151
|
Abstract
Autonomic dysreflexia (AD) is an uncontrolled increase in systolic blood pressure (by 20 mmHg or more) that occurs in those with spinal cord injuries at or above the 6th thoracic vertebrae. It usually occurs in the chronic phase of injury, at between 3 and 6 months after the injury is sustained. Most affected patients live in the community with varying levels of independence and will have contact with community nurses due to potential issues with bladder and bowel management. Therefore, community nurses may come into contact with patients in a dysreflexia crisis requiring prompt emergency treatment. Thus, the aim of this paper is to develop community nurses' understanding of AD so they are equipped with the necessary knowledge to help their clients.
Collapse
Affiliation(s)
- Sara Morgan
- Senior Lecturer Advanced Practice, University of South Wales, Pontypridd
| |
Collapse
|
152
|
Mirzaei F, Meshkini A, Habibi B, Salehpour F, Rafei E, Fathi W, Alavi SHN, Majdi A, Rahigh Aghasan S, Naseri Alavi SA. Ceftriaxone Plus Methylprednisolone Combination Therapy Versus Methylprednisolone Monotherapy in Patients With Acute Spinal Cord Injury: A Randomized, Triple-Blind Clinical Trial. Int J Spine Surg 2020; 14:706-712. [PMID: 33077437 PMCID: PMC7671452 DOI: 10.14444/7102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Guidelines do not suggest the routine use of methylprednisolone (MP) in patients with acute traumatic spinal cord injury (SCI). We tested the hypothesis regarding whether combination therapy with ceftriaxone and MP is superior to MP monotherapy in patients with acute traumatic SCI. METHODS In a randomized, triple-blind clinical trial, 60 patients with acute (first 8 hours of the injury) traumatic SCI were enrolled at the Tabriz University of Medical Sciences, Tabriz, Iran, between December 2016 and June 2017. Accordingly, the patients were randomly divided into 2 case and control groups (n = 30 each). Upon admission, all included patients received a bolus dose of MP at 33 mg/kg intravenously (IV) for 15 minutes. Then, after 45 minutes, MP infusion was continued for 24 to 48 hours at a 5.4 mg/kg IV dose. The case group received an additional dose of ceftriaxone at 1 g 2 times a day for 7 days through an IV route. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were checked and compared between case and control groups upon admission and on the fourth and eighth days. Also, sensory and motor functions were evaluated according to the American Spinal Injury Association (ASIA) grading score upon admission, on the third and seventh days, upon discharge and 6 months after admission. RESULTS Analyses showed a significant statistical difference between groups in the changes in CRP levels during days 1 and 4 (P = .001) and also during days 4 and 8 (P = .001). However, no significant statistical difference was detected in ESR levels changes between groups during days 1 and 4 (P = .073), and during days 4 and 8 (P = .069). ASIA scale was found to be significantly different between the MP plus ceftriaxone group and MP monotherapy upon admission and 6 months after treatment (P = .001 for both comparisons). However, the number of variations in the ASIA score had no significant statistical difference between groups 6 months after intervention (P = .465). CONCLUSION The addition of ceftriaxone to the routine therapeutic protocol of acute SCI is accompanied by improved inflammation markers and functional outcomes 6 months after the intervention.
Collapse
Affiliation(s)
- Farhad Mirzaei
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Meshkini
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Bohlool Habibi
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Firooz Salehpour
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ebrahim Rafei
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Wouria Fathi
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Alireza Majdi
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sepideh Rahigh Aghasan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Ahmad Naseri Alavi
- Department of Neurosurgery, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
153
|
Zipser CM, Pfender N, Spirig JM, Betz M, Aguirre J, Hupp M, Farshad M, Curt A, Schubert M. Study protocol for an observational study of cerebrospinal fluid pressure in patients with degenerative cervical myelopathy undergoing surgical deCOMPression of the spinal CORD: the COMP-CORD study. BMJ Open 2020; 10:e037332. [PMID: 32958488 PMCID: PMC7507854 DOI: 10.1136/bmjopen-2020-037332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Degenerative cervical myelopathy (DCM) is a disabling spinal disorder characterised by sensorimotor deficits of upper and lower limbs, neurogenic bladder dysfunction and neuropathic pain. When suspected, cervical MRI helps to reveal spinal cord compression and rules out alternative diagnoses. However, the correlation between radiological findings and symptoms is weak. Cerebrospinal fluid pressure (CSFP) analysis may complement the appreciation of cord compression and be used for intraoperative and postoperative monitorings in patients undergoing surgical decompression. METHODS AND ANALYSIS Twenty patients diagnosed with DCM undergoing surgical decompression will receive standardised lumbar CSFP monitoring immediately before, during and 24 hours after operation. Rest (ie, opening pressure, CSF pulsation) and stimulated (ie, Valsalva, Queckenstedt's) CSFP-findings in DCM will be compared with 20 controls and results from CSFP monitoring will be related to clinical and neurophysiological findings. Arterial blood pressure will be recorded perioperatively and postoperatively to calculate spinal cord perfusion pressure and spinal vascular reactivity index. Furthermore, measures of CSFP will be compared with markers of spinal cord compression by means of MR imaging. ETHICS AND DISSEMINATION The study protocol conformed to the latest revision of the Declaration of Helsinki and was approved by the local Ethics Committee of the University Hospital of Zurich (KEK-ZH number PB-2016-00623). The main publications from this study will cover the CSFP fluid dynamics and pressure analysis preoperative, perioperative and postoperative correlated with imaging, clinical scores and neurophysiology. Other publications will deal with preoperative and postoperative spinal perfusion. Furthermore, we will disseminate an analysis on waveform morphology and the correlation with blood pressure and ECG. Parts of the data will be used for computational modelling of cervical stenosis. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT02170155).
Collapse
Affiliation(s)
- Carl Moritz Zipser
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Nikolai Pfender
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Jose Miguel Spirig
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Jose Aguirre
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Markus Hupp
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| |
Collapse
|
154
|
Mushlin HM, Lessing N, Wessell AP, Chryssikos T, Pratt N, Caffes N, Oliver J, Aarabi B, Schwartzbauer G. The Effect of Elevated Mean Arterial Blood Pressure in Cervical Traumatic Spinal Cord Injury with Hemorrhagic Contusion. World Neurosurg 2020; 144:e405-e413. [PMID: 32889182 DOI: 10.1016/j.wneu.2020.08.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/23/2020] [Accepted: 08/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Hemorrhagic contusion in cervical spinal cord injury (CSCI) is poorly understood. We investigated hemorrhagic expansion in patients with CSCI with an assigned elevated mean arterial pressure (MAP) goal of >85 mm Hg. The change in hemorrhagic area and long-term follow-up data ≥6 months after injury was studied. METHODS A retrospective review was performed from 2005 to 2016 to identify patients with motor complete CSCI with 2 cervical magnetic resonance imaging (MRI) scans within 7 days of injury showing evidence of hemorrhagic contusion and assigned a MAP goal of >85 mm Hg for 7 days. T2-weighted MRI was used to calculate the hemorrhagic surface area in the sagittal plane. A calculated MAP was recorded for each blood pressure measure between the initial and follow-up MRI scans. The American Spinal Injury Association impairment scale (AIS) and American Spinal Injury Association motor scores were recorded at the final follow-up examination at ≥6 months. RESULTS A total of 193 patients were identified. The mean change in the hemorrhagic area was 24.0 mm2. Of the 193 patients, the AIS grade was A for 114 and B for 79 patients. Multiple logistic regression analysis demonstrated that the MAP and systolic blood pressure were nonsignificant predictors of hemorrhagic contusion expansion. An increased hemorrhagic contusion area on the follow-up MRI scan was associated with a reduced odds of AIS improvement of ≥1 and ≥2 points (odds ratio, 0.97; 95% confidence interval, 0.87-0.97; P = 0.028; and odds ratio, 0.92; 95% confidence interval, 0.99-1.13; P = 0.008, respectively) at the final ≥6-month follow-up examination. CONCLUSION The present study investigated the clinical safety of elevated MAP goals for patients with CSCI and hemorrhagic contusion. Elevated MAPs did not significantly increase the risk of hemorrhagic expansion in those with CSCI. We have also reported the use of hemorrhagic contusion size as a potential radiographic biomarker for neurological outcomes.
Collapse
Affiliation(s)
- Harry M Mushlin
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
| | - Noah Lessing
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aaron P Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Timothy Chryssikos
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nathan Pratt
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey Oliver
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA; Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA; Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| |
Collapse
|
155
|
Grin A, Krylov V, Lvov I, Talypov A, Dzukaev D, Kordonskiy A, Smirnov V, Karanadze V, Abdukhalikov B, Khushnazarov U, Aleynikova I, Kazakova E, Bogdanova O, Peyker A, Semchenko V, Aksenov A, Borzenkov A, Gulyy V, Torchinov S, Bagaev S, Toporskiy A, Nikitin A, Arakelyan S, Martikyan A, Oshchepkov S, Hovrin D, Kojev A, Khalatyan M. External Multicenter Study of Reliability and Reproducibility for Lower Cervical Spine Injuries Classification Systems-Part 1: A Comparison of Morphological Schemes. Global Spine J 2020; 10:682-691. [PMID: 32707018 PMCID: PMC7383795 DOI: 10.1177/2192568219868218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Multicenter observational survey study. OBJECTIVES To quantify and compare the inter- and intraobserver reliability of Allen-Fergusson (A-F), Harris, Argenson, and AOSpine (AOS) classifications for cervical spine injuries, in a multicentric survey of neurosurgeons with different levels of experience. METHODS We used data of 64 consecutive patients. Totally, 37 surgeons (from 7 centers), were included in the study. The initial assessment was returned by 36 raters. The second assessment performed after 1.5 months included 24 raters. RESULTS We received 15 111 answers for 3840 evaluations. Raters reached a fair general agreement of the A-F scale, while the experienced group achieved κ = 0.39. While all groups showed moderate interrater reliability for primary assessment of Harris scale (κ = 0.44), the κ value for experts decreased from 0.58 to 0.49. The Argenson scale demonstrated moderate and substantial agreement among all raters (κ = 0.47 and κ = 0.55, respectively). The AOS scheme primary assessment general kappa value for all types of injuries and across all raters was 0.49, reaching substantial agreement among experts (κ = 0.62) with moderate agreement across beginner and intermediate groups (κ = 0.48 and κ = 0.44, respectively). The second assessment general agreement kappa value reached 0.56. CONCLUSIONS We found the highest values of interobserver agreement and reproducibility among surgeons with different levels of experience with Argenson and AOSpine classifications. The AOSpine scale additionally incorporated more detailed description of compression injuries and facet-joint fractures. Agreement levels reached for Allen-Fergusson and Harris scales were fair and moderate, respectively, indicating difficulty of their application in clinical practice, especially by junior specialists.
