Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal Cord. 2012;50:365-372. [PMID: 22270188 DOI: 10.1038/sc.2011.178]

Transcutaneous spinal cord stimulation combined with locomotor training to improve walking ability in people with chronic spinal cord injury: study protocol for an international multi-centred double-blinded randomised sham-controlled trial (eWALK)

STUDY DESIGN

An international multi-centred, double-blinded, randomised sham-controlled trial (eWALK).

OBJECTIVE

To determine the effect of 12 weeks of transcutaneous spinal stimulation (TSS) combined with locomotor training on walking ability in people with spinal cord injury (SCI).

SETTING

Dedicated SCI research centres in Australia, Spain, USA and Scotland.

METHODS

Fifty community-dwelling individuals with chronic SCI will be recruited. Participants will be eligible if they have bilateral motor levels between T1 and T11, a reproducible lower limb muscle contraction in at least one muscle group, and a Walking Index for SCI II (WISCI II) between 1 and 6. Eligible participants will be randomised to one of two groups, either the active stimulation group or the sham stimulation group. Participants allocated to the stimulation group will receive TSS combined with locomotor training for three 30-min sessions a week for 12 weeks. The locomotor sessions will include walking on a treadmill and overground. Participants allocated to the sham stimulation group will receive the same locomotor training combined with sham stimulation. The primary outcome will be walking ability with stimulation using the WISCI II. Secondary outcomes will record sensation, strength, spasticity, bowel function and quality of life.

TRIAL REGISTRATION

ANZCTR.org.au identifier ACTRN12620001241921.

Quantitative cervical spine injury responses in whiplash loading with a numerical method of natural neural reflex consideration

BACKGROUND AND OBJECTIVE

Neural reflex is hypothesized as a regulating step in spine stabilizing system. However, neural reflex control is still in its infancy to consider in the previous finite element analysis of head-neck system for various applications. The purpose of this study is to investigate the influences of neural reflex control on neck biomechanical responses, then provide a new way to achieve an accurate biomechanical analysis for head-neck system with a finite element model.

METHODS

A new FE head-neck model with detailed active muscles and spinal cord modeling was established and globally validated at multi-levels. Then, it was coupled with our previously developed neuromuscular head-neck model to analyze the effects of vestibular and proprioceptive reflexes on biomechanical responses of head-neck system in a typical spinal injury loading condition (whiplash). The obtained effects were further analyzed by comparing a review of epidemiologic data on cervical spine injury situations.

RESULT

The results showed that the active model (AM) with neural reflex control obviously presented both rational head-neck kinematics and tissue injury risk referring to the previous experimental and epidemiologic studies, when compared with the passive model (PM) without it. Tissue load concentration locations as well as stress/strain levels were both changed due to the muscle activation forces caused by neural reflex control during the whole loading process. For the bony structures, the AM showed a peak stress level accounting for only about 25% of the PM. For the discs, the stress concentrated location was transferred from C2-C6 in the PM to C4-C6 in the AM. For the spinal cord, the strain concentrated locations were transferred from C1 segment to around C4 segment when the effects of neural reflex control were implemented, while the gray matter and white matter peak strains were reduced to 1/3 and 1/2 of the PM, respectively. All these were well correlated with epidemiological studies on clinical cervical spine injuries.

CONCLUSION

In summary, the present work demonstrated necessity of considering neural reflex in FE analysis of a head-neck system as well as our model biofidelity. Overall results also verified the previous hypothesis and further quantitatively indicated that the muscle activation caused by neural reflex is providing a protection for the neck in impact loading by decreasing the strain level and changing the possible injury to lower spinal cord level to reduce injury severity.

Bicycle-related cervical spine injuries

Background

Bicyclists are vulnerable road users. The aim of this paper was to describe all bicycle-related traumatic cervical spine injuries (CSIs) in the South-East region of Norway (2015-2019), and to investigate whether certain types of CSIs are typical for bicyclists.

Methods

Retrospective cohort study of prospectively collected registry data of all CSIs in the South-East region of Norway (3.0 million inhabitants), from 2015 to 2019. Patient characteristics, injury types, and treatment were summarized with descriptive statistics. Bayesian multivariable logistic regression was used to identify potential factors associated with occipital condyle fractures (OC-Fx) or odontoid fractures (OFx).

Results

During the five-year study period, 2,162 patients with CSIs were registered, and 261 (12%) were bicycle-related. The incidence of bicycle-related CSIs was 1.7/100,000 person-years. The median age of the patients with bicycle-related CSIs was 55 (IQR: 22) years, 83% were male, 71% used a helmet, 16% were influenced by ethanol, 12% had a concomitant cervical spinal cord injury (SCI), and 64% sustained multiple traumas. The three most common bicycle-related CSIs were C6/C7 fracture (Fx) (28%), occipital condyle Fx (OC-Fx) (23%) and C5/C6 Fx (19%). Patients with bicycle-related CSIs compared to patients with non-bicycle related CSIs were younger, more often male, had fewer comorbidities, more likely multiple traumas, more often had OC-Fx, and less often sustained an odontoid fracture (OFx). Multivariable logistic regression of potential risk factors for OC-Fx demonstrated a significantly increased risk of OC-Fx for bicyclists compared to non-bicyclists (OR=2.8).The primary treatment for bicycle-related CSIs was external immobilization in 187/261 (71.6%) cases, open surgical fixation in 44/261 (16.8%), and no treatment in 30/261 (11.5%).

Conclusion

Bicycle crashes are a frequent cause of CSIs in the Norwegian population and should be of concern to the public society. The three most common bicycle-related CSIs were C6/C7 fracture, occipital condyle fracture and C5/C6 fracture.

A Direct Comparison of Physical Versus Dihydrocapsaicin-Induced Hypothermia in a Rat Model of Traumatic Spinal Cord Injury

Spinal cord injury (SCI) is a devastating neurological condition with no effective treatment. Hypothermia induced by physical means (cold fluid) is established as an effective therapy in animal models of SCI, but its clinical translation to humans is hampered by several constraints. Hypothermia induced pharmacologically may be noninferior or superior to physically induced hypothermia for rapid, convenient systemic temperature reduction, but it has not been investigated previously in animal models of SCI. We used a rat model of SCI to compare outcomes in three groups: (1) normothermic controls; (2) hypothermia induced by conventional physical means; (3) hypothermia induced by intravenous (IV) dihydrocapsaicin (DHC). Male rats underwent unilateral lower cervical SCI and were treated after a 4-hour delay with physical cooling or IV DHC (∼0.60 mg/kg total) cooling (both 33.0 ± 1.0°C) lasting 4 hours; controls were kept normothermic. Telemetry was used to monitor temperature and heart rate during and after treatments. In two separate experiments, one ending at 48 hours, the other at 6 weeks, “blinded” investigators evaluated rats in the three groups for neurological function followed by histopathological evaluation of spinal cord tissues. DHC reliably induced systemic cooling to 32–33°C. At both the time points examined, the two modes of hypothermia yielded similar improvements in neurological function and lesion size compared with normothermic controls. Our results indicate that DHC-induced hypothermia may be comparable with physical hypothermia in efficacy, but more clinically feasible to administer than physical hypothermia.

Transcriptome-Wide N6-Methyladenosine Methylome Alteration in the Rat Spinal Cord After Acute Traumatic Spinal Cord Injury

Recent studies showed that RNA N6-methyladenosine (m6A) plays an important role in neurological diseases. We used methylated RNA immunoprecipitation sequencing (MeRIP-Seq) technology to generate the m6A modification map after traumatic spinal cord injury (TSCI). A total of 2,609 differential m6A peaks were identified after TSCI. Our RNA sequencing results after TSCI showed 4,206 genes with significantly altered expression. Cross-link analysis of m6A sequencing results and RNA sequencing results showed that 141 hyper-methylated genes were upregulated, 53 hyper-methylated genes were downregulated, 57 hypo-methylated genes were upregulated, and 197 hypo-methylated genes were downregulated. Among these, the important inflammatory response factor Tlr4 and the important member of the neurotrophin family Ngf were both upregulated and hyper-methylated after TSCI. This study provides that in the future, the epigenetic modifications of the genes could be used as an indicator of TSCI.

Central Neuropathic Pain Syndromes: Current and Emerging Pharmacological Strategies

Central neuropathic pain is caused by a disease or lesion of the brain or spinal cord. It is difficult to predict which patients will develop central pain syndromes after a central nervous system injury, but depending on the etiology, lifetime prevalence may be greater than 50%. The resulting pain is often highly distressing and difficult to treat, with no specific treatment guidelines currently available. This narrative review discusses mechanisms contributing to central neuropathic pain, and focuses on pharmacological approaches for managing common central neuropathic pain conditions such as central post-stroke pain, spinal cord injury-related pain, and multiple sclerosis-related neuropathic pain. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids have some evidence for efficacy in central neuropathic pain. Medications from other pharmacologic classes may also provide pain relief, but current evidence is limited. Certain non-pharmacologic approaches, neuromodulation in particular, may be helpful in refractory cases. Emerging data suggest that modulating the primary afferent input may open new horizons for the treatment of central neuropathic pain. For most patients, effective treatment will likely require a multimodal therapy approach.

