INTRODUCTION:Traumatic brain injuries (TBIs) are associated with substantial morbidity and mortality. We examined characteristics and outcomes among military personnel with battlefield-related penetrating TBI (pTBI) compared to closed TBI (cTBI) and non-head injuries (without cranial injuries). MATERIALS AND METHODS:Military personnel admitted to participating U.S. military hospitals (2009-2014) were classified based on injury patterns: pTBI, cTBI (head Abbreviated Injury Scale [AIS] ≥3), and non-head (≥1 non-head injury AIS ≥3). Propensity score and inverse probability of treatment weighting (IPTW) were used to assess associations with mortality, hospital stay, and infection burden. RESULTS:The study population included 106 pTBI patients, 259 cTBI patients, and 715 patients with non-head injuries. Patients with pTBIs were more severely injured with differing injury mechanisms compared to the other 2 groups. Patients with pTBIs had more critical care requirements versus both cTBI and non-head injury patients (P < .05) and longer hospitalization (median 27 days vs. 22; P = .041) compared to cTBI patients. More central nervous system (CNS) infections were diagnosed among patients with pTBIs (11.3%) versus cTBIs (1.2%) and non-head injuries (0.7%; P < .001). Although the overall proportion of patients who developed non-CNS infections was not significantly different between the TBI groups, there was a higher proportion among pTBI versus non-head injury patients (53.8% vs. 40.8%; P = .012). Patients with pTBIs also had less skin and soft-tissue infections and more pneumonia compared to non-head injury patients (P < .05). There was no significant difference in the proportion of mortality between the pTBI and cTBI patients (7.6% vs. 3.1%); however, it was higher compared to patients with non-head injuries (1.0%; P < .001). Sustaining any TBI (penetrating or closed) was associated with greater risk of mortality compared to non-head injuries (risk ratio: 3.71; 95% CI, 1.83-7.55). CONCLUSIONS:Patients with pTBIs are critically injured with substantial critical care requirements and morbidity. Between patients with pTBIs and cTBIs, there was not a significant difference in non-CNS infection burden or mortality, but pTBI patients did have longer hospitalization. When compared to severely injured military personnel with non-head injuries using propensity scores and IPTW analysis, sustaining a TBI (penetrating or closed) was not associated with having more non-CNS infections or a longer hospital stay. This may be a result of the high injury severity (median of 26) and relative occurrence of polytrauma in the total population. Patients with TBIs (penetrating or closed) did have a greater risk of mortality compared to patients with non-head injuries.

BACKGROUND AND OBJECTIVES:The objective of this study was to determine the utility of the pupillary light reflex use as a biomarker of mild traumatic brain injury (mTBI). METHODS:This prospective cohort study was conducted at The US Military Academy at West Point. Cadets underwent a standard battery of tests including Balance Error Scoring System, Sports Concussion Assessment Tool Fifth Edition Symptom Survey, Standard Assessment of Concussion, and measure of pupillary responses. Cadets who sustained an mTBI during training events or sports were evaluated with the same battery of tests and pupillometry within 48 hours of the injury (T1), at the initiation of a graded return to activity protocol (T2), and at unrestricted return to activity (T3). RESULTS:Pupillary light reflex metrics were obtained in 1300 cadets at baseline. During the study period, 68 cadets sustained mTBIs. At T1 (<48 hours), cadets manifested significant postconcussion symptoms (Sports Concussion Assessment Tool Fifth Edition P < .001), and they had decreased cognitive performance (Standardized Assessment of Concussion P < .001) and higher balance error scores (Balance Error Scoring System P < .001) in comparison with their baseline assessment (T0). The clinical parameters showed normalization at time points T2 and T3. The pupillary responses demonstrated a pattern of significant change that returned to normal for several measures, including the difference between the constricted and initial pupillary diameter (T1 P < .001, T2 P < .05), dilation velocity (T1 P < .01, T2 P < .001), and percent of pupillary constriction (T1 P < .05). In addition, a combination of dilation velocity and maximum constriction velocity demonstrates moderate prediction ability regarding who can return to duty before or after 21 days (area under the curve = 0.71, 95% CI [0.56-0.86]). CONCLUSION:This study's findings indicate that quantitative pupillometry has the potential to assist with injury identification and prediction of symptom severity and duration.