Collapse
Affiliation(s)
- Andrey Grin
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Vladimir Krylov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Ivan Lvov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
- Ivan Lvov, Sklifosovsky Research Institute of Emergency Care, B. Suharevskaya Pl. 3, Moscow 107945, Russia.
| | | | | | - Anton Kordonskiy
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - Vladimir Smirnov
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - Vasily Karanadze
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | | | | | - Irina Aleynikova
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - Elza Kazakova
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - Olesya Bogdanova
- Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | | | | | - Andrey Aksenov
- Moscow Spine Center of City Hospital No. 67, Moscow, Russia
| | | | - Vladimir Gulyy
- Moscow Spine Center of City Hospital No. 67, Moscow, Russia
| | | | - Sergey Bagaev
- Moscow Spine Center of City Hospital No. 67, Moscow, Russia
| | | | - Andrey Nikitin
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | | | | | | | | | | | | |
Collapse
|
156
|
Torregrossa F, Sallì M, Grasso G. Emerging Therapeutic Strategies for Traumatic Spinal Cord Injury. World Neurosurg 2020; 140:591-601. [PMID: 32797989 DOI: 10.1016/j.wneu.2020.03.199] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/26/2020] [Indexed: 01/18/2023]
Abstract
Spinal cord injury (SCI) is a debilitating neurologic condition with tremendous socioeconomic impact on affected individuals and the health care system. The treatment of SCI principally includes surgical treatment and marginal pharmacologic and rehabilitation therapies targeting secondary events with minor clinical improvements. This unsuccessful result mainly reflects the complexity of SCI pathophysiology and the diverse biochemical and physiologic changes that occur in the injured spinal cord. Once the nervous system is injured, cascades of cellular and molecular events are triggered at varying times. Although the cascade of tissue reactions and cell injury develops over a period of days or weeks, the most extensive cell death in SCI occurs within hours of trauma. This situation suggests that early intervention is likely to be the most promising approach to rescue the cord from further and irreversible cell damage. Over the past decades, a wealth of research has been conducted in preclinical and clinical studies with the hope to find new therapeutic strategies. Researchers have identified several targets for the development of potential therapeutic interventions (e.g., neuroprotection, replacement of cells lost, removal of inhibitory molecules, regeneration, and rehabilitation strategies to induce neuroplasticity). Most of these treatments have passed preclinical and initial clinical evaluations but have failed to be strongly conclusive in the clinical setting. This narrative review provides an update of the many therapeutic interventions after SCI, with an emphasis on the underlying pathophysiologic mechanisms.
Collapse
Affiliation(s)
- Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Marcello Sallì
- Department of Neurosensory and Motor Surgery, University of Palermo, Palermo, Italy
| | - Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy.
| |
Collapse
|
157
|
Haldrup M, Dyrskog S, Thygesen MM, Kirkegaard H, Kasch H, Rasmussen MM. Initial blood pressure is important for long-term outcome after traumatic spinal cord injury. J Neurosurg Spine 2020; 33:256-260. [PMID: 32197239 DOI: 10.3171/2020.1.spine191005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with traumatic spinal cord injury (TSCI) are at risk of developing neurogenic shock that causes hypotension and thereby secondary injury to the spinal cord due to ischemia. Hemodynamic treatment of patients with acute TSCI remains inadequately elucidated. Guidelines for management are divergent and based on limited evidence. To this end, the authors evaluated whether mean arterial blood pressure (MABP) during the prehospital and initial hospital phases of TSCI treatment is correlated with long-term neurological outcome. METHODS The authors performed a retrospective cohort study based on a chart review of MABP data collected during the prehospital transport, in the operating room (OR), and in the neurointensive care unit (NICU) during the first 7 days after trauma. Data from the NICU were divided into two periods: days 1-2 and days 3-7. Data were analyzed using Spearman's rank correlation to evaluate for any correlation between MABP and changes in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) score 1 year postinjury. In the analysis, the MABP target value was 80 mm Hg. Hypotension was treated with metaoxedrin or norepinephrine. Statistically significant differences were evaluated using Spearman's rank correlation coefficient. RESULTS The chart review yielded 129 patients treated for TSCI. The inclusion period was 2010-2017. For the prehospital transport measurements of MABP, the Spearman's rank correlation coefficient was a rho of 0.5662 (p < 0.001), for OR measurements it was a rho of 0.6818 (p < 0.001), and for the NICU measurements it was a rho of 0.4611 (p < 0.001); for NICU unit days 1-2 and days 3-7, the Spearman's rank correlation coefficient was a rho of 0.2209 (p = 0.0681). CONCLUSIONS Continuous MABP levels exceeding 80 mm Hg have a significant impact on neurological outcome-from earliest possible stabilization in the prehospital care, through hospital admission, the surgical phase, and into the first 2 days in the NICU.
Collapse
Affiliation(s)
- Mette Haldrup
- 1Department of Neurosurgery, CENSE-Spine, Aarhus University Hospital
| | - Stig Dyrskog
- 2Department of Neuro-Intensive Care, Aarhus University Hospital
| | | | | | - Helge Kasch
- 4Department of Clinical Medicine, Spinal Cord Injury Center of Western Denmark, Aarhus, Denmark
| | | |
Collapse
|
158
|
Wang MX, Beckmann NM. Imaging of pediatric cervical spine trauma. Emerg Radiol 2020; 28:127-141. [PMID: 32601894 DOI: 10.1007/s10140-020-01813-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/19/2020] [Indexed: 11/25/2022]
Abstract
While pediatric cervical spine injuries (CSI) are rare, they are associated with high morbidity and mortality and sometimes require expeditious surgical management. In this article, we aim to improve the diagnostic accuracy of pediatric CSI by reviewing normal pediatric cervical anatomy, typical pediatric CSI patterns, and common mimics of pediatric CSI. A literature review was conducted on pediatric CSI, its epidemiology, and the various imaging manifestations and mimics. The most common pediatric CSI occur in the upper cervical spine owing to the higher fulcrum and larger head at a young age, namely prior to age 9 years, while lower CSI occur more frequently in patients older than 9 years. While various craniocervical measurements may be utilized to identify craniocervical disruption, soft tissue injuries may be the only manifestation, thus making pediatric CSI difficult to diagnose on initial imaging. In the acute setting, CT cervical spine is an appropriate initial imaging modality for pediatric CSI evaluation. MRI serves as an additional tool to exclude or identify injuries when initial findings are equivocal. It is essential to recognize the unique anatomy and biomechanics of the pediatric spine and thus discern common pediatric CSI patterns and their mimics.
Collapse
Affiliation(s)
- Mindy X Wang
- Department of Diagnostic and Interventional Imaging, Memorial Hermann, Houston, TX, USA.
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA.
| | - Nicholas M Beckmann
- Department of Diagnostic and Interventional Imaging, Memorial Hermann, Houston, TX, USA
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA
| |
Collapse
|
159
|
Tropeano MP, Spaggiari R, Ileyassoff H, Mabunda DJD, Anania CD, Costa F, Fornari M, Sharif S, Zileli M, Park KB, Servadei F. Traumatic Spine Injury: Which Discrepancy Between the Research Output and the Actual Burden of the Disease? World Neurosurg 2020; 142:e117-e125. [PMID: 32592959 DOI: 10.1016/j.wneu.2020.06.131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Traumatic spinal injury (TSI) is a global health issue contributing to morbidity and mortality, especially in low- and middle-income countries. The aim of this study is to compare the epidemiological estimates of TSI with the corresponding amount of published papers for different regions. METHODS A bibliometric analysis was performed by collecting the number of publications concerning TSI from the PubMed database. Results were sorted according to the different geographical World Health Organization regions. A "publication-to-volume ratio" was obtained by comparing the average number of documents per year with the number of TSI cases across each region. RESULTS A total of 2304 articles were detected from 2008 to 2018. The major publishing regions were North America (AMR-US/Can: 843 articles, 36.6%) and Europe (EUR: 833, 36.2%), then Western Pacific (WPR: 410, 17.8%), Eastern Mediterranean (EMR: 73, 3.2%), South-East Asia (SEAR: 71, 3.1%), Latin America (AMR-L: 55, 2.4%), Africa (AFR: 19, 0.8%). The United States is the most publishing country in AMR-US/Can (86.0%), and Germany in EUR (22.4%). In 2018, EUR published 36.6% of papers versus AMR-US/Can 26.5% and WPR 25.7%, thanks to an increase in Chinese publications. The highest publication ratios of 4.63 and 2.68 were found for AMR-US/Can and EUR, respectively. The other were EMR (0.22), WPR (0.18), AMR-L (0.07), SEAR (0.03), and AFR (0.01). CONCLUSIONS A marked divide is currently found between countries with a high burden of TSI and those where there is most research interest, estimated as amount of publications. Data demonstrate the need for increased inclusiveness in guidelines generation from high-income countries including collection and analysis from low- and middle-income countries.
Collapse
Affiliation(s)
| | | | - Hernán Ileyassoff
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Carla D Anania
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Francesco Costa
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | | | - Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital, Karachi, Pakistan
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Franco Servadei
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| |
Collapse
|
160
|
Vaikuntam BP, Middleton JW, McElduff P, Walsh J, Pearse J, Connelly L, Sharwood LN. Gap in funding for specialist hospitals treating patients with traumatic spinal cord injury under an activity-based funding model in New South Wales, Australia. AUST HEALTH REV 2020; 44:365-376. [PMID: 32456773 DOI: 10.1071/ah19083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 12/05/2019] [Indexed: 11/23/2022]
Abstract
Objective The aim of this study was to estimate the difference between treatment costs in acute care settings and the level of funding public hospitals would receive under the activity-based funding model. Methods Patients aged ≥16 years who had sustained an incident traumatic spinal cord injury (TSCI) between June 2013 and June 2016 in New South Wales were included in the study. Patients were identified from record-linked health data. Costs were estimated using two approaches: (1) using District Network Return (DNR) data; and (2) based on national weighted activity units (NWAU) assigned to activity-based funding activity. The funding gap in acute care treatment costs for TSCI patients was determined as the difference in cost estimates between the two approaches. Results Over the study period, 534 patients sustained an acute incident TSCI, accounting for 811 acute care hospital separations within index episodes. The total acute care treatment cost was estimated at A$40.5 million and A$29.9 million using the DNR- and NWAU-based methods respectively. The funding gap in total costs was greatest for the specialist spinal cord injury unit (SCIU) colocated with a major trauma service (MTS), at A$4.4 million over the study period. Conclusions The findings of this study suggest a substantial gap in funding for resource-intensive patients with TSCI in specialist hospitals under current DRG-based funding methods. What is known about the topic? DRG-based funding methods underestimate the treatment costs at the hospital level for patients with complex resource-intensive needs. This underestimation of true direct costs can lead to under-resourcing of those hospitals providing specialist services. What does this paper add? This study provides evidence of a difference between true direct costs in acute care settings and the level of funding hospitals would receive if funded according to the National Efficient Price and NWAU for patients with TSCI. The findings provide evidence of a shortfall in the casemix funding to public hospitals under the activity-based funding for resource-intensive care, such as patients with TSCI. Specifically, depending on the classification system, the principal referral hospitals, the SCIU colocated with an MTS and stand-alone SCIU were underfunded, whereas other non-specialist hospitals were overfunded for the acute care treatment of patients with TSCI. What are the implications for practitioners? Although health care financing mechanisms may vary internationally, the results of this study are applicable to other hospital payment systems based on diagnosis-related groups that describe patients of similar clinical characteristics and resource use. Such evidence is believed to be useful in understanding the adequacy of hospital payments and informing payment reform efforts. These findings may have service redesign policy implications and provide evidence for additional loadings for specialist hospitals treating low-volume, resource-intensive patients.
Collapse
Affiliation(s)
- Bharat Phani Vaikuntam
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School - Northern, Faculty of Medicine and Health, The University of Sydney, St Leonards, Sydney, NSW 2065, Australia. ; ; ; and Corresponding author.