Developing a National Trauma Research Action Plan: Results from the Neurotrauma Research Panel Delphi Survey

BACKGROUND

In 2016, the National Academies of Science, Engineering and Medicine called for the development of a National Trauma Research Action Plan. The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. Given the public health burden of injuries to the central nervous system, neurotrauma was one of 11 panels formed to address this recommendation with a gap analysis and generation of high-priority research questions.

METHODS

We recruited interdisciplinary experts to identify gaps in the neurotrauma literature, generate research questions, and prioritize those questions using a consensus-driven Delphi survey approach. We conducted four Delphi rounds in which participants generated key research questions and then prioritized the importance of the questions on a 9-point Likert scale. Consensus was defined as 60% or greater of panelists agreeing on the priority category. We then coded research questions using an National Trauma Research Action Plan taxonomy of 118 research concepts, which were consistent across all 11 panels.

RESULTS

Twenty-eight neurotrauma experts generated 675 research questions. Of these, 364 (53.9%) reached consensus, and 56 were determined to be high priority (15.4%), 303 were deemed to be medium priority (83.2%), and 5 were low priority (1.4%). The research topics were stratified into three groups-severe traumatic brain injury (TBI), mild TBI (mTBI), and spinal cord injury. The number of high-priority questions for each subtopic was 46 for severe TBI (19.7%), 3 for mTBI (4.3%) and 7 for SCI (11.7%).

CONCLUSION

This Delphi gap analysis of neurotrauma research identified 56 high-priority research questions. There are clear areas of focus for severe TBI, mTBI, and spinal cord injury that will help guide investigators in future neurotrauma research. Funding agencies should consider these gaps when they prioritize future research.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level IV.

The past, present, and future of traumatic spinal cord injury therapies: a review

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Body Representation in Patients with Severe Spinal Cord Injury: A Pilot Study on the Promising Role of Powered Exoskeleton for Gait Training

Patients with spinal cord injury (SCI) complain of changes in body representation, potentially leading to negative physical and psychological consequences. The purpose of our study is to evaluate the effects of robotic training with the Ekso-GT on body representation (BR) and on the quality of life in patients with SCI. The trial was designed as a pilot, assessor-blinded study. Forty-two inpatients with a diagnosis of SCI, classified as either American Spinal Cord Injury Association Impairment Scale (AIS), were enrolled in this study and randomized into either a control (CG: n = 21) or an experimental (EG: n = 21) group. Patients in the EG received rehabilitation training with the Ekso-GT device, whereas the CG patients were trained with conventional physical therapy (CPT), which consisted of physical and occupational therapy and psychological support. We considered as a primary outcome the modified Body Uneasiness Test (MBUT), focusing on three specific subscales on the patient’s perception of BR, i.e., the Global Severity Index (MBUT-GSI), which is an indicator of body suffering; the Positive Symptom Distress Index (MBUT-PSDI) that expresses an individual’s psychological distress; and the Lower Limb MBUT (MBUT-LL), which indicates the subject’s perception of their thighs/legs. The Short-Form-12 Health Status Questionnaire (SF12) and the Beck’s Depression Inventory (BDI) were used as secondary outcomes to evaluate the effect of the training on the quality of life and the psychological status. Non-parametric statistical analysis showed that the effect of the two treatments was significantly different on MBUT (BR), SF-12 (quality of life), and, partially, BDI (mood). Particularly, patients belonging to the EG achieved a major improvement in nearly all test scores compared to those in the CG. Our data suggest that the Ekso-GT training could be helpful in achieving positive changes in BR in patients with chronic SCI, especially in reducing psychological distress (PSDI) and thigh/leg perception (MBUT-LL) with an overall improvement in quality of life (SF-12).

Expert-augmented automated machine learning optimizes hemodynamic predictors of spinal cord injury outcome

Artificial intelligence and machine learning (AI/ML) is becoming increasingly more accessible to biomedical researchers with significant potential to transform biomedicine through optimization of highly-accurate predictive models and enabling better understanding of disease biology. Automated machine learning (AutoML) in particular is positioned to democratize artificial intelligence (AI) by reducing the amount of human input and ML expertise needed. However, successful translation of AI/ML in biomedicine requires moving beyond optimizing only for prediction accuracy and towards establishing reproducible clinical and biological inferences. This is especially challenging for clinical studies on rare disorders where the smaller patient cohorts and corresponding sample size is an obstacle for reproducible modeling results. Here, we present a model-agnostic framework to reinforce AutoML using strategies and tools of explainable and reproducible AI, including novel metrics to assess model reproducibility. The framework enables clinicians to interpret AutoML-generated models for clinical and biological verifiability and consequently integrate domain expertise during model development. We applied the framework towards spinal cord injury prognostication to optimize the intraoperative hemodynamic range during injury-related surgery and additionally identified a strong detrimental relationship between intraoperative hypertension and patient outcome. Furthermore, our analysis captured how evolving clinical practices such as faster time-to-surgery and blood pressure management affect clinical model development. Altogether, we illustrate how expert-augmented AutoML improves inferential reproducibility for biomedical discovery and can ultimately build trust in AI processes towards effective clinical integration.

Demographic and Health Profiles of People Living With Traumatic Spinal Cord Injury in the United States During 2015-2019: Findings from the Spinal Cord Injury Model Systems Database

OBJECTIVE

To estimate the population profile of people living with traumatic spinal cord injury (TSCI) to help evaluate health care needs of this aging population.

DESIGN

Cross-sectional study.

SETTING

SCI Model Systems (SCIMS) centers in the United States.

PARTICIPANTS

Individuals (N=20,437) who: (1) incurred a TSCI between 1972 and 2019, (2) were initially treated at one of the SCIMS centers, and (3) were alive during the period from 2015 to 2019.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographics, injury characteristics, health conditions, and social participation, as compared with previous estimates in 2008 and general population statistics in 2017.

RESULTS

People living with TSCI during the period from 2015-2019 (mean years since injury, 18y; 79.4% male, and 62.5% White) were older (51.6 vs 45.0y) and had a higher percentage of C1-C4 (21.9% vs 17.0%) and American Spinal Injury Association Impairment Scale D injuries (31.5% vs 26.0%) compared with the 2008 TSCI population profile. Although the proportion of people with a bachelor's degree or higher was similar between the TSCI and general US populations (30.7% vs 32.0%), the employment rate was lower in the TSCI population (24.0% vs 59.5%). People are affected by various medical problems over time post TSCI. The prevalence of pain and urinary tract infection remained high over postinjury years, at 86.1% and 52.6%, respectively. Rehospitalization and depression were most common during the first year (34.9% and 22.3%, respectively), and pressure injury was more common among those 20 years or more postinjury (>30.0%). Health conditions declined with advanced age, including self-perceived health, diabetes, and institutional residence. People who survived TSCI for years, however, had relatively good degrees of independence and social participation.

CONCLUSION

Study findings highlight the need for greater involvement of primary care providers and geriatricians in the continuity of care for SCI to promote healthy aging. Improvement in employment should also be the target in promoting social participation and quality of life.

The science and engineering behind sensitized brain-controlled bionic hands

Advances in our understanding of brain function, along with the development of neural interfaces that allow for the monitoring and activation of neurons, have paved the way for brain-machine interfaces (BMIs), which harness neural signals to reanimate the limbs via electrical activation of the muscles or to control extracorporeal devices, thereby bypassing the muscles and senses altogether. BMIs consist of reading out motor intent from the neuronal responses monitored in motor regions of the brain and executing intended movements with bionic limbs, reanimated limbs, or exoskeletons. BMIs also allow for the restoration of the sense of touch by electrically activating neurons in somatosensory regions of the brain, thereby evoking vivid tactile sensations and conveying feedback about object interactions. In this review, we discuss the neural mechanisms of motor control and somatosensation in able-bodied individuals and describe approaches to use neuronal responses as control signals for movement restoration and to activate residual sensory pathways to restore touch. Although the focus of the review is on intracortical approaches, we also describe alternative signal sources for control and noninvasive strategies for sensory restoration.

