Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update

Comparing Blunt and Penetrating Trauma in Spinal Cord Injury: Analysis of Long-Term Functional and Neurological Outcomes

Background: Comparisons between patients with penetrating spinal cord injury (PSCI) and blunt spinal cord injury (BSCI) are scarce. Purpose: To describe baseline characteristics and neurological and functional outcomes for patients with BSCI and PSCI. Methods: Participants with BSCI (n = 5,316) and PSCI (n = 1,062) were extracted from the Spinal Cord Injury Model Systems database from January 1994 to January 2015. Participant injury and demographic characteristics were recorded. Outcomes were measured using the International Standards for Neurological Classification of Spinal Cord Injury and FIM motor scores. Outcomes for patients with American Spinal Injury Association Impairment Scale (AIS) complete injuries were analyzed separately from incomplete injuries at three time points: acute hospitalization, SCI rehabilitation, and 1-year follow-up. Results: Patients with PSCI compared to those with BSCI were more likely to present with complete injuries (56.8% vs 35.9%; p < .001) and were less likely to undergo spine surgery (19.6% vs 80.6%; p < .001). For incomplete injuries, no significant differences were observed between groups in FIM scores or AIS grade improvement at 1 year. For complete injuries, patients with BSCI showed an increased one-grade (15.7% vs 9.1%; p < .001) and three-grade (5.4% vs 1.9%; p = .014) AIS improvement at 1 year. Multivariate regression analysis demonstrated an independent effect for BSCI on AIS improvement at 1 year (odds ratio [OR], 1.74; 95% CI, 1.13-2.70; C-stat = 0.66). Conclusion: Patient with PSCI had more complete injuries and lower surgery rates. Patients with complete BSCI show greater AIS improvement at 1 year, and incomplete injuries show no difference in neurological improvement between groups. Overall, patients with PSCI demonstrated worse functional outcomes at 1 year.

Therapeutic systemic hypothermia for a pediatric patient with an isolated cervical spinal cord injury

Context: While uncommon, spinal cord injuries most frequently occur in adolescent and young adult males. Established treatment options are limited and focused on supportive care. Therapeutic systemic hypothermia is an emerging experimental treatment currently undergoing clinical trials in adults.Findings: Here we report a case of a 13-year-old male with an American Spinal Injury Association Impairment Scale grade C traumatic cervical spinal cord injury treated with 48 hours of therapeutic systemic hypothermia who made a complete neurological recovery. To our knowledge, this is the youngest such case report.Clinical relevance: This case suggests that consideration should be given to including pediatric patients in future clinical trials of therapeutic hypothermia for spinal cord injury.

Contrast-enhanced ultrasound to visualize hemodynamic changes after rodent spinal cord injury

OBJECTIVE

Traumatic spinal cord injury (tSCI) causes an almost complete loss of blood flow at the site of injury (primary injury) as well as significant hypoperfusion in the penumbra of the injury. Hypoperfusion in the penumbra progresses after injury to the spinal cord and is likely to be a major contributor to progressive cell death of spinal cord tissue that was initially viable (secondary injury). Neuroprotective treatment strategies seek to limit secondary injury. Clinical monitoring of the temporal and spatial patterns of blood flow within the contused spinal cord is currently not feasible. The purpose of the current study was to determine whether ultrafast contrast-enhanced ultrasound (CEUS) Doppler allows for detection of local hemodynamic changes within an injured rodent spinal cord in real time.

METHODS

A novel ultrafast CEUS Doppler technique was developed utilizing a research ultrasound platform combined with a 15-MHz linear array transducer. Ultrafast plane-wave acquisitions enabled the separation of higher-velocity blood flow in macrocirculation from low-velocity flow within the microcirculation (tissue perfusion). An FDA-approved contrast agent (microbubbles) was used for visualization of local blood flow in real time. CEUS Doppler acquisition protocols were developed to characterize tissue perfusion both during contrast inflow and during the steady-state plateau. A compression injury of the thoracic spinal cord of adult rats was induced using iris forceps.

RESULTS

High-frequency ultrasound enabled visualization of spinal cord vessels such as anterior spinal arteries as well as central arteries (mean diameter [± SEM] 145.8 ± 10.0 µm; 76.2 ± 4.5 µm, respectively). In the intact spinal cord, ultrafast CEUS Doppler confirmed higher perfusion of the gray matter compared to white matter. Immediately after compression injury of the thoracic rodent spinal cord, spinal cord vessels were disrupted in an area of 1.93 ± 1.14 mm2. Ultrafast CEUS Doppler revealed a topographical map of local tissue hypoperfusion with remarkable spatial resolution. Critical loss of perfusion, defined as less than 40% perfusion compared to the surrounding spared tissue, was seen within an area of 2.21 ± 0.6 mm2.

CONCLUSIONS

In our current report, we introduce ultrafast CEUS Doppler for monitoring of spinal vascular structure and function in real time. Development and clinical implementation of this type of imaging could have a significant impact on the care of patients with tSCI.

Update on critical care for acute spinal cord injury in the setting of polytrauma

Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

Clinical Trials in Traumatic Spinal Cord Injury

Traumatic spinal cord injury (SCI) results in impaired neurologic function that for many individuals is permanent and significantly impacts health, function, quality of life, and life expectancy. Many efforts have been taken to develop effective treatments for SCI; nevertheless, proven therapies targeting neurologic regeneration and functional recovery have been limited. Existing therapeutic approaches, including early surgery, strict blood pressure control, and consideration of treatment with steroids, remain debated and largely focus on mitigating secondary injury after the primary trauma has occurred. Today, there is more research being performed in SCI than ever before. Current clinical trials are exploring pharmacologic, cell-based, physiologic, and rehabilitation approaches to reduce secondary injury and also overcome barriers to neurorecovery. In the future, it is likely that tailored treatments combining many of these strategies will offer significant benefits for persons with SCI. This article aims to review key past, current and emerging neurologic and rehabilitation therapeutic approaches for adults with traumatic SCI.

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

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

Immediate reduction under general anesthesia and combined anterior and posterior fusion in the treatment of distraction-flexion injury in the lower cervical spine

BACKGROUND

Distraction-flexion of the lower cervical spine is a severe traumatic lesion, frequently resulting in paralysis. The optimal surgical treatment is controversial. It has been a challenge for orthopedic surgeons to manage distraction-flexion injury in the lower cervical spine while avoiding the risk of iatrogenic damage. Thus, safer strategies need to be designed and adopted.This study aimed to evaluate the clinical efficacy of immediate reduction under general anesthesia and combined anterior and posterior fusion in the treatment of distraction-flexion injury in the lower cervical spine.

METHODS

Twenty-four subjects of traumatic lower cervical spinal distraction-flexion were retrospectively analyzed from January 2010 to December 2013. Traffic accident was the primary cause of injury, with patients presenting with dislocated segments in C4-5 (n = 8), C5-6 (n = 10), and C6-7 (n = 6). Sixteen patients had unilateral facet dislocation and eight had bilateral facet dislocation. Spinal injuries were classified according to the American Spinal Injury Association (ASIA) impairment scale (2000 edition amended), with four cases of grade A, four cases of grade B, ten cases of grade C, four cases of grade D, and two cases of grade E. On admission, all patients underwent immediate reduction under general anesthesia and combined anterior and posterior fusion. The mean follow-up time was 3.5 years.

RESULTS

All operations were completed successfully, with no major complications. Postoperative X-rays showed satisfactory height for the cervical intervertebral space and recovery of the vertebral sequence. Bone fusion was completed within 4 to 6 months after surgery. Surgery also significantly improved neurological function in all patients.

CONCLUSION

Immediate reduction under general anesthesia and combined anterior and posterior fusion can be used to successfully treat distraction-flexion injury in the lower cervical spine, obtaining completed decompression, safe spinal re-alignment, and excellent immediate postoperative stability.

