ( = 0.00016), and had longer IMLL ( = 0.0097). In regression models, patients with sport injuries and inadequate decompression were suitable candidates for expansion duraplasty ( = 0.03). Further, 9.6% of patients failed bony decompression alone and either did (2) or would have (8) benefited from expansion duraplasty.
在创伤性颈脊髓损伤（tCSCI）患者中，提倡进行硬脊膜扩张以重新开放蛛网膜下腔空间并改善脊髓灌注、自动调节和脊髓压力反应指数（sPRX）。我们设计了这项研究，以根据磁共振成像（MRI）上脊髓周围无脑脊液（CSF）界面，来识别需要进行硬脊膜扩张的患者，前提是已经进行了充分的骨性减压。在 61 个月的时间里，104 例连续的美国脊髓损伤协会损伤分级（AIS）A-C 级 tCSCI 患者在术后接受 MRI 检查以评估手术减压的充分性。他们的平均年龄为 53.4 岁，89%为男性。61 例患者因坠落伤，31 例因机动车事故，11 例因运动损伤，1 例因袭击受伤。56 例患者的 AIS 分级为 A，18 例为 B，30 例为 C。54 例患者有骨折脱位；50 例患者无骨骼损伤证据。脊髓内病变长度（IMLL）的平均值为 46.9（标准差=19.4）mm。从损伤到减压的中位时间为 17 小时（四分位间距 15.2 小时）。术后，94 例患者的脊髓前后有脑脊液，判断减压充分，而 10 例患者的蛛网膜下腔在损伤中心处受压。在 2 例减压不充分且术后 MRI 显示减压不充分的患者中，进行了硬脊膜扩张。需要进行硬脊膜扩张的患者（即减压不充分的患者）明显更年轻（ <0.0001），AIS 分级为 A（ <0.0016），要么是运动损伤（6 例），要么是机动车事故（3 例）（ <0.0001），有骨折脱位（ = 0.00016），脊髓内病变长度更长（ = 0.0097）。在回归模型中，运动损伤和减压不充分的患者是硬脊膜扩张的合适人选（ = 0.03）。此外，9.6%的患者单独行骨性减压失败，要么（2 例）要么（8 例）需要行硬脊膜扩张。
