BACKGROUND:Guidelines for the management of acute spinal cord injury are based on a young age group suffering spinal fracture dislocations caused by high-impact trauma. The purpose of this study was to characterize our recent cervical spinal cord injury (cSCI) experience and compare it to this traditional demographic. We hypothesized that most cSCI patients now fall outside the scope of published guideline principles. METHODS:Cross-sectional cohort study. A detailed review was performed of cSCI patients admitted to our level 1 trauma institution over a 12-month period identifying demographics, injury types, and coded diagnoses cross-referenced from multiple archival systems RESULTS: Fifty-one patients with cSCI from blunt trauma were identified over the 1-year study period of which 82% did not have a spinal fracture or dislocation. cSCI patients without fracture/dislocation were older (mean age 62), had low-impact injuries (93%), and lower American Spinal Injury Association grades (98%). Patients with fracture/dislocation were younger (mean age 48), had high-impact injuries (77%), and higher American Spinal Injury Association grades (66%). Ninety-eight percent of our cSCI patients without fracture/dislocation presented with sensory and motor changes preferentially involving hands and arms in contrast to 11% of patients with fracture dislocation (P < 00001). CONCLUSIONS:cSCI patients without fracture/dislocation now represent the large majority of spinal cord injuries at our level I trauma center. The demographic is most consistent with central cord syndrome, implicating unique pathophysiology and natural history. Extrapolation of management principles from previous guideline efforts is not intuitively generalizable to this patient population.

BACKGROUND:Studies on acute spinal cord injury from fracture or dislocation (SCIwiFD) suggest surgery within 48 hours of injury maximizes neurologic recovery. However, the optimal timing of surgery for patients suffering SCI without fracture or dislocation (SCIwoFD) has not been established. Our experience suggests a need to critically reevaluate the role of early surgery. METHODS:We provide 2 illustrative cases raising concern for early surgery in SCIwoFD and performed a systematic meta-analysis examining differences in American Spinal Injury Association Motor Scores (AMS) for patients undergoing early (<48-96 hours from injury) versus late (>48-96 hours from injury) surgery. A random-effect meta-analysis was implemented using standardized mean difference (SMD) between baseline AMS and most recent follow-up to estimate effect size. RESULTS:Seven studies met inclusion criteria, with 210 patients undergoing early surgery and 279 undergoing late surgery. Overall, an SMD of -1.1 (95% CI: -1.3 to -0.9) was found (I² = 64%, P < 0.001), indicating a 1-point improvement in AMS after surgery at any time point. When comparing SMD between subgroups, there was no significant difference in AMS from baseline to follow-up between those who underwent early surgery versus late surgery (P = 0.39, df = 1). CONCLUSIONS:While there is considerable heterogeneity in the data, there is no significant difference in neurologic recovery seen in patients with SCIwoFD who undergo early surgical intervention compared to those who undergo surgery in a delayed fashion. Our anecdotal experience underscores the need to critically reexamine timing of surgery in this population.

Innovation is often seen as the hallmark of surgical progress. Yet in spine surgery, the rapid turnover of new implants, techniques, and technologies has created a quiet fatigue among surgeons, educators, and institutions. This Perspective examines the cultural and professional cost of unchecked innovation and calls for a more measured, data-driven approach that prioritizes long-term outcomes and sustainable adoption over novelty alone.

