Influential factors of the prognosis of patients with winter sports-induced traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema after emergency surgical treatment

Objective: To explore relevant influencing factors of the prognosis of patients with winter sports-induced traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema after emergency surgical treatment. Methods: A retrospective analysis was performed on 73 cases of traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema in The First Hospital Affiliated to Hebei North University from January 2020 to October 2022. The enrolled patients were divided into the good prognosis (n=17) group and poor prognosis (n=56) group according to the recovery of neurological function after six months of follow-up. The risk factors affecting the prognosis of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema after emergency surgery were analyzed by binary Logistic regression. Results: Among the enrolled 73 patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema, 56 cases showed significant improvement in ASIA Grade-6 months after operation, with an improvement rate of 76.71%. Further Logistic regression analysis revealed that concomitant diabetes, preoperative MSCC>40.83% and recovery rate of AMS <40.13% 3d after operation were independent risk factors affecting the poor prognosis of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema. Conclusions: Emergency surgery can improve the neurological function of patients with cervical spinal cord injury complicated with intramedullary hemorrhage and edema caused by winter sports. Concomitant diabetes, preoperative MSCC and recovery rate of AMS 3d after operation are the main factors affecting the prognosis of patients with emergency surgery.


INTRODUCTION
The popularity of winter sports has burgeoned with the opening of the world-famous Beijing Winter Olympic Games.There is a dramatic increase in the number of winter sports enthusiasts in the outdoor ice-snow tourism venues and winter sports venues in various regions, accompanied by significant increase in related sports injuries. 1According to a large number of reports, the head, neck and knee joints are the most vulnerable parts in winter sports, the most serious of which is traumatic spinal cord injury. 2Traumatic spinal cord injury, occurring possibly in the cervical, thoracic, lumbar other spinal cord segments, refers to a damage to the structure and function of the spinal cord caused by direct or indirect external forces. 3Cervical spinal cord injury is the most severe traumatic spinal cord injury, and common causes of injury include traffic accidents, falls, injuries, and sports injuries caused by competitive sports such as ice and snow sports.In severe cases, it can lead to paralysis or even death of the patient's limbs. 4,5Patients with traumatic cervical spinal cord injury may often suffer from secondary injuries such as hemorrhage and edema in the cervical spinal cord due to fracture compression.Such injuries are generally manifested as focal hemorrhage in the center of the injury, microvascular rupture in the central gray matter and extensive edema formation, which can aggravate the degree of injury to the patient's limb motor function. 6Therefore, timely and effective treatment may be beneficial to improve clinical efficacy and prognosis of patients with traumatic spinal cord injury complicated with intramedullary hemorrhage and edema.In the clinical practice currently, early emergency surgery is the major therapeutic approach for traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema, which has achieved good results. 7owever, there are still some patients with limb movement disorder or vesicorectal disturbance after surgery, which may affect their prognosis.Previous studies have confirmed that the degree of cervical spinal cord injury, neurological function grading, concomitant injuries, underlying medical diseases, and respiratory complications during trauma are factors that affect the prognosis of emergency surgery. 8Accordingly, the present study was performed primarily to discuss and analyze the relevant factors that affect the prognosis for patients with winter sports-induced traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema after emergency surgery, so as to provide reference for the prevention and treatment of traumatic cervical spinal cord injury caused by winter sports and the evaluation of the prognosis of patients receiving emergency surgery.

