Proposal of a Management Algorithm to Predict the Need for Expansion Duraplasty in American Spinal Injury Association Impairment Scale Grades A–C Traumatic Cervical Spinal Cord Injury Patients

Journal of Neurotrauma, 2022 · DOI: 10.1089/neu.2022.0218 · Published: December 1, 2022

Simple Explanation

This study aimed to identify patients with traumatic cervical spinal cord injuries who might benefit from a surgical procedure called expansion duraplasty, which helps to improve blood flow and reduce pressure on the spinal cord. The researchers looked at MRI scans to see if there was enough cerebrospinal fluid around the spinal cord after initial surgery. If not, expansion duraplasty might be needed. The study found that younger patients with specific types of injuries, such as those from sports or motor vehicle accidents, and those with more severe spinal cord damage, were more likely to need expansion duraplasty.

Study Duration

61 months

Participants

104 patients with traumatic cervical spinal cord injury (tCSCI)

Evidence Level

Not specified

Key Findings

1
Patients with sport injuries and inadequate decompression were suitable candidates for expansion duraplasty.
2
Adequate laminectomy based on intramedullary lesion length (IMLL) obviated the need for expansion duraplasty in nearly 90% of surgical patients.
3
Patients who needed duraplasty were signiﬁcantly younger and sustained quadriplageia after shallow dives or MVCs with obvious fracture-dislocations.

Research Summary

The study aimed to determine indications for expansion duraplasty in addition to adequate laminectomy in patients with AIS grades A-C tCSCI. The extent of the posterior cervical decompression was based on the intramedullary lesion length (IMLL)—one level of laminectomy was prescribed for each 15 mm of IMLL. In a small subset of patients, however, effacement of the swollen spinal cord against the dura may not be relieved with the projected laminectomy unless an expansion duraplasty is performed.

Practical Implications

Surgical Planning

The algorithm proposed can aid surgeons in pre-operative planning, particularly in determining the extent of laminectomy required based on IMLL.

Patient Selection

Younger patients with sports-related injuries or MVCs and complete quadriplegia should be considered high-risk for requiring expansion duraplasty.

Intraoperative Guidance

Real-time IOUS can be used to assess the adequacy of decompression during surgery, potentially reducing the need for post-operative MRI.

Study Limitations

1
The randomized controlled trial study of DISCUS48 may help resolve some of these uncertainties.
2
In addition, ISP monitoring as a support for expansion duraplasty has its own limitations of feasibility, complications, and inadequate validated outcome studies.
3
because we did not have ISP in these patients, we are unable to conclude decisively that there was increased pressure within the cord when the spinal cord is observed to be touching the dura on the post-operative MRI.

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