Matrine Directly Activates Extracellular Heat Shock Protein 90, Resulting in Axonal Growth and Functional Recovery in Spinal Cord Injured-Mice

After spinal cord injury (SCI), reconstruction of neuronal tracts is very difficult because an inhibitory scar is formed at the lesion site, in which several axonal growth inhibitors, such as chondroitin sulfate proteoglycans (CSPG), accumulate. We previously found that matrine, a major alkaloid in Sophora flavescens, enhanced axonal growth in neurons seeded on CSPG coating. The aims of this study were to investigate therapeutic effects of matrine in SCI mice and to clarify the underlying mechanism. Matrine was orally administered to contusion SCI mice. In the matrine-treated mice, motor dysfunction of the hindlimbs was improved, and the density of 5-HT-positive tracts was increased in the injured spinal cord. We explored putative direct binding proteins of matrine in cultured neurons using drug affinity responsive target stability (DARTS). As a result, heat shock protein 90 (HSP90) was identified, and matrine enhanced HSP90 chaperon activity. We then presumed that extracellular HSP90 is a matrine-targeting signaling molecule, and found that specific blocking of extracellular HSP90 by a neutralizing antibody completely diminished matrine-induced axonal growth and SCI amelioration. Our results suggest that matrine enhances axonal growth and functional recovery in SCI mice by direct activation of extracellular HSP90. Matrine could be a significant candidate for therapeutic drugs for SCI with a novel mechanism.

Worldwide Steroid Prescription for Acute Spinal Cord Injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To continue the line of a previous publication using steroid for acute spinal cord injury (SCI) by spine surgeons from Latin America (LA) and assess the current status of methylprednisolone (MP) prescription in Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) to determine targets for educational activities suitable for each region.

METHODS

The English version of a previously published questionnaire was used to evaluate opinions about MP administration in acute SCI in LA, EU, AP, NA, and ME. This Internet-based survey was conducted by members of AOSpine. The questionnaire asked about demographic features, background with management of spine trauma patients, routine administration of MP in acute SCI, and reasons for MP administration.

RESULTS

A total of 2659 responses were obtained for the electronic questionnaire from LA, EU, AP, NA, and ME. The number of spine surgeons that treat SCI was 2206 (83%). The steroid was used by 1198 (52.9%) surgeons. The uses of MP were based predominantly on the National Acute Spinal Cord Injury Study III study (n = 595, 50%). The answers were most frequently given by spine surgeons from AP, ME, and LA. These regions presented a statistically significant difference from North America (P < .001). The number of SCI patients treated per year inversely influenced the use of MP. The higher the number of patients treated, the lower the administration rates of MP observed.

CONCLUSIONS

The study identified potential targets for educational campaigns, aiming to reduce inappropriate practices of MP administration.

Motion and dural sac compression in the upper cervical spine during the application of a cervical collar in case of unstable craniocervical junction-A study in two new cadaveric trauma models

Background

Unstable conditions of the craniocervical junction such as atlanto-occipital dislocation (AOD) or atlanto-axial instability (AAI) are severe injuries with a high risk of tetraplegia or death. Immobilization by a cervical collar to protect the patient from secondary damage is a standard procedure in trauma patients. If the application of a cervical collar to a patient with an unstable craniocervical condition may cause segmental motion and secondary injury to the spinal cord is unknown.

The aim of the current study is (i) to analyze compression on the dural sac and (ii) to determine relative motion of the cervical spine during the procedure of applying a cervical collar in case of ligamentous unstable craniocervical junction.

Methods and findings

Ligamentous AOD as well as AOD combined with ligamentous AAI was simulated in two newly developed cadaveric trauma models. Compression of the dural sac and segmental angulation in the upper cervical spine were measured on video fluoroscopy after myelography during the application of a cervical collar. Furthermore, overall three-dimensional motion of the cervical spine was measured by a motion tracking system.

In six cadavers each, the two new trauma models on AOD and AOD combined with AAI could be implemented. Mean dural sac compression was significantly increased to -1.1 mm (-1.3 to -0.7 mm) in case of AOD and -1.2 mm (-1.6 to -0.6 mm) in the combined model of AOD and AAI. Furthermore, there is a significant increased angulation at the C0/C1 level in the AOD model. Immense three-dimensional movement up to 22.9° of cervical spine flexion was documented during the procedure.

Conclusion

The current study pointed out that applying a cervical collar in general will cause immense three-dimensional movement. In case of unstable craniocervical junction, this leads to a dural sac compression and thus to possible damage to the spinal cord.

Management of irreducible unilateral facet joint dislocations in subaxial cervical spine: two case reports and a review of the literature

Background

Skeletal and soft tissue damage are often associated with unilateral facet dislocations, which undoubtedly lead to instability of the spine and further increase difficulties in cervical reduction. This type of irreducible facet dislocation is usually accompanied with potential catastrophic consequences including neurological deficit and severe disability. Therefore, a consistent and evidence-based treatment plan is imperative.

Case presentation

The literature regarding the management of traumatic unilateral locked cervical facet dislocations was reviewed. Two patient cases (a 30-year-old Asian man and a 25-year-old Asian woman) who suffered irreducible cervical facet dislocations were presented. These two patients received surgical treatments including posterior reduction by poking facet joints, adjacent spinous process fixation by wire rope banding, anterior plate fixation, and intervertebral fusion after the failure of skull traction and closed reduction. At the postoperative 24-month follow-up, intervertebral fusion was achieved and our patients’ neurological status improved based on the American Spinal Injury Association scale, compared with their preoperative status.

Conclusions

Unilateral facet joint dislocations of subaxial cervical spine are difficult to reduce when complicated with posterior facet fractures or ligamentous injury. Magnetic resonance imaging can be beneficial for identifying ventral and dorsal compressive lesions, as well as ligamentous or capsule rupture. The combination of posterior reduction and anterior fixation with fusion has advantages in terms of clinical safety, ease of operation, and less iatrogenic damage.

Reporting of CT cervical spine after office hours by radiology trainees-analysis of discrepancy rates and RADPEER scores

PURPOSE

To review the errors made by radiology trainees in the reporting of cervical spine CTs (CCT) and to compare the discrepancy rates between the stages of training.

METHODS

All CCTs reported by trainees after office hours between January 2015 and December 2015 were retrospectively reviewed by a team of five musculoskeletal consultants with experience ranging between 7 and 15 years. Discrepancies between the provisional report by the trainee and the findings by the musculoskeletal consultants were graded according to the RADPEER scoring system. Sensitivity and specificity of the trainees were assessed.

RESULTS

Of 254 CCT provisional reports, there were 12 (4.7%) discrepancies, of which 5 (2.0%) discrepancies were likely to be clinically significant. We found a clinically significant difference between the stage of training of the trainee and RADPEER score (P = 0.023). The sensitivity and specificity of the senior radiology trainees were 97.0 and 98.1%, respectively, and that of the junior radiology trainees were 80 and 98.0% respectively (P = 0.039). Conditions misinterpreted as fractures include degenerative changes (n = 2) and nutrient vessel (n = 1). Other missed abnormalities include ossification of the posterior longitudinal ligament (n = 1), fracture of the foramen transversarium (n = 2), vertebral body fractures (n = 2), articular facet fractures (n = 2), and transverse process fractures (n = 2).

CONCLUSION

Cervical spine CTs performed after office hours can be safely interpreted by senior radiology trainees to a reasonable degree, although a targeted intervention to improve diagnostic performance of junior radiology trainees may be of clinical benefit.

Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging

BACKGROUND

Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging.

METHODS

This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016.

RESULTS

There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02).