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School - Northern, Faculty of Medicine and Health, The University of Sydney, St Leonards, Sydney, NSW 2065, Australia. ; ; ; and NSW State-wide Spinal Cord Injury Service, Agency for Clinical Innovation, Chatswood, Sydney, NSW 2067, Australia
| | - Patrick McElduff
- Health Policy Analysis Pty Ltd, St Leonards, Sydney, NSW 2065, Australia. ;
| | - John Walsh
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School - Northern, Faculty of Medicine and Health, The University of Sydney, St Leonards, Sydney, NSW 2065, Australia. ; ;
| | - Jim Pearse
- Health Policy Analysis Pty Ltd, St Leonards, Sydney, NSW 2065, Australia. ;
| | - Luke Connelly
- Centre for Business and Economics of Health, The University of Queensland, Brisbane, Qld 4072, Australia.
| | - Lisa N Sharwood
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School - Northern, Faculty of Medicine and Health, The University of Sydney, St Leonards, Sydney, NSW 2065, Australia. ; ;
| |
Collapse
|
161
|
Acute Spinal Cord Injury: Correlations and Causal Relations Between Intraspinal Pressure, Spinal Cord Perfusion Pressure, Lactate-to-Pyruvate Ratio, and Limb Power. Neurocrit Care 2020; 34:121-129. [PMID: 32435965 PMCID: PMC7940162 DOI: 10.1007/s12028-020-00988-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND/OBJECTIVE We have recently developed monitoring from the injury site in patients with acute, severe traumatic spinal cord injuries to facilitate their management in the intensive care unit. This is analogous to monitoring from the brain in patients with traumatic brain injuries. This study aims to determine whether, after traumatic spinal cord injury, fluctuations in the monitored physiological, and metabolic parameters at the injury site are causally linked to changes in limb power. METHODS This is an observational study of a cohort of adult patients with motor-incomplete spinal cord injuries, i.e., grade C American spinal injuries association Impairment Scale. A pressure probe and a microdialysis catheter were placed intradurally at the injury site. For up to a week after surgery, we monitored limb power, intraspinal pressure, spinal cord perfusion pressure, and tissue lactate-to-pyruvate ratio. We established correlations between these variables and performed Granger causality analysis. RESULTS Nineteen patients, aged 22-70 years, were recruited. Motor score versus intraspinal pressure had exponential decay relation (intraspinal pressure rise to 20 mmHg was associated with drop of 11 motor points, but little drop in motor points as intraspinal pressure rose further, R2 = 0.98). Motor score versus spinal cord perfusion pressure (up to 110 mmHg) had linear relation (1.4 motor point rise/10 mmHg rise in spinal cord perfusion pressure, R2 = 0.96). Motor score versus lactate-to-pyruvate ratio (greater than 20) also had linear relation (0.8 motor score drop/10-point rise in lactate-to-pyruvate ratio, R2 = 0.92). Increased intraspinal pressure Granger-caused increase in lactate-to-pyruvate ratio, decrease in spinal cord perfusion, and decrease in motor score. Increased spinal cord perfusion Granger-caused decrease in lactate-to-pyruvate ratio and increase in motor score. Increased lactate-to-pyruvate ratio Granger-caused increase in intraspinal pressure, decrease in spinal cord perfusion, and decrease in motor score. Causality analysis also revealed multiple vicious cycles that amplify insults to the cord thus exacerbating cord damage. CONCLUSION Monitoring intraspinal pressure, spinal cord perfusion pressure, lactate-to-pyruvate ratio, and intervening to normalize these parameters are likely to improve limb power.
Collapse
|
162
|
Tang G, Chen Y, Chen J, Chen Z, Jiang W. Deferoxamine Ameliorates Compressed Spinal Cord Injury by Promoting Neovascularization in Rats. J Mol Neurosci 2020; 70:1437-1444. [DOI: 10.1007/s12031-020-01564-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 04/22/2020] [Indexed: 02/07/2023]
|
163
|
Martinez-Perez R, Rayo N. Letter to the Editor Regarding “Influence of Preoperative Magnetic Resonance Imaging on Surgical Decision Making for Patients with Acute Traumatic Cervical Spinal Cord Injury: A Survey Among Experienced Spine Surgeons”. World Neurosurg 2020; 137:476-477. [DOI: 10.1016/j.wneu.2019.11.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/23/2019] [Indexed: 10/24/2022]
|
164
|
Abstract
No definite consensus exists for the clearance of the cervical spine (C-spine)
after blunt trauma, despite many validated algorithms, recommendations and
guidelines. We intend to answer the most relevant questions with which physicians
are confronted when clearing C-spines after blunt trauma in emergency departments
(EDs). To exclude significant C-spine injuries we designed an algorithm to be
compatible with clinical practice, to simplify patient management and avoid
unrewarding evaluation. We conducted an exploratory PubMed search including articles published from January
2000 to October 2018. Keywords used were “cervical spine”,
“injury”, “clearance”, “Canadian C-spine
Rule”, “CCR” and “national emergency x-radiography
utilization study”. Clinical and experimental studies were included in a
detailed review. We based our literature review on 33 articles. While answering fundamental triage
questions from daily clinical practice, the current literature is discussed in
detail. We designed an algorithm for the C-spine clearance suitable for any trauma
centre with a high-quality multiplanar reconstruction computerized tomography (CT)
scan continuously available. The high sensitivity of the Canadian C-spine Rule (CCR) prevents missing C-spine
injuries while limiting the amount of unnecessary radiologic examinations. Plain
radiographs were fully abandoned for C-spine clearance. A negative CT scan is
sufficient to clear the majority of C-spine injuries and allows for collar removal.
In case of motor symptoms or radio-clinical discrepancy, the advice of a specialized
spine surgeon must be requested. Magnetic resonance imaging must not be routinely
used. Neck pain despite negative imaging is not a reason to delay removal of stiff
cervical collars.
Cite this article: EFORT Open Rev 2020;5:253-259. DOI:
10.1302/2058-5241.5.190047
Collapse
Affiliation(s)
- Michaël Moeri
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Switzerland
| | - Dominique A Rothenfluh
- Oxford University Hospitals NHS Foundation Trust, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK
| | - Christoph J Laux
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Switzerland
| | - Dennis E Dominguez
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Switzerland.,Oxford University Hospitals NHS Foundation Trust, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK
| |
Collapse
|
165
|
Abstract
We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets. Key concepts are discussed such as intraspinal pressure and spinal cord perfusion pressure (SCPP) at the injury site, respectively, analogous to intracranial pressure and cerebral perfusion pressure for traumatic brain injury. The concept of spinal cord autoregulation is introduced and quantified using spinal pressure reactivity index (sPRx), which is analogous to pressure reactivity index for traumatic brain injury. The U-shaped relationship between sPRx and SCPP defines the optimum SCPP as the SCPP that minimizes sPRx (i.e., maximizes autoregulation), and suggests that not only ischemia but also hyperemia at the injury site may be detrimental. The observation that optimum SCPP varies between patients and temporally in each patient supports individualized management. We discuss multimodality monitoring, which revealed strong correlations between SCPP and injury site metabolism (tissue glucose, lactate, pyruvate, glutamate, glycerol), monitored by surface microdialysis. Evidence is presented that the dura is a major, but unappreciated, cause of spinal cord compression after TSCI; we thus propose expansion duroplasty as a novel treatment. Monitoring spinal cord blood flow at the injury site has revealed novel phenomena, e.g., 3 distinct blood flow patterns, local steal, and diastolic ischemia. We conclude that monitoring from the injured spinal cord in the intensive care unit is a safe technique that appears to enable optimized and individualized spinal cord perfusion.
Collapse
Affiliation(s)
- Samira Saadoun
- Academic Neurosurgery Unit, St. George's University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery Unit, St. George's University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK.
| |
Collapse
|
166
|
Emejulu JK, Malomo A, Oremakinde A, Onyia C, Nwaribe E, Ekweogwu O, Oseni A, Opara O, Iroegbu-Emeruem L, Otorkpa E, Komolafe E, Bankole O, Shehu B. Developing a Guideline for Neurotrauma in Nigeria. World Neurosurg 2020; 138:e705-e711. [PMID: 32179184 DOI: 10.1016/j.wneu.2020.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Nigerian Academy of Neurological Surgeons in 2019 resolved to standardize the practice of neurosurgery in Nigeria. It set up committees to standardize the various aspects of neurosurgery, such as neurotrauma, pediatrics, functional, vascular, skull base, brain tumor, and spine. The Committee on Neurotrauma convened and resolved to study most of the available protocols and guidelines in use in different parts of the world. OBJECTIVE To formulate a standard protocol for the practice of neurotrauma care within the Nigerian locality. METHODS The Committee split its membership into 3 subcommittees to cover the various aspects of the Neurotrauma Guidelines, such as neurotrauma curriculum, standard neurotrauma management protocols, and neurotrauma registry. Each subcommittee was to research on available models and formulate a draft for Nigerian neurotrauma. RESULTS All the 3 subcommittees had their reports ready on schedule. Each concurred that neurotrauma is a major public health challenge in Nigeria. They produced 3 different drafts on the 3 thematic areas of the project. The subcommittees are: 1. Subcommittee on Fellowship, Training and Research Curriculum; 2. Subcommittee on Standard Protocols and Management Guidelines; and 3. Subcommittee of the Nigerian Neurotrauma Registry. CONCLUSION The committee concluded that a formal protocol for neurotrauma care is long overdue in Nigeria for the standardization of all aspects of neurotrauma. It then recommended the adoption of these guidelines by all institutions offering services in Nigeria using the management protocols, opening a registry, and mounting researches on the various aspects of neurotrauma.
Collapse
Affiliation(s)
- Jude-Kennedy Emejulu
- Department of Surgery, Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Awka, Nigeria
| | - Adefolarin Malomo
- Department of Neurosurgery, University College Hospital and College of Medicine, Ibadan, Nigeria
| | | | - Chiazor Onyia
- Department of Surgery, Lagoon hospitals, Lagos, Nigeria
| | | | - Ofodile Ekweogwu
- Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Abidemi Oseni
- Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Oluwamayowa Opara
- Neurosurgery Unit, Regions Stroke and Neurosciences Hospital, Owerri, Nigeria
| | - Linda Iroegbu-Emeruem
- Department of Surgery, University of Port Harcourt Teaching Hospital, Choba, Nigeria
| | - Ega Otorkpa
- Department of Surgery, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Edward Komolafe
- Department of Surgery, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Olufemi Bankole
- Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Bello Shehu
- Department of Surgery, National Hospital, Abuja, Nigeria
| |
Collapse
|
167
|
Khaing ZZ, Cates LN, Hyde J, DeWees DM, Hammond R, Bruce M, Hofstetter CP. Contrast-Enhanced Ultrasound for Assessment of Local Hemodynamic Changes Following a Rodent Contusion Spinal Cord Injury. Mil Med 2020; 185:470-475. [DOI: 10.1093/milmed/usz296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
ABSTRACT
Introduction
Severe trauma to the spinal cord leads to a near complete loss of blood flow at the injury site along with significant hypoperfusion of adjacent tissues. Characterization and monitoring of local tissue hypoperfusion is currently not possible in clinical practice because available imaging techniques do not allow for assessment of blood flow with sufficient spatial and temporal resolutions. The objective of the current study was to determine whether ultrafast contrast-enhanced ultrasound (CEUS) imaging could be used to visualize and quantify acute hemodynamic changes in a rat traumatic spinal cord injury (SCI) model.
Materials and Methods
We used novel ultrasound acquisition and processing methods that allowed for measurements of local tissue perfusion as well as for assessment of structural and functional integrity of spinal vasculature.
Results
CEUS imaging showed that traumatic SCI results in (1) an area with significant loss of perfusion, which increased during the first hour after injury, (2) structural alterations of the spinal cord vasculature, and (3) significant slowing of arterial blood flow velocities around the injury epicenter.
Conclusion
We conclude that CEUS has the spatial and temporal sensitivity and resolution to visualize local tissue perfusion and vessel architecture, which maybe useful clinically to determine injury extent and severity in patients with SCI.
