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Although limited spontaneous recovery occurs after spinal cord injury (SCI), current knowledge reveals that multiple forms of axon growth in spared axons can lead to circuit reorganization and a detour or relay pathways. This hypothesis has been derived mainly from studies of the corticospinal tract (CST), which is the primary descending motor pathway in mammals. The major CST is the dorsal CST (dCST), being the major projection from cortex to spinal cord. Two other components often called "minor" pathways are the ventral and the dorsal lateral CSTs, which may play an important role in spontaneous recovery. Intravenous infusion of mesenchymal stem cells (MSCs) provides functional improvement after SCI with an enhancement of axonal sprouting of CSTs. Detailed morphological changes of CST pathways, however, have not been fully elucidated. The primary objective was to evaluate detailed changes in descending CST projections in SCI after MSC infusion. The MSCs were infused intravenously one day after SCI. A combination of adeno-associated viral vector (AAV), which is an anterograde and non-transsynaptic axonal tracer, was injected 14 days after SCI induction. The AAV with advanced tissue clearing techniques were used to visualize the distribution pattern and high-resolution features of the individual axons coursing from above to below the lesion. The results demonstrated increased observable axonal connections between the dCST and axons in the lateral funiculus, both rostral and caudal to the lesion core, and an increase in observable axons in the dCST below the lesion. This increased axonal network could contribute to functional recovery by providing greater input to the spinal cord below the lesion.

The management of cervical spine injuries in the elderly is often complicated by the presence of multiple medical comorbidities, and it is not uncommon for preoperative testing to reveal other conditions that require the postponement of surgery. However, the factors that affect the waiting time from injury to surgery have not been clarified. The purpose of this multicenter database study was to analyze the clinical features and identify the factors affecting the number of days waited between injury and surgery in elderly patients with a cervical spine injury.We retrospectively reviewed the case histories of 1512 Japanese patients with a cervical spinal injury, who were seen at 33 institutions. After excluding patients who were not initially receiving a surgery for cervical spinal injury, 694 patients were ultimately analyzed. Based on a multivariate mixed model, we determined the factors related to the number of days from injury to surgery.The mean time from injury to surgery was 12.3 days. Multivariate analysis revealed delays of 10.7 days for a renal disorder, 7.3 days for anticoagulant use, and 15.2 days for non-surgical thoracolumbar fracture as factors prolonging wait time. In contrast, a C3 or lower spine injury was significantly associated with a shortening of 9.5 days to surgery.This multicenter database study identified several factors influencing the time between injury and cervical spine surgery in elderly patients. While renal impairment, anticoagulant use, and non-surgical thoracolumbar fracture may increase the number of days to surgery, trauma to C3 or lower may expedite surgical treatment.

Retrospective analysis of prospectively collected multicenter observational data.The aim was to examine the preoperative factors affecting postoperative satisfaction following posterior lumbar interbody fusion (PLIF) and microendoscopic muscle-preserving interlaminar decompression (ME-MILD) in patients with degenerative lumbar spondylolisthesis (DLS).The technique involved in DLS surgery may either be decompression alone or decompression-fixation. Poor performance may occur after either of these surgical treatments. The author hypothesized that evaluating the correlation between preoperative quality of life and postoperative performance would aid in determining the optimal procedure.This study included 138 patients who underwent surgery for 1-level mild DLS. The authors performed PLIF for 79 patients and ME-MILD for 59 patients. When the satisfaction subscale of the Zurich Claudication Questionnaire exceeded 2 points, postoperative satisfaction was considered poor. The clinical characteristics were investigated. Responses to preoperative health-related quality of life questionnaires, such as the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), short form-36 health survey (SF-36), and visual analog scale, were compared between the satisfied and unsatisfied groups.In the PLIF group, no endogenous factors influenced postoperative satisfaction. The ME-MILD cohort's satisfied and unsatisfied patients differed significantly in terms of preoperative lumbar spine dysfunction ( P0.001) items of the JOABPEQ, role physical ( P =0.03), and role emotional ( P =0.03) items of the SF-36. A strong correlation ( r =-0.609 P =0.015) was found between preoperative lumbar spine dysfunction and postoperative satisfaction.In the ME-MILD group, preoperative lumbar spine function was correlated with postoperative satisfaction. Decompression alone may be ineffective in cases with decreased lumbar spine function prior to surgery. The degree of low back pain on movement should be considered before selecting the surgical method.3.