CONCLUSION

A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

Blunt, Penetrating and Strangulating; Suicidal, Homicidal, Accidental and Sport-Related Neck Injuries: a Case Series and Literature Review

Introduction:

Presentation of neck injuries in ER can be with or without neurological deficit. Trauma victims with multiple injuries should be examined for neck injuries as these injuries are potentially life threatening. Further neck movement should be restricted by applying the cervical collar until further radiological investigations rule out the spine injury. Early identification and treatment of neck injuries whether spine, vascular, or muscular injury improve the morbidity and mortality in polytrauma patients.

Case presentation:

In a series of case presentations of neck injuries through various modes, the first case of neck injury was related to road traffic accident presented with neck pain and paraplegia. In the second case, neck injury was due to suicidal hanging presented with ligature mark over the neck. Third case was related to Indian traditional sport-related neck injury presented with severe neck pain stiffness. In the fourth case, neck injury was due to gunshot and presented with bullet entry wound and quadriparesis.

Conclusion:

Neck injury in the absence of associated injuries is rarely seen after blunt and penetrating trauma, but can result in devastating outcomes if left unrecognized. A high index of suspicion and early intervention are critical.

Therapeutic potential of flavonoids in spinal cord injury

Spinal cord injury (SCI) is a catastrophic event that can profoundly affect a patient's life, with far-reaching social and economic effects. A consequential sequence of SCI is the significant neurological or psychological deficit, which obviously contributes to the overall burden of this condition. To date, there is no effective treatment for SCI. Therefore, developing novel therapeutic strategies for SCI is highly prioritized. Flavonoids, one of the most numerous and ubiquitous groups of plant metabolites, are the active ingredients of traditional Chinese medicine such as Scutellaria baicalensis Georgi (Huang Qin) or Ginkgo biloba (Ying Xin). Accumulated research data show that flavonoids possess a range of key pharmacological properties such as anti-inflammatory, anti-oxidant, anti-tumor, anti-viral, anti-cardiovascular disease, immunomodulatory, and neuroprotective effects. Based on this, the flavonoids show therapeutic potential for SCI diseases. In this paper, we will review the pharmacological properties of different types of flavonoids for the treatment of SCI diseases, and potential underlying biochemical mechanisms of action will also be described.

Review of clinical neurorestorative strategies for spinal cord injury: Exploring history and latest progresses

Clinical neurorestorative therapies recently made great progress for patients with spinal cord injury (SCI). This paper systemically reviews historical perspectives, recent advancements and achievements in SCI through key neurorestorative strategies. In this study, a search was performed in the PubMed, Scopus, and Scholar Google search engines using the keywords “neurorestorative strategies”, “spinal cord injury”, “cell therapy”, “neuromodulation”, and “nerve bridges”. Clinical studies published in the English language were included. It is paramount for academic community involved in this field to take the initiative of a multicenter randomized, double-blind, and placebo-control clinical study with high level of evidence-based treatments for most SCI neurorestorative strategies in patient management. It is of utmost need to establish standard therapeutic methods for patients with SCI as early as possible.

Acute management of cervical spine trauma

Traumatic cervical spine injuries represent a significant cause of morbidity and mortality in sports. Appropriate management of such injuries is critical to minimizing harm and facilitating optimal long-term recovery and outcome. Management strategies begin with emergency preparedness amongst sideline providers and extends to paramedic services and medical teams in the acute care setting. This chapter outlines the principles of treatment across the care continuum, with a primary focus on hospital-based care. Diagnostic imaging and equipment considerations are reviewed, with discussion of corticosteroid administration, therapeutic hypothermia, and traction of the cervical spine. Approaches to cervical spine stabilization and return to play are also detailed, with an emphasis on patient-centered care and individualized treatment approaches to the athlete.

The impact of spine stability on cervical spinal cord injury with respect to demographics, management, and outcome: a prospective cohort from a national spinal cord injury registry

BACKGROUND CONTEXT

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

PURPOSE

The study aimed to test the authors' hypothesis that spine stability can identify a unique group of patients with regard to demographics, management, and outcomes, which classic CCS definitions do not.

STUDY DESIGN/SETTING

This is a prospective observational study.

PATIENT SAMPLE

The sample included participants with cervical SCI included in a prospective Canadian registry.

OUTCOME MEASURES

The outcome measures were initial hospitalization length of stay, change in total motor score from admission to discharge, and in-hospital mortality.

METHODS

Patients with cervical SCI from a prospective Canadian SCI registry were grouped into stable and unstable spine cohorts. Bivariate analyses were used to identify differences in demographic, injury, management, and outcomes. Multivariate analysis was used to better understand the impact of spine stability on motor score improvement. No conflicts of interest were identified.

RESULTS

Compared with those with an unstable spine, patients with cervical SCI and a stable spine were older (58.8 vs. 44.1 years, p<.0001), more likely male (86.4% vs. 76.1%, p=.0059), and have more medical comorbidities. Patients with stable spine cervical SCI were more likely to have sustained their injury by a fall (67.4% vs. 34.9%, p<.0001), and have high cervical (C1-C4; 58.5% vs. 43.3%, p=.0009) and less severe neurologic injuries (ASIA Impairment Scale C or D; 81.3% vs. 47.5%, p<.0001). Those with stable spine injuries were less likely to have surgery (67.6% vs. 92.6%, p<.0001), had shorter in-hospital lengths of stay (median 84.0 vs. 100.5 days, p=.0062), and higher total motor score change (20.7 vs. 19.4 points, p=.0014). Multivariate modeling revealed that neurologic severity of injury and spine stability were significantly related to motor score improvement; patients with stable spine injuries had more motor score improvement.

CONCLUSIONS

We propose that classification of stable cervical SCI is more clinically relevant than classic CCS classification as this group was found to be unique with regard to demographics, neurologic injury, management, and outcome, whereas classic CCS classifications do not . This classification can be used to assess optimal management in patients where it is less clear if and when surgery should be performed.

Incidence and Natural Progression of Neurogenic Shock after Traumatic Spinal Cord Injury

Neurogenic shock, a distributive type of circulatory shock after spinal cord injury (SCI), results in profound hypotension. The consequent hemodynamic instability complicates clinical management, delays surgical intervention, and impacts neurological outcome. Moreover, the reported incidence of this condition varies significantly. We establish the true incidence of neurogenic shock by comparing the most common clinical definitions used to diagnose the condition. Further, we characterize the acute progression and recovery of neurogenic shock. Daily blood pressure, heart rate, and fluid management as well as vasopressor therapy and neurologic status were collected over 30 days from 84 adults admitted to our tertiary trauma center after cervical (n = 56) and thoracic (n = 28) SCI. We found that the reported incidence of neurogenic shock varied greatly depending on which clinical definition was applied. By using a novel combination of hemodynamic and laboratory criteria to define neurogenic shock, the calculated incidence (29% cervical SCI) in our sample most appropriately reflects the true incidence, finding that hypovolemia was the primary factor responsible for the inconsistency in incidence reports between studies. In addition, we found a characteristic decline in blood pressure after the first week post-injury and that fluid management is not currently an integral aspect of clinical management (all persons were treated at a net fluid intake ≤ zero). The results demonstrate the need for accurate identification of neurogenic shock through consistent and appropriate criteria, which is not only important from a clinical point of view, but also in establishing accurate epidemiology to responsibly allocate resources to its management.

Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury

BACKGROUND

Evidence indicates that, over time, patients with spinal cord injury (SCI) improve neurologically in various degrees. We sought to further investigate indicators of grade conversion in cervical SCI.

OBJECTIVE

To detect predictors of ASIA impairment scale (AIS) grade conversion in SCI following surgical decompression.

METHODS

In a retrospective study, demographics, clinical, imaging, and surgical data from 100 consecutive patients were assessed for predictors of AIS grade conversion.