Atlantoaxial rotatory subluxation (AARS) in the adult population is primarily trauma-induced. Conservative and surgical treatments have both been used successfully in treating AARS. In cases where AARS cannot be reduced by conservative measures, open reduction and fusion is the conventional treatment approach. This report details a novel approach for treating adult AARS, where an open reduction was performed without instrumentation or fusion. The patient, a 48-year-old female involved in a high-speed vehicular collision, initially underwent conservative treatment with Gardner Wells Tongs and manual traction. Despite these efforts, X-ray and computed tomography (CT) scans indicated persistent subluxation. Subsequently, the patient was taken to the operating room, where successful open reduction was achieved without the need for fusion or instrumentation. Preoperative imaging revealed rotatory subluxation of C1-2 with a comminuted and displaced fracture of the right C1-2 facet joint and a nondisplaced fracture of the base of the occiput. The surgical technique involved precise manual manipulation using a Cloward spreader and real-time assessment with O-arm 3D X-ray tomography to ensure successful reduction. The absence of significant laxity or instability during intraoperative testing led to the conclusion that fusion was unnecessary. This approach minimizes invasive tissue dissection and preserves natural cervical range of motion (ROM). Postoperatively, the patient was asymptomatic with no joint instability and demonstrated satisfactory alignment at follow-up.

OBJECTIVE:This study aimed to determine the validity of quantitative pupillometry to predict the length of time for return to full activity/duty after a mild traumatic brain injury (mTBI) in a cohort of injured cadets at West Point. METHODS:Each subject received baseline (T0) quantitative pupillometry, in addition to evaluation with the Balance Error Scoring System (BESS), Standardized Assessment of Concussion (SAC), and Sport Concussion Assessment Tool 5th Edition Symptom Survey (SCAT5). Repeat assessments using the same parameters were conducted within 48 hours of injury (T1), at the beginning of progressive return to activity (T2), and at the completion of progressive return to activity protocols (T3). Pupillary metrics were compared on the basis of length of time to return to full play/duty and the clinical scores. RESULTS:The authors' statistical analyses found correlations between pupillometry measures at T1, including end-initial diameter and maximum constriction velocity, with larger change and faster constriction predicting earlier return to play. There was also an association with maximum constriction velocity at baseline (T0), predicting faster return to play. CONCLUSIONS:The authors conclude that that pupillometry may be a valuable tool for assessing time to return to duty from mTBI by providing a measure of baseline resiliency to mTBI and/or autonomic dysfunction in the acute phase after mTBI.

BACKGROUND: Penetrating brain injuries are a potentially lethal injury associated with substantial morbidity and mortality. We examined characteristics and outcomes among military personnel who sustained battlefield-related open and penetrating cranial injuries during military conflicts in Iraq and Afghanistan.METHODS: Military personnel wounded during deployment (2009-2014) were included if they sustained an open or penetrating cranial injury and were admitted to participating hospitals in the United States. Injury characteristics, treatment course, neurosurgical interventions, antibiotic use, and infection profiles were examined.RESULTS: The study population included 106 wounded personnel, of whom 12 (11.3%) had an intracranial infection. Posttrauma prophylactic antibiotics were prescribed in more than 98% of patients. Patients who developed central nervous system (CNS) infections were more likely to have undergone a ventriculostomy ( p = 0.003), had a ventriculostomy in place for a longer period (17 vs. 11 days; p = 0.007), had more neurosurgical procedures ( p < 0.001), and have lower presenting Glasgow Coma Scale ( p = 0.01) and higher Sequential Organ Failure Assessment scores ( p = 0.018). Time to diagnosis of CNS infection was a median of 12 days postinjury (interquartile range, 7-22 days) with differences in timing by injury severity (critical head injury had median of 6 days, while maximal [currently untreatable] head injury had a median of 13.5 days), presence of other injury profiles in addition to head/face/neck (median, 22 days), and the presence of other infections in addition to CNS infections (median, 13.5 days). The overall length of hospitalization was a median of 50 days, and two patients died.CONCLUSION: Approximately 11% of wounded military personnel with open and penetrating cranial injuries developed CNS infections. These patients were more critically injured (e.g., lower Glasgow Coma Scale and higher Sequential Organ Failure Assessment scores) and required more invasive neurosurgical procedures. (J Trauma Acute Care Surg. 2023;95: S72-S78.)