The number of elderly patients with cervical trauma is increasing. Such patients are considered to be at high risk for delirium, which is an acute neuropsychological disorder that reduces the patient’s capacity to interact with their environment due to impairments in cognition. This study aimed to establish a risk score that predicts delirium in elderly patients with cervical SCI and/or cervical fracture regardless of treatment type. This retrospective cohort study included 1512 patients aged ≥65 years with cervical SCI and/or cervical fracture. The risk factors for delirium according to treatment type (surgical or conservative) were calculated using multivariate logistic regression. A delirium risk score was established as the simple arithmetic sum of points assigned to variables that were significant in the multivariate analyses. Based on the statistical results, the delirium risk score was defined using six factors: old age (≥80 years), hypoalbuminemia, cervical fracture, major organ injury, dependence on pre-injury mobility, and comorbid diabetes. The score’s area under the curve for the prediction of delirium was 0.66 (p < 0.001). Although the current scoring system must be validated with an independent dataset, the system remains beneficial because it can be used after screening examinations upon hospitalization and before deciding the treatment strategy.

Ossification of the posterior longitudinal ligament (OPLL) can be complicated cervical spinal cord injury (CSCI) by low energy trauma, which is increasing among the elderly and potentially life-threatening. However, the etiology and neurological outcome of CSCI with OPLL in the elderly remain unknown. Therefore, we conducted this multi-center retrospective cohort study, which identified 1,512 patients aged ≥ 65 years and diagnosed with CSCI on admission from 2010 to 2020. We analyzed the etiology in patients with OPLL. Moreover, we performed propensity score-adjusted analyses to compare the neurological outcomes between patients with and without OPLL. The primary outcome comprised the American Spine Injury Association (ASIA) impairment scale (AIS) grade and ASIA motor score (AMS). In 332 patients with OPLL, the men:women ratio was approximately 4:1. Half of all patients displayed low energy trauma-induced injury, and one-third of the patients had CSCI without a bony injury. The propensity score matching created 279 pairs. There was no significant difference in the AIS grade and AMS between the patients with and without OPLL during hospitalization, 6 months, and 12 months following injury. In summary, OPLL was not associated with neurological recovery in the elderly with CSCI.

We present the case of a 15-year-old girl. Two months after becoming aware of pain, she was diagnosed with a sacral tumor and referred to our department. She was diagnosed with a sacral Ewing’s sarcoma; after chemotherapy, it was determined that the tumor could be resected, so surgical treatment was performed. The sacrum and ilium were partially resected at the lower end of S1, and the lumbar vertebrae and pelvis were fixed with a pedicle screw and two iliac screws on each side of L3, and the sacral resection was reconstructed with a tibial strut allograft. No tumor recurrence or metastasis has been observed 1 year postoperatively. She developed bladder and rectal dysfunction, but she remained independent in activities of daily living and her daily life was not limited. The bone fusion in the reconstructed area confirmed the lack of instrumentation looseness. Surgical treatment for sacral Ewing’s sarcoma was performed to cure the patient. We believe that the tibial allograft contributed to the patient’s ability to walk on her own due to its high mechanical stability. Postoperative bone healing was observed with the same material, suggesting that the tibial allograft is useful for similar procedures.

Spinal cord injury (SCI) induces distal effects on neural activity in the brain. To date, precise, high quality anatomical studies have not been performed. The goal of this study was to delineate neuroanatomical enhancement of dormant pathways in the brain following SCI using an appropriate serotype of an adeno-associated-virus (AAV) with a CAG promotor.