RESULTS

American Spinal Injury Association motor score was 17.1. AIS grade was A in 52%, B in 29%, and C in 19% of patients. Surgical decompression took place on an average of 17.6 h following trauma (≤12 h in 51 and >12 h in 49). Complete decompression was verified by magnetic resonance imaging (MRI) in 73 patients. Intramedullary lesion length (IMLL) on postoperative MRI measured 72.8 mm, and hemorrhage at the injury epicenter was noted in 71 patients. Grade conversion took place in 26.9% of AIS grade A patients, 65.5% of AIS grade B, and 78.9% of AIS grade C. AIS grade conversion had statistical relationship with injury severity score, admission AIS grade, extent of decompression, presence of intramedullary hemorrhage, American Spinal Injury Association motor score, and IMLL. A stepwise multiple logistic regression analysis indicated IMLL was the sole and strongest indicator of AIS grade conversion (odds ratio 0.950, 95% CI 0.931-0.969). For 1- and 10-mm increases in IMLL, the model indicates 4% and 40% decreases, respectively, in the odds of AIS grade conversion.

CONCLUSION

Compared with other surrogates, IMLL remained as the only predictor of AIS grade conversion.

Mitochondrial-Based Therapeutics for the Treatment of Spinal Cord Injury: Mitochondrial Biogenesis as a Potential Pharmacological Target

Spinal cord injury (SCI) is characterized by an initial trauma followed by a progressive cascade of damage referred to as secondary injury. A hallmark of secondary injury is vascular disruption leading to vasoconstriction and decreased oxygen delivery, which directly reduces the ability of mitochondria to maintain homeostasis and leads to loss of ATP-dependent cellular functions, calcium overload, excitotoxicity, and oxidative stress, further exacerbating injury. Restoration of mitochondria dysfunction during the acute phases of secondary injury after SCI represents a potentially effective therapeutic strategy. This review discusses the past and present pharmacological options for the treatment of SCI as well as current research on mitochondria-targeted approaches. Increased antioxidant activity, inhibition of the mitochondrial permeability transition, alternate energy sources, and manipulation of mitochondrial morphology are among the strategies under investigation. Unfortunately, many of these tactics address single aspects of mitochondrial dysfunction, ultimately proving largely ineffective. Therefore, this review also examines the unexplored therapeutic efficacy of pharmacological enhancement of mitochondrial biogenesis, which has the potential to more comprehensively improve mitochondrial function after SCI.

Ameliorating Spinal Cord Injury in an Animal Model With Mechanical Tissue Resuscitation

BACKGROUND

Traumatic spinal cord injury (SCI) is a major worldwide cause of mortality and disability with limited treatment options. Previous research applying controlled negative pressure to traumatic brain injury in rat and swine models resulted in smaller injuries and more rapid recovery.

OBJECTIVE

To examine the effects of the application of a controlled vacuum (mechanical tissue resuscitation [MTR]) to SCI in a rat model under several magnitudes of vacuum.

METHODS

Controlled contusion SCIs were created in rats. Vacuums of -50 and -75 mm Hg were compared. Analysis included open-field locomotor performance, magnetic resonance imaging (in vivo T2, ex vivo diffusion tensor imaging and fiber tractography), and histological assessments.

RESULTS

MTR treatment significantly improved the locomotor recovery from a Basso, Beattie, and Bresnahan score of 7.8 ± 1.9 to 11.4 ± 1.2 and 10.7 ± 1.9 at -50- and -75-mm Hg pressures, respectively, 4 weeks after injury. Both pressures also reduced fluid accumulations > 10% by T2-imaging in SCI sites. The mean fiber number and mean fiber length were greater across injured sites after MTR treatment, especially with treatment with -50 mm Hg. Myelin volume was increased significantly by 60% in the group treated with -50 mm Hg.

CONCLUSION

MTR of SCI in a rat model is effective in reducing edema in the injured cord, preserving myelin survival, and improving the rate and quantity of functional recovery.

ABBREVIATIONS

BBB, Basso, Beattie, and BresnahanDTI, diffusion tensor imagingFA, fractional anisotropyMTR, mechanical tissue resuscitationMTR50, mechanical tissue resuscitation with 50-mm Hg subatmospheric pressureMTR75, mechanical tissue resuscitation with 75-mm Hg subatmospheric pressureROI, region of interestSCI, spinal cord injury.

The impact of blood pressure management after spinal cord injury: a systematic review of the literature

OBJECTIVE

Spinal cord injury (SCI) results in significant morbidity and mortality. Improving neurological recovery by reducing secondary injury is a major principle in the management of SCI. To minimize secondary injury, blood pressure (BP) augmentation has been advocated. The objective of this study was to review the evidence behind BP management after SCI.

METHODS

This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Using the PubMed database, the authors identified studies that investigated BP management after acute SCI. Information on BP goals, duration of BP management, vasopressor selection, and neurological outcomes were analyzed.

RESULTS

Eleven studies that met inclusion criteria were identified. Nine studies were retrospective, and 2 were single-cohort prospective investigations. Of the 9 retrospective studies, 7 reported a goal mean arterial pressure (MAP) of higher than 85 mm Hg. For the 2 prospective studies, the MAP goals were higher than 85 mm Hg and higher than 90 mm Hg. The duration of BP management varied from more than 24 hours to 7 days in 6 of the retrospective studies that reported the duration of treatment. In both prospective studies, the duration of treatment was 7 days. In the 2 prospective studies, neurological outcomes were stable to improved with BP management. The retrospective studies, however, were contradictory with regard to the correlation of BP management and outcomes. Dopamine, norepinephrine, and phenylephrine were the agents that were frequently used to augment BP. However, more complications have been associated with dopamine use than with the other vasopressors.

CONCLUSIONS

There are no high-quality data regarding optimal BP goals and duration in the management of acute SCI. Based on the highest level of evidence available from the 2 prospective studies, MAP goals of 85–90 mm Hg for a duration of 5–7 days should be considered. Norepinephrine for cervical and upper thoracic injuries and phenylephrine or norepinephrine for mid- to lower thoracic injuries should be considered.

Spinal Meninges and Their Role in Spinal Cord Injury: A Neuroanatomical Review

Current recommendations support early surgical decompression and blood pressure augmentation after traumatic spinal cord injury (SCI). Elevated intraspinal pressure (ISP), however, has probably been underestimated in the pathophysiology of SCI. Recent studies provide some evidence that ISP measurements and durotomy may be beneficial for individuals suffering from SCI. Compression of the spinal cord against the meninges in SCI patients causes a "compartment-like" syndrome. In such cases, intentional durotomy with augmentative duroplasty to reduce ISP and improve spinal cord perfusion pressure (SCPP) may be indicated. Prior to performing these procedures routinely, profound knowledge of the spinal meninges is essential. Here, we provide an in-depth review of relevant literature along with neuroanatomical illustrations and imaging correlates.

Rural and Urban Living in Persons with Spinal Cord Injury and Comparing Environmental Barriers, Their Health, and Quality-of-Life Outcomes

There is worldwide geographic variation in the epidemiology of traumatic spinal cord injury (tSCI). The aim of this study was to determine whether environmental barriers, health status, and quality-of-life outcomes differ between patients with tSCI living in rural or urban settings, and whether patients move from rural to urban settings after tSCI. A cohort review of the Rick Hansen SCI Registry (RHSCIR) was undertaken from 2004 to 2012 for one province in Canada. Rural/urban setting was determined using postal codes. Outcomes data at 1 year in the community included the Short Form-36 Version 2 (SF36v2™), Life Satisfaction Questionnaire, Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF), Functional Independent Measure® Instrument, and SCI Health Questionnaire. Statistical methodologies used were t test, Mann-Whitney U test, and Fisher's exact or χ2 test. In the analysis, 338 RHSCIR participants were included; 65 lived in a rural setting and 273 in an urban setting. Of the original patients residing in a rural area at discharge,10 moved to an urban area by 1 year. Those who moved from a rural to urban area reported a lower SF-36v2™ Mental Component Score (MCS; p = 0.04) and a higher incidence of depression at 1 year (p = 0.04). Urban patients also reported a higher incidence of depression (p = 0.02) and a lower CHIEF-SF total score (p = 0.01) indicating fewer environmental barriers. No significant differences were found in other outcomes. Results suggest that although the patient outcomes are similar, some patients move from rural to urban settings after tSCI. Future efforts should target screening mental health problems early, especially in urban settings.

