Acute complications of spinal cord injuries

Total Testosterone and Cortisol During Wheelchair Rugby Training in Athletes With Cervical Spinal Cord Injury

CONTEXT

Hormonal assessment in the sport context is important to monitor the physiological adaptations of athletes. However, Paralympic athletes, especially with cervical spinal cord injury (CSCI), may have different hormonal responses than nondisabled athletes. Therefore, the aim of this study was to evaluate the blood concentrations of total testosterone (TT) and cortisol (C) during acute (one training session) and chronic (1 and 2 month) training of athletes with CSCI in wheelchair rugby (WCR).

DESIGN

Longitudinal and observational study.

METHODS

Eight high-performance athletes with CSCI (31 [3.9] y; 75.6 [15.8] kg; 22.9 [4.2] kg/m2 body mass index; 6.2 [2] y of experience in sport) were evaluated at 3 different intervals (evaluations 1, 2, and 3 [E1, E2, and E3]) over 2 months of training. TT and C blood were evaluated before (pre) and after (post) the training sessions at each training moment, as well as the training load through the ratings of perceived exertion.

RESULTS

Athletes with CSCI had low TT concentrations. In acute training sessions, at E3, C decreases after the training session, unlike the TT/C ratio, which increased after the session. Regarding hormonal changes during chronic training at the end of the training period, unlike C, which increased. The training load (arbitrary units) decreased in E3 when compared with the other evaluation moments.

CONCLUSION

It was concluded that in chronic training, TT concentrations decreased, while C increased at the end of the 2 months of training. These results may indicate that training volume was high throughout training and that a reduction in training volume could benefit athletes. On the other hand, in the acute training session with reduced training load, a decrease in C was observed after the training session. This indicates that athletes may be well recovered in this training session. Therefore, we suggest acute and long-term hormonal assessment for athletes with CSCI as a strategy to monitor anabolic/catabolic hormonal status during WCR training.

Diaphragm Pacing in Spinal Cord Injury Can Significantly Decrease Mechanical Ventilation in Multicenter Prospective Evaluation

BACKGROUND

Cervical spinal cord injury (SCI) can lead to dependence on mechanical ventilation (MV) with significant morbidity and mortality. The diaphragm pacing system (DPS) was developed as an alternative to MV.

METHODS

We conducted a prospective single arm study of DPS in MV dependent patients with high SCI and intact phrenic nerves. Following device acclimation, pacing effectiveness to provide ventilation was evaluated. The primary endpoint was the number who could use DPS to breathe for four continuous hours without MV. Secondary endpoints included the number of patients that could use DPS 24 hours/day free of MV and the ability of DPS to maintain clinically acceptable tidal volume (Vt). In addition, we conducted a meta-analysis that included the prospective study along with data from four recently published studies to evaluate DPS hourly use.

RESULTS

Fifty-three patients were implanted in the prospective study. Most were male (77.4%) with a median time from injury to treatment of 28.3 (IQR 12.1, 83.3) months. Four- and 24-hour use occurred in 96.2% (95%CI - 87.0%, 99.5%) and 58.5% (95% CI - 44.1%, 74.9%), respectively. Four and 24-hour results in the meta-analysis cohort (n=196) exhibited similar results 92.2% (95% CI - 82.6%,96.7%) and 52.7% (95% CI - 36.2%,68.6%) using DPS for four and 24 hours, respectively. DPS use significantly exceeded the calculated basal tidal volume requirements by a mean of 48.4% (95% CI - 37.0, 59.9%; p<0.001).

CONCLUSIONS

This study demonstrates that in most ventilator-dependent patients, diaphragm pacing can effectively supplement or completely replace the need for MV and support basal metabolic requirements.

Five Different Lives after Suffering from Spinal Cord Injury: The Experiences of Nurses Who Take Care of Spinal Cord Injury Patients

According to statistics of Ministry of Health and Welfare, accidents were the sixth common causes of death in Taiwan in 2016. A total of 1200 new cases of spinal cord injury each year are caused by accidents and adverse effects. This study explored nurses' experience of caring for patients with spinal cord injury. Hermeneutic phenomenology was used in the data analysis. The five themes emerged: dramatic changes in life, life lost control, life after catastrophic injury, life takes turns for the worse for family, and the power of rebirth. This study revealed that accidents were the primary cause of spinal cord injury, and that nurses may neglect patients' mental and social care. Career guidance should be offered to spinal cord injury patients to ensure that they retain sociality. This study provides recommendations regarding a patient's and their family's post-injury adaption process. The sexual desire of patients should be further explored in future research.

Monitoring Spinal Cord Tissue Oxygen in Patients With Acute, Severe Traumatic Spinal Cord Injuries

Objectives

To determine the feasibility of monitoring tissue oxygen tension from the injury site (psctO2) in patients with acute, severe traumatic spinal cord injuries.

Design

We inserted at the injury site a pressure probe, a microdialysis catheter, and an oxygen electrode to monitor for up to a week intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), tissue glucose, lactate/pyruvate ratio (LPR), and psctO2. We analyzed 2,213 hours of such data. Follow-up was 6-28 months postinjury.

Setting

Single-center neurosurgical and neurocritical care units.

Subjects

Twenty-six patients with traumatic spinal cord injuries, American spinal injury association Impairment Scale A-C. Probes were inserted within 72 hours of injury.

Interventions

Insertion of subarachnoid oxygen electrode (Licox; Integra LifeSciences, Sophia-Antipolis, France), pressure probe, and microdialysis catheter.

Measurements and Main Results

psctO2 was significantly influenced by ISP (psctO2 26.7 +/- 0.3 mm Hg at ISP > 10 mmHg vs psctO2 22.7 +/- 0.8 mm Hg at ISP <= 10 mm Hg), SCPP (psctO2 26.8 +/- 0.3 mm Hg at SCPP < 90 mm Hg vs psctO2 32.1 +/- 0.7 mm Hg at SCPP >= 90 mm Hg), tissue glucose (psctO2 26.8 +/- 0.4 mm Hg at glucose < 6 mM vs 32.9 +/- 0.5 mm Hg at glucose >= 6 mM), tissue LPR (psctO2 25.3 +/- 0.4 mm Hg at LPR > 30 vs psctO2 31.3 +/- 0.3 mm Hg at LPR <= 30), and fever (psctO2 28.8 +/- 0.5 mm Hg at cord temperature 37-38[degrees]C vs psctO2 28.7 +/- 0.8 mm Hg at cord temperature >= 39[degrees]C). Tissue hypoxia also occurred independent of these factors. Increasing the FIO2 by 0.48 increases psctO2 by 71.8% above baseline within 8.4 minutes. In patients with motor-incomplete injuries, fluctuations in psctO2 correlated with fluctuations in limb motor score. The injured cord spent 11% (39%) hours at psctO2 less than 5 mm Hg (< 20 mm Hg) in patients with motor-complete outcomes, compared with 1% (30%) hours at psctO2 less than 5 mm Hg (< 20 mm Hg) in patients with motor-incomplete outcomes. Complications were cerebrospinal fluid leak (5/26) and wound infection (1/26).

Conclusions

This study lays the foundation for measuring and altering spinal cord oxygen at the injury site. Future studies are required to investigate whether this is an effective new therapy.

Dapsone, More than an Effective Neuro and Cytoprotective Drug

BACKGROUND

Dapsone (4,4'-diamino-diphenyl sulfone) is a synthetic derivative of sulfones, with the antimicrobial activity described since 1937. It is also a drug traditionally used in dermatological therapies due to its anti-inflammatory effect. In recent years its antioxidant, antiexcitotoxic, and antiapoptotic effects have been described in different ischemic damage models, traumatic damage, and models of neurodegenerative diseases, such as Parkinson's (PD) and Alzheimer's diseases (AD). Finally, dapsone has proven to be a safe and effective drug as a protector against heart, renal and pulmonary cells damage; that is why it is now employed in clinical trials with patients as a neuroprotective therapy by regulating the main mechanisms of damage that lead to cell death ObjectiveThe objective of this study is to provide a descriptive review of the evidence demonstrating the safety and therapeutic benefit of dapsone treatment, evaluated in animal studies and various human clinical trials Methods: We conducted a review of PubMed databases looking for scientific research in animals and humans, oriented to demonstrate the effect of dapsone on regulating and reducing the main mechanisms of damage that lead to cell death ConclusionThe evidence presented in this review shows that dapsone is a safe and effective neuro and cytoprotective treatment that should be considered for translational therapy.