The effect of extracorporeal shock wave therapy in acute traumatic spinal cord injury on motor and sensory function within 6 months post-injury: a study protocol for a two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled clinical trial

Background

The pathological mechanism in acute spinal cord injury (SCI) is dual sequential: the primary mechanical lesion and the secondary injury due to a cascade of biochemical and pathological changes initiated by the primary lesion. Therapeutic approaches have focused on modulating the mechanisms of secondary injury. Despite extensive efforts in the treatment of SCI, there is yet no causal, curative treatment approach available.

Extracorporeal shock wave therapy (ESWT) has been successfully implemented in clinical use. Biological responses to therapeutic shock waves include altered metabolic activity of various cell types due to direct and indirect mechanotransduction leading to improved migration, proliferation, chemotaxis, modulation of the inflammatory response, angiogenesis, and neovascularization, thus inducing rather a regeneration than repair.

The aim of this clinical study is to investigate the effect of ESWT in humans within the first 48 h after an acute traumatic SCI, with the objective to intervene in the secondary injury phase in order to reduce the extent of neuronal loss.

Methods

This two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled study has been initiated in July 2020, and a total of 82 patients with acute traumatic SCI will be recruited for the first stage in 15 participating hospitals as part of a two-armed three-stage adaptive trial design. The focused ESWT (energy flux density: 0.1–0.19 mJ/mm², frequency: 2–5 Hz) is applied once at the level of the lesion, five segments above/below, and on the plantar surface of both feet within the first 48 h after trauma.

The degree of improvement in motor and sensory function after 6 months post-injury is the primary endpoint of the study. Secondary endpoints include routine blood chemistry parameters, the degree of spasticity, the ability to walk, urological function, quality of life, and the independence in everyday life.

Discussion

The application of ESWT activates the nervous tissue regeneration involving a multitude of various biochemical and cellular events and leads to a decreased neuronal loss. ESWT might contribute to an improvement in the treatment of acute traumatic SCI in future clinical use.

Trial registration

ClinicalTrials.govNCT04474106

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06161-8.

General and bladder-related quality of life: A focus on women living with spinal cord injury

OBJECTIVE

To compare bladder symptoms, and urinary and overall quality of life (QOL) among women and men after Spinal cord injury (SCI), and to describe specific aspects of QOL among women with SCI.

METHODS

We used data from a prospective, multi-center, and cross-sectional study that was carried out from May 2019 to September 2020. Clinical and demographic details were obtained and participants completed two patient reported outcomes: the neurogenic bladder symptoms score-short form (NBSS-SF, which measures bladder symptoms and QOL) and the SF-12 (which measures overall physical and mental health QOL).

RESULTS

Our cohort included 135 women and 210 men with SCI. Among the women, the median age was 50, and 40% had a cervical SCI. For general QOL, women with SCI had physical functioning scores similar to men, but lower mental health scores on the SF-12 (46.85 vs. 49.76, p = 0.01). Women had significantly worse overall NBSS (10.76 vs. 9.08, p < 0.001) and NBSS continence domain scores (4.71 vs. 3.66, p < 0.001) compared to men. There were significant differences between overall QOL measures, and bladder symptoms based on bladder management techniques among the women. NBSS-SF symptom scores were better among women who used overactive bladder medications compared to women who did not (8.43 vs. 11.9, p = 0.02) and NBSS-SF QOL domain scores were significantly better among women who underwent surgery and those that used overactive bladder medications.

CONCLUSIONS

Women have more bladder symptoms (specifically incontinence) compared to men. Symptom burden and overall QOL vary among women who use different bladder management techniques and treatments.

Clinical Trials Using Mesenchymal Stem Cells for Spinal Cord Injury: Challenges in Generating Evidence

Spinal cord injury (SCI) remains an important public health problem which often causes permanent loss of muscle strength, sensation, and function below the site of the injury, generating physical, psychological, and social impacts throughout the lives of the affected individuals, since there are no effective treatments available. The use of stem cells has been investigated as a therapeutic approach for the treatment of SCI. Although a significant number of studies have been conducted in pre-clinical and clinical settings, so far there is no established cell therapy for the treatment of SCI. One aspect that makes it difficult to evaluate the efficacy is the heterogeneity of experimental designs in the clinical trials that have been published. Cell transplantation methods vary widely among the trials, and there are still no standardized protocols or recommendations for the therapeutic use of stem cells in SCI. Among the different cell types, mesenchymal stem/stromal cells (MSCs) are the most frequently tested in clinical trials for SCI treatment. This study reviews the clinical applications of MSCs for SCI, focusing on the critical analysis of 17 clinical trials published thus far, with emphasis on their design and quality. Moreover, it highlights the need for more evidence-based studies designed as randomized controlled trials and potential challenges to be addressed in context of stem cell therapies for SCI.

Effect of Velocity and Contact Stress Area on the Dynamic Behavior of the Spinal Cord Under Different Testing Conditions

Knowledge of the dynamic behavior of the spinal cord under different testing conditions is critical for our understanding of biomechanical mechanisms of spinal cord injury. Although velocity and contact stress area are known to affect external mechanical stress or energy upon sudden traumatic injury, quantitative investigation of the two clinically relevant biomechanical variables is limited. Here, freshly excised rat spinal-cord–pia-arachnoid constructs were tested through indentation using indenters of different sizes (radii: 0.25, 0.50, and 1.00 mm) at various loading rates ranging from 0.04 to 0.20 mm/s. This analysis found that the ex vivo specimen displayed significant nonlinear viscoelasticity at <10% of specimen thickness depth magnitudes. At higher velocity and larger contact stress area, the cord withstood a higher peak load and exhibited more sensitive mechanical relaxation responses (i.e., increasing amplitude and speed of the drop in peak load). Additionally, the cord became stiffer (i.e., increasing elastic modulus) and softer (i.e., decreasing elastic modulus) at a higher velocity and larger contact stress area, respectively. These findings will improve our understanding of the real-time complex biomechanics involved in traumatic spinal cord injury.

Cervical spinal hemisection alters phrenic motor neuron glutamatergic mRNA receptor expression

Upper cervical spinal cord injuries (SCI) disrupt descending inputs to phrenic motor neurons (PhMNs), impairing respiratory function. Unilateral spinal hemisection at C2 (C2SH) results in loss of ipsilateral rhythmic diaphragm muscle (DIAm) EMG activity associated with lower force behaviors accomplished by recruitment of smaller PhMNs that recovers over time in rats. Activity during higher force, non-ventilatory behaviors that recruit larger PhMNs is minimally impaired following C2SH. We previously showed neuroplasticity in glutamatergic receptor expression in PhMN post-C2SH with changes in NMDA receptor expression reflecting functional recovery. We hypothesize that C2SH-induced changes in glutamatergic receptor (AMPA and NMDA) mRNA expression in PhMNs vary with motor neuron size, with more pronounced changes in smaller PhMNs. Retrogradely-labelled PhMNs were classified in tertiles according to somal surface area and mRNA expression was measured using single-cell, multiplex fluorescence in situ hybridization. Ipsilateral to C2SH, a pronounced reduction in NMDA mRNA expression in PhMNs was evident at 3 days post-injury with similar impact on PhMNs in the lower size tertile (~68% reduction) and upper tertile (~60%); by 21DSH, there was near complete restoration of NMDA receptor mRNA expression across all PhMNs. There were no changes in NMDA mRNA expression contralateral to C2SH. There were no changes in AMPA mRNA expression at PhMNs on either side of the spinal cord or at any time-point post-C2SH. In summary, following C2SH there is ipsilateral reduction in PhMN NMDA mRNA expression at 3DSH that is not limited to smaller PhMN recruited in the generation of lower force ventilatory behaviors. The recovery of NMDA mRNA expression by 21DSH is consistent with evidence of spontaneous recovery of ipsilateral DIAm activity at this timepoint. These findings suggest a possible role for NMDA receptor mediated glutamatergic signaling in mechanisms supporting postsynaptic neuroplasticity at the PhMN pool and recovery of DIAm activity after cervical SCI.

The fourth column of the spine: Prevalence of sternal fractures and concurrent thoracic spinal fractures

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

This study aimed to identify the prevalence of concomitant thoracic spinal and sternal fractures and factors associated with concomitant fractures.

SUMMARY OF BACKGROUND DATA

The sternum has been implicated in stability of the upper thoracic spine, and both bony structures are included in the stable upper thoracic cage. High force trauma to the thorax can cause multiple fractures to different upper thoracic cage components.

METHODS

This is a retrospective analysis of electronic medical record data of patients treated at a Level 1 Trauma Center who underwent surgery for thoracic spinal fracture between 2008-2020. We recorded presence of concomitant sternal fracture, injury characteristics, hospital course data, and demographic information.

