The treatment of post –traumatic syringomyelia (PTS) is still debated in the literature. Bonfield’s meta –analysis, failed to demonstrate the superiority of one surgical technique over the others.
The purpose of this study is to review the outcomes of a cohort of patients with PTS undergoing surgery with the same surgical procedure including : arachnolysis and expansile duraplasty at the level of the injury mainly associated with a syringosubarachnoid shunt.
Method : Retrospective study of a cohort of SCI patients undergoing surgery of PTS in our University hospital.
Results
The data of 52 Patients have been reviewed. 36 men, 16 women, mean age at the time of surgery of 40.8 years (y). 75% of the patients suffered from complete SCI (AIS A). The level of injury was cervical in 15 cases, thoracic in 31, lumbar in 6. The mean time between trauma and first diagnosis was 11.4 years, between trauma and surgery 15.3 years.
The main symptoms and signs associated with PTS were : pain above (44.2%) or at the level of injury (11.4%), dissociated sensory loss ( 65.3%), motor weakness (44.2% above the level of injury).
Bladder function deterioration, autonomic dysreflexia and motor deterioration below the level of injury occured respectively in 8, 3, and 3 cases.
MRI Findings : All syrinx cavities started at the level of trauma and extended in the rostral direction in 20 cases, in the caudal direction in 10 cases and in both directions in 22. The preoperative average extent of the syrinxes was 11.3 levels.
Surgical procedure :
Group 1 : 40 patients underwent as first procedure, the association of arachnolysis, expansile duraplasty and placement of a syringosubarachnoid shunt. In this group, 31 cases showed no recurrence of the syrinx, the mean long term follow-up after the surgery was 8.2 y. The results of the surgery showed that 74% of the cases had improvement in pain, 77% had improvement in sensory loss and 74% in motor weakness. Post operative MRI findings showed a syrinx decrease and in many cases collapsed (75%) with a post operative average extent of 8 levels.
Group 2 : 12 patients underwent as first procedure the association of arachnolysis and expansile duraplasty without shunting. 6 cases showed no recurrence of the syrinx with a mean long term follow-up of 9.1 y and with an improvement in pain for 3 of the cases, in sensory loss for 1 and in motor weakness for 1, and on MRI, a decrease or collapse in 50 % of the cases.
Conclusion
Regarding to the literature, these results advocate for a surgical technique including arachnolysis, expansile duraplasty and syringosubarachnoid shunt. Shunt placement allows an immediate deflation of the cavity and arachnolysis and expansile duraplasty restore the CSF flow for the long term.

Bonfield &al : Surgical management of post-traumatic syringomyelia. Spine (Phila Pa 1976). 2010 Oct 1;35(21 Suppl):S245-58

Introduction: Early feeding (<24 hrs) post abdominal surgery has been routinely implemented in all patients as per the Enhanced Recovery Programme Guidelines for elective colorectal surgery 20131. This was proven safe and was well tolerated in ambulatory non-spinal cord injured patients. Only between 10 to 17% of patients developed post-operative ileus. Post-operative ileus is defined by the combination of at least two of the following five signs on or after the fourth post-operative day: nausea and vomiting, an inability to tolerate solid or semi-liquid diet during the preceding 24 hours, no gas or stool for the preceding 24 hours, abdominal distension and radiological evidence of ileus. However, spinal cord injured patients have a much slower colonic transit time due to their neurogenic bowel. In addition, spinal cord injured patients above T10 neurological levels have impaired sympathetic and parasympathetic innervation of the smooth muscles of the colon. Moreover, in the pathophysiology of ileus development and resolution, the sympathetic and parasympathetic systems play an explicit role. Considering these factors, would early post-operative feeding following abdominal surgery be well tolerated in spinal cord injured patients?
Method: Retrospective data were extracted from both electronic and paper records, between January 2013 and January 2019, of all spinal cord injured patients who underwent abdominal surgery. Patients were electively admitted at the National Spinal Injuries Centre in Stoke Mandeville Hospital. The primary outcome was the development of post-operative ileus after early feeding (<24hrs). Secondary outcome was the treatment of the post-operative ileus.
Results: There were 46 abdominal surgeries planned. 42 operations were performed and 4 were cancelled. Of the 42 operations, 36 patients received early feeding (<24hrs). 25% of these patients developed post-operative ileus. Out of the patients who developed ileus, 66.7% developed nausea and vomiting, 55.6% had the inability to tolerate food in the first 3 days, the mean time to produce a bowel result was 5.22 days post-surgery, 66.7% had abdominal distension and 22.2% had radiological evidence of ileus. Notably, 88.9% of patients had received treatment for post-operative ileus. Importantly, 25.9% of the patients without an ileus also required treatment, either with anti-emetics or extra laxatives. Overall, none of the patients had been given any chewing gum, additional Bisacodyl or Magnesium within 24 hours post-surgery as per the further recommendations of the Enhanced Recovery Programme for elective colorectal surgery.
Conclusion: Early postoperative feeding after abdominal surgery in spinal cord injured patients is not well tolerated. Further research needs to be done, to review if delaying feeding would reduce the signs of post-operative ileus and thereby reduce morbidity. Consideration should also be given to the additional recommendations of the Enhanced Recovery Programme after elective colorectal surgery, such as Magnesium, Bisacodyl, chewing gum and coffee, to determine if this would reduce the occurrence of post-operative ileus in this patient group.