Retrospective multicenter study.To investigate the neurological outcomes of older individuals treated with surgery versus conservative treatment for cervical spinal cord injury (CSCI) without bone injury.Thirty-three medical institutions in Japan.This study included 317 consecutive persons aged ≥65 years with CSCI without bone injury in participating institutes between 2010 and 2020. The participants were followed up for at least 6 months after the injury. Individuals were divided into surgery (n = 114) and conservative treatment (n = 203) groups. To compare neurological outcomes and complications between the groups, propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed.After propensity score matching, the surgery and conservative treatment groups comprised 89 individuals each. Surgery was performed at a median of 9.0 (3-17) days after CSCI. Baseline factors were comparable between groups, and the standardized difference in the covariates in the matched cohort was10%. The American Spinal Injury Association (ASIA) impairment scale grade and ASIA motor score (AMS) 6 months after injury and changes in the AMS from baseline to 6 months after injury were not significantly different between groups (P = 0.63, P = 0.24, and P = 0.75, respectively). Few participants who underwent surgery demonstrated perioperative complications such as dural tear (1.1%), surgical site infection (2.2%), and C5 palsy (5.6%).Conservative treatment is suggested to be a more favorable option for older individuals with CSCI without bone injuries, but this finding requires further validation.

In the current aging society, there has been a marked increase in the incidence of cervical spinal cord injury (CSCI) without major bone injury. This multi-center study aimed to identify predictors of neurological improvement in elderly patients with CSCI without major bone injury. The participants were 591 patients aged ≥65 years with CSCI without major bone injury and a minimum follow-up period of three months. Neurologic status was defined using the American Spinal Injury Association (ASIA) impairment scale (AIS). Univariate and multi-variate analyses were performed to identify prognostic factors for walking recovery in AIS A-C cases and full upper extremity motor recovery in AIS D cases. In AIS A-C cases, body mass index (odds ratio (OR): 1.112), magnetic resonance imaging signal change (OR: 0.240), AIS on admission (OR: 3.497), comorbidity of dementia/delirium (OR: 0.365), and post-injury pneumonia (OR: 0.194) were identified as independent prognostic factors for walking recovery. The prevalence of ossification of the posterior longitudinal ligament (OR: 0.494) was also found to be an independent prognostic factor in AIS B and C cases only. In AIS D cases, age (OR: 0.937), upper extremity ASIA motor score on admission (OR: 1.230 [per 5 scores]), and operation (OR: 0.519) were independent prognostic factors for full motor recovery. The severity of AIS at admission was the strongest predictor of functional outcomes. Promoting rehabilitation, however, through measures to reduce cognitive changes, post-injury pneumonia, and unhealthy body weight changes can contribute to greater neurological improvement in AIS A-C cases.

We aimed to retrospectively investigate the demographic characteristics and short-term outcomes of traumatic cervical spine injuries in patients with dementia. We enrolled 1512 patients aged ≥ 65 years with traumatic cervical injuries registered in a multicenter study database. Patients were divided into two groups according to the presence of dementia, and 95 patients (6.3%) had dementia. Univariate analysis revealed that the dementia group comprised patients who were older and predominantly female and had lower body mass index, higher modified 5-item frailty index (mFI-5), lower pre-injury activities of daily living (ADLs), and a larger number of comorbidities than patients without dementia. Furthermore, 61 patient pairs were selected through propensity score matching with adjustments for age, sex, pre-injury ADLs, American Spinal Injury Association Impairment Scale score at the time of injury, and the administration of surgical treatment. In the univariate analysis of the matched groups, patients with dementia had significantly lower ADLs at 6 months and a higher incidence of dysphagia up to 6 months than patients without dementia. Kaplan–Meier analysis revealed that patients with dementia had a higher mortality than those without dementia until the last follow-up. Dementia was associated with poor ADLs and higher mortality rates after traumatic cervical spine injuries in elderly patients.