Collapse
Affiliation(s)
- Zin Z Khaing
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Lindsay N Cates
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jeffrey Hyde
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Dane M DeWees
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Ryan Hammond
- Applied Physics Laboratory, Center for Industrial and Medical Ultrasound, The University of Washington, 1013 NE 40th Street, Seattle, WA 98105, USA
| | - Matthew Bruce
- Applied Physics Laboratory, Center for Industrial and Medical Ultrasound, The University of Washington, 1013 NE 40th Street, Seattle, WA 98105, USA
| | - Christoph P Hofstetter
- Department of Neurological Surgery, The University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| |
Collapse
|
168
|
The safety and efficacy of steroid treatment for acute spinal cord injury: A Systematic Review and meta-analysis. Heliyon 2020; 6:e03414. [PMID: 32095652 PMCID: PMC7033344 DOI: 10.1016/j.heliyon.2020.e03414] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/17/2019] [Accepted: 02/12/2020] [Indexed: 12/29/2022] Open
Abstract
Introduction The role for steroids in acute spinal cord injury (ASCI) remains unclear; while some studies have demonstrated the risks of steroids outweigh the benefits,a meta-analyses conducted on heterogeneous patient populations have shown significant motor improvement at short-term but not at long-term follow-up. Given the heterogeneity of the patient population in previous meta-analyses and the publication of a recent trial not included in these meta-analyses, we sought to re-assess and update the safety and short-term and long-term efficacy of steroid treatment following ASCI in a more homogeneous patient population. Materials and methods A literature search was conducted on PubMed, EMBASE and Cochrane Library through June 2019 for studies evaluating the utility of steroids within the first 8 h following ASCI. Neurological and safety outcomes were extracted for patients treated and not treated with steroids. Pooled effect estimates were calculated using the random-effects model. Results Twelve studies, including five randomized controlled trials (RCTs) and seven observational studies (OBSs), were meta-analyzed. Overall, methylprednisolone was not associated with significant short-term or long-term improvements in motor or neurological scores based on RCTs or OBSs. An increased risk of hyperglycemia was shown in both RCTs (RR: 13.7; 95% CI: 1.93, 97.4; 1 study) and OBSs (RR: 2.9; 95% CI: 1.55, 5.41; 1 study). Risk for pneumonia was increased with steroids; while this increase was not statistically significant in the RCTs (pooled RR: 1.16; 95% C.I: 0.59, 2.29; 3 studies), it reached statistical significance in the OBSs (pooled RR: 2.00; 95% C.I: 1.32, 3.02; 6 studies). There was no statistically significant increased risk of gastrointestinal bleeding, decubitus ulcers, surgical site infections, sepsis, atelectasis, venous thromboembolism, urinary tract infections, or mortality among steroid-treated ASCI patients compared to untreated controls in either RCTs or OBSs. Conclusions Methylprednisolone therapy within the first 8 h following ASCI failed to show a statistically significant short-term or long-term improvement in patients' overall motor or neurological scores compared to controls who were not administered steroids. For the same comparison, there was an increased risk of pneumonia and hyperglycemia compared to controls. Routine use of methylprednisone following ASCI should be carefully considered in the context of these results.
Collapse
|
169
|
P Ho V, A Dicker R, Haut ER. Dissemination, implementation, and de-implementation: the trauma perspective. Trauma Surg Acute Care Open 2020; 5:e000423. [PMID: 32154382 PMCID: PMC7046940 DOI: 10.1136/tsaco-2019-000423] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- Vanessa P Ho
- Departments of Surgery and Population and Quantitative Health Sciences, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Rochelle A Dicker
- Department of Surgery, David Geffen School of Medicine, Los Angeles, California, USA
| | - Elliott R Haut
- Departments of Surgery, Anesthesiology and Critical Care Medicine, and Emergency Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | |
Collapse
|
170
|
An explorative, biomechanical analysis of spine motion during out-of-hospital extrication procedures. Injury 2020; 51:185-192. [PMID: 31708085 DOI: 10.1016/j.injury.2019.10.079] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The extrication of patients following a road traffic collision is among the basic procedures in emergency medicine. Thus, extrication is a frequently performed procedure by most of the emergency medical services worldwide. The appropriate extrication procedure depends on the patient's current condition and accompanying injuries. A rapid extrication should be performed within a few minutes, and the cervical spine (at least) should be immobilized. To our knowledge, the scientific literature and current guidelines do not offer detailed recommendations on the extrication of injured patients. Thus, the aim of the current study is to compare the effectiveness of spinal stabilization during various out-of-hospital extrication procedures. METHODS This is an explorative, biomechanical analysis of spine motion during different extrication procedures on an example patient. Movement of the cervical spine was measured using a wireless human motion tracker. Movement of the thoracic and lumbar spine was quantified with 12 strain gauge sensors, which were positioned paravertebrally on both sites along the thoracic and lumbar spine. To interpret angular movement, a motionscore was developed based on newly defined axioms on the biomechanics of the injured spine. RESULTS Self-extrication showed the least spinal movement (overall motionscore sum = 667). Movement in the cervical spine could further be reduced by applying a cervical collar. The extrication by a rescue boa showed comparable results in overall spinal movement compared to the traditional extrication via spineboard (overall motionscore sum = 1862vs. 1743). Especially in the cervical spine, the spinal movement was reduced (motionscore sum = 339 vs. 595). However, the thoracic spine movement was increased (motionscore sum = 812 vs. 432). CONCLUSION In case of a suspected cervical spine injury, guided self-extrication seems to be the best option. If the patient is not able to perform self-extrication, using a rescue boa might reduce cervical spinal movement compared to the traditional extrication procedure. Since promising results are shown in the case of extrication using a patient transfer sheet that has already been placed below the driver, future developments should focus on novel vehicle seats that already include an extrication device.
Collapse
|
171
|
Aarabi B, Akhtar-Danesh N, Chryssikos T, Shanmuganathan K, Schwartzbauer GT, Simard JM, Olexa J, Sansur CA, Crandall KM, Mushlin H, Kole MJ, Le EJ, Wessell AP, Pratt N, Cannarsa G, Lomangino C, Scarboro M, Aresco C, Oliver J, Caffes N, Carbine S, Mori K. Efficacy of Ultra-Early (< 12 h), Early (12-24 h), and Late (>24-138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury. J Neurotrauma 2020; 37:448-457. [PMID: 31310155 PMCID: PMC6978784 DOI: 10.1089/neu.2019.6606] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12-24 h), and 15 underwent decompressive surgery late (> 24-138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862-0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.
Collapse
Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Noori Akhtar-Danesh
- School of Nursing and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Timothy Chryssikos
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Gary T. Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles A. Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenneth M. Crandall
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Harry Mushlin
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Matthew J. Kole
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth J. Le
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aaron P. Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan Pratt
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cara Lomangino
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Maureen Scarboro
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Carla Aresco
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jeffrey Oliver
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicholas Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephen Carbine
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kanami Mori
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
172
|
Chiricozzi E, Lunghi G, Di Biase E, Fazzari M, Sonnino S, Mauri L. GM1 Ganglioside Is A Key Factor in Maintaining the Mammalian Neuronal Functions Avoiding Neurodegeneration. Int J Mol Sci 2020; 21:E868. [PMID: 32013258 PMCID: PMC7037093 DOI: 10.3390/ijms21030868] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022] Open
Abstract
Many species of ganglioside GM1, differing for the sialic acid and ceramide content, have been characterized and their physico-chemical properties have been studied in detail since 1963. Scientists were immediately attracted to the GM1 molecule and have carried on an ever-increasing number of studies to understand its binding properties and its neurotrophic and neuroprotective role. GM1 displays a well balanced amphiphilic behavior that allows to establish strong both hydrophobic and hydrophilic interactions. The peculiar structure of GM1 reduces the fluidity of the plasma membrane which implies a retention and enrichment of the ganglioside in specific membrane domains called lipid rafts. The dynamism of the GM1 oligosaccharide head allows it to assume different conformations and, in this way, to interact through hydrogen or ionic bonds with a wide range of membrane receptors as well as with extracellular ligands. After more than 60 years of studies, it is a milestone that GM1 is one of the main actors in determining the neuronal functions that allows humans to have an intellectual life. The progressive reduction of its biosynthesis along the lifespan is being considered as one of the causes underlying neuronal loss in aged people and severe neuronal decline in neurodegenerative diseases. In this review, we report on the main knowledge on ganglioside GM1, with an emphasis on the recent discoveries about its bioactive component.
Collapse
Affiliation(s)
| | | | | | | | - Sandro Sonnino
- Department of Medical Biotechnology and Translational Medicine, University of Milano, 20090 Segrate, Milano, Italy; (E.C.)
| | | |
Collapse
|
173
|
Transcutaneous contrast-enhanced ultrasound imaging of the posttraumatic spinal cord. Spinal Cord 2020; 58:695-704. [PMID: 31965060 DOI: 10.1038/s41393-020-0415-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/21/2019] [Accepted: 12/09/2019] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Experimental animal study. OBJECTIVE The current study aims to test whether the blood flow within the contused spinal cord can be assessed in a rodent model via the acoustic window of the laminectomy utilizing transcutaneous ultrasound. SETTING Department of Neurological Surgery, University of Washington, Seattle WA. METHODS Long-Evans rats (n = 12) were subjected to a traumatic thoracic spinal cord injury (SCI). Three days and 10 weeks after injury, animals underwent imaging of the contused spinal cord using ultrafast contrast-enhanced ultrasound with a Vantage ultrasound research system in combination with a 15 MHz transducer. Lesion size and signal-to-noise ratios were estimated via transcutaneous, subcutaneous, or epidural ultrasound acquisition through the acoustic window created by the original laminectomy. RESULTS Following laminectomy, transcutaneous and subcutaneous contrast-enhanced ultrasound imaging allowed for assessment of perfusion and vascular flow in the contused rodent spinal cord. An average loss of 7.2 dB from transcutaneous to subcutaneous and the loss of 5.1 dB from subcutaneous to epidural imaging in signal-to-noise ratio (SNR) was observed. The hypoperfused injury center was measured transcutaneously, subcutaneously and epidurally (5.78 ± 0.86, 5.91 ± 0.53, 5.65 ± 1.07 mm2) at 3 days post injury. The same animals were reimaged again at 10 weeks following SCI, and the area of hypoperfusion had decreased significantly compared with the 3-day measurements detected via transcutaneous, subcutaneous, and epidural imaging respectively (0.69 ± 0.05, 1.09 ± 0.11, 0.95 ± 0.11 mm2, p < 0.001). CONCLUSIONS Transcutaneous ultrasound allows for measurements and longitudinal monitoring of local hemodynamic changes in a rodent SCI model.
Collapse
|
174
|
Silvestro S, Bramanti P, Trubiani O, Mazzon E. Stem Cells Therapy for Spinal Cord Injury: An Overview of Clinical Trials. Int J Mol Sci 2020; 21:E659. [PMID: 31963888 PMCID: PMC7013533 DOI: 10.3390/ijms21020659] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/17/2020] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
Spinal cord injury (SCI) is a traumatic lesion that causes disability with temporary or permanent sensory and/or motor deficits. The pharmacological approach still in use for the treatment of SCI involves the employment of corticosteroid drugs. However, SCI remains a very complex disorder that needs future studies to find effective pharmacological treatments. SCI actives a strong inflammatory response that induces a loss of neurons followed by a cascade of events that lead to further spinal cord damage. Many experimental studies demonstrate the therapeutic effect of stem cells in SCI due to their capacity to differentiate into neuronal cells and by releasing neurotrophic factors. Therefore, they appear to be a valid strategy to use in the field of regenerative medicine. The purpose of this paper is to provide an overview of clinical trials, recorded in clinical trial.gov during 2005-2019, aimed to evaluate the use of stem cell-based therapy in SCI. The results available thus far show the safety and efficacy of stem cell therapy in patients with SCI. However, future trials are needed to investigate the safety and efficacy of stem cell transplantation.