RESULTS

107 patients with thoracic spinal fractures had a sternal fracture prevalence of 18.7%. The average age was 53.2 [15-90]. 72 (67.3%) were male and 35 (32.7%) were female, 92 (85.9%) were White, 10 (9.3%) were African American, 3 (2.8%) were Hispanic, and 2 (1.9%) were Asian. The average age of patients with sternal fractures was 48.7 years, compared to those without sternal fractures, 54.3 years (P = 0.251). Patients with T1-T7 fractures [14 of 48 (29.2%)] had a significantly higher rate of sternal fractures compared to patients with T8-T12 fractures [6 of 59 (10.2%)] (P = 0.012). Patients with additional rib (P < 0.001), scapula (P = 0.01), clavicle fractures (P = 0.01), and those with multiple other thoracic fractures (P = 0.01) had significantly higher rates of sternal fractures compared to patients without these. Patients with concomitant sternal fractures [10 of 20 (50.0%)] had a significantly higher rate of respiratory complication during their hospital course than patients without concomitant sternal fracture [40 of 87 (46.0%)] (P < 0.001). Sex, age, mechanism of injury, fracture morphology, estimated blood loss during surgery, intraoperative complications, post-surgical intubation status, and post-surgical intubation duration were not associated with sternal fractures.

CONCLUSIONS

The prevalence of concomitant thoracic spinal fracture and sternal fracture in our series is 18.7%. T1-T7 fractures and presence of rib, scapula, and clavicle fractures were significantly associated with the presence of sternal fractures. Presence of concomitant sternal fracture was significantly associated with respiratory complication during hospital course.

Incidence of bladder cancer in neuro-urological patients in France: a nationwide study

PURPOSE

The purpose of this study was to evaluate the incidence of bladder cancer (BCa) in patients with the main neurological diseases that induce neurogenic lower urinary tract dysfunction, namely, multiple sclerosis (MS), spinal cord injury (SCI) and spina bifida (SB).

METHODS

We conducted a retrospective analysis of nationwide data from the French Hospital Discharge Database (PMSI) from January 2010 to December 2018. The incidence of BCa was calculated in patients with MS, SCI and SB. Incidence, sex, age, radical cystectomy after BCa diagnosis and in-hospital deaths were compared between the three groups. The Chi² and Kruskal-Wallis tests were used for qualitative and quantitative data comparisons, respectively.

RESULTS

Overall, 2015 neuro-urological patients (mean (± SD) age: 65.4 ± 12.3 years) were hospitalized in France between 2010 and 2018 with a new diagnosis of BCa. In neuro-urological patients, BCa was more frequent in men than in women (sex ratio: 3.08). The incidence of BCa in neuro-urological patients was 174.9/100,000 persons/year. The incidence of BCa was 791.1/100,000 persons/year in SCI compared to 56.6 in MS and 113.8 in SB (p < 0.0001). After the initial diagnosis of BCa, 551 (27.3%) patients underwent a radical cystectomy and 613 (30.4%) died in hospital after BCa diagnosis.

CONCLUSIONS

The incidence of BCa in France between 2010 and 2018 was 174.9/100 000 persons/year, and was particularly high in patients with SCI.

Regenerative Rehabilitation and Stem Cell Therapy Targeting Chronic Spinal Cord Injury: A Review of Preclinical Studies

Stem cell medicine has led to functional recovery in the acute-to-subacute phase of spinal cord injury (SCI), but not yet in the chronic phase, during which various molecular mechanisms drastically remodel the tissue and render it treatment-resistant. Researchers are attempting to identify effective combinatorial treatments that can overcome the refractory state of the chronically injured spinal cord. Regenerative rehabilitation, combinatorial treatment with regenerative medicine that aims to elicit synergistic effects, is being developed. Rehabilitation upon SCI in preclinical studies has recently attracted more attention because it is safe, induces neuronal plasticity involving transplanted stem cells and sensorimotor circuits, and is routinely implemented in human clinics. However, regenerative rehabilitation has not been extensively reviewed, and only a few reviews have focused on the use of physical medicine modalities for rehabilitative purposes, which might be more important in the chronic phase. Here, we summarize regenerative rehabilitation studies according to the effector, site, and mechanism. Specifically, we describe effects on transplanted cells, microstructures at and distant from the lesion, and molecular changes. To establish a treatment regimen that induces robust functional recovery upon chronic SCI, further investigations are required of combinatorial treatments incorporating stem cell therapy, regenerative rehabilitation, and medication.

Comparison of Patient Preference, Understanding, and Sentiment for Minimally Invasive Versus Open Spine Surgery

STUDY DESIGN

Retrospective questionnaire analysis.

OBJECTIVE

The goal of this study was to analyze patients' understanding and preferences for minimally invasive spine (MIS) versus open spine surgery.

SUMMARY OF BACKGROUND DATA

MIS surgery is increasing in prevalence. However, there is insufficient literature to evaluate how the availability of MIS surgery influences the patients' decision-making process and perceptions of spine procedures.

METHODS

A survey was administered to patients who received a microdiscectomy or transforaminal lumbar interbody fusion between 2016 and 2020. All eligible patients were stratified into two cohorts based on the use of minimally invasive techniques. Each cohort was administered a survey that evaluated patient preferences, perceptions, and understanding of their surgery.

RESULTS

One hundred fifty two patients completed surveys (MIS: 88, Open: 64). There was no difference in time from surgery to survey (MIS: 2.1 ± 1.4 yrs, Open: 1.9 ± 1.4 yrs; P = 0.36) or sex (MIS: 56.8% male, Open: 53.1% male; P = 0.65). The MIS group was younger (MIS: 53.0 ± 16.9 yrs, Open: 58.2 ± 14.6 yrs; P = 0.05). More MIS patients reported that their technique influenced their surgeon choice (MIS: 64.0%, Open: 37.5%; P  < 0.00001) and increased their preoperative confidence (MIS: 77.9%, Open: 38.1%; P  < 0.00001). There was a trend towards the MIS group being less informed about the intraoperative specifics of their technique (MIS: 35.2%, Open: 23.4%; P = 0.12). More of the MIS cohort reported perceived advantages to their surgical technique (MIS: 98.8%, Open: 69.4%; P < 0.00001) and less reported disadvantages (MIS: 12.9%, Open: 68.8%; P < 0.00001). 98.9% and 87.1% of the MIS and open surgery cohorts reported a preference for MIS surgery in the future.

CONCLUSION

Patients who received a MIS approach more frequently sought out their surgeons, were more confident in their procedure, and reported less perceived disadvantages following their surgery compared with the open surgery cohort. Both cohorts would prefer MIS surgery in the future. Overall, patients have positive perceptions of MIS surgery.Level of Evidence: 3.

Influence of age on acute traumatic spinal cord injury in Saint Petersburg, Russia

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate influence of age after traumatic spinal cord injury (TSCI).

SETTING

13 specialized hospitals with neurosurgical departments of Saint Petersburg, Russia.

METHODS

Charts of all patients admitted with TSCI to the city hospitals 2012-2016. Demographic and clinical characteristics, surgical interventions, complications, mortality rate, and hospital stays were recorded.

RESULTS

311 patients with TSCI were included. TSCI was more common in younger age. Mean age (SD) was 42.4 (16.8) years. Patients were divided into four age groups: 18-29, 30-44, 45-59 and ≥60 years. The group ≥60 years had the lowest percentage of concomitant traumatic brain injury (TBI), 25%, versus 43% in TSCI < 60 years, p < 0.05. Low falls were the most frequent cause in patients aged 60 years and older, and led to less severe neurological deficits (p < 0.05). Complications were most frequent in motor complete TSCI (AIS A and AIS B) and in persons with combined TSCI and TBI at older age. Total complication rate was 67% at the age of ≥60 years versus 38% <60 years in TSCI with TBI (p < 0.05). Respiratory complications occurred in 67% ≥45 years versus 45% <45 years, p < 0.05. In-hospital mortality rate after TSCI was higher in the oldest age group.

CONCLUSIONS

Respiratory complications are common and the in-hospital mortality is higher among elderly people. Older patients with TSCI and TBI are at high risk for complications.

Development of a clinical prediction rule for patients with cervical spinal cord injury who have difficulty in obtaining independent living

BACKGROUND CONTEXT

A simple and easy to use clinical prediction rule (CPR) to detect patients with a cervical spinal cord injury (SCI) who would have difficulty in obtaining independent living status is vital for providing the optimal rehabilitation and education in both care recipients and caregivers. A machine learning approach was recently applied to the field of rehabilitation and has the possibility to develop an accurate and useful CPR.

PURPOSE

The aim of this study was to develop and assess a CPR using a decision tree algorithm for predicting which patients with a cervical SCI would have difficulty in obtaining an independent living.

STUDY DESIGN

The present study was a cohort study.