For older patients with decreased reserve function, traumatic cervical spine injuries frequently lead to early mortality. However, the prognostic factors for early mortality remain unclear. This study included patients aged ≥65 years and hospitalized for treatment of traumatic cervical spine injuries in 78 hospitals between 2010 and 2020. Early mortality was defined as death within 90 days after injury. We evaluated the relationship between early mortality and the following factors: age, sex, body mass index, history of drinking and smoking, injury mechanisms, presence of a cervical spine fracture and dislocation, cervical ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, American Spinal Injury Association Impairment Scale, concomitant injury, pre-existing comorbidities, steroid administration, and treatment plan. Overall, 1512 patients (mean age, 75.8 ± 6.9 years) were included in the study. The early mortality rate was 4.0%. Multivariate analysis identified older age (OR = 1.1, p < 0.001), male sex (OR = 3.7, p = 0.009), cervical spine fracture (OR = 4.2, p < 0.001), complete motor paralysis (OR = 8.4, p < 0.001), and chronic kidney disease (OR = 5.3, p < 0.001) as risk factors for early mortality. Older age, male sex, cervical spine fracture, complete motor paralysis, and chronic kidney disease are prognostic factors for early mortality in older patients with traumatic cervical spine injuries.

Study Design Retrospective multicenter study Objectives To investigate changes over a 10-years period in the profile of cervical spine and spinal cord injuries among the elderly in Japan. Methods The current multicenter study was a retrospective analysis of inpatients aged ≥65 years, suffering cervical fracture (CF) and/or cervical spinal cord injury (CSCI). We analyzed 1413 patients’ epidemiology (from 2010 to 2019). Moreover, 727 patients who underwent surgical treatment were analyzed in 2 groups: the early (2010-2014) and late period (2015-2019). Results Both the number of patients and number of surgical patients showed a significant increasing trend ( P < .001), while the mean age, the distribution of injury levels and paralysis severity, and the proportion of surgical indications remained the same. The number of surgical patients doubled from 228 to 499 from the early to late periods. Posterior surgery was the most common approach (90.4%), instrumentation surgery with screws increased significantly, and the range of fusion was significantly longer in the late period (2.1 vs 2.7 levels, P = .001). Significantly worsening neurological symptoms were recorded in the late period (1.3% vs 5.8%, P = .006), with C5 palsy being the major one. Otherwise, perioperative, major, and other complications, including mortality, did not differ significantly in incidence. Conclusions Both the number of elderly CF and/or CSCI patients and number of patients undergoing surgery increased dramatically over the decade without any change in profile. Instrumentation surgeries with screws increased, without an increase in systemic complications.

Study design A retrospective analysis of prospectively collected multicenter observational data. Objective The aim of this study was to compare the health-related quality of life (HR-QOL) of double-door laminoplasty (DDL) and selective laminoplasty (SL) in patients with degenerative cervical myelopathy (DCM) in two institutions, with a minimum follow-up of 5 years. Summary of background data No study has compared DDL and SL regarding postoperative HR-QOL with a follow-up of more than 5 years. Methods One-hundred ninety patients who underwent DDL (n = 77) or SL (n = 113) participated in this study. Short-form 36 (SF-36), Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), Neck Disability Index (NDI), and visual analog scale (VAS) values were compared between the groups. Results Thirty-seven DDL and 52 SL patients were evaluated. The mean follow-up period was 8 years and the follow-up rate was 46.8%. No significant differences were found regarding age and JOA score at baseline. At the follow-up, there were no significant differences in SF-36, JOACMEQ, and VAS score, while the NDI score for headache and sleeping were higher in the SL group. After dividing the SL group into short and long SL subgroups, the long SL subgroup showed a significantly lower score in bodily pain in SF-36, lower and bladder function in JOACMEQ, and pain intensity, personal care, headaches, and sleeping in NDI compared with the other groups. Conclusion No significant differences were found in SF-36, JOA score, and NDI, except for the NDI subscale of headache and sleeping. The subgroup analysis showed that the long SL group showed a decreased QOL compared with the short SL and DDL groups. Level of evidence 3.