BACKGROUND AND OBJECTIVES:The California-Mexico border wall height extension has been associated with increased rates of traumatic injuries. We sought to determine whether the US-Mexico border wall fortifications are associated with increased rates and severity of neurological injuries after falls and increased hospital resource utilization across the Southwestern border. METHODS:Patients who presented to UC San Diego, Banner University of Arizona, or South Texas Health System trauma center after a fall from the US-Mexico border wall between 2016 and 2022 were identified and categorized as "preheight extension" or "postheight extension." Patient demographic information, injury characteristics, and neurosurgical interventions were recorded. Univariable and multivariable analyses were performed to determine the impact of patient factors on outcomes. RESULTS:A total of 304 patients with 331 neurological injuries were included. Injuries grew 556% from 18 in 2016 to 118 in 2022. The preheight extension cohort comprised 52 patients (median age 29 years, 60% male), whereas the postheight extension cohort comprised 252 patients (median age 30 years, 66% male). On a per-month basis, there were significantly more spinal (0.36 vs 1.77, P < .001) and traumatic brain injuries (0.09 vs 0.33, P < .001) in the postheight extension cohort. The number of neurological injuries (0.43 vs 1.91, P < .001) and operative injuries per month (0.13 vs 0.61, P < .001) also increased. Postheight extension patients had greater hospital lengths of stay (6 vs 8 days, P < .001) and charges ($92 825 vs $221 613, P < .001). Using a Poisson regression model adjusted for sites and border apprehensions, the number of neurological injuries was 0.51 (95% CI [0.22-0.94], P = .02) per month higher in the postheight extension cohort. CONCLUSION:The US-Mexico border wall height extension is associated with a significant rise in neurological injuries and morbidity for immigrants, and an increase in hospital resource utilization. We hope these consequences are taken into consideration in future border policy decisions.

Indications and techniques for sacropelvic fixation continue to evolve as new advancements in biomechanical understanding and technologies develop. Currently there are multiple techniques that exist in the literature, with more recent meta- analyses pointing to S2AI screws having reduced infection rates and hardware removal compared to iliac screws. However, there is no demonstrated difference in pseudoarthrosis rates and both techniques remain viable options to obtain fixation.

BACKGROUND:In Part I of this series we identified spinal cord injury without fracture or dislocation (SCIwoFD) as having become the most common type of spinal cord injury at our level I trauma center. The purpose of this paper was to examine two databases, one local and one national, to determine whether this population could be discovered using traditional search techniques. METHODS:We analyzed ICD-10 codes applied by our institution to SCIwoFD patients identified in Part I for accuracy and appropriateness. Concurrently, we queried the National Inpatient Sample (NIS) database between 2015 and 2019 to identify an anticipated increase in SCIwoFD patients compared to patients with more traditional spinal cord injury (SCI) associated with fracture/dislocation. RESULTS:The most common ICD-10 diagnosis provided for SCIwoFD patients at our institution was coded as cervicalgia (33%) followed by cervical spinal stenosis (21%). Five percent were coded for myelopathy, while central cord syndrome was coded in only 2%. Within the NIS, SCIwoFD was reported in only 15% of patients in sharp contrast to 82% of our own patients (P < 0.00001). Conversely, SCI associated with fracture/dislocation comprised 85% of all reported NIS cSCIs holding steady at this level during the study period, as did central cord syndrome (7%) and traumatic spondylopathy (1%). CONCLUSIONS:Neither our institutional database nor the NIS allows for appropriate identification of patients suffering SCIwoFD. Properly constructed SCI-specific registries are likely to provide the only opportunity from which to establish best practice parameters for this new 21st-century demographic of SCI.

Background The objective of this study was to understand how spine surgeons learn minimally invasive spine surgery (MISS) and how the COVID-19 pandemic impacted the educational experience of MISS. Potential solutions for increasing the spine surgeon's access to MISS educational resources were also discussed.Methods An internet survey was distributed to neurosurgical and orthopedic spine surgeons across multiple online platforms from April to June 2021, asking specific questions about education and training for MISS. Online survey tools were used to contact spine surgeons in the five geographical continents.Results A total of 303 spine surgeons responded to the survey: 272 (89.7%) neurosurgeons and 31 (10.3%) orthopedic surgeons. The six countries with the greatest number of participants were: Argentina ( n = 70; 23.1%), India ( n = 47; 15.5%), Brazil ( n = 34; 11.2%), Pakistan ( n = 10; 3.3%), Mexico ( n = 9; 3.0%), and Chile ( n = 8; 2.6%).Conclusion Most spine surgeons were able to attend virtual learning events during the pandemic, but cadaveric study was still considered the gold standard for learning MISS. Multidisciplinary effort is needed to develop structured curriculums for teaching MISS that include a variety of educational tools such as cadaver laboratory, guidance from experienced surgeons, and virtual demonstrations.