Risk factors for pulmonary complication following fixation of spine fractures

BACKGROUND CONTEXT

Previous studies have suggested pulmonary complications are common among patients undergoing fixation for traumatic spine fractures. This leads to prolonged hospital stay, worse functional outcomes, and increased economic burden. However, only limited prognostic information exists regarding which patients are at greatest risk for pulmonary complications.

PURPOSE

This study aimed to identify factors predictive of perioperative pulmonary complications in patients undergoing fixation of spine fractures.

STUDY DESIGN/SETTING

A retrospective review in a level 1 trauma center was carried out.

PATIENT SAMPLE

The patient sample comprised 302 patients with spinal fractures who underwent operative fixation.

OUTCOME MEASURES

The outcome measures were postoperative pulmonary complications (physiological and functional measures).

MATERIALS AND METHODS

Demographic and injury features were recorded, including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, mechanism of injury, injury characteristics, and neurologic status. Treatment details, including surgery length, timing, and approach were reviewed. Postoperative pulmonary complications were recorded after a minimum of 6 months' follow-up.

RESULTS

Forty-seven pulmonary complications occurred in 42 patients (14%), including pneumonia (35), adult respiratory distress syndrome (ARDS) (10), and pulmonary embolism (2). Logistic regression found spinal cord injury (SCI) to be most predictive of pulmonary complications (odds ratio [OR]=4.4, 95% confidence interval [CI] 1.9-10.1), followed by severe chest injury (OR 2.7, 95% CI 1.1-6.9), male gender (OR 2.7, 95% CI 1.1-6.8), and ASA classification (OR 2.3, 95% CI 1.4-4.0). Pulmonary complications were associated with significantly longer hospital stays (23.9 vs. 7.7 days, p<.01), stays in the intensive care unit (ICU) (19.9 vs. 3.4 days, p<.01), and increased ventilator times (13.8 days vs. 1.9 days, p<.01).

CONCLUSIONS

Several factors predicted development of pulmonary complications after operative spinal fracture, including SCI, severe chest injury, male gender, and higher ASA classification. Practitioners should be especially vigilant for of postoperative complications and associated injuries following upper-thoracic spine fractures. Future study must focus on appropriate interventions necessary for reducing complications in these high-risk patients.

Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury

OBJECTIVE

To determine whether spinal cord perfusion pressure (SCPP) as measured with a lumbar intrathecal catheter is a more predictive measure of neurologic outcome than the conventionally measured mean arterial pressure (MAP).

METHODS

A total of 92 individuals with acute spinal cord injury were enrolled in this multicenter prospective observational clinical trial. MAP and CSF pressure (CSFP) were monitored during the first week postinjury. Neurologic impairment was assessed at baseline and at 6 months postinjury. We used logistic regression, systematic iterations of relative risk, and Cox proportional hazard models to examine hemodynamic patterns commensurate with neurologic outcome.

RESULTS

We found that SCPP (odds ratio 1.039, p = 0.002) is independently associated with positive neurologic recovery. The relative risk for not recovering neurologic function continually increased as individuals were exposed to SCPP below 50 mm Hg. Individuals who improved in neurologic grade dropped below SCPP of 50 mm Hg fewer times than those who did not improve (p = 0.012). This effect was not observed for MAP or CSFP. Those who were exposed to SCPP below 50 mm Hg were less likely to improve from their baseline neurologic impairment grade (p = 0.0056).

CONCLUSIONS

We demonstrate that maintaining SCPP above 50 mm Hg is a strong predictor of improved neurologic recovery following spinal cord injury. This suggests that SCPP (the difference between MAP and CSFP) can provide useful information to guide the hemodynamic management of patients with acute spinal cord injury.

Effects of Respiratory Training on Heart Rate Variability and Baroreflex Sensitivity in Individuals With Chronic Spinal Cord Injury

OBJECTIVE

To evaluate the effects of pressure threshold respiratory training (RT) on heart rate variability and baroreflex sensitivity in persons with chronic spinal cord injury (SCI).

DESIGN

Before-after intervention case-controlled clinical study.

SETTING

SCI research center and outpatient rehabilitation unit.

PARTICIPANTS

Participants (N=44) consisted of persons with chronic SCI ranging from C2 to T11 who participated in RT (n=24), and untrained control subjects with chronic SCI ranging from C2 to T9 (n=20).

INTERVENTIONS

A total of 21±2 RT sessions performed 5 days a week during a 4-week period using a combination of pressure threshold inspiratory and expiratory devices.

MAIN OUTCOME MEASURES

Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), and beat-to-beat arterial blood pressure and heart rate changes during the 5-second-long maximum expiratory pressure maneuver (5s MEP) and the sit-up orthostatic stress test, acquired before and after the RT program.

RESULTS

In contrast to the untrained controls, individuals in the RT group experienced significantly increased FVC and FEV₁ (both P<.01) in association with improved quality of sleep, cough, and speech. Sympathetically (phase II) and parasympathetically (phase IV) mediated baroreflex sensitivity both significantly (P<.05) increased during the 5s MEP. During the orthostatic stress test, improved autonomic control over heart rate was associated with significantly increased sympathetic and parasympathetic modulation (low- and high-frequency change: P<.01 and P<.05, respectively).

CONCLUSIONS

Inspiratory-expiratory pressure threshold RT is a promising technique to positively affect both respiratory and cardiovascular dysregulation observed in persons with chronic SCI.

Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial

BACKGROUND

For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury.

METHODS

This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings.

RESULTS

Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease.

CONCLUSIONS

For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.

LEVEL OF EVIDENCE

Diagnostic tests, level II.

CCL-2 as a possible early marker for remission after traumatic spinal cord injury

STUDY DESIGN

Prospective observational study.

OBJECTIVES

To describe the correlation between CCL-2, CCL-3, CCL-4 and CXCL-5 serum levels and remission after traumatic spinal cord injury (SCI) in a human protocol compared with animal studies.

SETTING

Germany, Rhineland-Palatinate (Rheinland-Pfalz).

METHODS

We examined the serum levels of CCL-2, CCL-3, CCL-4 and CXCL-5 over a 12-week period; in particular, at admission and 4, 9 and 12 h, 1 and 3 days and 1, 2, 4, 8 and 12 weeks after trauma. According to our study design, we matched 10 patients with TSCI and neurological remission with 10 patients with an initial ASIA A grade and no neurological remission. In all, 10 patients with vertebral fracture without neurological deficits served as control. Our analysis was performed using a Luminex Cytokine Panel. Multivariate logistic regression models were used to examine the predictive value with respect to neurological remission vs no neurological remission.

RESULTS

The results of our study showed differences in the serum expression patterns of CCL-2 in association with the neurological remission (CCL-2 at admission P=0.013). Serum levels of CCL-2 and CCL-4 were significantly different in patients with and without neurological remission. The favored predictive model resulted in an area under the curve (AUC) of 93.1% in the receiver operating characteristic (ROC) analysis.