Collapse
Affiliation(s)
- Serena Silvestro
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (S.S.); (P.B.)
| | - Placido Bramanti
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (S.S.); (P.B.)
| | - Oriana Trubiani
- Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” Chieti-Pescara, 66100 Chieti, Italy;
| | - Emanuela Mazzon
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (S.S.); (P.B.)
| |
Collapse
|
175
|
Predictors of Intraspinal Pressure and Optimal Cord Perfusion Pressure After Traumatic Spinal Cord Injury. Neurocrit Care 2020; 30:421-428. [PMID: 30328047 PMCID: PMC6420421 DOI: 10.1007/s12028-018-0616-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background/Objectives We recently developed techniques to monitor intraspinal pressure (ISP) and spinal cord perfusion pressure (SCPP) from the injury site to compute the optimum SCPP (SCPPopt) in patients with acute traumatic spinal cord injury (TSCI). We hypothesized that ISP and SCPPopt can be predicted using clinical factors instead of ISP monitoring. Methods Sixty-four TSCI patients, grades A–C (American spinal injuries association Impairment Scale, AIS), were analyzed. For 24 h after surgery, we monitored ISP and SCPP and computed SCPPopt (SCPP that optimizes pressure reactivity). We studied how well 28 factors correlate with mean ISP or SCPPopt including 7 patient-related, 3 injury-related, 6 management-related, and 12 preoperative MRI-related factors. Results All patients underwent surgery to restore normal spinal alignment within 72 h of injury. Fifty-one percentage had U-shaped sPRx versus SCPP curves, thus allowing SCPPopt to be computed. Thirteen percentage, all AIS grade A or B, had no U-shaped sPRx versus SCPP curves. Thirty-six percentage (22/64) had U-shaped sPRx versus SCPP curves, but the SCPP did not reach the minimum of the curve, and thus, an exact SCPPopt could not be calculated. In total 5/28 factors were associated with lower ISP: older age, excess alcohol consumption, nonconus medullaris injury, expansion duroplasty, and less intraoperative bleeding. In a multivariate logistic regression model, these 5 factors predicted ISP as normal or high with 73% accuracy. Only 2/28 factors correlated with lower SCPPopt: higher mean ISP and conus medullaris injury. In an ordinal multivariate logistic regression model, these 2 factors predicted SCPPopt as low, medium–low, medium–high, or high with only 42% accuracy. No MRI factors correlated with ISP or SCPPopt. Conclusions Elevated ISP can be predicted by clinical factors. Modifiable factors that may lower ISP are: reducing surgical bleeding and performing expansion duroplasty. No factors accurately predict SCPPopt; thus, invasive monitoring remains the only way to estimate SCPPopt. Electronic supplementary material The online version of this article (10.1007/s12028-018-0616-7) contains supplementary material, which is available to authorized users.
Collapse
|
176
|
Işık GÇ, Demirci OL, Çorbacıoğlu ŞK, Çevik Y. Effects of 20-degree spinal immobilization on respiratory functions in otherwise healthy volunteers with android-type obesity. Am J Emerg Med 2020; 38:60-64. [DOI: 10.1016/j.ajem.2019.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/10/2019] [Accepted: 04/12/2019] [Indexed: 10/27/2022] Open
|
177
|
Srivastava RN, Agrahari AK, Singh A, Chandra T, Raj S. Effectiveness of bone marrow-derived mononuclear stem cells for neurological recovery in participants with spinal cord injury: A randomized controlled trial. Asian J Transfus Sci 2019; 13:120-128. [PMID: 31896919 PMCID: PMC6910030 DOI: 10.4103/ajts.ajts_44_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 12/02/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND: Complete lesion after spinal cord injury (SCI) remains irreversible with little hope of neurological recovery. Newer interventions such as re-stimulation of damaged neurons using artificial agents and the use of stem cells for neuronal regeneration have shown promising results. AIM: This study was undertaken for evaluating the neurological status of acute SCI participants after stem cell augmentation and comparing them with other treatment methods. SETTING AND DESIGN: Randomized controlled trial in the northern Indian population. MATERIALS AND METHODS: A total 193 SCI participants of complete paraplegia with unstable T4–L2 injury having thoracolumbar injury severity score ≥4 were enrolled in this study. Participants were randomly allocated for three different treatment modalities, namely, conventional with stem cell augmentation (Group-1), conventional (Group-2), and conservative (Group-3). Neurological recovery after 1 year was evaluated through the ASIA Impairment Scale (AIS)-grading, sensory, and motor scores. STATISTICAL ANALYSIS: T-test for sensory-motor score analysis of each group and analysis of variance for comparison of same variables between the groups. RESULTS: After 1-year significant difference was observed in the AIS-grade, sensory and motor scores in-Group 1 (P < 0.001). In Group-1 versus 2, the mean difference at 1 year for AIS grade, sensory and motor scores were 0.40 (P = 0.010, 95% confidence interval [CI] 0.075–0.727), 8.52 (P = 0.030, 95% CI 0.619–16.419), and 4.55(P = 0.003, 95% CI 1.282–7.815), respectively. In Group-1 versus 3, 1.03, 19.02 and 7.22 (P < 0.001 for each of the parameters) and in Group-2 versus 3, 0.63 (P < 0.001), 10.49 (P = 0.009), and 2.68 (P = 0.019), respectively. CONCLUSIONS: Significant motor neurological recovery and AIS-grade promotion was observed in Group-1 as compared to Group-2 and 3.
Collapse
Affiliation(s)
| | - Ashok Kumar Agrahari
- Department of Orthopedic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Alka Singh
- Department of Orthopedic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Tulika Chandra
- Department of Transfusion Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Saloni Raj
- Department of Orthopedic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| |
Collapse
|
178
|
Nam K, Lee Y, Park HP, Chung J, Yoon HK, Kim TK. Cervical Spine Motion During Tracheal Intubation Using an Optiscope Versus the McGrath Videolaryngoscope in Patients With Simulated Cervical Immobilization: A Prospective Randomized Crossover Study. Anesth Analg 2019; 129:1666-1672. [PMID: 31743188 DOI: 10.1213/ane.0000000000003635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND In patients with an unstable cervical spine, maintenance of cervical immobilization during tracheal intubation is important. In McGrath videolaryngoscopic intubation, lifting of the blade to raise the epiglottis is needed to visualize the glottis, but in patients with an unstable cervical spine, this can cause cervical spine movement. By contrast, the Optiscope, a rigid video-stylet, does not require raising of the epiglottis during tracheal intubation. We therefore hypothesized that the Optiscope would produce less cervical spine movement than the McGrath videolaryngoscope during tracheal intubation. The aim of this study was to compare the Optiscope with the McGrath videolaryngoscope with respect to cervical spine motion during intubation in patients with simulated cervical immobilization. METHODS The primary outcome of the study was the extent of cervical spine motion at the occiput-C1, C1-C2, and C2-C5 segments. In this randomized crossover study, the cervical spine angle was measured before and during tracheal intubation using either the Optiscope or the McGrath videolaryngoscope in 21 patients with simulated cervical immobilization. Cervical spine motion was defined as the change in angle at each cervical segment during tracheal intubation. RESULTS There was significantly less cervical spine motion at the occiput-C1 segment using the Optiscope rather than the McGrath videolaryngoscope (mean [98.33% CI]: 4.7° [2.4-7.0] vs 10.4° [8.1-12.7]; mean difference [98.33% CI]: -5.7° [-7.5 to -3.9]). There were also fewer cervical spinal motions at the C1-C2 and C2-C5 segments using the Optiscope (mean difference versus the McGrath videolaryngoscope [98.33% CI]: -2.4° [-3.7 to -1.2]) and -3.7° [-5.9 to -1.4], respectively). CONCLUSIONS The Optiscope produces less cervical spine motion than the McGrath videolaryngoscope during tracheal intubation of patients with simulated cervical immobilization.
Collapse
Affiliation(s)
- Karam Nam
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Younsuk Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Medical Center Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hee-Pyoung Park
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jaeyeon Chung
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Kyu Yoon
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Kyong Kim
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
179
|
[Development and first application testing of a new protocol for preclinical spinal immobilization in children : Assessment of indications based on the E.M.S. IMMO Protocol Pediatric]. Unfallchirurg 2019; 123:289-301. [PMID: 31768566 DOI: 10.1007/s00113-019-00744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND To protect the spine from secondary damage, spinal immobilization is a standard procedure in prehospital trauma management. Immobilization protocols aim to support emergency medicine personnel in quick decision making but predominantly focus on the adult spine; however, trauma mechanisms and injury patterns in adults differ from those in children and applying adult prehospital immobilization protocols to pediatric patients may be insufficient. Adequate protocols for children with spinal injuries are currently unavailable. OBJECTIVE The aim of this study was (i) to develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) to perform a first analysis of the quality of results if the protocol is used by emergency personnel. MATERIAL AND METHODS Based on a structured literature search a new immobilization protocol was developed. Analysis of the quality of results was performed by a questionnaire containing four case scenarios in order to assess correct decision making. The decision about spinal immobilization was made without and with the utilization of the protocol. RESULTS The E.M.S. IMMO Protocol Pediatric was developed based on the literature. The analysis of the quality of results was performed involving 39 emergency medicine providers. It could be shown that if the E.M.S. IMMO Protocol Pediatric was used, the correct type of immobilization was chosen more frequently. A total of 38 out of 39 participants evaluated the protocol as helpful. CONCLUSION The E.M.S. IMMO Protocol Pediatric provides decision-making support whether pediatric spine immobilization is indicated with respect to the cardiopulmonary status of the patient. In a first analysis, the E.M.S. IMMO Protocol Pediatric improves decision making by emergency medical care providers.
Collapse
|
180
|
The Effect of Different Acupuncture Therapies on Neurological Recovery in Spinal Cord Injury: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:2371084. [PMID: 31772592 PMCID: PMC6854954 DOI: 10.1155/2019/2371084] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/18/2019] [Indexed: 02/05/2023]
Abstract
Many acupuncture therapies were used to treat spinal cord injury (SCI) and its complications. The difference in efficacy among these therapies has not been assessed. To compare the efficacy of different acupuncture therapies for SCI, we searched databases (PubMed, Embase, Cochrane Library, CNKI, and WanFang) for relevant RCTs in both English and Chinese before June 2019 that reported the association between acupuncture therapies and SCI. The RCTs were categorized according to the location of the acupoints used in them. The neural function was assessed by American Spinal Injury Association (ASIA) motor score, and daily living ability was accessed by Modified Barthel Index (MBI) after SCI. In total, 22 trials involving 1644 participants were included. The pairwise meta-analysis and random effects model network meta-analysis were conducted. The results indicated that exercise combined with electro-acupuncture (EA) is superior to exercise without acupuncture in improving the ASIA motor score. EA was associated with a significantly higher improvement in the MBI score than exercise alone, except for EA of head + limbs and limbs. Additionally, EA on the head + back and back + front (chest and abdomen) rank the top in both increasing the ASIA motor score and the MBI score. Acupuncture can significantly increase motor function and daily living ability of individuals who suffer from SCI, especially acupuncture of the back + front or the head + back. The evidence supports acupuncture of the back + front or the head + back as an effective treatment for SCI.