METHODS
A retrospective analysis was performed on the clinical data of 73 cases of traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema in The First Hospital Affiliated to Hebei North University from January 2020 to October 2022.During the follow-up period of six months, the patients survived with the preoperative and postoperative ASIA grades recovered to at least one grade.Collection of clinical data: General data of these patients were collected from the electronic medical record system of our hospital, including preoperative American Spinal Cord Injury Association (ASIA) neurological function classification, 11 intramedullary edema length (IEL) by preoperative MRI, intramedullary hemorrhage length (IHL) by MRI, intramedullary spinal cord compression (MSCC) and recovery rate of American Spinal Injury Association (ASIA) motor score (AMS), 12 complicated with soft tissue injury or not, surgical method (anterior approach, posterior approach or combined approach), AMS recovery rate before and 3d after operation, endotracheal intubation, albumin level, postoperative rehabilitation treatment or not, AIS classification six months after operation.AMS recovery rate refers to the percentage of the difference between postoperative  ) and compared by independent two-sample t-test between groups.Meanwhile, counting data were described by rates, and the inter-group difference was compared by using χ 2 test.The risk factors affecting the prognosis of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema after emergency surgery were analyzed by binary Logistic regression.A two-tailed P<0.05 was considered to have significant difference.

RESULTS
All the 73 patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema were followed up for 6-12 months, with an average of (10.60±1.62)months.No patients were lost to follow-up, and the follow-up rate was 100%.Three of them died within six months after operation, including one case of respiratory failure, two cases of pulmonary infection, and one case of deep venous thrombosis of lower limb, with a mortality rate of 4.11%.
Among the enrolled 73 patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema, 56 cases showed significant improvement in ASIA grade six months after operation, with an improvement rate of 76.71% (Table-I).
As described in Table-II to III, the poor prognosis of winter sports-induced traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema was associated with their age, concomitant diabetes, level of cervical spinal cord injury, preoperative IEL, preoperative IHL, preoperative MSCC and recovery rate of AMS 3d after operation (P<0.05).While the prognosis showed no relationship with the patient's gender, BMI, hypertension or coronary heart disease, smoking history, time from injury to admission, time from injury to emergency surgery, complicated with soft tissue injury or not, surgical method, preoperative AMS, AIS classification six months after operation, endotracheal intubation, albumin level and rehabilitation treatment (P>0.05).
Our study further assigned the variables with differences in Table-II to III that affected the poor prognosis of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema, with the significant level set as α=0.05.The assignment of dependent and independent variables is shown in Table -