Study design Retrospective Cohort Study Objective The purpose of this study was to investigate the prognosis of respiratory function in elderly patients with cervical spinal cord injury (SCI) and to identify predictive factors. Methods We included 1353 cases of elderly cervical SCI patients collected from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were defined as the respiratory disability group. Patients’ background characteristics, injury mechanism, injury form, neurological disability, complications, and treatment methods were compared between the disability and non-disability groups. Multiple logistic regression analysis was used to examine the independent factors. Patients who required respiratory management for 6 months or longer after injury and those who died of respiratory complications were classified into the severe disability group and were compared with minor cases who were weaned off the respirator. Results A total of 104 patients (7.8%) had impaired respiratory function. Comparisons between the disabled and non-disabled groups and between the severe and mild injury groups yielded distinct trends. In multiple logistic regression analysis, age, blood glucose level, presence of ossification of posterior longitudinal ligament (OPLL), anterior vertebral hematoma, and critical paralysis were selected as independent risk factors. Conclusion Age, OPLL, severe paralysis, anterior vertebral hematoma, hypoalbuminemia, and blood glucose level at the time of injury were independent factors for respiratory failure. Hyperglycemia may have a negative effect on respiratory function in this condition.

Study design Retrospective analysis of prospectively collected observational data. Objective This study aimed to evaluate the slippage, sagittal alignment, and range of motion (ROM) after selective laminectomy (SL) in patients who had cervical spondylotic myelopathy (CSM) with degenerative spondylolisthesis (DS). Summary of background data Clinical outcomes have been reported for both decompression and fusion surgeries for DS of the lumbar spine. However, only a few reports have examined cervical spine spondylolisthesis. Materials and methods This study included 178 patients who underwent SL for CSM. Those with ossification of the posterior longitudinal ligament were excluded. Slippage >2 mm was defined as spondylolisthesis, and spondylolisthesis progression was defined as an additional displacement >2 mm on a neutral radiograph. The slippage, translational motion, C2-C7 angle, local kyphosis, and ROM were examined before and ≥2 years after surgery. Radiologic parameters were evaluated according to the slip direction and the number of laminae removed. Results DS was observed in 29 patients (16.3%); 24 patients, comprising 9 and 15 in the anterolisthesis and retrolisthesis groups, respectively, were successfully followed up for more than 2 years. Preoperative and postoperative radiologic changes in slippage, translational motion, C2-C7 angle, local kyphosis, and ROM were not remarkable in either group regardless of the number of laminae removed. Revision surgery for the progression of DS and alignment deterioration was not required in any patient of either group. Conclusions SL does not affect DS, sagittal alignment, or ROM irrespective of the slip direction and the number of laminae removed, even after >2 years after surgery. Given the preservation of the posterior elements, SL may be an effective treatment for CSM with DS. Level of evidence Level IV.

STUDY DESIGN A retrospective cohort study of consecutive patients. OBJECTIVE To investigate whether adequate flexion-extension was acquired in standard functional radiographs in lumbar spondylolisthesis. SUMMARY OF BACKGROUND DATA In lumbar spondylolisthesis, flexion-extension radiographs taken in the standing position are most commonly used to evaluate spinal instability. However, these functional radiographs occasionally depend on the patient's effort and cooperation, they can provide different results. METHODS This study included 92 consecutive patients diagnosed with L4-5 degenerative lumbar spondylolisthesis. We analyzed the flexion-extension radiographs taken with the patient being led by the hand (LH) and those taken without LH (NLH). Sagittal translation (ST), segmental angulation (SA), posterior opening (PO), and lumbar lordosis (LL) were measured on functional radiographs taken in both tests. Then, ST, SA, PO, detection rate of instability, and LL observed in LH were compared with those observed in NLH. Furthermore, the correlation of the difference was evaluated between ST, lumbar angulation, and LL. RESULTS A relative value of ST was 9.5% ± 4.3% in LH and 5.6% ± 3.3% in NLH, which differed significantly (P