Collapse
|
181
|
Exploration of surgical blood pressure management and expected motor recovery in individuals with traumatic spinal cord injury. Spinal Cord 2019; 58:377-386. [PMID: 31649323 PMCID: PMC7062632 DOI: 10.1038/s41393-019-0370-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/03/2019] [Accepted: 10/08/2019] [Indexed: 02/06/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE To assess the impact of mean arterial blood pressure (MAP) during surgical intervention for spinal cord injury (SCI) on motor recovery. SETTING Level-one Trauma Hospital and Acute Rehabilitation Hospital in San Jose, CA, USA. METHODS Twenty-five individuals with traumatic SCI who received surgical and acute rehabilitation care at a level-one trauma center were included in this study. The Surgical Information System captured intraoperative MAPs on a minute-by-minute basis and exposure was quantified at sequential thresholds from 50 to 104 mmHg. Change in International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor score was calculated based on physiatry evaluations at the earliest postoperative time and at discharge from acute rehabilitation. Linear regression models were used to estimate the rate of recovery across the entire MAP range. RESULTS An exploratory analysis revealed that increased time within an intraoperative MAP range (70-94 mmHg) was associated with ISNCSCI motor score improvement. A significant regression equation was found for the MAP range 70-94 mmHg (F[1, 23] = 5.07, r2 = 0.181, p = 0.034). ISNCSCI motor scores increased 0.039 for each minute of exposure to the MAP range 70-94 mmHg during the operative procedure; this represents a significant correlation between intraoperative time with MAP 70-94 and subsequent motor recovery. Blood pressure exposures above or below this range did not display a positive association with motor recovery. CONCLUSIONS Hypertension as well as hypotension during surgery may impact the trajectory of recovery in individuals with SCI, and there may be a direct relationship between intraoperative MAP and motor recovery.
Collapse
|
182
|
Minnema AJ, Mehta A, Boling WW, Schwab J, Simard JM, Farhadi HF. SCING-Spinal Cord Injury Neuroprotection with Glyburide: a pilot, open-label, multicentre, prospective evaluation of oral glyburide in patients with acute traumatic spinal cord injury in the USA. BMJ Open 2019; 9:e031329. [PMID: 31601596 PMCID: PMC6797422 DOI: 10.1136/bmjopen-2019-031329] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Acute traumatic spinal cord injury (tSCI) is a devastating neurological disorder with no pharmacological neuroprotective strategy proven effective to date. Progressive haemorrhagic necrosis (PHN) represents an increasingly well-characterised mechanism of secondary injury after tSCI that negatively impacts neurological outcomes following acute tSCI. Preclinical studies evaluating the use of the Food and Drug Administration-approved sulfonylurea receptor 1-transient receptor potential melastatin 4 channel blocker glyburide in rodent models have shown reduced secondary microhaemorrhage formation and the absence of capillary fragmentation, the pathological hallmark of PHN. METHODS AND ANALYSIS In this initial phase multicentre open-label pilot study, we propose to enrol 10 patients with acute cervical tSCI to primarily assess the feasibility, and safety of receiving oral glyburide within 8 hours of injury. Secondary objectives include pharmacokinetics and preliminary evaluations on neurological recovery as well as blood and MRI-based injury biomarkers. Analysis will be performed using the descriptive and non-parametric statistics. ETHICS AND DISSEMINATION Glyburide has been shown as an effective neuroprotective agent in preclinical tSCI models and in the treatment of ischaemic stroke with the additional risk of a hypoglycaemic response. Given the ongoing secondary injury and the traumatic hyperglycaemic stress response seen in patients with tSCI, glyburide; thus, offers an appealing neuroprotective strategy to supplement standard of care treatment. The study protocol was approved by the Ohio State University Biomedical Institutional Review Board. The protocol was amended in February 2017 with changes related to study feasibility and patient recruitment. Specifically, the route of administration was changed to the oral form to allow for streamlined and rapid drug administration, and the injury-to-drug time window was extended to 8 hours in an effort to further enhance enrolment. Participants or legally authorised representatives are informed about the trial and its anticipated risks orally and in written form using an approved informed consent form prior to inclusion. The findings of this study will be disseminated to the participants and to academic peers through scientific conferences and peer-reviewed journal publications. TRIAL REGISTRATION NUMBERS NCT02524379 and 2014H0335.
Collapse
Affiliation(s)
- Amy Janelle Minnema
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - A Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Warren W Boling
- Department of Neurological Surgery, Loma Linda University, Loma Linda, California, USA
| | - Jan Schwab
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - J Marc Simard
- Department of Neurological Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - H Francis Farhadi
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
183
|
Hadley MN, Walters BC. The case for the future role of evidence-based medicine in the management of cervical spine injuries, with or without fractures. J Neurosurg Spine 2019; 31:457-463. [PMID: 31574462 DOI: 10.3171/2019.6.spine19652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/19/2019] [Indexed: 11/06/2022]
Abstract
The authors believe that the standardized and systematic study of immobilization techniques, diagnostic modalities, medical and surgical treatment strategies, and ultimately outcomes and outcome measurement after cervical spinal trauma and cervical spinal fracture injuries, if performed using well-designed medical evidence-based comparative investigations with meaningful follow-up, has both merit and the remarkable potential to identify optimal strategies for assessment, characterization, and clinical management. However, they recognize that there is inherent difficulty in attempting to apply evidence-based medicine (EBM) to identify ideal treatment strategies for individual cervical fracture injuries. First, there is almost no medical evidence reported in the literature for the management of specific isolated cervical fracture subtypes; specific treatment strategies for specific fracture injuries have not been routinely studied in a rigorous, comparative way. One of the vulnerabilities of an evidenced-based scientific review in spinal cord injury (SCI) is the lack of studies in comparative populations and scientific evidence on a given topic or fracture pattern providing level II evidence or higher. Second, many modest fracture injuries are not associated with vascular or neural injury or spinal instability. The application of the science of EBM to the care of patients with traumatic cervical spine injuries and SCIs is invaluable and necessary. The dedicated multispecialty author groups involved in the production and publication of the two iterations of evidence-based guidelines on the management of acute cervical spine and spinal cord injuries have provided strategic guidance in the care of patients with SCIs. This dedicated service to the specialty has been carried out to provide neurosurgical colleagues with a qualitative review of the evidence supporting various aspects of care of these patients. It is important to state and essential to understand that the science of EBM and its rigorous application is important to medicine and to the specialty of neurosurgery. It should be embraced and used to drive and shape investigations of the management and treatment strategies offered patients. It should not be abandoned because it is not convenient or it does not support popular practice bias or patterns. It is the authors' view that the science of EBM is essential and necessary and, furthermore, that it has great potential as clinician scientists treat and study the many variations and complexities of patients who sustain acute cervical spine fracture injuries.
Collapse
Affiliation(s)
- Mark N Hadley
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Beverly C Walters
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
- 2Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| |
Collapse
|
184
|
Choi SH, Sung CH, Heo DR, Jeong SY, Kang CN. Incidence of acute spinal cord injury and associated complications of methylprednisolone therapy: a national population-based study in South Korea. Spinal Cord 2019; 58:232-237. [DOI: 10.1038/s41393-019-0357-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/25/2019] [Accepted: 08/31/2019] [Indexed: 10/26/2022]
|
185
|
Sacino A, Rosenblatt K. Early Management of Acute Spinal Cord Injury-Part I: Initial Injury to Surgery. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2019; 6:213-221. [PMID: 34012997 DOI: 10.1055/s-0039-1694688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Acute spinal cord injury is a devastating event associated with substantial morbidity worldwide. The pathophysiology of spinal cord injury involves the initial mechanical trauma and the subsequent inflammatory response, which may worsen the severity of neurologic dysfunction. Interventions have been studied to reduce the extent of primary injury to the spinal cord through preventive measures and to mitigate secondary insult through early specialized care. Management, therefore, is multifold, interdisciplinary, and begins immediately at the time of injury. It includes the trauma triage, acute management of the circulatory and respiratory systems, and definitive treatment, mainly with surgical decompression and stabilization.
Collapse
Affiliation(s)
- Amanda Sacino
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Kathryn Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| |
Collapse
|
186
|
Grassner L, Wutte C, Zimmermann G, Grillhösl A, Schmid K, Weiβ T, Maier W, Hauck S, Hollerith T, Vogel M, Bierschneider M, Vastmans J, Thomé C, Gonschorek O, Strowitzki M. Influence of Preoperative Magnetic Resonance Imaging on Surgical Decision Making for Patients with Acute Traumatic Cervical Spinal Cord Injury: A Survey Among Experienced Spine Surgeons. World Neurosurg 2019; 131:e586-e592. [PMID: 31404692 DOI: 10.1016/j.wneu.2019.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Early decompression after acute spinal cord injury (SCI) is recommended. Acute care is crucial, but optimal management is unclear. The aim of this study was to investigate the role of preoperative magnetic resonance imaging (MRI) in addition to computed tomography (CT) in surgical decision making for acute cervical SCI. METHODS All patients with cervical SCI between 2008 and 2016 who had preoperative CT and MRI (n = 63) at the Trauma Center Murnau, Germany, were included. We administered a survey to 10 experienced spine surgeons (5 neurosurgeons, 5 trauma surgeons) regarding the surgical management. First, the surgeons were shown clinical information and CT scans. Two months later, the survey was repeated with additional MRI. Corresponding percentages of change and agreement were obtained for each rater and survey item. Finally, results from both parts of the survey were compared with the definitive treatment option (i.e., real-world decision). RESULTS MRI modified surgical timing in a median of 41% of patients (interquartile range 38%-56%). In almost every fifth patient (17%), no surgery would have been indicated with CT alone. The advocated surgical approach was changed in almost half of patients (median 48%, interquartile range 33%-49%). Surgically addressed levels were changed in a median of 57% of patients (interquartile range 56%-60%). MRI led to higher agreement with the real-world decision concerning addressed levels (median 35% vs. 73%), timing (median 51% vs. 57%), and approach (median 44% vs. 65%). CONCLUSIONS Preoperative MRI influenced surgical decision making substantially in our cohort and has become a new standard for patients with cervical SCI in our institution if medically possible.
Collapse
Affiliation(s)
- Lukas Grassner
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany; Center for Spinal Cord Injuries, BG Trauma Center Murnau, Murnau, Germany; Institute for Molecular Regenerative Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria; Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria.
| | - Christof Wutte
- Center for Spinal Cord Injuries, BG Trauma Center Murnau, Murnau, Germany
| | - Georg Zimmermann
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler Medical Center and Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Grillhösl
- Department of Neuroradiology, BG Trauma Center Murnau, Murnau, Germany
| | - Katharina Schmid
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany
| | - Thomas Weiβ
- Department of Spine Surgery, BG Trauma Center Murnau, Murnau, Germany
| | - Walter Maier
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany
| | - Stefan Hauck
- Department of Spine Surgery, BG Trauma Center Murnau, Murnau, Germany
| | - Tobias Hollerith
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany
| | - Matthias Vogel
- Center for Spinal Cord Injuries, BG Trauma Center Murnau, Murnau, Germany
| | | | - Jan Vastmans
- Center for Spinal Cord Injuries, BG Trauma Center Murnau, Murnau, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Oliver Gonschorek
- Department of Spine Surgery, BG Trauma Center Murnau, Murnau, Germany
| | - Martin Strowitzki
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany
| |
Collapse
|
187
|
Squair JW, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Parent S, Christie S, Bailey C, Dhall S, Charest-Morin R, Street J, Ailon T, Paquette S, Dea N, Fisher CG, Dvorak MF, West CR, Kwon BK. Empirical targets for acute hemodynamic management of individuals with spinal cord injury. Neurology 2019; 93:e1205-e1211. [PMID: 31409736 DOI: 10.1212/wnl.0000000000008125] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 04/25/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the hemodynamic conditions associated with optimal neurologic improvement in individuals with acute traumatic spinal cord injury (SCI) who had lumbar intrathecal catheters placed to measure CSF pressure (CSFP). METHODS Ninety-two individuals with acute SCI were enrolled in this multicenter prospective observational clinical trial. We monitored mean arterial pressure (MAP) and CSFP during the first week after injury and assessed neurologic function at baseline and 6 months after injury. We used relative risk iterations to determine transition points at which the likelihood of either improving neurologically or remaining unchanged neurologically was equivalent. These transition points guided our analyses in which we examined the linear relationships between time spent within target hemodynamic ranges (i.e., clinical adherence) and neurologic recovery. RESULTS Relative risk transition points for CSFP, MAP, and spinal cord perfusion pressure (SCPP) were linearly associated with neurologic improvement and directed the identification of key hemodynamic target ranges. Clinical adherence to the target ranges was positively and linearly related to improved neurologic outcomes. Adherence to SCPP targets, not MAP targets, was the best indicator of improved neurologic recovery, which occurred with SCPP targets of 60 to 65 mm Hg. Failing to maintain the SCPP within the target ranges was an important detrimental factor in neurologic recovery, particularly if the target range is set lower. CONCLUSION We provide an empirical, data-driven approach to aid institutions in setting hemodynamic management targets that accept the real-life challenges of adherence to specific targets. Our results provide a framework to guide the development of widespread institutional management guidelines for acute traumatic SCI.