Diffusional kurtosis imaging as a possible prognostic marker of cervical incomplete spinal cord injury outcome: a prospective pilot study

BACKGROUND

Spinal cord injury (SCI) is associated with substantial chronic morbidity and mortality. Routine imaging techniques such as T1- and T2-weighted magnetic resonance imaging (MRI) are not effective in predicting neurological deficiency grade or outcome. Diffusional kurtosis imaging (DKI) is an MR imaging technique that provides microstructural information about biological tissue. There are no longitudinal prospective studies assessing DKI metrics in acute traumatic SCI. Therefore, the purpose of this study was to establish a DKI protocol for acute SCI and correlate the DKI metrics to the functional neurological outcome of the patients.

METHODS

Eight consecutive SCI patients referred to our institution with cervical SCI were included in the study. An acute diagnostic MRI scan was supplemented with a novel fast, mean kurtosis DKI protocol, which describes the average deviation from Gaussian diffusional along nine different directions. Mean kurtosis values were measured at the injury site and normalized to the mean kurtosis values of a non-injured site. At discharge form specialized rehabilitation, patients were evaluated using the Spinal Cord Independence Measure-III (SCIM-III). The DKI metrics and SCIM-III were analysed using Spearman's rank correlation.

RESULTS

This pilot study found a significant correlation between decreasing mean kurtosis values at the injury site of the spinal cord and higher grade of disability measured by the SCIM-III (p = 0.002).

CONCLUSION

This pilot study found that DKI may be a valuable tool as a prognostic marker in the acute phase of SCI.

Functional resveratrol-biodegradable manganese doped silica nanoparticles for the spinal cord injury treatment

Spinal cord injury (SCI) causes secondary injury, accompanied by pathological changes such as oxidative stress, inflammation and neuronal apoptosis. This leads to permanent disabilities such as paralysis and loss of movement or sensation. Due to the ineffectiveness of drugs passing through the blood spinal cord barrier (BSCB), there is currently no effective treatment for SCI. The aim of this experiment was to design plasma complex component functionalized manganese-doped silica nanoparticles (PMMSN) with a redox response as a targeted drug carrier for resveratrol (RES), which effectively transports insoluble drugs to cross the BSCB. RES was adsorbed into PMMSN with a particle size of approximately 110 ​nm by the adsorption method, and the drug loading reached 32.61 ​± ​3.38%. The RES release results for the loaded sample (PMMSN-RES) showed that the PMMSN-RES exhibited a release slowly effect. In vitro and vivo experiments demonstrated that PMMSN-RES decreased reactive oxygen species (ROS) and malondialdehyde (MDA), increased superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activities, reduced the expression of inflammatory (TNF-α, IL-1β and IL-6) and apoptotic cytokines (cleaved caspase-3) in spinal cord tissue after SCI. In summary, PMMSN-RES may be a potential pharmaceutical preparation for the treatment of SCI by reducing neuronal apoptosis and inhibiting inflammation caused by reducing oxidative stress to promote the recovery of mouse motor function.

Central Recruitment: A process for engaging and recruiting individuals with spinal cord injury/disease in research at Toronto Rehabilitation Institute

CONTEXT

Insufficient recruitment is a barrier to research and limits statistical power. We describe an initiative aimed to streamline recruitment and consent processes for inpatients with spinal cord injury or disease (SCI/D) via implementation of a Central Recruitment (CR) process. The CR process adhered to ethical standards, reduced participant burden, and maximized research participation.

METHODS

In this CR process, the inpatient's nurse affirmed suitability for research approach based on fluency, cognition and health stability. A patient research liaison (PRL) was the sole contact for information regarding the research process, and introduced ongoing studies, screened for eligibility, and completed the consent process(es).

RESULTS

Over five and a half years, 1,561 inpatients with SCI/D were screened for eligibility upon admission, of whom 80% (1256/1561) were deemed suitable for the PRL approach. Of those suitable for the CR process, 80% (1001/1256) agreed to discuss current research opportunities, 46% (235/516) consented to participate in one or more studies, and 86% (856/1001) agreed to future research contact.

CONCLUSION

This process adhered to ethical procedures and reduced the burden of having multiple researchers approach each individual inpatient regarding research participation, with high consent rates for low-risk studies. Future evaluation of the process scalability is underway.

Application and progress of three-dimensional bioprinting in spinal cord injury

Spinal cord injury (SCI) is a central nervous system disorder that can lead to sensory and motor dysfunction, which can seriously increase pressure and economic burden on families and societies. The current SCI treatment is mainly to stabilize the spine, prevent secondary damage, and control inflammation. Drug treatment is limited to early, large-scale use of steroids to reduce the effects of edema after SCI. In short, there is no direct treatment for SCI. Recent 3D bioprinting development provides a new solution for SCI treatment: a series of spinal cord bionic scaffolds are being developed to improve spinal cord function after injury. This paper reviews the pathophysiological characteristics of SCI, current treatment methods, and the progress of 3D bioprinting in SCI. Finally, its challenges and prospects in SCI treatment are summarized.

Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

Background

Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI).

Methods

We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression.

Results

We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression.

Conclusions

Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.

Decreasing pressure injuries and acute care length of stay in patients with acute traumatic spinal cord injury

OBJECTIVES

Identifying factors associated with the occurrence of pressure injuries (PI) during acute care and with longer length of stay (LOS), focusing on modifiable factors that can be addressed and optimized by the acute rehabilitation team.

DESIGN

Prospective cohort study.

SETTING

A single Level-1 trauma center specialized in SCI care.

PARTICIPANTS

A cohort of 301 patients with acute TSCI was studied.

OUTCOME MEASURES

The primary outcome was the occurrence of PI during acute care stay. The secondary outcome was acute care LOS. Bivariate and multivariate logistic or linear regression analyses were performed to determine the association between non-modifiable factors and outcomes (PI of any stage and acute LOS), whereas bivariate and hierarchical multivariate logistic or linear regression analyses were used for modifiable factors.

RESULTS

When controlling for the level and severity of the TSCI, the occurrence of pneumonia (OR = 2.1, CI = 1.1-4.1) was significantly associated with the occurrence of PI. When controlling for the level and severity of the TSCI, the occurrence of medical complications (PI, urinary tract infection and pneumonia) and lesser daily therapy resulted in significantly longer acute care LOS (P < .001).

CONCLUSIONS

Prevention of PI occurrence and the optimization of the acute care LOS represent crucial challenges of the acute rehabilitation team, as they are significantly associated with higher functional outcomes. Patients who develop pneumonia may benefit from more aggressive prevention strategies to reduce PI occurrence. Systematic protocols for the prevention of complications as well as greater volume of therapy interventions should be considered to optimize the acute care LOS.

A Systematic Review of the Effects of Community Transition Programs on Quality of Life and Hospital Readmissions for Adults With Traumatic Spinal Cord Injury

OBJECTIVE

To investigate the effects of community transition programs for adults with traumatic spinal cord injury (tSCI) on hospital readmissions and quality of life (QOL).

DATA SOURCES

Seven databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Google Scholar, the Joanna Briggs Institute database, OTseeker, and PEDro) and reference lists of relevant articles were searched from inception through March 2020.

