A. V. Sytnik

Fractures of the thoracic and lumbar spine are the main volume of injuries in the surgical practice of a neurosurgeon. Classification of injuries is important for standardizing the description of vertebral fractures and collecting statistical data. Important classification parameters are completeness, reliability, and reproducibility. In this paper, a detailed description and illustration of the most significant classifications of injuries of the thoracic and lumbar spine is carried out.

The objective is to present a clinical case of successful treatment of a patient with recurrent spondylitis at the cervical level.Clinical case. A 65-year-old patient was diagnosed with purulent spondylodiscitis at the level of C₆-C₇ vertebrae with the epidural and paravertebral abscesses and spinal cord compression. Emergency left colotomy, paravertebral abscess dissection, corporectomy of the C₆ vertebra, abscess removal, anterior spondylodesis with bone autograft and titanium plate were performed. Massive antibacterial therapy was prescribed. After the operation, the volume of movement in the left limbs was restored, and on the 15^th day after the operation, the patient was discharged. On the 36^th day after discharge, she was hospitalized again with hematuria. A recurrence of suppuration in the area of the operation and phlegmon of both feet was revealed. Revision of the surgical wound and rehabilitation of the purulent focus on the neck, surgical intervention for phlegmon were performed. In purulent foci, Staphylococcus aureus was verified, which is sensitive to the main antibacterial drugs. Antibacterial therapy was continued, then, after changing the microflora in the wound, other antibiotics were prescribed. There was a pain in the area of the left spinal root C₅. The connection of the fistula course with the titanium plate, the increase of pathological kyphosis at the level of the overlying vertebrae was found. The wound was examined, the titanium plate was removed, and the halo device was applied to correct the pathological kyphosis. After the operation, the radicular pain syndrome regressed, and the axis of the cervical spine was restored. After 1 month, the posterior combined fixation of the cervical spine at the C₃-Th₇ level was performed, and the halo device was dismantled. After 6 months, the patient was stopped wearing the Philadelphia neck collar, no recurrence of suppuration was observed, and a complete regression of neurological disorders was noted. After 1 year, a complete bone block is preserved between the C₄-C₇ vertebrae.Conclusion. The presented clinical case clearly illustrates the complexity of managing patients with inflammatory diseases of the cervical spine. Currently, there is no single treatment strategy for patients with spondylitis.

The study objective is to evaluate feasibility and effectiveness of decompressive craniectomy (DC) for treatment оf supratentorial hypertensive intracerebral hematomas (ICH).Materials and methods. Between 1996 to 2019, 97 patients with supratentorial hypertensive ICHs underwent surgical treatment. DC was performed in 50 patients (primary - in 41, secondary - in 9). Putaminal hematomas were diagnosed in 30 patients, subcortical - in 20. The comparison group consisted of 47 patients, of which 20 had osteoplastic craniotomy (OPC) with microsurgical removal of ICH, and 27 had endoscopic aspiration (EA). The performed DCa were treated as unjustified (decreased brain dislocation without prolapse of the brain substance into the trepanation defect), ineffective (preservation of brain dislocation and absence of prolapse of the brain substance into the trepanation defect, as well as small size of the trepanation hole) and effective (prolapse of the brain substance into the trepanation defect and regression of transverse brain dislocation).Results. DC was effective only in 22 (44 %) patients (13 - primary, 9 - secondary). Among patients with subcortical ICH, mortality rate after DC was equal to that after OPC and EA. Among patients with putaminal ICH, the mortality rate after DC was significantly higher than after OPC and EA. Among the patients who underwent primary EA and delayed DC (due to recurrent ICH), postoperative mortality rate was significantly higher than among the patients who underwent repeated EA of recurrent ICH. However, there were no fatal outcomes among patients who underwent delayed DC due to increased edema and transverse dislocation of the brain without recurrent ICH.Conclusion. In the surgical treatment of supratentorial hypertensive ICH, decompressive effect of DC was achieved only in 44 % of patients. Open removal of putaminal hematomas in combination with DC was unjustified, mortality rate was 66 %. Primary DC with removal of ICH is indicated in patients with subcortical hematomas with a volume >50 cm³ , with transverse dislocation >7 mm, deep deafness or sopor. Delayed DC, regardless of the location of ICH, is recommended in case of increased edema and transverse dislocation of the brain in patients without recurrent hemorrhage.

The treatment results of 30 patients with non-specific purulent diseases of the spine were analyzed using various methods — primary or secondary stabilization of the spinal column, local negative pressure method, prolonged local antibiotic therapy method and various implants. The results were rated as «excellent» in 16 patients, «good» in 7 people, «satisfactory» in 4 cases (relapses) and 3 patients died. The results obtained indicate the need for a personalized approach to treatment tactics, the feasibility of staged treatment and the use of additional methods.