Collapse
Affiliation(s)
- Jordan W Squair
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Lise M Bélanger
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Angela Tsang
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Leanna Ritchie
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Jean-Marc Mac-Thiong
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Stefan Parent
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Sean Christie
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Christopher Bailey
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Sanjay Dhall
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Raphaele Charest-Morin
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - John Street
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Tamir Ailon
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Scott Paquette
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Nicolas Dea
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Charles G Fisher
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Marcel F Dvorak
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Christopher R West
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada
| | - Brian K Kwon
- From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada.
| |
Collapse
|
188
|
Abstract
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.
Collapse
|
189
|
Magistretti PJ, Geisler FH, Schneider JS, Li PA, Fiumelli H, Sipione S. Gangliosides: Treatment Avenues in Neurodegenerative Disease. Front Neurol 2019; 10:859. [PMID: 31447771 PMCID: PMC6691137 DOI: 10.3389/fneur.2019.00859] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/24/2019] [Indexed: 01/09/2023] Open
Abstract
Gangliosides are cell membrane components, most abundantly in the central nervous system (CNS) where they exert among others neuro-protective and -restorative functions. Clinical development of ganglioside replacement therapy for several neurodegenerative diseases was impeded by the BSE crisis in Europe during the 1990s. Nowadays, gangliosides are produced bovine-free and new pre-clinical and clinical data justify a reevaluation of their therapeutic potential in neurodegenerative diseases. Clinical experience is greatest with monosialo-tetrahexosyl-ganglioside (GM1) in the treatment of stroke. Fourteen randomized controlled trials (RCTs) in overall >2,000 patients revealed no difference in survival, but consistently superior neurological outcomes vs. placebo. GM1 was shown to attenuate ischemic neuronal injuries in diabetes patients by suppression of ERK1/2 phosphorylation and reduction of stress to the endoplasmic reticulum. There is level-I evidence from 5 RCTs of a significantly faster recovery with GM1 vs. placebo in patients with acute and chronic spinal cord injury (SCI), disturbance of consciousness after subarachnoid hemorrhage, or craniocerebral injuries due to closed head trauma. In Parkinson's disease (PD), two RCTs provided evidence of GM1 to be superior to placebo in improving motor symptoms and long-term to result in a slower than expected symptom progression, suggesting disease-modifying potential. In Alzheimer's disease (AD), the role of gangliosides has been controversial, with some studies suggesting a "seeding" role for GM1 in amyloid β polymerization into toxic forms, and others more recently suggesting a rather protective role in vivo. In Huntington's disease (HD), no clinical trials have been conducted yet. However, low GM1 levels observed in HD cells were shown to increase cell susceptibility to apoptosis. Accordingly, treatment with GM1 increased survival of HD cells in vitro and consistently ameliorated pathological phenotypes in several murine HD models, with effects seen at molecular, cellular, and behavioral level. Given that in none of the clinical trials using GM1 any clinically relevant safety issues have occurred to date, current data supports expanding GM1 clinical research, particularly to conditions with high, unmet medical need.
Collapse
Affiliation(s)
- Pierre J. Magistretti
- Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
- Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
- Department of Psychiatry, Center for Psychiatric Neurosciences, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Fred H. Geisler
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jay S. Schneider
- Parkinson's Disease Research Unit, Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, Philadelphia, PA, United States
| | - P. Andy Li
- Department of Pharmaceutical Sciences, Biomanufacturing Research Institute Technology Enterprise (BRITE), North Carolina Central University, Durham, NC, United States
| | - Hubert Fiumelli
- Biological and Environmental Science and Engineering Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
- Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
- Department of Psychiatry, Center for Psychiatric Neurosciences, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Simonetta Sipione
- Department of Pharmacology, Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
190
|
Abstract
PURPOSE OF REVIEW Spinal cord injury (SCI) shows an incidence of 10.4-83 cases/million/year globally and remains a significant source of morbidity and cost to society. Despite greater understanding of the pathophysiology of SCI, neuroprotective and regenerative approaches to treatment have had limited clinical utility to date. Here, we review the key components of supportive care that are thus the mainstay of therapy and that have improved outcomes for victims of acute SCI in recent decades. RECENT STUDIES Current management strategies for acute SCI involve early surgical decompression and fixation, the use of vasopressor medications for mean arterial blood pressure (MAP) augmentation to improve spinal cord perfusion, and corticosteroids. We highlight recent literature supporting the role of norepinephrine in acute SCI management and also an emerging neurocritical care strategy that seeks to optimize spinal cord perfusion pressure with the assistance of invasive monitoring. This review will highlight key pathophysiologic principles and targets for current acute clinical treatments in SCI, which include early surgical decompression, MAP augmentation, and corticosteroids. We discuss anticipated future research in these areas and focus on potential risks inherent to these treatments.
Collapse
Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1 - Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
| |
Collapse
|
191
|
Satyarthee GD. Reader response: Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. Neurology 2019; 90:904. [PMID: 29735776 DOI: 10.1212/wnl.0000000000005466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
192
|
Okoroafor F, Krishna A, Purcell M, Mathieson C. Impressive neurological recovery following C-spine dislocation in a patient on long term immunosuppression. Br J Neurosurg 2019:1-3. [DOI: 10.1080/02688697.2019.1630553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Francois Okoroafor
- University Hospital Ayr, Ayr, United Kingdom of Great Britain and Northern Ireland
| | - Arun Krishna
- University Hospital Ayr, Ayr, United Kingdom of Great Britain and Northern Ireland
| | - Mariel Purcell
- Queen Elizabeth National Spinal Injuries Unit, National Spinal Injuries Unit, Southern General Hospital, Glasgow, United Kingdom of Great Britain and Northern Ireland
| | - Calan Mathieson
- Queen Elizabeth National Spinal Injuries Unit, National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
193
|
Longo M, Gelfand Y, De la Garza Ramos R, Echt M, Kinon MD, Yanamadala V, Yassari R. Perioperative Complications and Mortality Following Anterior Odontoid Screw Fixation in Elderly Patients: A National Database Analysis. World Neurosurg 2019; 129:e776-e781. [PMID: 31289000 DOI: 10.1016/j.wneu.2019.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify predictors of short-term mortality and complications after anterior odontoid screw fixation. METHODS This was a retrospective analysis of a national database. The American College of Surgeons National Quality Improvement Database was queried using Current Procedural Terminology codes to identify patients aged ≥60 years who underwent surgery for anterior fixation of odontoid fracture admitted from 2007 to 2016. Univariate analysis and subsequent multivariate analysis were used to analyze risk factors for postoperative complications and 30-day postoperative mortality. Complications were defined as surgical-site infection, wound breakdown, pneumonia, venous thromboembolism, stroke, myocardial infarction, sepsis, renal progressive renal insufficiency/acute kidney injury, or cardiac arrest. RESULTS A total of 198 patients were identified. Mean age was 77.7 (±8.7) years and 60.6% were female. Overall mortality rate was 7.6%, and the complication rate was 9.1%. In multivariate analysis, dependent functional status (0.012; odds ratio [OR] 5.2; 95% confidence interval [CI] 1.42-18.72) and preoperative systemic inflammatory response syndrome (P = 0.011; OR 6.2; 95% CI 1.52-25.79) predicted mortality. Emergency case status (P = 0.033; OR 3.4; 95% CI 1.10-10.70) predicted perioperative complications. Age was not significantly associated with either complications or mortality in multivariate analysis. CONCLUSIONS Functional dependence and preoperative systemic inflammatory response syndrome predict mortality following odontoid screw placement. Although age often is considered a limiting factor in pursuing surgical intervention in patients with odontoid fracture, age did not independently increase odds of either complications or perioperative mortality in this analysis. Further studies are needed to explore these findings.
Collapse
Affiliation(s)
- Michael Longo
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Yaroslav Gelfand
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rafael De la Garza Ramos
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Murray Echt
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Merritt D Kinon
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Vijay Yanamadala
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Reza Yassari
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
| |
Collapse
|
194
|
Hallisey SD, Greenwood JC. Beyond Mean Arterial Pressure and Lactate: Perfusion End Points for Managing the Shocked Patient. Emerg Med Clin North Am 2019; 37:395-408. [PMID: 31262411 DOI: 10.1016/j.emc.2019.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients in shock present frequently to the emergency department. The emergency physician must be skilled in the resuscitation of both differentiated and undifferentiated shock. Early, aggressive resuscitation of patients in shock is essential, using macrocirculatory, microcirculatory, and clinical end points to guide interventions. Therapy should focus on the restoration of oxygen delivery to match tissue demand. This article reviews the evidence supporting common end points of resuscitation for common etiologies of shock and limitations to their use.
Collapse
Affiliation(s)
- Stephen D Hallisey
- Department of Emergency Medicine, University of Pennsylvania - Perelman School of Medicine, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, USA.
| | - John C Greenwood
- Department of Emergency Medicine, University of Pennsylvania - Perelman School of Medicine, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania - Perelman School of Medicine, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19014, USA
| |
Collapse
|
195
|
Ellingson BM, Woodworth DC, Leu K, Salamon N, Holly LT. Spinal Cord Perfusion MR Imaging Implicates Both Ischemia and Hypoxia in the Pathogenesis of Cervical Spondylosis. World Neurosurg 2019; 128:e773-e781. [PMID: 31077900 DOI: 10.1016/j.wneu.2019.04.253] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Although a number of studies have implicated ischemia and hypoxia in the pathogenesis of cervical spondylosis, quantification remains difficult and the role of ischemia and hypoxia on disease progression and disease severity in human cervical spondylosis remains largely unknown. Therefore, the objective of this study was to assess spinal cord perfusion and oxygenation in human cervical spondylosis and examine the relationship between perfusion, degree of spinal cord compression, and neurological status. METHODS Twenty-two patients with cervical spondylosis with or without myelopathy received a dynamic susceptibility contrast perfusion MRI exam consisting of a novel spin-and-gradient echo echoplanar acquisition before, during, and following gadolinium-based contrast injection. Estimation of relative spinal cord blood volume (rSCBV), the reversible relaxation rate (R2á), and relative oxygen extraction fraction (rOEF = R2á/rSCBV) was performed at the site of compression and compared with anterior-posterior spinal cord diameter and modified Japanese Orthopedic Association (mJOA) score, a measure of neurological impairment. RESULTS rSCBV was linearly correlated with both anterior-posterior cord diameter (R2 = 0.4667, P = 0.0005) and mJOA (R2 = 0.2274, P = 0.0248). R2á was linearly correlated with mJOA (R2 = 0.3998, P = 0.0016) but not cord diameter (R2 = 0.055; P = 0.2950). Also, rOEF was correlated with both cord diameter (R2 = 0.3440, P = 0.0041) and mJOA (R2 = 0.4699, P = 0.0004). CONCLUSIONS Results support the hypothesis that spinal cord compression results in ischemia and hypoxia, and the degree of ischemia and hypoxia is proportional to the degree of neurological impairment.