STUDY SELECTION

Original research studies were included that (1) evaluated interventions designed to support individuals aged 18-65 years with newly acquired tSCI in navigating the transition from subacute care to the community and (2) reported data for QOL or hospital readmission outcomes. Searches identified 4694 studies, and 26 of these met the selection criteria.

DATA EXTRACTION

Two reviewers independently screened and assessed all studies, extracting information about study type, methodological strengths and weaknesses, participant and intervention characteristics, comparator, and significant results. Any discrepancies were resolved by a third reviewer.

DATA SYNTHESIS

Studies were grouped according to primary intervention: peer mentoring (n=8), telehealth (n=5), education (n=5), independent living (n=3), occupational therapy (n=1), counseling (n=1), and patient navigation (n=4). Reviewers used the Let Evidence Guide Every Decision appraisal tool rubric to grade the body of evidence for each intervention type. Moderate level evidence supports the positive effects of peer mentoring, and low level evidence indicates positive effects of telehealth, education, independent living, and occupational therapy interventions. Peer mentoring, telehealth, and patient navigation were the only intervention types that included hospital readmission outcomes. Of these, peer mentoring had the most evidence, with 3 of the 4 studies that included hospital readmission outcomes demonstrating statistically significant improvements.

CONCLUSIONS

In general, there is a paucity of high-quality evidence with sufficiently similar characteristics to demonstrate and compare benefits from program participation. When high quality studies have been conducted, they have obtained mixed results. Of the different intervention types, peer mentorship has the strongest supporting evidence. Further research is needed to identify specific intervention components that are most effective in improving QOL and reducing hospital readmission for specific subgroups of individuals recovering from tSCI.

Alginate scaffolds improve functional recovery after spinal cord injury

PURPOSE

In this systematic review and meta-analysis, the use of alginate for the repair of the damaged spinal cord was investigated.

METHODS

After an extensive search of databases including MEDLINE, SCOPUS, EMBASE and Web of Science, an initial screening was performed based on inclusion and exclusion criteria. The full text of related articles was reviewed and data mining was performed. Data were analyzed by calculating the mean of ratios between treated and untreated groups using STATA software. Subgroup analysis was also performed due to heterogeneity. Articles were subjected to quality control and PRISMA guidelines were followed.

RESULTS

Twelve studies and 17 experiments were included in the study. After SCI, alginate hydrogel had a moderate effect on motor function recovery (SMD = 0.64; 95% CI 0.28-1.00; p < 0.0001) and alginate scaffolds loaded with drugs, growth factors, or cells on the SCI group compared with untreated SCI animals showed has a strong effect in the treatment of SCI (SMD = 2.82; 95% CI 1.49-4.145; p < 0.0001). Treatment with drug/cell in combination with alginate was more strongly significant compared to the groups treated with drug/cell alone (SMD = 4.55; 95% CI 1.42-7.69; p < 0.0001). Alginate alone or in combination therapy when used as an implant, had a more significant effect than injection.

CONCLUSION

These findings suggest that alginate is an efficient scaffold for functional recovery and even a much better scaffold for drug/cell delivery after SCI.

A review of spinal cord perfusion pressure guided interventions in traumatic spinal cord injury

PURPOSE

To evaluate the causality between interventions on spinal cord perfusion pressure and neurological outcome in traumatic spinal cord injury.

METHODS

A systematic review was conducted in concordance with PRISMA guidelines. The literature was found in the EMBASE, PUBMED, SCOPUS, and WEB OF SCIENCE. Eligible studies included those that reported measurements and interventions on the spinal cord perfusion pressure in either animals or patients suffering from spinal cord injury. Only studies that reported a clinical or relevant clinical outcome measure (i.e., neurophysiology) were included.

RESULTS

The search yielded 795 unique records, and six studies were included after careful review. These studies suggested a positive correlation between spinal cord perfusion pressure and neurological outcome, but conclusions on causality could not be made.

CONCLUSION

In spite of growing indications that neurological outcomes are related to the spinal cord perfusion pressure in traumatic spinal cord injuries, a solid conclusion cannot be made due to the limited literature available. Additional well-designed studies are needed to address this issue.

Cervical cord injury complicated by acute mesenteric ischemia

Acute mesenteric ischemia is a rare, life-threatening complication of cervical cord injury. This case report emphasized the importance of prompt diagnosis and treatment of this complication.

A 60-year old Japanese man with no co-morbidities was diagnosed as a C2 cervical cord injury and traumatic brain injury after a fall-down trauma. He was admitted to the intensive care unit after cord decompression surgery. Nine days later, he presented tachycardia and hypotension. Ultrasound showed dilated intestines and ascites. Intestinal ischemia was suspected based on the contrast-enhanced computed tomography scan. We performed prompt surgical resection of a broad part of the small intestines. The ischemic region of the intestines was segmental and the cause was attributed to a non-occlusive mechanism.

Acute mesenteric ischemia can be fatal and a delay in diagnosis leads to poor outcomes. We focus on predisposing factors in patients with cervical cord injuries and how to prevent this serious diagnosis.

Nonocclusive mesenteric ischemia secondary to spinal cord injury: an autopsy case

INTRODUCTION

Spinal cord injury (SCI) is a major direct cause of accidental death. Cervical SCI can lead to death in a short time period by neurogenic shock. Prompt vasopressor administration is recommended for patients with SCI accompanied by hypotension (systolic blood pressure < 90 mmHg). We herein present the first fatal case of nonocclusive mesenteric ischemia (NOMI) secondary to cervical SCI in a patient who suddenly died 1 week after an accidental fall.

CASE PRESENTATION

A 72-year-old man without medical history of cardiovascular disease suffered tetraplegia with a neurological level at C4 after a fall accident. He was fully conscious with stable respiratory ability, and the systolic blood pressure was maintained at >90 mmHg without vasopressor agents. High fever occurred 7 days after the accident and he died in the next morning. Autopsy revealed segmental intestinal necrosis from the ileum to the ascending colon, without mesenteric embolism, or severe arteriosclerosis.

DISCUSSION

This case implies that maintenance of >90-mmHg systolic blood pressure can insufficiently keep the blood flow to prevent NOMI, and the mean arterial blood pressure of >85 mmHg can be more plausible as suggested in the guideline. Monitoring the mean arterial blood pressure in acute SCI is useful not only for neurological recovery but also for the maintenance of vital intestinal perfusion.

Dysphagia in cervical spinal cord injury: How international literature trends can guide South African practice patterns - A scoping review

BACKGROUND

The limited data regarding dysphagia in high-level spinal cord injuries (SCIs) stem from economically developed countries. Dysphagia is prevalent in patients with cervical SCI; however, in a South African context, speech-language pathologists (SLPs) are not seen as key when managing this population. This may result in patients not being screened or identified early, leading to possible complications. The literature could provide useful insight on how best to address this clinical gap.

OBJECTIVES

The aim of my study was to conduct a scoping review on the description of dysphagia, the risk factors for developing dysphagia post-SCI and the practice patterns of team members working with dysphagia in cervical SCIs.

METHODS

A five-step scoping review was undertaken. Data were analysed by using descriptive statistics as well as a thematic analysis by using a top-down approach.

RESULTS

Through the process of screening according to the inclusion and exclusion criteria, 25 articles were included. Primarily, the pharyngeal phase was affected, which can lead to an aspiration pneumonia. The key risk factors were the presence of a tracheostomy tube, the use of ventilation and anterior spinal cord surgery. There was little mention regarding specific practice patterns, but an interdisciplinary approach was suggested as the most efficient model.

CONCLUSIONS

Specific guidelines and management options need to be considered for a South African context, given the high incidence of trauma-related injuries. There needs to be locally produced research, providing suggestions on how different team members can screen and identify dysphagia within this population. Solutions need to be unique, and contextually responsive and appropriate.

CLINICAL IMPLICATIONS

The team members and the roles of these different team members need to be re-examined in order to ensure the early identification and management of cervical SCI patients who are at risk of developing a dysphagia.