PATIENT SAMPLE

In the present study, the data was obtained from the nationwide Japan Rehabilitation Database (JRD). The data on the SCIs was collected from 10 hospitals and the data was collected from the registries obtained between 2005 and 2015. The severity of SCI can vary, and patient prognosis differs depending on the damage site. In this study, the patients with cervical SCI were included.

OUTCOME MEASURES

In this study, the degree of the independent living at discharge was investigated. The degree of the independent living was classified and listed as below: independent in social, independent at home, need care at home, independent at facility, need care at facility. In this study, the independent in social and independent at home were defined as "independent," and the other situations were defined as "non-independent."

METHODS

We performed a classification and regression tree (CART) analysis to develop the CPR to predict whether the cervical SCI patients obtain an independent living at discharge. The area under the curve, the classification accuracy, sensitivity, specificity, and positive predictive value were used for model evaluation.

RESULTS

A total of 4181 patients with SCI were registered in the JRD and the CART analysis was performed for 1282 patients with the cervical SCI. The Functional Independence Measure (FIM) total score and the American Spinal Injury Association impairment scale were identified as the first and second discriminators for predicting the degree of the independence, respectively. Subsequently, the CART model identified FIM eating, the residual function level, and the FIM bed to chair transfer as next discriminators. Each parameter for evaluating the CART model were the area under the curve 0.813, the classification accuracy 78.6%, the sensitivity 80.7%, the specificity 75.1%, and the positive predictive value 84.5%.

CONCLUSIONS

In this study, we developed a clinically useful CPR with moderate accuracy to predict whether the cervical SCI patients obtain independent living at the discharge.

Pediatric Traumatic Spinal Cord Injury in the United States: A National Inpatient Analysis

BACKGROUND

Traumatic spinal cord injury (tSCI) is a debilitating neurological condition often associated with lifelong disability. Despite this, there are limited data on pediatric tSCI epidemiology in the United States.

OBJECTIVES

Our primary objective was to estimate tSCI hospitalization rates among children, including by age, sex, and race. Secondary objectives were to characterize tSCI hospitalizations and examine associations between sociodemographic characteristics and tSCI etiology.

METHODS

We used the 2016 Kids' Inpatient Database to examine tSCI hospitalizations among children (<21 years). Descriptive statistics were used to report individual and care setting characteristics for initial tSCI hospitalizations. We used Census Bureau data to estimate tSCI hospitalization rates (number of pediatric tSCI hospitalizations / number of US children) and logistic regression modeling to assess associations between documented sociodemographic characteristics and injury etiology.

RESULTS

There were 1.48 tSCI admissions per 100,000 children; highest rates of hospitalization involved older (15-20 years), male, and Black children. Hospitalization involving male (adjusted odds ratio [AOR] 0.43; 95% CI, 0.33-0.58) or Black (AOR 0.37; 95% CI, 0.25-0.55) children were less likely to involve a motor traffic accident. Hospitalizations of Black children were significantly more likely to have a diagnosis of tSCI resulting from a firearm incident (AOR 18.97; 95% CI, 11.50-31.28) or assault (AOR 11.76; 95% CI, 6.75-20.50) compared with hospitalizations of White children.

CONCLUSION

Older, male, and Black children are disproportionately burdened by tSCI. Implementation of broad health policies over time may be most effective in reducing pediatric tSCI hospitalizations and preventable injuries.

Spinal cord injury and neurogenic lower urinary tract dysfunction: what do we know and where are we going?

One of the well reported but difficult to manage symptoms of spinal cord injury (SCI) is neurogenic lower urinary tract dysfunction (NLUTD). The type of NLUTD is variable based on location and extent of injury. SCI affects more males and NLUTD is especially debilitating for men with incomplete injury. This review summarizes the anatomical basis of NLUTD in SCI and discusses current diagnostic and management strategies that are being utilized clinically. The last two sections address new innovations and emerging discoveries with the goal of increasing scientific interest in improving treatment options for people with SCI. Areas warranting further investigation are pinpointed to address current gaps in knowledge and/or appropriate technology.

Music Therapy for Anxiety and Pain After Spinal Cord Injury: A Pilot Study

Background

Music therapy (MT) programs have been used in various health care settings to reduce patients’ pain, anxiety, and stress. However, few studies have investigated its effects on patients with spinal cord injury (SCI), a frequently serious event requiring extensive rehabilitation.

Objective

This pilot study evaluated the feasibility of offering music-assisted relaxation (MAR) during rehabilitation for patients with SCI. We also measured the effect of MAR on the patients’ pain, anxiety, and stress levels.

Methods

Patients were hospitalized at Mayo Clinic (Rochester, Minnesota) from September 2015 through September 2017 for rehabilitation of an SCI. Eligible patients received 2, 20-minute, personalized MAR sessions. Interventions were facilitated by a board-certified music therapist (MT-BC) and included diaphragmatic breathing, guided imagery, and passive muscle relaxation with live guitar accompaniment and spoken, improvised, or singing voice. Two surveys (Generalized Anxiety Disorder [GAD-7] and Perceived Stress Scale [PSS-10]) were used at the time of study consent and again upon hospital dismissal. Pain, anxiety, and relaxation were assessed before and after both MT sessions with visual analog scales (VASs), scored from 0 to 10. Participants completed a 7-question satisfaction survey after the second MAR session.

Results

Twenty patients were enrolled (12 men, 8 women); 13 (65%) completed the MAR interventions. The mean (SD) age was 53.7 (17.7) years. VAS scores for pain significantly improved after both sessions (P ≤ .02). VAS scores for anxiety also significantly improved after both sessions (P ≤ .02), as did VAS scores for relaxation (P ≤ .02 for both). The satisfaction survey indicated that patients generally believed that they benefited from MT. Rehabilitation staff indicated that MT did not interfere with routine clinical care.

Conclusion

MT with live MAR is a feasible treatment for patients with SCI and may be effective for reducing their pain and anxiety.

Epidemiological Review of Spinal Cord Injury due to Road Traffic Accidents in Latin America

Spinal cord injury (SCI) is a disease that affects the normal function of the spinal cord. Road traffic accidents (RTAs) represent the main cause of SCI worldwide. SCI may generate physical disability and economic dependency, which is especially significant in low- and middle-income countries such as most of the Latin American countries. The main objective of this study was to present an epidemiological review of SCI secondary to RTAs. Stronger evidence on this condition in Latin America is important for future-specific data collection and prevention strategies. A literature review was carried out using specific search strategies in databases of indexed journals from the period 2000 to 2019. Data on SCI secondary to RTAs in the Latin American region were collected and analyzed. After initial screening and removal of duplicates, 16 articles met the inclusion criteria and were chosen for analysis. Data from 7 Latin American countries were retrievable. On average, RTAs were responsible for 40.81% of SCI. Data from different studies are heterogeneous. Car accidents and moto accidents were equally responsible for SCIs (50.61% vs. 49.06%). The thoracic segments were the most commonly affected (57.87%). Males in their 30s were the most affected category (76.6%). SCI due to RTAs may represent a severe but preventable condition that affects mostly men in their productive age, generating important social and economic issues. Data about this condition in Latin America are scarce, and could limit prevention and treatment strategies. Prospective data collection about this condition is recommended.

Spinal cord injury and degenerative cervical myelopathy

Spinal cord injury (SCI) often results in impaired respiratory function. Paresis or paralysis of inspiratory and expiratory muscles can lead to respiratory dysfunction depending on the level and severity of the injury, which can affect the management and care of SCI patients. Respiratory dysfunction after SCI is more severe in high cervical injuries, with vital capacity (VC) being an essential indicator of overall respiratory health. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Respiratory management includes mechanical ventilation and tracheostomy in high cervical SCI, while noninvasive ventilation is more common in patients with lower cervical and thoracic injuries. Mechanical ventilation can negatively impact the function of the diaphragm and weaning should start as soon as possible. Patients can sometimes be weaned from mechanical ventilation with assistance of electrical stimulation of the phrenic nerve or the diaphragm. Respiratory muscle training regimens may also improve patients' inspiratory function following SCI. Despite the critical advances in preventing, diagnosing, and treating respiratory complications, they continue to significantly affect persons living with SCI. Additional studies of interventions to reduce respiratory complications are likely to further decrease the morbidity and mortality associated with these injuries.