Background Although spinal cord injury (SCI) is a major cause of disability, current therapeutic options remain limited. Recent progress in cellular therapy with mesenchymal stem cells (MSCs) has provided improved function in animal models of SCI. We investigated the safety and feasibility of intravenous infusion of MSCs for SCI patients and assessed functional status after MSC infusion. Methods In this phase 2 study of intravenous infusion of autologous MSCs cultured in auto-serum, a single infusion of MSCs under Good Manufacturing Practice (GMP) production was delivered in 13 SCI patients. In addition to assessing feasibility and safety, neurological function was assessed using the American Spinal Injury Association Impairment Scale (ASIA), International Standards for Neurological and Functional Classification of Spinal Cord (ISCSCI-92). Ability of daily living was assessed using Spinal Cord Independence Measure (SCIM-III). The study protocol was based on advice provided by the Pharmaceuticals and Medical Devices Agency in Japan. The trial was registered with the Japan Medical Association (JMA-IIA00154). Results No serious adverse events were associated with MSC injection. There was neurologic improvement based on ASIA grade in 12 of the 13 patients at six months post-MSC infusion. Five of six patients classified as ASIA A prior to MSC infusion improved to ASIA B (3/6) or ASIA C (2/6), two ASIA B patients improved to ASIA C (1/2) or ASIA D (1/2), five ASIA C patients improved and reached a functional status of ASIA D (5/5). Notably, improvement from ASIA C to ASIA D was observed one day following MSC infusion for all five patients. Assessment of both ISCSCI-92, SCIM-III also demonstrated functional improvements at six months after MSC infusion, compared to the scores prior to MSC infusion in all patients. Conclusion While we emphasize that this study was unblinded, and does not exclude placebo effects or a contribution of endogenous recovery or observer bias, our observations provide evidence supporting the feasibility, safety and functional improvements of infused MSCs into patients with SCI.

Recent evidence has demonstrated that remote responses in the brain, as well as local responses in the injured spinal cord, can be induced after spinal cord injury (SCI). Intravenous infusion of mesenchymal stem cells (MSCs) has been shown to provide functional improvements in SCI through local therapeutic mechanisms that provide neuroprotection, stabilization of the blood-spinal cord barrier, remyelination, and axonal sprouting. In the present study, we examined the brain response that might be associated with the functional improvements induced by the infused MSCs after SCI. Genome-wide RNA profiling was performed in the motor cortex of SCI rats at 3 days post-MSC or vehicle infusion. Then, quantitative reverse transcription-polymerase chain reaction (qRT-PCR) data revealed that the "behaviorally-associated differentially expressed genes (DEGs)" were identified by the Pearson's correlation analysis with the behavioral function, suggesting that the "behaviorally-associated DEGs" may be related to the functional recovery after systemic infusion of MSCs in SCI. These results suggested that the infused MSCs alter the gene expression signature in the brain and that these expression changes may contribute to the improved function in SCI.

Vascular complications of distal femoral fractures are rare but can have disastrous consequences if not recognised and treated promptly. We present the case of a 55-year-old woman who developed a pseudoaneurysm of the superficial femoral artery after osteosynthesis to repair a supracondylar femoral fracture. Eight weeks after surgery, swelling of the right thigh persisted and was accompanied by severe pain. Enhanced computed tomography revealed a pseudoaneurysm in the medial aspect of the affected thigh. Open surgical repair was performed by direct arterial suture. Although the true aetiology of the development of the pseudoaneurysm is unknown, a bony fragment from the reduction manoeuvre may have damaged the adventitia of the superficial femoral artery. In cases of continuous thigh swelling after osteosynthesis to repair a supracondylar femoral fracture, a diagnosis of pseudoaneurysm should be considered and treatment should be initiated immediately.