Prognosis of C4 dislocation with spinal cord injury following psychological intervention

OBJECTIVE

To investigate the effect of psychological intervention on the prognosis of patients with C4 dislocation and spinal cord injury.

METHODS

We investigated target patients admitted between 2010 and 2018. Patients' mental state, quality of life and neurological function at different time points were evaluated to examine the relationship between psychological intervention and recovery and prognosis of acute and critical spinal cord injury.

RESULTS

All patients showed improvements in clinical symptoms, neurological function and quality of life. Psychological intervention significantly improved Zung Self-Rating Anxiety Scale score, Zung Self-Rating Depression Scale score and SF-36 Mental Component Summary score within 3 months. Japanese Orthopaedic Association neurological function score and SF-36 Physical Component Summary score were significantly improved after 1-year follow-up. Psychological intervention did not improve 2-year survival.

CONCLUSION

Timely and professional psychological intervention can eliminate the psychological disorders of C4 dislocation patients with spinal cord injury. This has a positive effect on their quality of life and prognosis.

Effects of acute neurologic disease on the heart

Patients with acute neurologic disease often also have evidence of cardiac dysfunction. The cardiac dysfunction may result in a number of clinical signs including abnormal EKG changes, variations in blood pressure, development of cardiac arrhythmias, release of cardiac biomarkers, and reduced ventricular function. Although typically reversible, these cardiac complications are important to recognize as they are associated with increased morbidity and mortality. In this chapter, we discuss the suspected pathophysiology, clinical presentation, and management of the cardiac dysfunction that occur as a consequence of different types of acute neurologic illness.

Clinical treatment and medication in decreasing the development of major depression caused by spinal fracture

BACKGROUND

Chronic pain and limited activities of daily living after spinal fracture may induce the occurrence of major depression (MD); however, risk factors regarding medications, surgical intervention, and severity of fracture are unclear. We aimed to analyze risk factors of MD development after spinal fracture.

METHODS

This was a retrospective database study, using the health care database of the Taiwan government. We included 11,225 patients with new spinal fracture (study group), and 33,675 matched patients without fracture (comparison group). We respectively reviewed data of each participant for 3 years to assess the development of MD. The Cox proportional hazards model was used to determine the prevalence of MD, after adjusting for patient demographics, medications, surgical interventions, spinal cord involvement, and postfracture comorbidities.

RESULTS

In total, 187 fracture patients (1.7%) and 281 nonfracture patients (0.8%) developed new-onset MD (hazard ratio [HR]:1.96, (95% confidence interval [CI]: 1.63-2.36)). Spinal cord involvement (HR: 2.96, 95% CI: 2.54-3.42) and postfracture comorbidities (HR: 3.51, 95% CI: 2.86-3.97) obviously increased the risk of MD.

CONCLUSIONS

Patients with spinal fracture (spinal cord involvement and postfracture comorbidities) were more likely to develop MD. Early surgical interventions (vertebroplasty) and medications (narcotics) may decrease the risk of MD.

Safety and feasibility of exoskeleton-assisted walking during acute/sub-acute SCI in an inpatient rehabilitation facility: A single-group preliminary study

Context/objective: Information on the safety and feasibility of lower extremity powered exoskeletons for persons with acute/sub-acute spinal cord injury (SCI) is limited. Understanding the safety and feasibility of employing powered exoskeletons in acute/sub-acute (<6 months post injury) at a SCI acute inpatient rehabilitation (SCI-AIR) facility could guide clinical practice and provide a basis for larger clinical trials on efficacy and effectiveness. Design: Single group observational study. Setting: SCI-AIR. Participants: Participants (n = 12; age: 28-71 years; 58% AIS D; 58% male) with neurological levels of injuries ranging from C2 to L3. Interventions: Up to 90 min of exoskeleton-assisted locomotor training was provided up to three times per week during SCI-AIR. Outcome measures: Safety of device use during inpatient locomotor training was quantified as the number of adverse events (AE) per device exposure hour. Feasibility of device use was defined in terms of protocol compliance, intensity, and proficiency. Results: Concerning safety, symptomatic hypotension was the most common AE reported at 111-events/exoskeleton-hours. Protocol compliance had a mean (SD) of 54% (30%). For intensity, 77% of participants incorporated variable assistance into at least 1 walking session; 70% of participants' sessions were completed with a higher RPE than the physical therapist. In proficiency, 58% achieved at least minimal assistance when walking with the device. Conclusion: Exoskeleton training in SCI-AIR can be safe and feasible for newly injured individuals with SCI who have clinically defined ambulatory goals. Nonetheless, sufficient controls to minimize risks for AEs, such as hypotensive events, are required.

Pivotal Role of Cervical Rotation for Rehabilitation Outcomes in Patients with Subaxial Cervical Spinal Cord Injury

BACKGROUND

Limitation of active cervical range of motion as a sequel of both spinal instrumentation and neurological injury may occur after Cervical Spinal Cord Injury (CSCI) surgery. The majority of tasks performed in daily life require a minimum of Active Cervical Range of Motion (ACROM). The aim of this study was to report ACROM in patients with subaxial CSCI, and in a control group with asymptomatic cervical spine.

METHODS

A cross-sectional study was performed in 46 cases of traumatic complete motor CSCI and 41 asymptomatic cases. Patients underwent quantitative measurement of ACROM on six movements, using an analogue inclinometer, and rehabilitation status assessment on the Spinal Cord Independence Measure (SCIM) III.

RESULTS

Forty-six CSCI cases and 41 asymptomatic controls were included. Mean flexion, extension, rotation, and lateral inclination were significantly lower in the CSCI group than in controls (P<0.0001). SCIMIII self-care subscores in the CSCI group showed significant correlation with mean cervical rotation (correlation coefficient, +0.508, P=0.0003). Regression analysis on mean ACROM in the CSCI group, yielded significant a negative correlation with age (P=0.037).

CONCLUSIONS

CSCI significantly affected ACROM. Also, restriction of cervical rotation had significant negative correlation with SCIM-III self-care subscores.

Extracellular vesicles isolated from human olfactory ensheathing cells enhance the viability of neural progenitor cells

OBJECTIVE

Acquired neurological diseases such as severe traumatic brain or spinal cord injury (SCI) cause irreversible disability. Olfactory ensheathing cell (OEC) transplantation has been trialed as a promising SCI treatment. Extracellular vesicles (EVs), which regulate cell-cell interactions, have recently garnered extensive research interests and emerged as a non-cell-based therapy in neurological disorders, including in SCI animal models. However, there have been no reports of human OEC-EVs and their beneficial effects on neuron regeneration. Here, we investigated the effects of EVs isolated from human OEC on the viability of neuronal cells.

METHODS

EVs were isolated from primary human OECs (hOECs) by serial ultracentrifugation. The hOEC-EVs were characterized by transmission electron microscopy, western blotting, and nanoparticle tracking analyses. We conducted CCK8 and lactate dehydrogenase assays to assess the cell proliferation and cytotoxicity of neural progenitor cells (NPCs) exposed to hOEC-EVs. Tert-butyl hydroperoxide (t-BHP) was utilized to mimic oxidative stress-induced cytotoxicity in NPCs.

RESULTS

The modal diameter of hOEC-derived EVs was 113.2 nm. Expressions of EV markers such as CD9, CD63, and CD81 were detected by western blotting. hOEC-derived EVs enhanced the proliferation of NPCs and ameliorated cell cytotoxicity mediated by t-BHP.

DISCUSSION

Our findings reveal a role for hOEC-derived EVs in NPC proliferation and oxidative stress-induced neuronal toxicity model. These results may be useful for developing non-cell therapy OEC-EV-based treatment in acquired nervous system disease.