Introduction: After spinal cord injury (SCI), even completely paralyzed patient sometimes presents substantial neurological recovery. However, it remains difficult to predict the extent of neurological recovery. It is partially because there are so many potential factors to influence recovery, including the timing of surgery, the extent of spinal shock, and type of fracture dislocation, and age. The purpose of the current study is to determine the critical factor for motor recovery of completely paralyzed SCI cases.

Methods: All medical records of cervical SCI cases from 2011 to 2017 were retrospectively checked at the two major SCI centers in Japan. To minimize the influence of acute spinal shock, only subjects presenting complete paralysis at 72 hours after injury were analyzed. Age, timing of surgery, sex, type of dislocation, ASIA impairment scale (AIS), neurological level of injury (NLI) of motor function, and ASIA motor score (MS) were analyzed. Recovery was determined by the improvement of 1 or more of AIS, 1 or more of motor NLI, or 2 or more of MS. For statistical analysis, T-test, Kruskal-Wallis with Steel Dwass test and Fisher’s exact test were used.

Results: Total of 27 cases were matched for analysis, and the average of their ages was 58.8 (21 - 79). The average of the follow-up period was 11.0 months (4.6 - 18.9). All cases had fracture dislocations and received decompression and fusion surgeries. The average time period from injury to surgery was 16.0 hours (1.0 - 39.8). 15 cases (55%) presented improvement of motor NLI, and 1 case showed sensory recovery only. No cases revealed motor recovery in lower extremities. Among all analyzed factors, only age showed a statistical difference between recovery and non-recovery groups. Then, all cases were classified into 3 groups based on age, the rate of recovery cases in each group was 100% (6 out of 6 cases) in the young group (below 50 years old), 57% (8 out of 14 cases) in the middle group (from 50 to 69 years old), and 29% (2 out of 7 cases) in the aged group (above 69). Further, the young group demonstrated statistically better MS than the aged group (5.2 vs 0.1 points improvement).

Discussion: The current study demonstrated that age was a critical factor for segmental motor recovery of severe cervical SCI cases. Even determined as AIS A at 72 hours after injury, all patient below 50 years old presented improvement of MS or motor NLI, which could significantly affect upper extremities functions. This better recovery in younger cases might be partially due to greater plasticity of central nervous system or more intensive rehabilitation. Further study is necessary to elucidate its detailed mechanism and to achieve accurate prognosis system for SCI.

INTRODUCTION: An essential step of implementing preventive strategies for pressure injury in the spinal cord injury (SCI) population is the accurate determination of pressure injury risk. The SCI Pressure Sore Onset Risk Screening (SCI-PreSORS) instrument was recently developed at Toronto Rehabilitation Institute - University Health Network (TRI-UHN, Toronto, Ontario). The SCI-PreSORS is a simple screening instrument composed of four binary items addressing pressure injury history, ambulation, transfer ability (determined using Functional Independence Measure (FIM)), and toileting ability (determined using FIM). The purpose of the current analysis was to investigate the generalizability of the SCI-PreSORS using retrospective data of individuals participating in inpatient SCI rehabilitation at three additional sites.

METHODS: Data was collected as part of a pressure injury-related best practice implementation initiative conducted by the SCI Knowledge Mobilization Network (SCI-KMN). The SCI-PreSORS was originally developed at TRI-UHN with data abstracted retrospectively from the medical charts of 807 individuals participating in inpatient SCI rehabilitation. To ascertain generalizability, the SCI-PreSORS was determined retrospectively for inpatients participating in three additional SCI rehabilitation programs - St. Joseph’s Health Care – Parkwood Institute (SJHC; London, Ontario; n=303), Foothills Medical Centre (FMC; Calgary, Alberta; n=215), and Glenrose Rehabilitation Hospital (GRH; Edmonton, Alberta; n=202). Pressure injury incidence during inpatient rehabilitation was the dependent variable. Area under the curve (AUC) and false negative rates were calculated to determine the diagnostic accuracy of the SCI-PreSORS.

RESULTS: Pressure injury incidence (any stage) was 14.6% at TRI-UHN, 12.1% at FMC, 8.4% at GRH, and 6.3% at SJHC. When assessed at TRI-UHN using a retrospective cohort (n = 807), the SCI-PreSORS demonstrated excellent sensitivity (0.97), acceptable specificity (0.45), acceptable AUC (0.76), and a low false negative rate (0.50%). When applied retrospectively to other sites, the SCI-PreSORS demonstrated lower AUCs at GRH (0.67), FMC (0.60), and SJHC (0.63). The composite AUC for the three external sites was 0.62. Instruments with an AUC < 0.70 are generally considered to have poor accuracy. Compared to the other sites, FMC demonstrated a higher false negative rate, 3.72% vs. 0.50% (GRH) and 0.99% (SJHC). The composite false negative rate was 1.53%. Given the ramifications of pressure injury, it is important to minimize the FN rate and our goal for the SCI-PreSORS was < 1%. Overall, the percentage of individuals that the SCI-PreSORS deemed at risk for pressure injury was as follows - TRI-UHN (52%), FMH (55%), SJHC (61%), and GRH (63%).

CONCLUSIONS: AUCs for the SCI-PreSORS were lower when determined retrospectively at three additional inpatient SCI rehabilitation programs; suggesting reduced diagnostic accuracy. False negative rates were comparable (with the exception of one site). A prospective evaluation of SCI-PreSORS performance is ongoing. Given the limitations of retrospective data and accompanying analysis, the prospective study will provide additional and important insight into the utility of the SCI-PreSORS for determining pressure injury risk.