OBJECTIVE:There is continuing uncertainty about the safety of early chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI). The objective of this paper was to 1) calculate the risk of progression of posttraumatic intracranial hemorrhage (ICH) after VTE chemoprophylaxis, and 2) compare the probability of ICH progression in early versus late VTE prophylaxis. METHODS:The authors searched for English-language literature from database inception to January 2023. Two independent reviewers selected studies on post-TBI VTE chemoprophylaxis in hospitalized patients. Study parameters included ICH progression (as determined by follow-up imaging after starting chemoprophylaxis) in relation to use versus nonuse, timing, and type of VTE chemoprophylaxis. Pertinent variables included author, year, study type, demographic variables, cranial and systemic Injury Severity Scores, and data documenting ICH progression or indirect evidence of TBI worsening after the initiation of VTE chemoprophylaxis. RESULTS:Thirty studies fulfilled the inclusion criteria. There was a 7.0% (95% CI 4.0%-10.0%) risk of CT-documented ICH progression following VTE chemoprophylaxis in the prophylactically treated group. There was no difference between the early versus late VTE prophylaxis groups for ICH progression (12 studies; OR 0.79 [95% CI 0.56-1.12]). There was also no significant difference in CT-documented ICH progression between the prophylactically treated and nontreated groups (5 studies; OR 0.57 [95% CI 0.28-1.18]). CONCLUSIONS:The review of the literature shows that VTE chemoprophylaxis 72 hours after TBI is considered safe by the majority of authors. This meta-analysis did not reveal any evidence of increased risk of ICH when starting VTE chemoprophylaxis earlier, i.e., within 72 hours of TBI; however, it is important to emphasize that only a small number of lower-quality studies addressed the 48-hour or 24-hour time point. A randomized noninferiority trial should be the next step in answering the question of early (within 72 hours) VTE chemoprophylaxis after TBI.

Background: Chondromas, benign cartilaginous primary bone tumors, seldom occur in the spine. Most spinal chondromas arise from the cartilaginous parts of the vertebra. Chondromas originating from the intervertebral disc are extraordinarily rare. Case Description: A 65-year-old female experienced recurrence of low back pain and left-sided lumbar radiculopathy after microdiscectomy and microdecompression. A mass continuous with the intervertebral disc was found to be compressing the left L3 nerve root and was resected. Histologic examination revealed a benign chondroma. Conclusion: Chondromas developing from the intervertebral disc are extremely rare; we could find only 37 reported cases. Identification of these chondromas is difficult because until surgical resection they are almost indistinguishable from herniated intervertebral discs. Here, we describe a patient with residual/recurrent lumbar radiculopathy caused by a chondroma originating from the L3–4 intervertebral disc. When a patient has recurrence of spinal nerve root compression after discectomy, a chondroma arising from the intervertebral disc is an uncommon but possible etiology.