Clinical Trials of Stem Cell Treatment for Spinal Cord Injury

There are more than one million patients worldwide suffering paralysis caused by spinal cord injury (SCI). SCI causes severe socioeconomic problems not only to the patients and their caregivers but also to society; therefore, the development of innovative treatments is crucial. Many pharmacological therapies have been attempted in an effort to reduce SCI-related damage; however, no single therapy that could dramatically improve the serious long-term sequelae of SCI has emerged. Stem cell transplantation therapy, which can ameliorate damage or regenerate neurological networks, has been proposed as a promising candidate for SCI treatment, and many basic and clinical experiments using stem cells for SCI treatment have been launched, with promising results. However, the cell transplantation methods, including cell type, dose, transplantation route, and transplantation timing, vary widely between trials, and there is no consensus regarding the most effective treatment strategy. This study reviews the current knowledge on this issue, with a special focus on the clinical trials that have used stem cells for treating SCI, and highlights the problems that remain to be solved before the widespread clinical use of stem cells can be adopted.

[Neurophysiological methods for predicting outcome in cases of spine and spinal cord injury]

The purpose of the review was to determine the capabilities of neurophysiological examination for predicting the outcome of spinal injury. We have analyzed the methods of neurophysiological examination of spinal cord function and the role of these data in prediction of functional recovery in patients with complicated vertebral-spinal injury. Application of functional diagnostic methods for spinal shock was also considered.

Spinal cord injury/dysfunction and medication management: a qualitative study exploring the experiences of community-dwelling adults in Ontario, Canada

Purpose: To explore the attitudes, beliefs and experiences pertaining to the management of prescribed and unprescribed medications among community-dwelling adults with spinal cord injury/dysfunction (SCI/D) in Ontario, Canada.Materials and Methods: In-depth semi-structured interviews were conducted by telephone. Each interview was audio-recorded, transcribed verbatim and analyzed using inductive thematic analysis.Results: Of the 19 participants, 11 were male and 8 were female, with an age range from 36 to 76 years; 14 participants had traumatic SCI and 5 had non-traumatic spinal cord dysfunction. All but three participants were taking five or more medications, including prescription medications, over-the-counter medications and natural health products. The three main themes identified were: disruptive nature of medications, fear of negative outcomes and self-management: playing a critical role.Conclusions: Medication management is a complex, multifaceted and non-linear process. Persons with SCI/D described experiences with medication-taking that are not well understood by current medication management frameworks. Thus, it is essential to broaden our lens and situate persons with SCI/D medication-taking experiences within self-management frameworks to allow for a more comprehensive and reflective understanding of their experiences. Based on the findings from this study, recommendations for future research, practice and policy have been suggested.IMPLICATIONS FOR REHABILITATIONPersons with spinal cord injury/dysfunction identified numerous challenges and concerns with medication use post-injury.Educational medication management programs should be implemented post-discharge to improve the state of knowledge around medications (indication, side effects, strategies for taking medications) and how to optimize medication management.In order to optimize experiences and outcomes, there is a need for explicit and ongoing discussions around medication management between persons with spinal cord injury/dysfunction and their healthcare providers.

Immunization with neural-derived peptides increases neurogenesis in rats with chronic spinal cord injury

Aims

Immunization with neural‐derived peptides (INDP) has demonstrated to be a promising therapy to achieve a regenerative effect in the chronic phase of the spinal cord injury (SCI). Nevertheless, INDP‐induced neurogenic effects in the chronic stage of SCI have not been explored.

Methods and Results

In this study, we analyzed the effect of INDP on both motor and sensitive function recovery; afterward, we assessed neurogenesis and determined the production of cytokines (IL‐4, IL‐10, and TNF alpha) and neurotrophic factors (BDNF and GAP‐43). During the chronic stage of SCI, rats subjected to INDP showed a significant increase in both motor and sensitive recovery when compared to the control group. Moreover, we found a significant increase in neurogenesis, mainly at the central canal and at both the dorsal and ventral horns of INDP‐treated animals. Finally, INDP induced significant production of antiinflammatory and regeneration‐associated proteins in the chronic stages of SCI.

Conclusions

These findings suggest that INDP has a neurogenic effect that could improve motor and sensitive recovery in the chronic stage of SCI. Moreover, our results also envision the use of INDP as a possible therapeutic strategy for other trauma‐related disorders like traumatic brain injury.

An observational study of feeding practice in ventilated patients with spinal cord injury

BACKGROUND AND AIMS

Cervical spinal cord injuries (CSCI) are frequently complicated by respiratory failure requiring prolonged invasive mechanical ventilation in the intensive care unit (ICU). Providing adequate nutrition may be an important factor in the recovery of respiratory muscle function for ventilator weaning. The aim of this study was to examine the practical implementation of a multi-disciplinary approach to nutrition combining indirect calorimetry and the modified Harris Benedict equation to achieve target rates of nutrition for patients with CSCI.

MATERIALS AND METHODS

A retrospective observational study was performed by collecting data of normal nutrition practice in a series of adult ventilated patients with CSCI admitted between 2014 and 2017 to the ICU. Administered calories by enteral nutrition and measured total energy expenditure (TEE) by indirect calorimetry were recorded for the first 3-weeks. Calculations were performed to measure the adequacy of calorie administration relative to TEE. Average daily temperatures and minute ventilation were recorded to support evidence for hypermetabolism. TEE estimates using the modified Harris Benedict equation were compared to indirect calorimetry measures for each patient.

RESULTS

Sixteen patients were included in the study. Calorie administration rapidly increased to a plateau of 2300-2400 kcal per day over the first four days. The median measured TEE by indirect calorimetry was initially high, starting at 3472 kcal/day and decreasing to 2784 kcal/day at three weeks. However, there was wide variation in energy expenditure amongst patients. Average daily temperatures and minute ventilation were high supporting hypermetabolism. Adequacy of calorie administration to TEE ranged between 76 and 86 percent through the study period. There was relatively wide variation when comparing estimates of TEE using the modified Harris Benedict equation versus indirect calorimetry.

CONCLUSIONS

A multi-disciplinary approach to nutrition in ventilated patients with CSCI, incorporating indirect calorimetry, achieves target rates of nutrition. Our findings suggest that a hypermetabolic response may be common but variable in this population and subsequently both under and over feeding may be a risk if nutrition targets are not guided by indirect calorimetry. Further prospective research using protocoled indirect calorimetry measures would be beneficial to ascertain accurate energy requirements for this group of patients and also determine whether feeding to target influences weaning off the ventilator.

An Epidemiological Overview of Spinal Trauma in the Kingdom of Saudi Arabia

INTRODUCTION

The World Report on Road Traffic Injury Prevention indicates that by 2020, road traffic injuries will be a major killer, accounting for half a million deaths and 15 million disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) has one of the highest rates of spinal cord injuries in the world, with 62 people injured per 1 million, and the injuries are mostly due to traffic accidents.

METHODS

All polytrauma patients associated with spinal injuries admitted to Prince Mohammed bin Abdul Aziz Hospital (PMAH), Riyadh, from January 2017 to June 2018, were included in this study. Patients with old spinal injuries, any previous spinal surgery, spine infection, or concomitant diagnosed malignancies or osteoporotic collapse with or without falls were excluded. All patients underwent whole-spine computed tomography scan and, in selective cases, magnetic resonance imaging of the spine.

RESULTS

Of the 230 patients, 90.0% were male, and 60% were in the second and third decades. Motor vehicle accidents were responsible for 83% of the cases, of which 50% of the victims were the drivers, and 80% were passengers with no seatbelt on. Nearly 50% of the spinal injuries were associated with injuries in the other body parts. Cervical spine injury accounted for 44% of the cases, followed by the lumbar spine injury. Twenty five percent of the patients presented with fixed neurologic deficit in the form of quadriplegia or paraplegia (ASIA-A). The mortality rate was 1.3%.

CONCLUSIONS

This study revealed that motor vehicle accidents are a major cause of spinal injuries in the KSA. One-fourth of the spinal Injuries are associated with complete spinal cord injuries. Therefore, in order to prevent lifelong disability in the young population, a nationwide program should be initiated to prevent road traffic accidents.