Collapse
Affiliation(s)
- Benjamin M Ellingson
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Department of Physics and Biology in Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA.
| | - Davis C Woodworth
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Department of Physics and Biology in Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Kevin Leu
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Noriko Salamon
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Langston T Holly
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| |
Collapse
|
196
|
Neal CJ, McCafferty RR, Freedman B, Helgeson MD, Rivet D, Gwinn DE, Rosner MK. Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery in the Deployed Setting. Mil Med 2019; 183:83-91. [PMID: 30189075 DOI: 10.1093/milmed/usy096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Indexed: 01/26/2023] Open
Abstract
This Cervical and Thoracolumbar Spine Injury Evaluation, Transport, and Surgery Clinical Practice Guideline (CPG) is designed to provide guidance to the deployed provider when they are treating a combat casualty who has sustained a spine or spinal cord injury. The CPG objective for the treatment and the movement of these patients is to maintain spinal stability through transport, perform decompression when urgently needed, achieve definitive stabilization when appropriate, avoid secondary injury, and prevent deterioration of the patient's neurological condition. Thorough and accurate documentation of the patient's neurological examination is crucial to ensure appropriate management decisions are made as the patient transits through the evacuation system. The use of this CPG should be in conjunction with good clinical judgment.
Collapse
Affiliation(s)
- Chris J Neal
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | | | - Brett Freedman
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | | | - Dennis Rivet
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | - David E Gwinn
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | - Michael K Rosner
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| |
Collapse
|
197
|
Divi SN, Schroeder GD, Mangan JJ, Tadley M, Ramey WL, Badhiwala JH, Fehlings MG, Oner FC, Kandziora F, Benneker LM, Vialle EN, Rajasekaran S, Chapman JR, Vaccaro AR. Management of Acute Traumatic Central Cord Syndrome: A Narrative Review. Global Spine J 2019; 9:89S-97S. [PMID: 31157150 PMCID: PMC6512200 DOI: 10.1177/2192568219830943] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES To provide an updated overview of the management of acute traumatic central cord syndrome (ATCCS). METHODS A comprehensive narrative review of the literature was done to identify evidence-based treatment strategies for patients diagnosed with ATCCS. RESULTS ATCCS is the most commonly encountered subtype of incomplete spinal cord injury and is characterized by worse sensory and motor function in the upper extremities compared with the lower extremities. It is most commonly seen in the setting of trauma such as motor vehicles or falls in elderly patients. The operative management of this injury has been historically variable as it can be seen in the setting of mechanical instability or preexisting cervical stenosis alone. While each patient should be evaluated on an individual basis, based on the current literature, the authors' preferred treatment is to perform early decompression and stabilization in patients that have any instability or significant neurologic deficit. Surgical intervention, in the appropriate patient, is associated with an earlier improvement in neurologic status, shorter hospital stay, and shorter intensive care unit stay. CONCLUSIONS While there is limited evidence regarding management of ATCCS, in the presence of mechanical instability or ongoing cord compression, surgical management is the treatment of choice. Further research needs to be conducted regarding treatment strategies and patient outcomes.
Collapse
Affiliation(s)
- Srikanth N Divi
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - John J Mangan
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Madeline Tadley
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Wyatt L Ramey
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | | | | | | | | | | | | | | | - Jens R Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Alexander R Vaccaro
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| |
Collapse
|
198
|
Lewis SJ, Wong IHY, Strantzas S, Holmes LM, Vreugdenhil I, Bensky H, Nielsen CJ, Zeller R, Lebel DE, de Kleuver M, Germscheid N, Alanay A, Berven S, Cheung KMC, Ito M, Polly DW, Shaffrey CI, Qiu Y, Lenke LG. Responding to Intraoperative Neuromonitoring Changes During Pediatric Coronal Spinal Deformity Surgery. Global Spine J 2019; 9:15S-21S. [PMID: 31157143 PMCID: PMC6512195 DOI: 10.1177/2192568219836993] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
STUDY DESIGN Retrospective case study on prospectively collected data. OBJECTIVES The purpose of this explorative study was: 1) to determine if patterns of spinal cord injury could be detected through intra-operative neuromonitoring (IONM) changes in pediatric patients undergoing spinal deformity corrections, 2) to identify if perfusion based or direct trauma causes of IONM changes could be distinguished, 3) to observe the effects of the interventions performed in response to these events, and 4) to attempt to identify different treatment algorithms for the different causes of IONM alerts. METHODS Prospectively collected neuromonitoring data in pre-established forms on consecutive pediatric patients undergoing coronal spinal deformity surgery at a single center was reviewed. Real-time data was collected on IONM alerts with >50% loss in signal. Patients with alerts were divided into 2 groups: unilateral changes (direct cord trauma), and bilateral MEP changes (cord perfusion deficits). RESULTS A total of 97 pediatric patients involving 71 females and 26 males with a mean age of 14.9 (11-18) years were included in this study. There were 39 alerts in 27 patients (27.8% overall incidence). All bilateral changes responded to a combination of transfusion, increasing blood pressure, and rod removal. Unilateral changes as a result of direct trauma, mainly during laminotomies for osteotomies, improved with removal of the causative agent. Following corrective actions in response to the alerts, all cases were completed as planned. Signal returned to near baseline in 20/27 patients at closure, with no new neurological deficits in this series. CONCLUSION A high incidence of alerts occurred in this series of cases. Dividing IONM changes into perfusion-based vs direct trauma directed treatment to the offending cause, allowing for safe corrections of the deformities. Patients did not need to recover IONM signal to baseline to have a normal neurological examination.
Collapse
Affiliation(s)
- Stephen J. Lewis
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- AOSpine Knowledge Forum Deformity, Davos, Switzerland
| | - Ian H. Y. Wong
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Samuel Strantzas
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Laura M. Holmes
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ian Vreugdenhil
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Hailey Bensky
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Reinhard Zeller
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David E. Lebel
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Ahmet Alanay
- AOSpine Knowledge Forum Deformity, Davos, Switzerland
| | - Sigurd Berven
- AOSpine Knowledge Forum Deformity, Davos, Switzerland
| | | | - Manabu Ito
- AOSpine Knowledge Forum Deformity, Davos, Switzerland
| | | | | | - Yong Qiu
- AOSpine Knowledge Forum Deformity, Davos, Switzerland
| | | |
Collapse
|
199
|
Pinchi E, Frati A, Cantatore S, D'Errico S, Russa RL, Maiese A, Palmieri M, Pesce A, Viola RV, Frati P, Fineschi V. Acute Spinal Cord Injury: A Systematic Review Investigating miRNA Families Involved. Int J Mol Sci 2019; 20:E1841. [PMID: 31013946 PMCID: PMC6515063 DOI: 10.3390/ijms20081841] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/06/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023] Open
Abstract
Acute traumatic spinal cord injury (SCI) involves primary and secondary injury mechanisms. The primary mechanism is related to the initial traumatic damage caused by the damaging impact and this damage is irreversible. Secondary mechanisms, which begin as early as a few minutes after the initial trauma, include processes such as spinal cord ischemia, cellular excitotoxicity, ionic dysregulation, and free radical-mediated peroxidation. SCI is featured by different forms of injury, investigating the pathology and degree of clinical diagnosis and treatment strategies, the animal models that have allowed us to better understand this entity and, finally, the role of new diagnostic and prognostic tools such as miRNA could improve our ability to manage this pathological entity. Autopsy could benefit from improvements in miRNA research: the specificity and sensitivity of miRNAs could help physicians in determining the cause of death, besides the time of death.
Collapse
Affiliation(s)
- Enrica Pinchi
- Department SAIMLAL, "Sapienza" University of Roma, 00161 Rome, Italy.
| | - Alessandro Frati
- IRCCS "Neuromed" ⁻ Neurosurgery Division, 86077 Pozzilli. (IS) Italy.
- NESMOS Department ⁻ Neurosurgery Division, "Sapienza" University of Roma, 00189 Rome, Italy.
| | - Santina Cantatore
- Forensic Pathology Institute, University of Foggia, 71122 Foggia, Italy.
| | - Stefano D'Errico
- Department SAIMLAL, "Sapienza" University of Roma, 00161 Rome, Italy.
- Legal Medicine Division, Ospedale Sant'Andrea, 00189 Rome, Italy.
| | - Raffaele La Russa
- Department SAIMLAL, "Sapienza" University of Roma, 00161 Rome, Italy.
- IRCCS "Neuromed" ⁻ Neurosurgery Division, 86077 Pozzilli. (IS) Italy.
| | - Aniello Maiese
- Department SAIMLAL, "Sapienza" University of Roma, 00161 Rome, Italy.
- IRCCS "Neuromed" ⁻ Neurosurgery Division, 86077 Pozzilli. (IS) Italy.
| | - Mauro Palmieri
- NESMOS Department ⁻ Neurosurgery Division, "Sapienza" University of Roma, 00189 Rome, Italy.
| | - Alessandro Pesce
- IRCCS "Neuromed" ⁻ Neurosurgery Division, 86077 Pozzilli. (IS) Italy.
- NESMOS Department ⁻ Neurosurgery Division, "Sapienza" University of Roma, 00189 Rome, Italy.
| | | | - Paola Frati
- Department SAIMLAL, "Sapienza" University of Roma, 00161 Rome, Italy.
- IRCCS "Neuromed" ⁻ Neurosurgery Division, 86077 Pozzilli. (IS) Italy.
| | - Vittorio Fineschi
- Department SAIMLAL, "Sapienza" University of Roma, 00161 Rome, Italy.
- IRCCS "Neuromed" ⁻ Neurosurgery Division, 86077 Pozzilli. (IS) Italy.
| |
Collapse
|
200
|
Sharwood LN, Joseph A, Guo C, Flower O, Ball J, Middleton JW. Heterogeneous emergency department management of published recommendation defined hypotension in patients with acute traumatic spinal cord injury: A multi-centre overview. Emerg Med Australas 2019; 31:967-973. [PMID: 30968575 DOI: 10.1111/1742-6723.13290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 02/20/2019] [Accepted: 03/02/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Evidence-based management for patients with acute traumatic spinal cord injury (TSCI) in the ED has a critical impact on long-term outcomes. Acute hypotension post-injury may compromise spinal cord perfusion and extend neurological damage. Published guidelines recommend mean arterial blood pressure (BP) maintenance between 85 and 90 mmHg for 7 days post-injury; the extent to which this is followed in Australia is unknown. METHODS Prospective observational study of patients ≥16 years with TSCI, treated at 48 hospitals across two Australian states. Mean arterial BPs were recorded in the Ambulance, and ED arrival and discharge. Patients' medical records documented treatment provided (intravenous fluids, vasopressors or both) for BP augmentation. Hypotension was defined as mean arterial BP <85 mmHg, per the American Association of Neurological Surgeons guidelines. RESULTS The 208 patients with TSCI in the present study were more likely to receive BP augmentation if they experienced direct transport to a Spinal Cord Service hospital (OR 5.57, 95% CI 2.32-10.11), had a cervical level injury (OR 2.32, 95% CI 1.01-5.5) or were hypotensive on ED arrival (OR 2.42, 95% CI 1.34-4.39). Of the 112 patients who were hypotensive, 71 (63.4%) received treatment for this; however, the majority (76%) remained hypotensive on discharge. CONCLUSION Hypotensive patients' post-TSCI experienced heterogeneous ED care discordant with published guidelines; varying by hospital type. Specialist care and more severe injury increased likelihood of guideline adherence. Lack of adherence may influence patient outcomes. Level 1 evidence is needed along with consistent guideline implementation and clinician training to likely improve TSCI management and outcomes.
Collapse
Affiliation(s)
- Lisa N Sharwood
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Joseph
- Trauma Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Cici Guo
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Oliver Flower
- Intensive Care Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jonathon Ball
- Department of Neurosurgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|