Spinal cord injury (SCI) causes severe disability, and the current inability to restore function to the damaged spinal cord leads to lasting detrimental consequences to patients. One strategy to reduce SCI morbidity involves limiting the spread of secondary damage after injury. Previous studies have shown that connexin 43 (Cx43), a gap junction protein richly expressed in spinal cord astrocytes, is a potential mediator of secondary damage. Here, we developed a specific inhibitory antibody, mouse-human chimeric MHC1 antibody (MHC1), that inhibited Cx43 hemichannels, but not gap junctions, and reduced secondary damage in 2 incomplete SCI mouse models. MHC1 inhibited the activation of Cx43 hemichannels in both primary spinal astrocytes and astrocytes in situ. In both SCI mouse models, administration of MHC1 after SCI significantly improved hind limb locomotion function. Remarkably, a single administration of MHC1 30 minutes after injury improved the recovery up to 8 weeks post-SCI. Moreover, MHC1 treatment decreased gliosis and lesion sizes, increased white and gray matter sparing, and improved neuronal survival. Together, these results suggest that inhibition of Cx43 hemichannel function after traumatic SCI reduces secondary damage, limits perilesional gliosis, and improves functional recovery. By targeting hemichannels specifically with an antibody, this study provides a potentially new, innovative therapeutic approach in treating SCI.

The management of patients with elevated intracranial pressure (ICP) requires a systematic approach. After the failure of tier zero, tier one, and tier two therapies, all potential secondary causes of elevated ICP must be reviewed. Up to 28% of patients with blunt traumatic brain injury (TBI) develop cerebral sinus venous thrombosis (CSVT), among these, patients up to 55% have occlusive thrombi. A literature review revealed a dearth of specific treatment guidelines in this scenario. Here, we present one such case of refractory elevated ICP due to occlusive CSVT secondary to skull fractures. Initial CT venogram (CTV) on admission showed an occlusive CSVT; however, subsequent CTV on the post-trauma day (PTD) 4 and 6 showed non-occlusive thrombi only. The risks of worsening acute TBI-related hemorrhage with systemic anticoagulation versus the benefit of treating an occlusive CSVT are discussed here. In cases of occlusive CSVT with refractory elevated ICP and stable intracranial hemorrhage, the benefit of anticoagulation may outweigh the overall risks of hemorrhage expansion as prolonged uncontrolled ICP elevation is inevitably fatal. In this case, anticoagulation started on PTD 6, led to the resolution of ICP elevation and an excellent outcome for the patient, who was discharged to an acute rehab center, subsequently discharged home with no residual motor deficits, and was able to resume employment. Further prospective trials are necessary to develop guidelines for the management of occlusive CSVT in patients with severe TBI and to determine which patient populations are likely to benefit from early initiation of therapeutic anticoagulation.

Dengler, Bradley MD; Chick, Robert C MD; Plaza-Wuthrich, Sonia PhD; Muir, Mark MD; Bartanusz, Viktor Author Information

Benign low back pain is frequent in the lucratively active population. Degenerative changes are considered the most frequent causes. The identification of pain generators remain challenging. Bone marrow lesions, Modic changes, are frequently associated with benign low back pain, mostly type 1. The etiology of Modic changes is unknown, both infectious and autoimmune mechanisms have been suggested. Despite the strong association of Modic changes with low back pain it is not clear whether lumbar surgery (lumbar fusion, total disc replacement) has any role in the management of these patients. We conclude that all available evidence in literature is inconclusive and future studies are needed addressing more precisely the question of minimal clinically important difference (MCID) while considering of all confounding factors influencing outcome.

Les lombalgies aspécifiques sont fréquentes. Les changements dégénératifs semblent en être la raison. Il y a une grande prévalence des changements de l’os sous-chondral, décrits par Modic sur IRM, chez les patients souffrant de lombalgies, surtout les Modic type 1. Les changements de type Modic semblent faire partie du même processus pathologique et deux étiologies, une infectieuse et l’autre auto-immune, ont été décrites. Il n’y a pas d’évidence qu’une prise en charge chirurgicale, spondylodèse ou prothétique discale, soit recommandée. Les études sont souvent rétrospectives et présentent des biais de sélection. Les futures études devraient inclure un plus grand nombre de patients et répondre à la question de la différence minimum cliniquement importante (MCID, minimal clinically important difference).