Protective effect of D-pinitol on the experimental spinal cord injury in rats

Spinal cord injury (SCI) is the major cause of the spinal damage affecting motor and sensory function. Thus, the present study was conducted to investigate the effect of D-pinitol (PN) on spinal cord injury in rats. The PN showed to recover motor function near to normal via modulating oxidative stress, inflammatory response and cellular apoptosis in SCI rats. PN also causes modulation of Bcl2 family proteins and reduces the level of NF-ĸB and LOX-1 in dose dependent manner. The PN causes reduction of NLRP3, TNF-α and iNOS, with increase in caspase-1 together with modulation of MAPK mediators. It has been suggested that, D-pinitol exert protective action against SCI via inhibition of apoptosis, inflammation and oxidative stress, via modulating Bcl-2 genes and MAPK pathway.

Urodynamic Parameters in Spinal Cord Injury-Induced Neurogenic Bladder Rats after Stem Cell Transplantation: A Narrative Review

Neurogenic bladder (NGB) secondary to spinal cord injury (SCI) is accompanied with several complications such as urinary tract deterioration, urinary incontinence, and consequently lower quality of life (QoL), significant morbidities, and occasionally death. Current therapeutic methods have some side effects and there is no treatment for the upper urinary tract injuries. Stem cell therapy is a promising method for treating this condition. However, the best timing and the best route of its transplantation have not yet been determined. Animal models of SCI, especially in rats, are the most commonly used method for evaluating the efficacy of cell therapy in NGB improvement, and the most common assessment method is the urodynamic studies (UDS). However, there are variations in the range of UDS parameters among the published studies. The current review aimed to discuss the effect of stem cell transplantation on bladder dysfunction recovery based on urodynamic parameters after SCI in rats. For this purpose, the cell source, doses, the route of administration, and the complete UDS equipment and its parameters were summarized in SCI models in rats. In some urodynamic test results, to some extent, an improvement in the lower urinary system function was observed in each treatment group. However, this improvement was far from full functional recovery. The average cell dose was about 1 million cells in every injected site. In most studies, the stem cells (SCs) were transplanted 9 days after the injury using PE-50 and PE-60. Many researchers have recommended further experimental and clinical studies to confirm this treatment modality.

Survival and Integration of Transplanted Olfactory Ensheathing Cells are Crucial for Spinal Cord Injury Repair: Insights from the Last 10 Years of Animal Model Studies

Olfactory ensheathing cells (OECs), the glial cells of the primary olfactory nervous system, support the natural regeneration of the olfactory nerve that occurs throughout life. OECs thus exhibit unique properties supporting neuronal survival and growth. Transplantation of OECs is emerging as a promising treatment for spinal cord injury; however, outcomes in both animals and humans are variable and the method needs improvement and standardization. A major reason for the discrepancy in functional outcomes is the variability in survival and integration of the transplanted cells, key factors for successful spinal cord regeneration. Here, we review the outcomes of OEC transplantation in rodent models over the last 10 years, with a focus on survival and integration of the transplanted cells. We identify the key factors influencing OEC survival: injury type, source of transplanted cells, co-transplantation with other cell types, number and concentration of cells, method of delivery, and time of transplantation after the injury. We found that two key issues are hampering optimization and standardization of OEC transplantation: lack of (1) reliable methods for identifying transplanted cells, and (2) three-dimensional systems for OEC delivery. To develop OEC transplantation as a successful and standardized therapy for spinal cord injury, we must address these issues and increase our understanding of the complex parameters influencing OEC survival.

Severity and neurosurgical management of patients with traumatic spinal fractures in Saudi Arabia: a cross sectional study

Introduction

Road traffic accidents (RTAs) are the most frequent cause of traumatic spinal injuries (TSIs), which account for up to 33.6% of all spinal fractures. The Kingdom of Saudi Arabia (KSA) is one of the countries which has high rates of SCIs and bears the economic burden of that situation.

Methods

120 patients were included in this study, using a stringent set of inclusion and exclusion criteria. The patients were followed-up from the point of triage to admission and discharge. We analysed the clinical notes of the patients to determine the severity of their traumatic spinal injuries, the neurosurgical management carried out, and other prognosticating factors such as blood transfusion and the Glasgow Coma Scale (GCS). The data collected was analysed anonymously, and the confidentiality of all participants was respected.

Results

Most of the patients were young adults and adolescents under the age of 40 (n = 96). There was a male preponderance of 84.1%. With respect to spinal injury stratification, 55 patients had cervical spine fractures, 10 patients had cervical lacerations, 85 patients had thoracolumbar spinal fractures, and 10 patients had thoracolumbar spinal lacerations. 35 patients had other fractures documented. All 120 patients were followed up to assess the management of their traumatic spinal injuries. 66.6% (n= 80) of all patients were managed conservatively, whereas the remaining 33.3% (n=40) were managed surgically.

Conclusion

Trauma is an important cause of spinal injuries (TSIs), and untreated TSIs may lead to poor clinical outcome, especially if the cervical region is involved.

Roles of miRNAs in spinal cord injury and potential therapeutic interventions

Spinal cord injury (SCI) affects approximately 200,000 individuals per year worldwide. There are more than 27 million people worldwide living with long-term disability due to SCI. Historically, it was thought that the central nervous system (CNS) had little ability for regeneration; however, more recent studies have demonstrated potential for repair within the CNS. Because of this, there exists a renewed interest in the discovery of novel approaches to promote regeneration in the CNS including the spinal cord. It is important to know the roles of the microRNAs (miRNAs) in modulation of pathogenesis in SCI and the potentials of the miRNA-based clinical interventions for controlling post-injury symptoms and improving functional recovery. The miRNAs, which are non-coding RNAs with an average of 22 nucleotides in length, are post-transcriptional gene regulators that cause degradation of the target mRNAs and thus negatively control their translation. This review article focuses on current research related to miRNAs and their roles in modulating SCI symptoms, asserting that miRNAs contribute to critical post-SCI molecular processes including neuroplasticity, functional recovery, astrogliosis, neuropathic pain, inflammation, and apoptosis. In particular, miR-96 provides a promising therapeutic opportunity to improve the outcomes of clinical interventions, including the way SCI injuries are evaluated and treated.

Pressure ulcer knowledge, beliefs and practices in a group of South Africans with spinal cord injury

Study design

A quantitative, descriptive study using a cross-sectional survey.

Objectives

To describe the pressure ulcer knowledge, beliefs and practices amongst persons with SCI, who received rehabilitation at a Cape Town rehabilitation centre.

Setting

A rehabilitation centre for clients with physical disabilities in Cape Town, South Africa.

Methods

A quantitative, descriptive study, that employed consecutive sampling, was done. Participants included inpatients (n = 30), outpatients (n = 33) and peer supporters (n = 8). Data were collected during April and March 2015 with a questionnaire developed through collating existing questionnaires and adapting it for the study context. This rendered a knowledge score and data on beliefs and practices. The Fisher's exact test was used for comparative analysis (p < 0.05).

Results

The mean combined knowledge score was 42.7%. The majority of participants (88.7%) believed pressure ulcers to be serious and 45% thought they were likely to develop a PU. They believed daily skin checks (80.3%), weight shifting (86%) and limiting sitting time (80.3%) could prevent PU development. Study participants indicated that they did not regularly follow guideline recommended practices like regular pressure relief (51%) (36 participants) or daily skin inspection (38%) (27 participants) and 37% (26 participants) reported being current smokers.

Conclusion

Participants showed a lack of knowledge, which might have affected their pressure ulcer prevention practices negatively. The study findings can be used to assist with the development of a contextually relevant training programme on pressure care.