The study objective is to review the Russian and foreign studies and to identify an optimal classification system for lower cervical spine injuries. Materials and methods. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We conducted a search for articles published in English (PubMed database) and Russian (eLIBRARY.ru). The inclusion criteria were as follows: available full text, patient age ≥18 years, and information on one of the validation phases for classifications according to L. Audige et al. Results. A total of 30 articles were eligible. Of them, 3 studies were published in Russian (by one group of authors); however, they didn’t contain required statistical parameters and had duplicated data; therefore, they were excluded from the analysis. Out of 27 articles published in English, 8 articles met all the criteria and were included into the systematic review. The AOSpine and Subaxial Injury Classification Systems demonstrated the highest reliability and reproducibility of the results. The Allen–Fergusson classification has lower intraobserver and interobserver agreement coefficients, but it can give a clearer visual representation of injuries. We also assessed J. Harris classification system. The reliability of the scale developed by С . Argenson et al. was not evaluated. The analyzed publications contained no data for full evaluation of the Cervical Spine Injury Severity Score. Our analysis clearly demonstrated the need for a more thorough evaluation of all available scales and classifications. This study should be multicenter and involve experts with different levels of experience (from residents to experienced spinal surgeons). Moreover, it should analyze not only the reproducibility of individual classifications, but also the aspects of learning and the relationship between individual scales and systems. The main study limitations included insufficient number of publications, small sample sizes, heterogeneity of groups, and differences in the experience of experts. Conclusion. The AOSpine and Subaxial Injury Classification Systems are the most reliable classification systems. However, the data available in literature is not sufficient for a full comparison of all existing scales and systems. Further multicenter studies on the reliability of classifications are needed to select an optimal one.

This article provides a detailed illustrated description of currently available classification and scoring systems for lower cervical spine injuries (including Allen–Fergusson, J. Harris et al., C. Argenson et al., and AOSpine classifications, Subaxial Injury Classification System and Cervical Spine Injury Severity Score). The present review primarily aims to discuss the advantages and disadvantages of each classification system.

The study objective is to analyze surgical outcomes in patients with hemorrhagic stroke treated by endoscopic aspiration in five regional vascular centers in Russia and to evaluate capabilities and benefits of this surgical procedure. Material and methods. The study included 296 patients with hemorrhagic stroke (with various locations of the hemorrhage) that underwent endoscopic aspiration between 2006 and 2018 at one of the following institutions: N.V. Sklifosovsky Research Institute for Emergency Medicine (Moscow), City Clinical Emergency Hospital No. 1 (Omsk), Regional Clinical Hospital (Yaroslavl), N.A. Semashko Republic Clinical Hospital (Simferopol), Irkutsk Regional Clinical Hospital. Neurosurgery departments of these healthcare institutions are the parts of regional vascular centers. We used Glasgow Outcome Scale to evaluate outcomes of surgical treatment. Results. Complete recovery was observed in 52 (17.5 %) patients, while 52 (17.5 %) patients developed moderate disability and 131 patients (44.5 %) developed severe disability. Four (1.5 %) patients developed a vegetative state. Fifty-seven (19 %) patients died after surgery. Conclusion. The experience of treating hemorrhagic stroke in five neurosurgical centers demonstrates that endoscopic aspiration of hypertensive intracerebral hemorrhages is in no way inferior to microsurgery. It ensures satisfactory results and can be used in patients with various hemorrhages.

The study objective is to evaluate the effectiveness and the safety of different cerebrospinal fluid drainage methods and intrathecal fibrinolytic therapy in the prevention of cerebral vasospasm and improving outcomes in patients with massive subarachnoid hemorrhage. Materials and methods. The study was performed on 86 patients with massive aneurismal subarachnoid hemorrhage (Hijdra score >15) who had clipping surgery within 72 h after symptoms onset. We used lumbal drainage in 12 patients (group 1), combined lumbal and cisternal drainage in 24 patients (group 2), lumbal and cisternal drainage with intrathecal fibrinolytic therapy with recombinant staphylokinase in 25 patients (group 3); control group (group 4) included 25 patients with similar clinical and instrumental data. Results. Incidence of unfavorable outcome and symptomatic cerebral vasospasm was 83 and 83 %, respectively (in group 1), 36.8 and 47.4 % (in group 2), 9.1 and 9.1 % (in group 3), 76 and 60 % (in group 4). Conclusion. The proposed intrathecal fibrinolytic therapy with recombinant staphylokinase may be effective and safe to reduce the severity of cerebral vasospasm, improve clinical outcome and lower frequency of normal pressure hydrocephalus after aneurysm rupture.