INTRODUCTION: Connexion 43, a gap junction protein, is expressed abundantly in the central nervous system (CNS) and has been implicated in propagating secondary injury in the CNS. In this report we use a monoclonal antibody against Cx43 hemichannel to study the effects of regulating Cx43 activity during spinal cord injury (SCI) in a mouse model. METHODS: C57BL/6 male mice underwent T10 to 12 laminectomies and were injured using a impactor at a speed of 3 m/s, displacement of 2 mm and dwelling time of 1500 ms. Mice were randomly assigned to C x 43+ SCI (n = 5), Igg+ SCI (n = 3), or vehicle + SCI (n = 1) group and drugs were administered 30 minutes after injury. The Basso Mouse Scale (BMS) and rotarod testing was used to track functional recovery up to 6 weeks after injury. In addition, immunohistochemistry was performed to assess for the inflammatory response. RESULTS: Blocking of Cx43 promoted faster recovery of locomotor function after SCI. At 6 weeks Cx43 ab treated animals achieved a mean BMS score of 7.8 (SD 1.68) compared with 1.3 (SD 1.04) in the Igg group (P < .01). Cx43 ab treated mice regained 80% of their pre-SCI ability to spend time on accelerating rotarod as opposed to only 25% in the control group (P < .05). Immunohistochemical staining for astrogliotic scarring showed a 6.3-fold increase in GFAP signal in Igg-treated mice compared with 1.3 in the Cx43-treated animals at day 14 (P = .065). These trends persisted at day 56 (P < .01). Neun staining for neurons showed a 25% decrease in Neun signal in Igg-treated mice compared with 2% in Cx43-treated mice (P < .05) at day 14. CONCLUSION: Mice treated with Cx43 monoclonal antibody show improved functional recovery and neuronal survival and decreased astrogliosis compared with Igg-treated mice. Combined, these results confirm Cx43 hemichannel as a viable therapeutic target for traumatic SCI.

Industry sponsorship of clinical research of degenerative diseases of the spine has been associated with excessive positive published results as compared to research carried out without industry funding. We sought the rates of publication of clinical trials of degenerative diseases of the spine based on funding source as a possible explanation for this phenomenon. We reviewed all clinical trials registered at clinicaltrials.gov relating to degenerative diseases of the spine as categorized under six medical subject heading terms (spinal stenosis, spondylolisthesis, spondylolysis, spondylosis, failed back surgery syndrome, intervertebral disc degeneration) and with statuses of completed or terminated. These collected studies were categorized as having, or not having, industry funding. Published results for these studies were then sought within the clinicaltrials.gov database itself, PubMed and Google Scholar. One hundred sixty-one clinical trials met these criteria. One hundred nineteen of these trials had industry funding and 42 did not. Of those with industry funding, 45 (37.8%) had identifiable results. Of those without industry funding, 17 (40.5%) had identifiable results. There was no difference in the rates of publication of results from clinical trials of degenerative diseases of the spine no matter the funding source.