The Safety and Feasibility of Exoskeletal-Assisted Walking in Acute Rehabilitation After Spinal Cord Injury

OBJECTIVE

To assess safety and feasibility for persons with acute spinal cord injury (SCI) using the robotic exoskeleton.

DESIGN

Case series observational study.

SETTING

A level-1 trauma center in Canada with both acute and tertiary inpatient SCI rehabilitation units.

PARTICIPANTS

Eight male and 3 female (N=11) participants were recruited with a mean age of 41 years and with neurologic level of injury (C6-L2) and severity (American Spinal Injury Association Impairment Scale [AIS] A-D). The time since injury is a range of 3-15 weeks at the onset of training.

INTERVENTIONS

Up to 25 one-hour sessions of exoskeletal-assisted walking gait training, with participants less than 6 months from initial SCI.

MAIN OUTCOME MEASURES

Cardiopulmonary outcomes including blood pressure, heart rate, and peripheral oxygen saturation; and perceived physical exertion using the Borg CR10 Scale were recorded. Gait parameters were measured by 6-minute walk test (6MWT) and 10-meter walk test (10MWT). Up Time, walk time, and number of steps were detailed longitudinally. Safety was assessed with regard to pain, falls, and skin integrity.

RESULTS

No serious adverse events occurred. Blood pressure decreased following initial sit to stand and increased during walking. Symptoms of hypotension were rare and improved with increased number of sessions. Perceived exertion was reported on average to be moderate (mean of 3.1). There was no significant increase in pain scores by Visual Analog Scale. On 6MWT, participants covered more distance (mean [m] ± SD, 117.1±11.7) in session 25 compared to session 2 (mean [m] ± SD, 47.6±6.6). On the 10MWT, all participants showed consistently improved gait speed; with participants traveling an average of 3.2 times faster during their last training session (mean [m/s] ± SD, 0.40±0.04) in comparison to session 2 (mean [m/s] ± SD, 0.12±0.01).

CONCLUSIONS

Exoskeletal-assisted walking in acute rehabilitation (<6mo) following SCI appears to be both safe and feasible.

Epidemiological characteristics and early complications after spinal cord injury in Former Yugoslav Republic of Macedonia

Study design

Prospective cohort study

Objectives

To describe epidemiological data and complications after acute traumatic spinal cord injury (tSCI) in Former Yugoslav Republic of Macedonia (FYROM).

Setting

University Clinic for Traumatology, Orthopedics, Anesthesia and Intensive Care Unit and Emergency Center (TOARILUC), Mother Teresa, Skopje, FYROM.

Method

During the inclusion period March 2015 to September 2016, 38 tSCI patients were included. MRI, CT scan, and clinical examinations including International Standards for Neurological Classification of SCI were performed at admission. The information included: demographic data, transport type, date of admission and discharge, past illnesses, addiction habits, cause and type of injury, injury level, associated injuries, injury-related complications, and mortality.

Results

Mean age was 43 years (median 41, range 17–83). Seventeen patients had a complete and 15 an incomplete SCI, six were unknown. Most frequent causes for tSCI were traffic accidents (42%) and falls (40%), 24% of the accidents were contracted at work. Sixteen patients were ventilator dependent at some point during the acute period. Common complications were pressure ulcers, gastrointestinal-related, and infections. Hospital length of stay (LOS) ranged from 1 to 73 days. The in-hospital mortality rate was 32%.

Conclusion

The annual incidence of tSCI in FYROM was in 2015–16 13 persons/million inhabitants per year. The epidemiological profile of tSCI in FYROM implies that preventive measures should be taken to reduce incidence of accidents in traffic and at work places. The high mortality rate and complications underline further actions to improve the acute care of tSCI in FYROM.

Traumatic Spinal Cord Injury

PURPOSE OF REVIEW

This article provides an update on the acute and subacute management and prognostication of patients with traumatic spinal cord injury.

RECENT FINDINGS

Immobilization of the spine and spine clearance should be individualized depending on the ability to perform a reliable neurologic examination, the presence of neck pain, and the imaging findings. Early surgery (within 24 hours) to achieve definitive cord decompression and spine stabilization may be beneficial. Ensuring adequate oxygenation and perfusion and avoiding secondary systemic complications remain the goals of the critical care of these patients. No neuroprotective treatment has been shown to improve outcomes. In fact, the use of high-dose methylprednisolone is now generally discouraged because of its major systemic adverse effects. Survivors of severe cervical traumatic spinal cord injury typically sustain substantial long-term functional impairment. Advances in our understanding of neuroregenerative strategies, especially stem cell transplantation, can offer the future hope of functional improvement to the many patients currently living with the consequences of traumatic spinal cord injury. Yet, at present, these therapies remain strictly investigational.

SUMMARY

The treatment of traumatic spinal cord injury remains supportive, and prognosis is still poor for patients who are severely affected. While much remains to be learned about how to optimize the acute management of these patients, future efforts would be most useful if focused on injury prevention and the development of effective neuroregenerative therapies.

Filling the Gap: Neural Stem Cells as A Promising Therapy for Spinal Cord Injury

Spinal cord injury (SCI) can lead to severe motor, sensory and social impairments having a huge impact on patients’ lives. The complex and time-dependent SCI pathophysiology has been hampering the development of novel and effective therapies. Current treatment options include surgical interventions, to stabilize and decompress the spinal cord, and rehabilitative care, without providing a cure for these patients. Novel therapies have been developed targeting different stages during trauma. Among them, cell-based therapies hold great potential for tissue regeneration after injury. Neural stem cells (NSCs), which are multipotent cells with inherent differentiation capabilities committed to the neuronal lineage, are especially relevant to promote and reestablish the damaged neuronal spinal tracts. Several studies demonstrate the regenerative effects of NSCs in SCI after transplantation by providing neurotrophic support and restoring synaptic connectivity. Therefore, human clinical trials have already been launched to assess safety in SCI patients. Here, we review NSC-based experimental studies in a SCI context and how are they currently being translated into human clinical trials.

Progression of local kyphosis after conservative treatment for compressive cervical spine fracture with spinal cord injury

Introduction

Compressive-flexion type cervical spine fracture is typically accompanied by apparent dislocation of the facet joints, undesirable cervical alignment, and devastating neurological dysfunction, which provides strong rationale for rendering prompt operative treatment. However, the validity of conservative treatment for compressive-flexion cervical spine injury in cases with preserved congruity of the facet joints has yet to be elucidated. The purpose of this study is to evaluate the long-term outcome of cervical alignment following conservative treatment for compressive-flexion cervical spine injury with preserved congruity of the facet joints.

Methods

A total of 662 patients who experienced spinal cord injury from 2007 to 2017 were included and underwent retrospective review in a single institute. Thirteen patients were identified as receiving conservative therapy following compressive-flexion cervical spine fractures with spinal cord injury. Clinical and radiological results were collected, including vertical fractures of the vertebral column, laminar fractures, progression of local kyphosis, and neurological status. The degree of the local cervical kyphosis was evaluated with two methods: the posterior tangent method and the endplate method.

Results

All 13 patients were male, and the mean age at the time of injury was 28.4 years. The mean follow-up period was 3 years. Although none of the patients presented neurological deterioration after the injury, the degree of local kyphosis was increased at the time of final follow-up compared to what was observed at the time of injury. Patient age at the time of injury and concurrent vertical fracture of vertebral body could have been influencing factors for the progression of the kyphosis. While laminar fracture affected the kyphosis at the time of injury, it was not a strong influencing factor of the overall progression of local kyphosis.

Conclusions

The conservative option for the compressive-flexion cervical injury allowed us to treat without exacerbating neurological symptoms as long as the facet joints are preserved. However, in terms of cervical alignment, surgical stabilization may have been desirable for these patients. Notably, the younger patients and the patients with vertical fracture of the cervical vertebral column in this type of injury required closer observation to help prevent the progression of local kyphosis.