- BACKGROUND: Magnetic resonance imaging (MRI) is increasingly used as an adjunct to spinal soft tissue evaluation in cervical spine (C -spine) trauma; however, the utility of this information remains controversial. In this consecutive observational study, we reviewed the utility of MRI in patients with C -spine trauma. - METHODS: We identified patients in real time over a 2year period as they presented to our level 1 trauma center for C -spine computed tomography (CT) scan followed by MRI. MRI was obtained by the trauma team prior to the spine service consultation if (1) they were unable to clear the C -spine according to protocol or (2) if the on -call radiologist reported a concern for ligamentous integrity from the CT findings. - RESULTS: Thirty-three patients, including 19 males (58%) and 14 females, with a mean age of 54 years, were referred to the spine service for concerns of ligamentous instability. The most common mechanisms of injury were motor vehicle accidents (n = 13) and falls (n = 11). MRI demonstrated ligamentous signal change identified by the radiologist as potentially unstable in all patients. Fifteen patients (45%) had multiple C -spine ligaments affected. The interspinous ligament was involved most frequently (28%), followed by the ligamentum flavum (21%) and supraspinous ligament (15%). All patients underwent dynamic upright Cspine X-rays that were interpreted by both the ordering surgeon and radiologist. There was no evidence of instability in any patient; concurrence between X-ray interpretation was 100%. The cervical collar was successfully removed in all cases. No patients required late surgical intervention, and there were no return visits to the emergency department of a spinal nature. - CONCLUSIONS: MRI signal change within the ligaments of the C -spine should be interpreted with caution in the setting of trauma. To physicians less familiar with spinal biomechanics, MRI findings may be perceived in an inadvertently alarming manner. Bony alignment and, when indicated, dynamic upright X-rays remain the gold standard for evaluating the ligamentous integrity of the C -spine.

-BACKGROUND: COVID-19 has impacted neurosurgical care around the world. But reports describing patient admission trends during the pandemic have provided limited time frames and diagnoses. The purpose of this paper was to analyze the impact of COVID-19 on neuro-surgical care provided to our emergency department during the outbreak.METHODS: Patient admission data were collected based on a list of 35 ICD-10 codes, which were placed into 1 of 4 categories: head and spine trauma ("Trauma"), head and spine infection ("Infection"), degenerative spine ("Degen-erative"), and subarachnoid hemorrhage/brain tumor ("Con-trol"). Emergency department (ED) consultations to the Neurosurgery Department were collected from March 2018 to March 2022, representing 2 years before COVID and 2 years of pandemic. We hypothesized that Control cases would remain stable throughout the 2 time periods while Trauma and Infection would decrease. Because of wide-spread clinic restrictions, we postulated Degenerative (spine) cases presenting to the ED would increase.RESULTS: During the first 2 years of the COVID pandemic, Neurosurgical Trauma and Degenerative ED patients decreased compared with prepandemic levels, while Cranial and Spinal infections increased and continued to do so during the pandemic period studied. Brain tumors and sub-arachnoid hemorrhages (Control cases) did not change in a significant way throughout the 4-year analysis.CONCLUSIONS: The COVID pandemic significantly altered the demographics of our Neurosurgical ED patient population and continues to do so.

OBJECTIVE:Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the inherently increased surgical risks in older patients. The objective of this study was to compare fusion rates and outcomes between operative and nonoperative treatments of type II odontoid fractures in the older population. METHODS:A systematic literature review was performed to identify studies reporting the management of type II odontoid fractures in patients older than 65 years from database inception to September 2022. A meta-analysis was performed to compare rates of fusion, stable and unstable nonunion, mortality, and complication. RESULTS:Forty-six articles were included in the final review. There were 2822 patients included in the different studies (48.9% female, 51.1% male), with a mean ± SD age of 81.5 ± 3.6 years. Patients in the operative group were significantly younger than patients in the nonoperative group (81.5 ± 3.5 vs 83.4 ± 2.5 years, p < 0.001). The overall (operative and nonoperative patients) fusion rate was 52.9% (720/1361). The fusion rate was higher in patients who underwent surgery (74.3%) than in those who underwent nonoperative management (40.3%) (OR 4.27, 95% CI 3.36-5.44). The likelihood of stable or unstable nonunion was lower in patients who underwent surgery (OR 0.37, 95% CI 0.28-0.49 vs OR 0.32, 95% CI 0.22-0.47). Overall, 4.8% (46/964) of nonoperatively managed patients subsequently required surgery due to treatment failure. Patient mortality across all studies was 16.6% (452/2721), lower in the operative cohort (13.2%) than the nonoperative cohort (19.0%) (OR 0.64, 95% CI 0.52-0.80). Complications were more likely in patients who underwent surgery (26.0% vs 18.5%) (OR 1.55, 95% CI 1.23-1.95). Length of stay was also higher with surgery (13.6 ± 3.8 vs 8.1 ± 1.9 days, p < 0.001). CONCLUSIONS:Patients older than 65 years of age with type II odontoid fractures had higher fusion rates when treated with surgery and higher stable nonunion rates when managed nonoperatively. Complications and length of stay were higher in the surgical cohort. Mortality rates were lower in patients managed with surgery, but this phenomenon could be related to surgical selection bias. Fewer than 5% of patients who underwent nonoperative treatment required revision surgery due to treatment failure, suggesting that stable nonunion is an acceptable treatment goal.

