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Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study.

Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC - J. Neurotrauma (2015)

Bottom Line: Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord.In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group.Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients.

View Article: PubMed Central - PubMed

Affiliation: 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom .

ABSTRACT
We recently showed that, after traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression. This is an open label, prospective trial comparing combined bony and dural decompression versus laminectomy. Twenty-one patients with acute severe TSCI had re-alignment of the fracture and surgical fixation; 11 had laminectomy alone (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy+duroplasty group). Primary outcomes were magnetic resonance imaging evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy+duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group. Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. We conclude that, after TSCI, laminectomy+duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy alone.

No MeSH data available.


Related in: MedlinePlus

Duroplasty increases space round the injured spinal cord. (A) T2 magnetic resonance imaging (MRI; top) before and after laminectomy, and (middle) before and after laminectomy+duroplasty, showing mid-sagittal anteroposterior diameter of the most compressed part of the dura (Di), the anteroposterior diameter of the mid-vertebral dura above the level of injury (Da), and the anteroposterior diameter of the mid-vertebral dura below the level of injury (Db). (Bottom) Percent increase in Di after laminectomy versus laminectomy+duroplasty. Points are patients, lines are means. (B) Top: Post-operative T2 magnetic resonance imaging (MRI) looking for cerebrospinal fluid (CSF) round the injured cord. Bottom: Numbers of patients with and without CSF around the injured cord. (C) Post-operative T2 MRI looking for expansion of the injured cord into the duroplasty. (D) T2 MRI in an American Spinal Injury Association A patient (left) before surgery, (middle) at two weeks after surgery (arrow shows pseudomeningocele), and (right) at six months after surgery (no pseudomeningocele). LAMI, laminectomy; LAMI+DURO, laminectomy+duroplasty. p<0.05*, 0.01**.
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f2: Duroplasty increases space round the injured spinal cord. (A) T2 magnetic resonance imaging (MRI; top) before and after laminectomy, and (middle) before and after laminectomy+duroplasty, showing mid-sagittal anteroposterior diameter of the most compressed part of the dura (Di), the anteroposterior diameter of the mid-vertebral dura above the level of injury (Da), and the anteroposterior diameter of the mid-vertebral dura below the level of injury (Db). (Bottom) Percent increase in Di after laminectomy versus laminectomy+duroplasty. Points are patients, lines are means. (B) Top: Post-operative T2 magnetic resonance imaging (MRI) looking for cerebrospinal fluid (CSF) round the injured cord. Bottom: Numbers of patients with and without CSF around the injured cord. (C) Post-operative T2 MRI looking for expansion of the injured cord into the duroplasty. (D) T2 MRI in an American Spinal Injury Association A patient (left) before surgery, (middle) at two weeks after surgery (arrow shows pseudomeningocele), and (right) at six months after surgery (no pseudomeningocele). LAMI, laminectomy; LAMI+DURO, laminectomy+duroplasty. p<0.05*, 0.01**.

Mentions: All patients had good quality pre-operative MRI scans. MRI scans performed at 2-3 weeks after surgery were uninterpretable due to artifact from the metal construct in five patients (four laminectomy, one laminectomy+duroplasty). Before surgery, the laminectomy versus the laminectomy+duroplasty groups had comparable AP diameter (mean±standard error) of the dural sac at and near the level of injury; Di(preop)=8.1±0.6 mm versus 6.6±0.7 mm and (Da+Db)/2=11.1±0.5 mm versus 10.8±0.7 mm. Comparison of the pre-operative versus post-operative (done at two to three weeks) MRI scan revealed that duroplasty increased the AP diameter of the dural canal at the injury site significantly more than laminectomy alone (Fig. 2A). CSF signal around the cord—an indicator of satisfactory decompression of the swollen spinal cord—was evident in the MRI scans done at 2-3 weeks of 78 % of laminectomy+duroplasty versus 0 % of laminectomy patients (Fig. 2B). In 78 % of laminectomy+duroplasty patients, the spinal cord expanded into the space created by the duroplasty (Fig. 2C).


Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study.

Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC - J. Neurotrauma (2015)

Duroplasty increases space round the injured spinal cord. (A) T2 magnetic resonance imaging (MRI; top) before and after laminectomy, and (middle) before and after laminectomy+duroplasty, showing mid-sagittal anteroposterior diameter of the most compressed part of the dura (Di), the anteroposterior diameter of the mid-vertebral dura above the level of injury (Da), and the anteroposterior diameter of the mid-vertebral dura below the level of injury (Db). (Bottom) Percent increase in Di after laminectomy versus laminectomy+duroplasty. Points are patients, lines are means. (B) Top: Post-operative T2 magnetic resonance imaging (MRI) looking for cerebrospinal fluid (CSF) round the injured cord. Bottom: Numbers of patients with and without CSF around the injured cord. (C) Post-operative T2 MRI looking for expansion of the injured cord into the duroplasty. (D) T2 MRI in an American Spinal Injury Association A patient (left) before surgery, (middle) at two weeks after surgery (arrow shows pseudomeningocele), and (right) at six months after surgery (no pseudomeningocele). LAMI, laminectomy; LAMI+DURO, laminectomy+duroplasty. p<0.05*, 0.01**.
© Copyright Policy - open-access
Related In: Results  -  Collection

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f2: Duroplasty increases space round the injured spinal cord. (A) T2 magnetic resonance imaging (MRI; top) before and after laminectomy, and (middle) before and after laminectomy+duroplasty, showing mid-sagittal anteroposterior diameter of the most compressed part of the dura (Di), the anteroposterior diameter of the mid-vertebral dura above the level of injury (Da), and the anteroposterior diameter of the mid-vertebral dura below the level of injury (Db). (Bottom) Percent increase in Di after laminectomy versus laminectomy+duroplasty. Points are patients, lines are means. (B) Top: Post-operative T2 magnetic resonance imaging (MRI) looking for cerebrospinal fluid (CSF) round the injured cord. Bottom: Numbers of patients with and without CSF around the injured cord. (C) Post-operative T2 MRI looking for expansion of the injured cord into the duroplasty. (D) T2 MRI in an American Spinal Injury Association A patient (left) before surgery, (middle) at two weeks after surgery (arrow shows pseudomeningocele), and (right) at six months after surgery (no pseudomeningocele). LAMI, laminectomy; LAMI+DURO, laminectomy+duroplasty. p<0.05*, 0.01**.
Mentions: All patients had good quality pre-operative MRI scans. MRI scans performed at 2-3 weeks after surgery were uninterpretable due to artifact from the metal construct in five patients (four laminectomy, one laminectomy+duroplasty). Before surgery, the laminectomy versus the laminectomy+duroplasty groups had comparable AP diameter (mean±standard error) of the dural sac at and near the level of injury; Di(preop)=8.1±0.6 mm versus 6.6±0.7 mm and (Da+Db)/2=11.1±0.5 mm versus 10.8±0.7 mm. Comparison of the pre-operative versus post-operative (done at two to three weeks) MRI scan revealed that duroplasty increased the AP diameter of the dural canal at the injury site significantly more than laminectomy alone (Fig. 2A). CSF signal around the cord—an indicator of satisfactory decompression of the swollen spinal cord—was evident in the MRI scans done at 2-3 weeks of 78 % of laminectomy+duroplasty versus 0 % of laminectomy patients (Fig. 2B). In 78 % of laminectomy+duroplasty patients, the spinal cord expanded into the space created by the duroplasty (Fig. 2C).

Bottom Line: Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord.In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group.Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients.

View Article: PubMed Central - PubMed

Affiliation: 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom .

ABSTRACT
We recently showed that, after traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression. This is an open label, prospective trial comparing combined bony and dural decompression versus laminectomy. Twenty-one patients with acute severe TSCI had re-alignment of the fracture and surgical fixation; 11 had laminectomy alone (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy+duroplasty group). Primary outcomes were magnetic resonance imaging evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy+duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group. Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. We conclude that, after TSCI, laminectomy+duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy alone.

No MeSH data available.


Related in: MedlinePlus