CONCLUSIONS

Our results indicate that peripheral serum analysis is a suitable concept for predicting the patient's potential for neurological remission after TSCI. Furthermore, the initial CCL-2 concentration provides an additional predictive value compared with the NLI (neurological level of injury). Therefore, the present study introduces a promising approach for future monitoring concepts and tracking techniques for current therapies. The results indicate that future investigations with an enlarged sample size are needed in order to develop monitoring, prognostic and scoring systems.

Intraspinal Pressure Monitoring and Extensive Duroplasty in the Acute Phase of Traumatic Spinal Cord Injury: A Systematic Review

OBJECTIVE

The prognosis in cervical spinal cord injury is poor, and surgical and neurointensive care management need further improvement. Monitoring of the intraspinal pressure (ISP) at an early stage after traumatic spinal cord injury (tSCI) is useful clinically.

MATERIALS AND METHODS

Obtaining continuous spinal cord perfusion pressure (SCPP) measurements based on the difference between mean arterial pressure and ISP allows offering best medical and surgical treatment during this critical phase of tSCI. A search was carried out with PubMed, Embase, and Google Scholar up to January 10, 2017. Articles resulting from these searches and relevant references cited in those articles were reviewed.

RESULTS

The optimal SCPP was found to be between 90 and 100 mm Hg and mean arterial pressure of 110-130. Laminectomy alone was found to be ineffective in the reduction of ISP because it does not lower the pressure exerted by dura on the swollen spinal cord. Therefore, bony decompression with durotomy or duroplasty seems to be the procedure of choice to reduce the ISP less than 20 mm Hg.

CONCLUSIONS

A randomized controlled trial is required to determine whether laminectomy with durotomy and monitoring of ISP with SCPP optimization improve neurological recovery after tSCI.

Neuroprotective effect of combining tanshinone IIA with low-dose methylprednisolone following acute spinal cord injury in rats

The present study compared the potential neuroprotective effect of tanshinone IIA (TIIA) monotherapy, methylprednisolone (MP) monotherapy and combined treatment in an adult acute spinal cord injury (ASCI) rat model. The current study used the weight-drop method (Allen's Impactor) in the rat model and the mechanical scratch method in primary spinal cord neuron culture to determine whether the combined treatment was able to reduce the required dosage of MP in the treatment of ASCI to produce a similar or improved therapeutic effect. In vivo male Sprague Dawley rats (n=60) were randomly divided into 5 groups, of which 12 rats were selected for the sham group and T9-T11 laminectomies, leading to ASCI, were performed on 48 of the 60 rats using a 10 g ×25 mm weight-drop at the level of T10 spinal cord. Therefore, the ASCI group (n=12) included the 'laminectomy and weight-drop'. The remaining 36 ASCI model animals were subdivided into 3 groups (n=12 each group): TIIA group (30 mg/kg/day), MP group (30 mg/kg) and combined treatment group (TIIA 30 mg/kg/day + MP 20 mg/kg). Neuronal function following ASCI was evaluated using the Basso Beattie Bresnahan (BBB) locomotor rating scale. Levels of the anti-apoptotic factor B-cell lymphoma-2 (Bcl-2), the pro-apoptotic factors Bcl-2 associated protein X (Bax) and caspase-3, and the inflammatory associated factor nuclear factor-κB, were analyzed by western blot analysis. Immunohistochemistry was used to detect caspase-3. To investigate the underlying mechanism, the anti-oxidative effect of combination TIIA and MP treatment was assessed by measuring the activity of malondialdehyde (MDA) and superoxide dismutase (SOD) in ASCI. In agreement with the experiment in vivo, primary neurons were prepared from the spinal cord of one-day-old Sprague-Dawley rats' and co-cultured with astrocytes from the brain cortex. The injury of neurons was induced by mechanical scratch and levels of apoptosis factors were analyzed by western blot analysis. The results of the current study indicated that injured animals in the combined treatment group exhibited a significant increase in BBB scores (P<0.05). TIIA + MP combined treatment and MP treatment was observed to reduce the expression of pro-apoptotic factors and promote neuron survival in vivo and in vitro. Combined treatment may promote neuroprotection through reduced apoptosis and inflammation caused by ASCI, similar to MP alone. Combined treatment reversed the decrease of SOD and the increase of MDA level caused by ASCI. In addition, combined treatment decreased the expression of caspase-3 in the neurons following ASCI in rats, as indicated by immunofluorescence double labeling. Overall, the present study indicates that the combined treatment of TIIA and MP may protect the neurons by stimulating the rapid initiation of neuroprotection following ASCI and reduce the dosage of MP in the treatment of ASCI required to produce the same or improved neuroprotective effects in vivo and in vitro.

Clinical Features, Management, and Prognostic Factors of Spontaneous Epidural Spinal Hematoma: Analysis of 24 Cases

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical emergency. It presents as acute spinal cord compression and usually requires surgical decompression. The patients who will benefit most from decompression surgery are unknown, and the factors associated with prognosis remain controversial. The purpose of our study was to identify the clinical features, treatments, and main factors related to the prognosis of SSEH.

METHODS

We reviewed the records of 24 patients treated for SSEH from September 2010 to January 2016 at West China Hospital. Clinical features, radiologic images, treatment methods, and clinical outcomes were reviewed retrospectively. To ascertain which factors were related to outcomes, statistical analysis was performed.

RESULTS

Among 24 patients, 19 presented with severe initial neurologic deficits (American Spinal Injury Association grade A-C) underwent decompressive surgery, and the remaining patients (initial American Spinal Injury Association grade D or E) received conservative treatment. Among the 19 patients in the operation group, seven (36.8%) had good outcomes, whereas 12 (63.2%) had poor outcomes. All patients in the conservative group had good outcomes.

CONCLUSIONS

SSEH is a rare but serious illness. It is more likely that SSEH arises from a ruptured internal vertebral venous plexus. The initial neurologic status is the determining factor influencing the treatment method and clinical outcome. The number of involved segments cannot be used to decide the treatment method or predict prognosis. Patients with shorter operative intervals appear to have better neurologic recovery.

Anterior Surgical Fixation for Cervical Spine Flexion-Distraction Injuries

BACKGROUND

Optimal surgical management for flexion-distraction cervical spine injuries remains controversial with current guidelines recommending anterior, posterior, and circumferential approaches. Here, we determined the incidence of and examined risk factors for clinical and radiographic failure in patients with 1-segment cervical distraction injuries having undergone anterior surgical fixation.

METHODS

A retrospective review of 57 consecutive patients undergoing anterior fixation for subaxial flexion-distraction cervical injuries between 2008 and 2012 at our institution was performed. The primary outcome was the number of patients requiring additional surgical stabilization and/or radiographic failure. Data collected included age, gender, mechanism and level of injury, facet pattern injury, and vertebral end plate fracture.

RESULTS

A total of 6 patients failed clinically and/or radiographically (11%). Four patients (7%) required additional posterior fixation. Although 2 other patients identified met radiographic failure criteria, at follow-up they had fused radiographically, were stable clinically, and no further treatment was pursued. Progressive kyphosis and translation were found to be significantly correlated with need for revision (P < 0.05 and P = 0.02, respectively). No differences were identified for all other clinical and radiologic factors assessed, including unilateral or bilateral facet injury, facet fracture, and end plate fracture.

CONCLUSION

This study contributes to the growing body of evidence supporting anterior fixation alone for flexion-distraction injuries. Findings suggest that current measurements of radiographic failure including segmental translation and kyphosis may predict radiographic failure and need for further surgical stabilization in some patients. Future follow-up studies assessing for independent risk factors for anterior approach failure with a validated predictive scoring model should be considered.