Evaluation of the Clinical Efficacy of Stem Cell Transplantation in the Treatment of Spinal Cord Injury: A Systematic Review and Meta-analysis

Stem cell transplantation has been applied to treat spinal cord injury (SCI) in clinical trials for many years. However, the clinical efficacies of stem cell transplantation in SCI have been quite diverse. The purpose of our study was to systematically investigate the efficacy of stem cell transplantation in patients with SCI. The PubMed, Web of Science, Ovid-Medline, Cochrane Library, China National Knowledge Infrastructure, VIP, Wanfang, and SinoMed databases were searched until October 27, 2020. Quantitative and qualitative data were analyzed by Review Manager 5.3 and R. Nine studies (n = 328) were included, and the overall risk of bias was moderate. The ASIA Impairment Scale (AIS) grading improvement rate was analyzed in favor of stem cell transplantation group [odds ratio (OR) = 6.06, 95% confidence interval (CI): 3.16–11.62, P < 0.00001]. Urodynamic indices also showed improvement in bladder function. In subgroup analyses, the results indicated that in patients with complete (AIS A) SCI, with the application of cell numbers between n*(10⁷–10⁸), two cell types (i.e., bone marrow–derived mesenchymal stem cells and bone marrow mononuclears), and treatment time of more than 6 months, stem cell transplantation was more beneficial for sensorimotor function (P < 0.05 for all groups). The risk of fever incidence in the stem cell transplantation group was 4.22 (95% CI: 1.7–10.22, P = 0.001), and principal component analysis (PCA) suggested it was more related to transplanted cell numbers. Thus, stem cell transplantation can promote functional recovery in SCI patients. Moreover, the type and quantity of transplanted stem cells and treatment time are important factors affecting the therapeutic effect of stem cell transplantation in SCI. Further studies are needed to evaluate the effects and elucidate the mechanisms of these factors on stem cell therapy in SCI.

Quantifying an Upper Extremity Everyday Task With 3D Kinematic Analysis in People With Spinal Cord Injury and Non-disabled Controls

Objectives: Upper extremity function after spinal cord injury (SCI) is an important factor for performance of activities of daily living. An objective assessment of upper extremity function preferably in purposeful daily tasks is essential in understanding its impact on real-life activities. This study aimed to identify which movement parameters of upper extremity, measured by kinematic analysis during a purposeful daily task, are impaired in people with cervical or thoracic SCI.

Materials and Methods: The study included 29 adults (mean 59.5 years, 9 women and 20 men) with cervical (n = 19) or thoracic (n = 10) established complete (n = 15) or incomplete (n = 14) SCI, and 54 non-disabled controls with commensurable age and sex (mean 59 years, 15 women, 39 men). The 3D kinematic data were captured with a five-camera system during a standardized unilateral daily task (drinking from a glass). In SCI, the upper extremity functioning of each arm was assessed with Action Research Arm Test (ARAT). Having a full score in ARAT indicated full functioning; a score of <57 points indicated limited functioning. Kinematic data from full functioning arms (n = 27) and limited functioning arms (n = 30) in SCI were compared with the non-dominant arms (n = 54) in controls.

Results: In the limited upper extremity functioning group, movement time, smoothness, arm abduction, wrist angle, trunk displacement, and inter-joint coordination, but not peak velocity of the hand, angular velocity of elbow, and relative time to peak velocity, all differed from controls. In the full upper extremity functioning group, arm abduction alone was significantly different from controls.

Conclusions: The findings demonstrate that apart from measures of peak velocity, kinematic measures of movement quality including movement time, smoothness, trunk displacement, and joint angles are impaired in people with limited upper extremity functioning after SCI. The study provides robust results applicable to a representative population of individuals with established cervical or thoracic SCI. The results suggest that kinematic analysis might be useful for those with limited functioning in order to get a better understanding of the specific movement impairments in daily tasks after SCI.

Traumatic spinal cord injury mortality from 2006 to 2016 in China

Purpose: To report on the national traumatic spinal cord injury (TSCI) mortality of China population, and assess sex-, age-, location-, and cause-specific mortality rates, respectively.Methods: A population-based longitudinal study based on mortality data from the Disease Surveillance Points system of China, 2006-2016. TSCI was defined according to the 10th International Classification of Disease. Negative binomial regression was used to test the significance of the change in overall and subgroup mortality rate.Results: Age-adjusted TSCI mortality rate increased by 64% from 2006 to 2016, ranging from 0.19 to 0.34 per 100,000 population. The crude mortality was 0.31 per 100,000 population in 2016. Males and rural residents had higher TSCI mortality rates than females and urban residents. The age-adjusted TSCI mortality rate increased 53% for males, 107% for females, 75% in an urban area, and 59% in a rural area. In comparison with insignificant change in the age group of 0-44 years, TSCI mortality increased 56% and 147% in age groups of 45-64 years and 65 years. Falls accounted for 45.4% of total mortality.Conclusions: TSCI mortality rates were higher in males and in rural residents than in females and in urban residents during the study time period. TSCI mortality increased quickly as age increased; adults aged 65 years and older had the highest mortality rate. Falls and motor vehicle crashes were the two most common causes of TSCI mortality. More prevention efforts are needed to reduce a number of deaths from TSCI injury considering a substantial increase in TSCI mortality.

Patterns of Upper Extremity Reconstruction for Patients With Tetraplegia Across the United States: A Retrospective Study

PURPOSE

The rates of upper extremity reconstruction for patients with tetraplegia remain low. We performed a retrospective study to assess recent reconstruction rates and delineate factors associated with the occurrence of reconstruction.

METHODS

We examined the National Inpatient Sample database (2012-2017) for the rate of reconstruction for patients with tetraplegia. The details of provider distribution characteristics and neighborhood attributes were obtained from the American Medical Association Physician Masterfile and based on the area deprivation index, respectively. We calculated the mean reconstruction rate per year and generated multivariable logistic regression models to examine the influence of patient factors, hospital characteristics, and provider distribution on the odds of undergoing functional reconstruction for tetraplegia patients.

RESULTS

Among 404,660 encounters with patients with tetraplegia, only 1,430 (0.4%) patients underwent upper extremity reconstruction from 2012 to 2017, with a mean rate of 238 procedures per year. We identified 5,450 hand surgeons, 12,751 physiatrists, and 444 spinal cord injury specialists, with variation in their national distribution. A greater number of surgeons near SCIS was associated with increased probability of reconstruction (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.12). The odds of surgery were greater for patients receiving care at urban teaching (OR 5.00, 95% CI 3.35-7.47) or urban nonteaching (OR 1.71, 95% CI 1.11-2.63) hospitals, whereas those at private nonprofit (OR 0.67, 95% CI 0.58-0.78) or investor-owned (OR 0.65, 95% CI 0.52-0.82) hospitals had lower odds. Although most patients had insurance coverage, patients with a higher income or those who received subsidized care had greater odds of undergoing reconstruction.

CONCLUSIONS

Reconstruction rates remain low and are correlated with the environment of care, financial factors, and provider availability. Policies that focus on reducing these factors in addition to increasing interspecialty collaboration could improve access to surgery for patients with tetraplegia.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Multimorbidity of overweight and obesity alongside anxiety and depressive disorders in individuals with spinal cord injury

OBJECTIVE

To compare the prevalence of anxiety/depression and overweight/obesity (Aim 1) and the multimorbidity of these conditions (Aim 2) in a sample of adults with and without spinal cord injury (SCI). Aim 3 was to examine whether overweight/obese individuals with SCI differ on the prevalence of anxiety/depressive disorders compared to non-overweight/obese individuals with SCI.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Individuals ≥16 years old who had patient encounters between January 1, 2011, and February 28, 2018. In total, 761 598 individuals were included, of which 3136 had SCI.

MAIN OUTCOME MEASURES

Individuals were identified as diagnosed with SCI, anxiety and/or depressive disorders, and overweight/obesity using the International Classification of Diseases.

RESULTS

Age-adjusted odds ratios (ORs) were calculated using logistic regression. In contrast to non-SCI individuals, those with SCI had increased odds of anxiety disorders (OR: 3.58, 95% CI [3.29-3.90]), depressive disorders (OR: 4.33, 95% CI [3.95-4.74]), and overweight/obesity (OR: 3.08, 95% CI [2.80-3.38]). Pertaining to multimorbidity, individuals with SCI had increased odds of having overweight/obesity alongside anxiety disorders (OR: 4.30, 95% CI [3.71-4.98]) and overweight/obesity alongside depressive disorders (OR: 4.69, 95% CI [4.01-5.47]) compared to those without SCI. Individuals with SCI who were diagnosed as overweight/obese had increased odds of having anxiety disorders (OR: 2.54, 95% CI [2.06-3.13]), and depressive disorders (OR: 2.70, 95% CI [2.18-3.36]), relative to non-overweight/obese individuals with SCI.

CONCLUSIONS

This work is among the first to find evidence that individuals with SCI are at heightened odds of overweight/obesity alongside anxiety and/or depressive disorders. This early work holds clinical implications for treating these interrelated comorbidities in SCI.

Molecular Expression Profile of Changes in Rat Acute Spinal Cord Injury

Background: Spinal cord injury (SCI) is a highly lethal and debilitating disease with a variety of etiologies. To date, there is no effective therapeutic modality for a complete cure. The pathological mechanisms of spinal cord injury at the molecular gene and protein expression levels remain unclear.