Study Design. An in vitro, cadaveric biomechanical study. Objective. The aim of the present study was to compare single‐segment posterior instrumentation and fracture‐level screws with single/multilevel posterior fixation and corpectomy in a simulated, unstable burst fracture model. Summary of Background Data. The optimal extent of instrumentation for surgical cases of non‐neoplastic vertebral body pathologies remains uncertain. Although several clinical studies demonstrate advantages of short segment instrumentation with index‐level screws over more extensive corpectomy and anterior–posterior techniques, a comprehensive biomechanical comparison of these techniques is currently lacking. Methods. Six bovine spines (T11–L5) were tested in flexion, extension, lateral bending (LB), and axial rotation (AR) following simulated burst fracture at L2. Posterior instrumentation included 1 level above/below (1LF) and 2 levels above/below fracture level (2LF), intermediate or index screws at fracture level (FF), and cross‐connectors above/below fracture level (CC). Anterior corpectomy devices included expandable corpectomy spacers with/without integrated screws, ACDi and ACD, respectively FORTIFY‐Integrated/FORTIFY; Globus Medical, Inc., PA. Constructs were tested in the following order: (1) Intact; (2) 1LF; (3) 1LF and CC; (4) 1LF and FF; (5) 1LF, CC, and FF; (6) 2LF; (7) 2LF and CC; (8) 2LF and FF; (9) 2LF, CC, and FF; (10) 2LF and ACD; (11) 2LF, ACD, and CC; (12) 1LF and ACDi; (13) 1LF, ACDi, and CC. Results. During flexion, all constructs except 1LF reduced motion relative to intact (P ⩽ 0.05). Anterior support was most stable, but no differences were found between constructs (P ≥ 0.05). Every construct reduced motion in extension, though no differences were found between constructs and intact (P ≥ 0.05). During LB, all constructs reduced motion relative to intact (P ⩽ 0.05); 2LF constructs further reduced motion (P ⩽ 0.05). No construct returned AR motion to intact, with significant increases in 1LF and ACDi, 2LF and ACD, and 2LF, ACD, and CC (P ⩽ 0.05). Cross‐connectors and fracture screws reinforced each other in posterior‐only constructs, providing maximum stability (P ≥ 0.05). Conclusions. This biomechanical comparison study found no significant superiority of combined anterior–posterior constructs over short segment fracture screw fixation, only multilevel posterior instrumentation with and without anterior support, providing increased stability in LB. Biomechanical equivalency suggests that short segment fracture screw intervention may provide appropriate stabilization for non‐neoplastic pathologies involving the anterior and middle vertebral columns. Level of Evidence: 2

Recurrent giant cell tumor (GCT) of the cervical spine represents a significant therapeutic challenge. We present a case of 16-year-old boy with widespread cervical recurrence of GCT 1 year after radical tumor resection via C2 spondylectomy. Computed tomography and magnetic resonance imaging of the cervical spine showed massive recurrence of the tumor with soft tumor mass compressing the spinal cord, osteolytic lesion of the right C1 lateral mass, and complete osteolytic destruction of the C3 vertebral body. The tumor was extending ventrally involving the carotid artery (Fig. 1). Radical surgical reintervention not being conceivable, parallel to conventional external beam radiation therapy (54 Gy in 30 fractions), the patient was started on intravenous monthly 4-mg zoledronic acid treatment for 1 year. At 30-month follow-up after the initiation of zoledronic acid therapy, the patient was asymptomatic, resumed school, and started driving. Imaging studies showed ossification of the tumor, no hardware loosening, and good cervical spine alignment with sufficient space available for the spinal cord (Fig. 2). We suggest that anti-osteoclast therapy should be considered as first-line treatment for GCTs of the spine, especially for those cases where complete tumor resection is not possible. Surgery should be reserved for decompression and stabilization in patients with progressive neurological deficit and spinal instability [ 1 Balke M. Campanacci L. Gebert C. Picci P. Gibbons M. Taylor R. et al. Bisphosphonate treatment of aggressive primary, recurrent and metastatic giant cell tumor of bone. BMC Cancer. 2010; 10: 462 Crossref PubMed Scopus (108) Google Scholar , 2 Mattei T.A. Ramos E. Rehman A.A. Shaw A. Patel S.R. Mendel E. Sustained long-term complete regression of a giant cell tumor of the spine after treatment with denosumab. Spine J. 2014; 14: e15-e21 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar , 3 Gille O. Oliviera B.A. Guerin P. Lepreux S. Richez C. Vital J.M. Regression of giant cell tumor of the cervical spine with bisphosphonate as single therapy. Spine. 2012; 37: E396-E399 Crossref PubMed Scopus (28) Google Scholar ].