OBJECTIVE: We sought to determine the extent to which polytrauma significantly impacts intrahospital mortality among patients with complete cervical spinal cord injury (cSCI) and to assess whether an organ system-based approach would be appropriate as a mortality predictor as compared with conventional standards to help guide prognosis and management. METHODS: We retrospectively reviewed patient medical records and assessed the type of associated trauma at presentation. We then reviewed its correlation with mortality in patients who were admitted at our institution between 2012 and 2021. Types of associated trauma were classified under the following: traumatic brain injury, abdominal injury, thoracic injury, orthopedic injury, craniofacial injury, genitourinary injury, and vascular injury. RESULTS: Thirty patients with complete cSCIs were identified. Increased organ system-based polytrauma had a statistically significant increase in intrahospital mortality (P = 0.01). Using the logistic regression model, for each additional gain in organ system-based trauma, patients had a 2.455 odds ratio of mortality (P = 0.03, 95% confidence interval 1.171 - 6.348). Zero other organ system injuries in the setting of cSCI provided a predictive mortality probability of 6.6%. One organ system-based trauma provided a 14.8% intrahospital mortality probability, 2 traumas provided a 29.9% mortality probability, 3 traumas provided a 51.1% mortality probability, and 4 other organ-system traumas provided a 72.0% mortality probability. The predictive prognostic accuracy of using number of organ system-based trauma to predict mortality probability was quantified at area under the curve = 0.8264 (95% confidence interval 0.6729 - 0.9799, P = 0.01). CONCLUSIONS: Our research shows that an increased number of organ system injuries is associated with greater intrahospital mortality in polytrauma patients with complete cSCI.

BACKGROUND Spinal hematomas are a rare entity with broad etiologies, which stem from idiopathic, tumor-related, and vascular malformation etiologies. Less common causes include traumatic blunt nonpenetrating spinal hematomas with very few cases being reported. In the present manuscript presents a case report and review of the literature of a rare traumatic entity of a cervical subarachnoid hematoma in association with Brown-Séquard syndrome in a patient on anticoagulants. Searches were performed on PubMed and Embase for specific terms related. OBSERVATIONS A well-documented case of an 83-year-old female taking anticoagulants with traumatic cervical subarachnoid hematoma presenting as Brown-Séquard syndrome was reported. Six similar cases were identified, scrutinized, and analyzed in the literature review. LESSONS Traumatic blunt nonpenetrating cervical spine subarachnoid hematomas are a rare entity that can happen more specifically in anticoagulant users and in patients with arthritic changes and stenosis of the spinal canal. Rapid neurological deterioration and severe disability warrant early aggressive surgical treatment. This report has the intention to record this case in the medical literature for registry purposes.