Methods: This study used single-cell transcriptomic analysis and protein microarray analysis to analyzes changes in the gene expression profiles of cells and secretion of inflammatory factors respectively, around the lesion site in a rat SCI model.

Results: Single-cell transcriptomic analysis found that three types of glial cells (microglia, astrocyte, and oligodendrocyte) becomes activated after acute injury, with GO exhibiting a variety of inflammatory-related terms after injury, such as metabolic processes, immune regulation, and antigen presentation. Protein microarray results showed that the levels of four inflammatory cytokines favoring SCI repair decreased while the levels of nine inflammatory cytokines hindering SCI repair increased after injury.

Conclusion: These findings thus reveal the changes in cellular state from homeostatic to reactive cell type after SCI, which contribute to understand the pathology process of SCI, and the potential relationship between glial cells and inflammatory factors after SCI, and provides new theoretical foundation for further elucidating the molecular mechanisms of secondary SCI.

Early Trauma Predictors of Mobility in People with Spinal Cord Injury

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

This study aims to assess the potential value of very early trauma variables such as Abbreviated Injury Scale (AIS) and the Injury Severity Score for predicting independent ambulation following a traumatic spinal cord injury (TSCI).

SUMMARY OF BACKGROUND DATA

Several models for prediction of ambulation early after TSCI have been published and validated. The vast majority rely on the initial examination of American Spinal Injury Association (ASIA) impairment scale and level of injury; however, in many locations and clinical situations this examination is not feasible early after the injury.

METHODS

Patient characteristics, trauma data, and ASIA scores on admission to rehabilitation were collected for each of the 144 individuals in the study. Outcome measure was the indoor mobility item of the Spinal Cord Independence Measure taken upon discharge from rehabilitation. Univariate and multivariable models were created for each predictor, Odds ratios (ORs) were obtained by a multivariable logistic regression analysis, and area under the receiver operator curve was calculated for each model.

RESULTS

We observed a significant correlation between the trauma variables and independent ambulation upon discharge from rehabilitation. Of the early variables, the AIS for the spine region showed the strongest correlation.

CONCLUSION

These findings support using preliminary trauma variables for early prognostication of ambulation following a TSCI, allowing for tailored individual interventions.Level of Evidence: 3.

An Autopsy-Based Analysis of Fatal Road Traffic Collisions: How the Pattern of Injury Differs with the Type of Vehicle

In Italy, in only 2018, 3310 people died in road traffic accidents, more than in any other European country. Since the revelation of this occurrence, the authors carried out an analysis aimed at investigating if there was a difference in the injury patterns among different road users. A retrospective post-mortem study on road traffic fatalities was performed, which had been autopsied at the Institute of Forensic Medicine of Milan. First, the authors analyzed the epidemiological data of all the 1022 road traffic accidents subjected to an autopsy from 2007 to 2019. Secondly, further analysis of individual autopsy reports was carried out. For this purpose, 180 autopsies belonging to 5 different categories were analyzed: car, pedestrian, motorbike, bicycle, and truck. Seventy-six percent of road traffic fatalities were male, 54% were between 10 and 49 years of age, and 62% of the patients died before arriving at a hospital. “Multiple injuries” was the main cause of death. Traumatic brain injuries were particularly high in pedestrians and cyclists. In car, motorbike, and truck fatalities, thoracic and abdominal injuries were the most frequent. Therefore, pedestrians and cyclists had a higher prevalence for traumatic head injuries, while car, motorcycle, and truck occupants, on the other hand, had a higher prevalence for thoracic and abdominal injuries.

Effects of age on survival and neurological recovery of individuals following acute traumatic spinal cord injury

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate the effects of older age at the time of injury on the individuals' survival and neurological recovery within the first year after acute traumatic spinal cord injury (tSCI).

SETTING

United States.

METHODS

This study included all participants enrolled into the First National Acute Spinal Cord Injury Study (NASCIS-1). Outcome measures included survival and neurological recovery (as assessed using the NASCIS motor and sensory scores) within the first year after tSCI. Data analyses of neurological recovery were adjusted for major potential confounders.

RESULTS

The study included 39 females and 267 males with overall mean age of 31 years who mostly sustained cervical severe tSCI after motor vehicle accidents or falls. Survival rates among older individuals are significantly lower than among younger individuals within the first year following tSCI (p < 0.0001). Among who survived the first year of tSCI, there were no statistically significant difference between older survivors and younger survivors regarding motor and sensory recovery in the multiple regression analyses adjusted for major potential confounders.

CONCLUSIONS

The results of this retrospective study suggest that older age at the injury onset is associated with lower survival rate within the first year following tSCI. However, older individuals have similar potential to recover from their initial neurological impairment to younger individuals after tSCI. The results of this study combined to the recent literature underline the need for multidisciplinary team approach to the management of the elderly with acute SCI is essential to maximize their recovery.

Psychometric properties of the spinal cord injury-quality of life (SCI-QOL) Resilience item bank in a sample with spinal cord injury and chronic pain

PURPOSE

To describe the psychometric properties (e.g., data distribution characteristics, convergent/discriminant validity, internal consistency reliability, and test administration characteristics) of the spinal cord injury quality of life measurement system (SCI-QOL) Resilience item bank delivered as a computer adaptive test (CAT) in a sample of individuals with chronic pain and spinal cord injury (SCI).

METHODS

Descriptive statistics were calculated to investigate variable data distribution characteristics. Correlation analyses were conducted for convergent and discriminant validity. Item response theory-derived reliability was calculated for the SCI-QOL Resilience CAT.

RESULT

One hundred thirty-three adults with SCI (N = 133; 73.5% male, 26.5% female) were enrolled. Sample mean T score on the SCI-QOL Resilience measure was 48.40, SD = 8.60 (min = 29.4; max = 70.0). The CAT administered between 4 (most common, 41.4% of cases) and 12 (9% of cases) items with the Mean_#items = 5.73, SD = 2.45. The SCI-QOL Resilience CAT scores were normally distributed, with very low ceiling (0%) and floor (3%) effects. The SCI-QOL Resilience CAT had a reliability of 0.89, and the mean length of time for respondents to complete the SCI-QOL Resilience CAT was 44.34 s. SCI-QOL Resilience CAT validity was supported by significant moderate correlations with pain acceptance, depressive symptoms, pain catastrophizing, positive affect and well-being, and pain interference (convergent validity) and small non-significant correlations with age, sex, injury level, pain intensity, mobility level, and years since injury (discriminant validity).

CONCLUSION

The SCI-QOL Resilience CAT demonstrated good convergent and discriminant validity. The CAT administration characteristics were impressive: With few items (low response burden), the scale achieved good reliability.

Functional independence in the Finnish spinal cord injury population

Study design

A cross-sectional survey of the Finnish population with spinal cord injury (FinSCI database).

Objectives

To describe the functional independence of the population with spinal cord injury (SCI) in Finland and to identify how generic and lesion characteristics affect their functional independence.

Setting

The participants were recruited from the registers of three SCI outpatient clinics responsible for lifelong follow-up and care for people with SCI in Finland.

Methods

The data were retrieved from FinSCI (n = 1772). The response rate was 50% (n = 884). The Spinal Cord Independence Measure-Self Report (SCIM-SR) was used. The data were analyzed with univariate testing, factor analyses, and multiple linear regression models.

Results

The median (percentiles 25; 75) SCIM-SR total score was 76.0 (58.8; 89.0), and the score was 18.0 (13.0; 20:0) for the self-care sub-scale, 33.0 (25.0; 39.0) for the respiration and sphincter management sub-scale and 29.0 (16.0; 36.8) for the mobility sub-scale. The higher the neurological level in groups AIS A, B, and C, the lower the functional ability. Group AIS D at any injury level had the highest level of functional ability. Age and the number of years since injury negatively influenced the SCIM-SR scores for every sub-scale.

Conclusion

Based on the International Spinal Cord Injury Core Data Set, the severity of SCI can differentiate persons with SCI according to their functional ability. The results suggest that SCI affects individuals’ health more than ageing alone does, thereby reducing the functional ability and independence of persons with SCI over time.

Nutritional interventions for spinal cord injury: preclinical efficacy and molecular mechanisms

Spinal cord injury (SCI) is a debilitating condition that leads to motor, sensory, and autonomic impairments. Its intrinsic pathophysiological complexity has hindered the establishment of effective treatments for decades. Nutritional interventions (NIs) for SCI have been proposed as a route to circumvent some of the problems associated with this condition. Results obtained in animal models point to a more holistic effect, rather than to specific modulation, of several relevant SCI pathophysiological processes. Indeed, published data have shown NI improves energetic imbalance, oxidative damage, and inflammation, which are promoters of improved proteostasis and neurotrophic signaling, leading ultimately to neuroprotection and neuroplasticity. This review focuses on the most well-documented Nis. The mechanistic implications and their translational potential for SCI are discussed.