Outcomes following an adaptive rock climbing program in a person with an incomplete spinal cord injury: A case report

Purpose: The purpose of this case report was to document outcomes following a rock climbing program for an individual with an incomplete spinal cord injury (SCI). Case Description: The participant was a 61 year-old male who sustained a C6 cervical AIS D SCI. Initially, he was only able to climb 30% of the rock wall with assistance and was unable to climb unassisted. Intervention: Outcome measures included muscle strength, arm girth, the Mini-Balance Evaluation Systems Test (Mini-BESTest), distance climbed, climbing performance, and the Quality of Life Profile for Adults with Physical Disabilities. The intervention included two 90-min sessions per week for 19 weeks. One session comprised traditional physical therapy and the second took place at an indoor rock climbing gym. Outcomes: Following the intervention, he was able to climb 100% of the wall with assistance and 48% unassisted. He made improvements in all categories of the quality of life scale, while changes in muscle strength and arm girth varied. No improvements were noted in balance. Conclusions: A task-based physical therapy program focusing on strengthening and rock climbing-specific activities improved the rock climbing ability of an individual with an incomplete cervical SCI.

Stimulation of paralysed quadriceps muscles with sequentially and spatially distributed electrodes during dynamic knee extension

BACKGROUND

During functional electrical stimulation (FES) tasks with able-bodied (AB) participants, spatially distributed sequential stimulation (SDSS) has demonstrated substantial improvements in power output and fatigue properties compared to conventional single electrode stimulation (SES). The aim of this study was to compare the properties of SDSS and SES in participants with spinal cord injury (SCI) in a dynamic isokinetic knee extension task simulating knee movement during recumbent cycling.

METHOD

Using a case-series design, m. vastus lateralis and medialis of four participants with motor and sensory complete SCI (AIS A) were stimulated for 6 min on both legs with both electrode setups. With SES, target muscles were stimulated by a pair of electrodes. In SDSS, the distal electrodes were replaced by four small electrodes giving the same overall stimulation frequency and having the same total surface area. Torque was measured during knee extension by a dynamometer at an angular velocity of 110 deg/s. Mean power of the left and right sides (P_meanL,R) was calculated from all stimulated extensions for initial, final and all extensions. Fatigue is presented as an index value with respect to initial power from 1 to 0, whereby 1 means no fatigue.

RESULTS

SDSS showed higher P_meanL,R values for all four participants for all extensions (increases of 132% in participant P1, 100% in P2, 36% in P3 and 18% in P4 compared to SES) and for the initial phase (increases of 84%, 59%, 66%, and 16%, respectively). Fatigue resistance was better with SDSS for P1, P2 and P4 but worse for P3 (0.47 vs 0.35, 0.63 vs 0.49, 0.90 vs 0.82 and 0.59 vs 0.77, respectively).

CONCLUSION

Consistently higher P_meanL,R was observed for all four participants for initial and overall contractions using SDSS. This supports findings from previous studies with AB participants. Fatigue properties were better in three of the four participants. The lower fatigue resistance with SDSS in one participant may be explained by a very low muscle activation level in this case. Further investigation in a larger cohort is warranted.

Minimally Invasive and Regenerative Therapeutics

Advances in biomaterial synthesis and fabrication, stem cell biology, bioimaging, microsurgery procedures, and microscale technologies have made minimally invasive therapeutics a viable tool in regenerative medicine. Therapeutics, herein defined as cells, biomaterials, biomolecules, and their combinations, can be delivered in a minimally invasive way to regenerate different tissues in the body, such as bone, cartilage, pancreas, cardiac, skeletal muscle, liver, skin, and neural tissues. Sophisticated methods of tracking, sensing, and stimulation of therapeutics in vivo using nano-biomaterials and soft bioelectronic devices provide great opportunities to further develop minimally invasive and regenerative therapeutics (MIRET). In general, minimally invasive delivery methods offer high yield with low risk of complications and reduced costs compared to conventional delivery methods. Here, minimally invasive approaches for delivering regenerative therapeutics into the body are reviewed. The use of MIRET to treat different tissues and organs is described. Although some clinical trials have been performed using MIRET, it is hoped that such therapeutics find wider applications to treat patients. Finally, some future perspective and challenges for this emerging field are highlighted.

Functional outcomes in geriatric patients with spinal cord injuries at a tertiary care rehabilitation hospital in Saudi Arabia

Study design

Retrospective study.

Objective

To identify demographic features, clinical characteristics, and complications associated with spinal cord injuries/disorders (SCI/D) among elderly individuals at a rehabilitation hospital and to measure the functional outcomes of rehabilitation.

Setting

Rehabilitation hospital in King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.

Methods

The study was conducted in elderly individuals (aged ≥65 years) with SCI/D, admitted to an inpatient rehabilitation program between October 2014 and 2015. Demographic and clinical data were recorded along with functional independence measure (FIM) score at admission (FIMa) and discharge (FIMd). Data were descriptively analyzed. Association of non-metric and metric variables with complications was measured using χ², and Student's t-test, respectively.

Results

Twenty-four individuals with SCI/D (95.8% were male and retired) with mean (standard deviation, SD) age of 72.3 (6.3) years were included. The most common co-morbidities were hypertension (75.0%), and diabetes mellitus (58.3%). Degenerative cervical myelopathy (33.3%) was the most common cause of SCD. Of all, nine (37.5%) individuals had clinical complications (urinary tract infection(UTI); 8/9, surgical wound infection; 1/9). Mean (SD) hospitalization period during inpatient rehabilitation was 66.0 (13.9) days. Mean (SD) FIMa scores improved from 71.7 (17.3) to 85.3 (16.8) at discharge. Co-morbidities associated with complications were peripheral vascular disease, ischemic heart disease, and stroke.

Conclusion

In Saudi Arabia, non-traumatic spinal etiologies are the most frequent cause of spinal cord dysfunction in the elderly. Male gender, hypertension, and diabetes mellitus were high-risk factors among the geriatric age group with SCI/D. Elderly individuals with SCI/D without complications can have a shorter hospitalization period and higher functional gains during rehabilitation.

First-in-Man Intrathecal Application of Neurite Growth-Promoting Anti-Nogo-A Antibodies in Acute Spinal Cord Injury

Background. Neutralization of central nervous system neurite growth inhibitory factors, for example, Nogo-A, is a promising approach to improving recovery following spinal cord injury (SCI). In animal SCI models, intrathecal delivery of anti-Nogo-A antibodies promoted regenerative neurite growth and functional recovery. Objective. This first-in-man study assessed the feasibility, safety, tolerability, pharmacokinetics, and preliminary efficacy of the human anti-Nogo-A antibody ATI355 following intrathecal administration in patients with acute, complete traumatic paraplegia and tetraplegia. Methods. Patients (N = 52) started treatment 4 to 60 days postinjury. Four consecutive dose-escalation cohorts received 5 to 30 mg/2.5 mL/day continuous intrathecal ATI355 infusion over 24 hours to 28 days. Following pharmacokinetic evaluation, 2 further cohorts received a bolus regimen (6 intrathecal injections of 22.5 and 45 mg/3 mL, respectively, over 4 weeks). Results. ATI355 was well tolerated up to 1-year follow-up. All patients experienced ≥1 adverse events (AEs). The 581 reported AEs were mostly mild and to be expected following acute SCI. Fifteen patients reported 16 serious AEs, none related to ATI355; one bacterial meningitis case was considered related to intrathecal administration. ATI355 serum levels showed dose-dependency, and intersubject cerebrospinal fluid levels were highly variable after infusion and bolus injection. In 1 paraplegic patient, motor scores improved by 8 points. In tetraplegic patients, mean total motor scores increased, with 3/19 gaining >10 points, and 1/19 27 points at Week 48. Conversion from complete to incomplete SCI occurred in 7/19 patients with tetraplegia. Conclusions. ATI335 was well tolerated in humans; efficacy trials using intrathecal antibody administration may be considered in acute SCI.