OBJECTIVE:To conduct a bibliometric review of literature on posterior ligamentous complex (PLC) injury in thoracolumbar trauma to guide future research.METHODS:A keyword-based search was conducted from January 2000 to September 2021 using the Scopus database. Relevant publications were analyzed for year of publication, authorship, publishing journal, institution and country of origin, subject matter, and article type. Content analysis of clinical articles was also performed, analyzed for sample size, retrospective versus prospective study design, single-center versus multicenter study, and level of evidence.RESULTS:The search yielded 262 publications published in 61 journals by 537 authors from 162 institutions and 29 countries. Thomas Jefferson University, University of Calgary, and University of Toronto had the largest number of publications related to posterior ligamentous complex injury. Authors from the United States, Canada, and China were the most frequent contributors in terms of the number of publications. Spine was the most prolific and top-cited journal, and A.R. Vaccaro was the most prolific author. The most cited publication was "A New Classification of Thoracolumbar Injuries: The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status" by Vaccaro et al. Most of the publications were case studies, with diagnostic accuracy being the most frequently discussed topic. The sample size for a large portion of the case series was <50. Most case series were retrospective studies conducted at a single center.CONCLUSIONS:Our review provides an extensive list of the most historically significant thoracolumbar PLC injury articles, acknowledging key contributions made to the advancement of this research area.

Study Design Systematic Review and Meta-Analysis. Objectives The elderly have an increased risk of perioperative complications for Adult Spinal Deformity (ASD) corrections. Stratification of these perioperative complications based on risk type and specific risk factors, however, remain unclear. This paper will systematically review perioperative risk factors in the elderly undergoing ASD correction stratified by type: medical, implant-related, proximal junctional kyphosis (PJK), and need for revision surgery. Methods A systematic review was performed using the PRISMA guidelines. A query of PubMed was performed to identify publications pertinent to ASD in the elderly. Publications included in this review focused on patients ≥65 years old who underwent operative management for ASD to assess for risk factors of perioperative complications. Results A total of 734 unique citations were screened resulting in ten included articles for this review. Pooled incidence of perioperative complications included medical complications (21%), implant-related complications (16%), PJK (29%), and revision surgery (13%). Meta-analysis calculated greater preoperative PT (WMD 2.66; 95% Cl .36–4.96; P = .02), greater preoperative SVA (WMD 2.24; 95% Cl .62–3.86; P = .01), and greater postoperative SVA (WMD .97; 95% Cl .03–1.90; P = .04) to significantly correlate with development of PJK with no evidence of publication bias or concerns in study heterogeneity. Conclusions There is a paucity of literature describing perioperative complications in the elderly following ASD surgery. Appropriate understanding of modifiable risk factors for the development of medical and implant-related complications, proximal junctional kyphosis, and revision surgeries presents an opportunity to decrease morbidity and improve patient outcomes.

BACKGROUND: Acute traumatic central cord syndrome (ATCCS) is the most common form of spinal cord injury in the United States. Treatment remains controversial, which is a consequence of ATCCS having an inherently different natural history from conventional spinal cord injury, thus requiring a separate classification system. We devised a novel Central Cord Score (CCscore), which both guides treatment and tracks improvement over time with symp-toms specific to ATCCS. METHODS: Medical records of patients with a diagnosis of ATCCS were retrospectively reviewed at a single insti-tution. The CCscore was devised based on signs, symp-toms, and imaging findings we believed to be critical in assessing severity of ATCCS. Numeric values were assigned for distal upper extremity motor strength, upper extremity sensation, ambulatory status, magnetic reso-nance imaging cord signal, and urinary retention. RESULTS: We identified 51 patients with follow-up data; there were 17 cases of mild injury (CCscore 1-5), 23 mod-erate cases (CCscore 6-10), and 11 severe cases (CCscore 11-15). Patients treated surgically had significantly greater improvement in upper extremity motor scores and total CCscore only up to 3 months. In terms of timing of surgery, patients treated <24 hours after injury had significantly improved upper extremity motor scores and overall CCscores at last follow-up of double dagger 3 months. CONCLUSIONS: Based on these data and their align-ment with past literature, the CCscore is able to objectively and specifically categorize the severity and outcome of ATCCS, which represents a step forward in the quest to determine the ultimate efficacy and timing of surgery for ATCCS.

This article reviews the historical origins of central cord syndrome (CCS), the mechanism of injury, pathophysiology, and clinical implications. CCS is the most common form of incomplete spinal cord injury. CCS involves a spectrum of neurologic deficits preferentially affecting the hands and arms. Evidence suggests that in the twenty-first century CCS has become the most common form of spinal cord injury overall. In an era of big data and the need to standardize this particular diagnosis to unite outcome data, we propose redefining CCS as any adult cervical spinal cord injury in the absence of fracture/dislocation.