Epidemiological changes in traumatic spinal cord injuries for the last 30 years (1990-2019) in South Korea

STUDY DESIGN

Retrospective descriptive study.

OBJECTIVES

To identify the characteristics of and epidemiological trends in traumatic spinal cord injuries (TSCIs) in Korea from 1990 to 2019.

SETTING

National Rehabilitation Center affiliated with the Ministry of Health and Welfare in Korea.

METHODS

The medical records of 3395 individuals with TSCIs were retrospectively reviewed. Three groups were formed based on onset period (1990-1999, 2000-2009, and 2010-2019) and six groups based on age (≤15, 16-30, 31-45, 46-60, 61-75, and ≥76 years). Pearson's chi-square and analysis of variance tests were used for statistical analysis.

RESULTS

From 1990 to 2019, the mean age (standard deviation, [SD]) at the time of injury increased from 32.4 (SD = 12.4) years in the 1990s to 47.1 (SD = 16.2) years in the 2010s (F = 222.317 p = <0.001). Land transport and falls were the most common causes of TSCIs. The number of injuries from land transport gradually decreased, while that from falls increased (24.9% in 1990s to 46.3% in 2010s [χ² = 134.415 p < 0.001]). In the >60 years group, falls were the most common cause of injury, which resulted in 42.9% TSCIs in the 1990s to 59.1% in the 2010s (χ²= 10.398, p > 0.05). Tetraplegia (n = 769, 58.6%) was more common than paraplegia; incomplete tetraplegia (entire population: =564, 43%; >60 years group: n = 186, 43%) was the highest in the 2010s.

CONCLUSIONS

Falls have been the most common cause of TSCIs after 2010s. Implementing national education and campaigns for preventing falls is important to reduce/prevent TSCIs caused by falls in the aged population.

Nanoparticles in traumatic spinal cord injury: therapy and diagnosis

Nanotechnology has been previously employed for constructing drug delivery vehicles, biosensors, solar cells, lubricants and as antimicrobial agents. The advancement in synthesis procedure makes it possible to formulate nanoparticles (NPs) with precise control over physico-chemical and optical properties that are desired for specific clinical or biological applications. The surface modification technology has further added impetus to the specific applications of NPs by providing them with desirable characteristics. Hence, nanotechnology is of paramount importance in numerous biomedical and industrial applications due to their biocompatibility and stability even in harsh environments. Traumatic spinal cord injuries (TSCIs) are one of the major traumatic injuries that are commonly associated with severe consequences to the patient that may reach to the point of paralysis. Several processes occurring at a biochemical level which exacerbate the injury may be targeted using nanotechnology. This review discusses possible nanotechnology-based approaches for the diagnosis and therapy of TSCI, which have a bright future in clinical practice.

How Are Adenosine and Adenosine A2A Receptors Involved in the Pathophysiology of Amyotrophic Lateral Sclerosis?

Adenosine is extensively distributed in the central and peripheral nervous systems, where it plays a key role as a neuromodulator. It has long been implicated in the pathogenesis of progressive neurogenerative disorders such as Parkinson’s disease, and there is now growing interest in its role in amyotrophic lateral sclerosis (ALS). The motor neurons affected in ALS are responsive to adenosine receptor function, and there is accumulating evidence for beneficial effects of adenosine A_2A receptor antagonism. In this article, we focus on recent evidence from ALS clinical pathology and animal models that support dynamism of the adenosinergic system (including changes in adenosine levels and receptor changes) in ALS. We review the possible mechanisms of chronic neurodegeneration via the adenosinergic system, potential biomarkers and the acute symptomatic pharmacology, including respiratory motor neuron control, of A_2A receptor antagonism to explore the potential of the A_2A receptor as target for ALS therapy.

Unmet health care needs and inequality: A cross-country comparison of the situation of people with spinal cord injury

Objective

To estimate and compare unmet health care needs of persons with spinal cord injury (SCI) across countries, the causes of these shortfalls, and the role of income.

Data Sources

We analyzed cross‐sectional data of 20 countries from the International Spinal Cord Injury (InSCI) survey, a compendium of comparable data on the living situation of persons with SCI. Data included information on high‐, middle‐, and low‐income countries. The survey comprises information on 12,095 participants.

Study Design

We used logit regressions to estimate the probability of unmet health care needs of persons with SCI and its causes. We adjusted the results by the individuals' characteristics and countries' fixed effects. We disaggregated the results by income decile of individuals in each country.

Data Collection/Extraction Methods

The inclusion criteria for the InSCI survey were adults aged 18 years and older with SCI living in the community, who were able to respond to the survey and who provided informed consent.

Principal Findings

Unmet health care needs are significant for people with long‐term conditions like SCI, where people in low‐income groups tend to be more affected. Among the barriers to meeting health care needs, the foremost is health care cost (in 11 of the 20 countries), followed by transportation and service availability. Persons with SCI in Morocco reported the highest probability of unmet health care needs in the sample, 0.54 (CI: 047–0.59), followed well behind by South Africa, 0.27 (CI: 0.20–0.33), and Brazil, 0.26 (CI: 0.20–0.33). In contrast, persons with SCI in Spain, 0.06 (CI: 0.04–0.08), reported the lowest probability of unmet health care needs, closely followed by Norway, 0.07 (CI: 0.05–0.09), Thailand, 0.08 (CI: 0.05–0.11), France, 0.08 (CI: 0.06–0.11), and Switzerland, 0.09 (CI: 0.07–0.10).

Conclusions

SCI is a long‐term, irreversible health condition characterized by physical impairment and a series of chronic illness. This makes SCI a high‐need, high‐cost group that faces significant unmet health care needs, which are mainly explained by the costs of health services, transportation, and services availability. This situation is prevalent in low‐, middle‐, and high‐income countries, where persons in lower income groups are disproportionately affected. To improve the situation, a combination of measures from the health and social systems are required.

Epidemiological characteristics of traumatic cervical spinal cord injury in Chongqing, China, from 2009 to 2018

STUDY DESIGN

Hospital-based retrospective epidemiological research.

OBJECTIVES

To describe the epidemiological and demographic features of patients with traumatic cervical spinal cord injury in Chongqing, China from 2009 to 2018.

SETTING

Army Military Medical University Xinqiao Hospital in Chongqing.

METHODS

All patients diagnosed traumatic CSCI admitted to Xinqiao hospital from 2009 to 2018 were retrospectively reviewed. Data elements referred from the International SCI Core Data Set, included date of birth, date of injury, gender, etiology of injury, vertebral injury, associated injury, ventilatory assistance, and neurological status were collected.

RESULTS

A total of 503 patients with TCSCI met the criteria. The mean age of patients with TCSCI was 50.3 ± 13.9 years (15-85 years), and the male-to-female ratio was 4.7:1. Fall (67.2%) was the leading cause of injury, followed by transport (22.3%). The most common neurologic level of injury (NLI) was C5, accounting for 38.2%. The number of AIS D was the largest, accounting for 42%.

CONCLUSIONS

The results indicated that TCSCI occurred most frequently in the middle age and fall was the leading cause of injury. The number of patients with TCSCI was larger in male than in female. The most common NLI occurred in C5, and AIS D had the largest numbers.

Electrical epidural stimulation of the cervical spinal cord: implications for spinal respiratory neuroplasticity after spinal cord injury

Traumatic cervical spinal cord injury (cSCI) can lead to damage of bulbospinal pathways to the respiratory motor nuclei and consequent life-threatening respiratory insufficiency due to respiratory muscle paralysis/paresis. Reports of electrical epidural stimulation (EES) of the lumbosacral spinal cord to enable locomotor function after SCI are encouraging, with some evidence of facilitating neural plasticity. Here, we detail the development and success of EES in recovering locomotor function, with consideration of stimulation parameters and safety measures to develop effective EES protocols. EES is just beginning to be applied in other motor, sensory, and autonomic systems; however, there has only been moderate success in preclinical studies aimed at improving breathing function after cSCI. Thus, we explore the rationale for applying EES to the cervical spinal cord, targeting the phrenic motor nucleus for the restoration of breathing. We also suggest cellular/molecular mechanisms by which EES may induce respiratory plasticity, including a brief examination of sex-related differences in these mechanisms. Finally, we suggest that more attention be paid to the effects of specific electrical parameters that have been used in the development of EES protocols and how that can impact the safety and efficacy for those receiving this therapy. Ultimately, we aim to inform readers about the potential benefits of EES in the phrenic motor system and encourage future studies in this area.