DISCUSSION
The general public generally lacks professional training in ice and snow sports, which is prone to injuries to the spine, hip, and knee joints. 13Traumatic cervical spinal cord injury is a common spinal injury in ice and snow sports injuries.Patients are prone to motor and sensory dysfunction, as well as limb paralysis.In severe cases, it can lead to breathing difficulties due to diaphragmatic paralysis, and even suffocation and death. 14ntramedullary hemorrhage and edema are caused by the rupture of gray matter blood vessels in the spinal cord caused by spinal cord injury, indicating severe spinal cord injury in patients and reflecting their neurological function after spinal cord injury. 15Its treatment mainly aims to alleviate the progression of the disease and intervene in secondary injuries through early surgical surgery combined with drug therapy and rehabilitation treatment.However, there are many factors that affect prognosis in clinical practice, which have different effects on the recovery of spinal cord function in patients after surgery. 16,17This study mainly explores the relevant factors that affect the prognosis of emergency surgical treatment in patients with traumatic cervical spinal cord injury combined with intramedullary hemorrhage and edema caused by ice and snow sports.
The traditional view is that surgery will further exacerbate spinal cord injury, so patients with spinal cord injury are prohibited from undergoing surgical treatment.With the improvement of surgical and anesthesia techniques, surgical decompression for acute cervical spinal cord injury has been widely applied, and research has confirmed that patients can achieve good clinical results after emergency surgical treatment.The results of this study showed that among the 73 patients with traumatic cervical spinal cord injury combined with intramedullary hemorrhage and edema who were included in the study, 52 patients had a good prognosis after a 6-month follow-up, accounting for 71.23%.This is basically consistent with the research results of Sharma A et al. indicating that emergency surgery can significantly improve the prognosis of patients. 18Traumatic cervical spinal cord injury combined with intramedullary hemorrhage and edema can initiate secondary injury on the basis of mechanical injury, leading to peripheral neuronal and axonal damage, further exacerbating the degree of injury.ASIA injury grading is a recognized standard for evaluating the degree of spinal cord injury, which can quantitatively evaluate spinal cord injury. 19Surgery can relieve compression caused by spinal cord edema and hematoma, achieve stability of the cervical spine, improve blood supply to the cervical spinal cord, and promote the recovery of spinal cord nerve function in patients.In this study, 56 patients with traumatic cervical spinal cord injury caused by ice and snow sports combined with intramedullary hemorrhage and edema achieved significant improvement in ASIA grading at six months after surgery, with an improvement rate of 76.71%, indicating that emergency surgery can effectively promote the recovery of their neurological and motor functions.
The neurological recovery of patients with traumatic cervical spinal cord injury may be unpredictable, and there are many factors that affect the patient's neurological recovery.Older patients often experience osteoporosis and a significant decrease in immune defense function, which is not conducive to the recovery of spinal cord injury.In patients with diabetes, abnormal glucose metabolism leads to high glucose status in the body, which has a certain killing and damage effect on nerve cells and can affect the functional status of the spinal cord. 20MRI can clearly display the relationship between the spinal cord and surrounding tissues, making it the best imaging basis for evaluating neurological impairment.It is characterized by edema signals or abnormal high signals in the bone marrow, which is a typical manifestation of bone contusion and often indicates poor prognosis. 21Preoperative IEL, IHL, and MSCC are common MRI evaluation indicators for spinal cord injury, while AMS is the MRI score for postoperative spinal cord compression signs, The higher the score, the more severe the degree of spinal cord compression in imaging.The recovery rate of AMS is a reliable indicator of postoperative imaging improvement and prognosis evaluation in cervical spinal cord injury.The severity of nerve injury in patients with traumatic cervical spinal cord injury combined with intramedullary hemor-Patients with winter sports-induced traumatic cervical spinal cord  22,23 The recovery rate of AMS at three days after surgery is a predictive factor for neurological function recovery at six months after surgery in patients with traumatic cervical spinal cord injury accompanied by intramedullary hemorrhage and edema.The results of this study show that the poor prognosis of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema is related to their age, diabetes, cervical spinal cord injury level, preoperative IEL, preoperative IHL, preoperative MSCC and postoperative recovery rate of 3 days AMS.Logistic regression analysis showed that diabetes, preoperative MSCC and postoperative recovery rate of AMS were independent risk factors affecting the prognosis of emergency surgery in patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema.

Limitations of study:
It includes small sample size, the absence of analysis of the impact of different emergency surgical methods and severity of the disease on the prognosis of patients, which require in-depth verification based on expanded sample size in the future.

CONCLUSIONS
Emergency surgery can improve the neurological function of patients with cervical spinal cord injury complicated with intramedullary hemorrhage and edema caused by winter sports.Concomitant diabetes, preoperative MSCC and recovery rate of AMS 3d after operation are risk factors affecting the prognosis of patients with emergency surgery.

Source of funding:
The study was sponsored by Hebei Province Technology Innovation Guidance Plan Science and Technology Winter Olympics special project of 2020 (NO.20477707D), 2023 Zhangjiakou Science and Technology Plan Project(2322032D), and 2024 Hebei Province Medical Applicable Technology tracking item.

Ethical Approval: The
study was approved by the Institutional Ethics Committee of The First Hospital Affiliated to Hebei North University (No.:2022-035; Date: May 15, 2022), and written informed consent was obtained from all participants.

Table - I
: Analysis of postoperative follow-up of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema.
Patients with winter sports-induced traumatic cervical spinal cord

Table -
II: Comparison of clinical characteristics of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema between the poor prognosis group and the good prognosis group [cases (%), ].

Table - III
: Comparison of MRI imaging parameters of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema between the poor prognosis group and the good prognosis group [cases (%), ].

Table - V
: Multi-factor analysis of prognosis of patients with traumatic cervical spinal cord injury complicated with intramedullary hemorrhage and edema.