Surgical Neurostimulation for Spinal Cord Injury

Traumatic spinal cord injury (SCI) is a devastating neurological condition characterized by a constellation of symptoms including paralysis, paraesthesia, pain, cardiovascular, bladder, bowel and sexual dysfunction. Current treatment for SCI involves acute resuscitation, aggressive rehabilitation and symptomatic treatment for complications. Despite the progress in scientific understanding, regenerative therapies are lacking. In this review, we outline the current state and future potential of invasive and non-invasive neuromodulation strategies including deep brain stimulation (DBS), spinal cord stimulation (SCS), motor cortex stimulation (MCS), transcutaneous direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in the context of SCI. We consider the ability of these therapies to address pain, sensorimotor symptoms and autonomic dysregulation associated with SCI. In addition to the potential to make important contributions to SCI treatment, neuromodulation has the added ability to contribute to our understanding of spinal cord neurobiology and the pathophysiology of SCI.

Tanshinone IIA improves functional recovery in spinal cord injury-induced lower urinary tract dysfunction

Tanshinone IIA, extracted from Salvia miltiorrhiza Bunge, exerts neuroprotective effects through its anti-inflammatory, anti-oxidative and anti-apoptotic properties. This study intravenously injected tanshinone IIA 20 mg/kg into rat models of spinal cord injury for 7 consecutive days. Results showed that tanshinone IIA could reduce the inflammation, edema as well as compensatory thickening of the bladder tissue, improve urodynamic parameters, attenuate secondary injury, and promote spinal cord regeneration. The number of hypertrophic and apoptotic dorsal root ganglion (L6-S1) cells was less after treatment with tanshinone IIA. The effects of tanshinone IIA were similar to intravenous injection of 30 mg/kg methylprednisolone. These findings suggested that tanshinone IIA improved functional recovery after spinal cord injury-induced lower urinary tract dysfunction by remodeling the spinal pathway involved in lower urinary tract control.

Improving care standards for patients with spinal trauma combining a modified e-Delphi process and stakeholder interviews: a study protocol

INTRODUCTION

Around 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year; a relatively low incidence injury with extremely high long-term associated costs. Care standards are inconsistent nationally, lacking in consensus across important components of care such as prehospital spinal immobilisation, timing of surgery and timeliness of transfer to specialist services. This study aims to develop 'expertly defined' and agreed standards of care across the majority of disciplines involved for these patients.

METHODS AND ANALYSIS

A modified e-Delphi process will be used to gain consensus for best practice across specific clinical early care areas for the patient with TSCI; invited participants will include clinicians across Australia with relevant and significant expertise. A rapid literature review will identify available evidence, including any current guidelines from 2005 to 2015. Level and strength of evidence identified, including areas of contention, will be used to formulate the first round survey questions and statements. Participants will undertake 2-3 online survey rounds, responding anonymously to questionnaires regarding care practices and indicating their agreement or otherwise with practice standard statements. Relevant key stakeholders, including patients, will also be interviewed face to face.

ETHICS AND DISSEMINATION

Ethics approval for this study was obtained by the NSW Population & Health Services Research Ethics Committee on 14 January 2016 (HREC/12/CIPHS/74). Seeking comprehensive understanding of how the variation in early care pathways and treatment can be addressed to achieve optimal patient outcomes and economic costs; the overall aim is the agreement to a consistent approach to the triage, treatment, transport and definitive care of acute TSCI victims. The agreed practice standards of care will inform the development of a Clinical Pathway with practice change strategies for implementation. These standards will offer a benchmark for state-wide and potentially national policy.

Traumatic cervical spine fractures in the adult

This article reviews fractures of the cervical spine, highlighting the pertinent goals of initial management, the indications for different imaging modalities and the different fracture patterns. Basic principles of management of these different fracture patterns are outlined.

Autonomic dysreflexia: a cardiovascular disorder following spinal cord injury

Autonomic dysreflexia (AD) is a serious cardiovascular disorder in patients with spinal cord injury (SCI). The primary underlying cause of AD is loss of supraspinal control over sympathetic preganglionic neurons (SPNs) caudal to the injury, which renders the SPNs hyper-responsive to stimulation. Central maladaptive plasticity, including C-fiber sprouting and propriospinal fiber proliferation exaggerates noxious afferent transmission to the SPNs, causing them to release massive sympathetic discharges that result in severe hypertensive episodes. In parallel, upregulated peripheral vascular sensitivity following SCI exacerbates the hypertensive response by augmenting gastric and pelvic vasoconstriction. Currently, the majority of clinically employed treatments for AD involve anti-hypertensive medications and Botox injections to the bladder. Although these approaches mitigate the severity of AD, they only yield transient effects and target the effector organs, rather than addressing the primary issue of central sympathetic dysregulation. As such, strategies that aim to restore supraspinal reinnervation of SPNs to improve cardiovascular sympathetic regulation are likely more effective for AD. Recent pre-clinical investigations show that cell transplantation therapy is efficacious in reestablishing spinal sympathetic connections and improving hemodynamic performance, which holds promise as a potential therapeutic approach.

Exam 4 Questions

A 73-year-old male with a history of hypertension and hyperlipidemia is currently in the stroke unit after suffering a right middle cerebral artery infarct. His symptoms started 2 h prior to arrival at the hospital, and tPA was administered. The patient is plegic on the left side and with mild dysarthria, but is otherwise neurologically intact. His labwork is within normal limits. Which of the following describes the optimal deep venous thrombosis (DVT) prophylaxis regimen for this patient?A.

Wait 6 h post tPA, then administer unfractionated heparin (UFH) along with intermittent pneumatic compression (IPC)

B.

Wait 24 h post tPA, then administer UFH along with IPC

C.

Wait 6 h post tPA, then administer low molecular weight heparin (LMWH) along with IPC

D.

Wait 24 h post tPA, then administer LMWH along with IPC

E.

IPC only for the first 72 h, then LMWH or UFH after obtaining follow-up imaging

All of the following causes of acute encephalitis have the matching characteristic radiological features except:A.

Autoimmune limbic encephalitis: T2/FLAIR hyperintensity in the mesial temporal lobes

B.

Cytomegalovirus: T2/FLAIR hyperintensity in the subependymal white matter

C.

JC virus: T2/FLAIR hyperintensity in the parieto-occipital lobes and corpus callosum

D.

Herpes simplex virus type 1: restricted diffusion in frontal/temporal lobes and insular cortex

E.

Varicella zoster: T2/FLAIR hyperintensity in the brainstem

Which of the following categorizations is most accurate regarding acute respiratory distress syndrome (ARDS) in the setting of subarachnoid hemorrhage (SAH)?A.

Non-neurogenic, non-cardiogenic

B.

Neurogenic, non-cardiogenic

C.

Neurogenic, cardiogenic

D.

Non-neurogenic, cardiogenic

E.

None of the above accurately reflect ARDS in SAH

A 52-year-old female is admitted to the ICU with a Hunt-Hess 1, modified Fisher 2 subarachnoid hemorrhage. Her past medical history is significant for hypertension, diabetes mellitus, and chronic renal insufficiency. She undergoes craniotomy for surgical clipping of an anterior cerebral artery aneurysm, and does not experience any additional complications. Two weeks later, she begins complaining of left calf pain, and a lower extremity sonogram demonstrated a proximal deep venous thrombosis (DVT). The patient weighs 60 kg. Her laboratory values are as follows: sodium 142 mEq/L, potassium 3.4 mEq/L, carbon dioxide 18 mEq/L, blood urea nitrogen (BUN) 70 mg/dL, and serum creatinine 2.5 mg/dL. What would be the optimal treatment for this patient’s proximal DVT?A.

Unfractionated heparin infusion for at least 5 days concomitantly with warfarin therapy

B.

Low molecular weight heparin 60 mg twice a day for at least 5 days concomitantly with warfarin therapy

C.

Fondaparinux 7.5 mg daily for 5 days followed by warfarin therapy

D.

Apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily

E.

Rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily

All of the following are currently implicated in uremic encephalopathy except:A.

Derangements in cerebral metabolism

B.

Alterations in the blood-brain barrier

C.

Accumulation of circulating toxins

D.

Imbalance of endogenous neurotransmitters

E.

Recurrent lobar hemorrhages

A 70-year-old female is hospitalized with a recent ischemic infarct. As part of stroke core measures, you obtain a hemoglobin A1c of 10.0. What is an approximate estimation of this patient’s average blood glucose level over the last several months?A.

70 mg/dL

B.

100 mg/dL

C.

130 mg/dL

D.

190 mg/dL

E.

240 mg/dL

A 28-year-old female with no known past medical history is in the ICU in status epilepticus, with anti-N-methyl D-aspartate (NMDA) receptor antibodies isolated in the cerebrospinal fluid. Which of the following is most likely to identify the root cause of her illness?A.

Transvaginal ultrasound

B.

Contrast-enhanced CT of the chest

C.

Contrast-enhanced CT of the brain

D.

Virtual colonography

E.

Thorough examination of the skin, particularly in sun-exposed areas

A 17-year-old male with no significant past medical history collapses during a high school football game, and goes into cardiac arrest. He did not have any complaints earlier in the day. The patient is brought to a nearby hospital, where is he resuscitated, intubated, and transferred to the ICU for further management. The patient is currently undergoing therapeutic hypothermia, and a work-up is underway to determine the cause of his sudden collapse. Which of the following is the most likely diagnosis?A.

Rupture of a previously undiagnosed cerebral aneurysm

B.

Hypertrophic cardiomyopathy

C.

Commotio cordis

D.

Severe hyponatremia and cerebral edema

E.

Brugada syndrome

A 31-year-old female at 38 weeks gestation is currently hospitalized for the treatment of preeclampsia. Due to her medical condition, her obstetrician is currently considering induced labor. At which point will this patient no longer be at risk for developing frank seizure activity as a result of her condition?A.

48 h postpartum

B.

1 week after delivery

C.

2 weeks after delivery

D.

4 weeks after delivery

E.

6 weeks after delivery

A 38-year-old male with no prior medical history presents to the emergency department with fever and severe headaches for several days. A CT scan of the brain is unremarkable, and the results of a lumbar puncture are pending. What is the most appropriate empiric antimicrobial regimen at this time?A.

Cefazolin and vancomycin

B.

Ceftriaxone and vancomycin

C.

Ceftriaxone, vancomycin and ampicillin

D.

Piperacillin/tazobactam and vancomycin

E.

Meropenem and vancomycin

The majority of intramedullary spinal cord neoplasms are:A.

Astrocytomas

B.

Meningiomas

C.

Metastatic lesions

D.

Ependymomas

E.

Hemangioblastomas

Which of the following derived parameter formulas is correct?A.

Cardiac index = cardiac output x body surface area

B.

Stroke volume = cardiac output/heart rate

C.

Systemic vascular resistance = 80 × (mean arterial pressure/cardiac output)

D.

Pulmonary vascular resistance = 80 × (mean pulmonary artery pressure/cardiac output)

E.

All of the above are correct

A 23-year-old female marathon runner is currently in the ICU after suffering from heat stroke following an outdoor run on a particularly hot summer day. She was initially delirious in the emergency department, but progressed to coma and respiratory failure requiring mechanical ventilation. Her oral temperature is 42.1 °C. Which of the following would be most effective in reducing this patient’s severe hyperthermia?A.

Regularly scheduled alternating acetaminophen and ibuprofen

B.

Spraying room temperature water on the patient, followed by fanning

C.

Ice water immersion

D.

Dantrolene sodium, 2.5 mg/kg

E.

Application of ice packs to the groin and axilla

Hyperinsulinemia-euglycemia (HIE) therapy may be useful for toxicity related to which of the following?A.

Tricyclic antidepressants

B.

Calcium channel blockers

C.

Aspirin

D.

Digoxin

E.

Lithium

A 71-year-old female with a history of alcohol abuse is currently intubated in the ICU following a catastrophic spontaneous left basal ganglia hemorrhage with resultant herniation. You have just declared her brain dead. The patient’s family agrees to make her an organ donor, and the organ donation coordinator requests you initiate levothyroxine therapy. Which of the following benefits would be expected with this treatment?A.

Increase the number of solid organs available for transplant

B.

Eliminate the need for hepatic biopsy prior to liver transplant

C.

Eliminate the need for cardiac catheterization prior to heart transplant

D.

Eliminate the need for bronchoscopy prior to lung transplant

E.

Reduce the need for supplementation of sodium, potassium, calcium, and magnesium

Which of the following is not an element of the Full Outline of Unresponsiveness (FOUR) score?A.

Eye opening

B.

Respiratory function

C.

Brainstem reflexes

D.

Motor response

E.

Verbal response

A 23-year-old female is currently in the ICU with status asthmaticus. She was initially on noninvasive positive pressure ventilation, with an arterial blood gas (ABG) as follows: pH 7.13, pCO₂ 60 mmHg, PaO₂ is 61 mmHg, HCO₃ 24 mmol/L, and oxygen saturation of 90%. She is given continuous inhaled albuterol, intravenous steroids, and magnesium sulfate. She subsequently becomes more lethargic and is intubated, with settings as follows: volume assist-control, rate of 12 breaths/min, tidal volume of 500 cc, PEEP of 5 cm H₂O, and FiO₂ of 50%. Peak airway pressure is 50 cm H₂O and plateau pressure is 15 cm H₂O. A stat portable chest x-ray shows hyperinflation with no pneumothorax. A repeat ABG after 30 min of invasive ventilation shows the following: pH of 7.24, pCO₂ 49 mmHg, PaO₂ 71 mmHg, HCO₃ is 25 mmol/L. Which of the following should be performed next?A.

Increase rate to 16

B.

Increase tidal volume to 600 cc

C.

Initiate bicarbonate infusion

D.

Switch to pressure assist-control

E.

Maintain current settings

Which of the following mechanisms is implicated in super-refractory status epilepticus?A.

Influx of proinflammatory molecules

B.

Upregulation of NMDA receptors

C.

Upregulation of molecular transport molecules

D.

Downregulation of GABA receptors

E.

All of the above

A 85-year-old male with a history nephrolithiasis, mild dementia, and alcohol abuse presented to the emergency department after a fall from standing, and was found to a right holohemispheric subdural hematoma. His clot was evacuated successfully, in spite of his oozing diathesis in the operating room (INR on arrival was 1.4 with a platelet count of 88 × 10³/μL). His serum transaminases are twice the normal value, and he has had refractory chronic hyponatremia. He has had three convulsions during this week of hospitalization, in spite of levetiracetam therapy at 1.5 g twice a day. Over the past 24 h, he has had a marked increase in agitation. He has also just had a 5-s run of non-sustained ventricular tachycardia, and his systolic blood pressure is now 85 mmHg. You are considering discontinuing his levetiracetam and starting a new agent. Which of the following would be the best choice in this scenario?A.

Carbamazepine

B.

Phenytoin

C.

Valproate

D.

Lacosamide

E.

Topiramate

A 65-year-old male with a history of COPD on rescue albuterol and ipratropium is diagnosed with myasthenia gravis, and started on an acetylcholinesterase inhibitor. He returns several days later complaining of increased salivation and worsening bronchial secretions in the absence of fevers, purulent sputum, or increasing dyspnea. These symptoms are not relieved by use of his albuterol. On exam, he has slightly decreased air movement throughout both lung fields without any clear wheezing, no focal rales, and a normal inspiratory to expiratory ratio. Which treatment option is most likely to be beneficial?A.

Increase frequency of short-acting ß₂ agonist use

B.

Add a standing long-acting inhaled ß₂ agonist

C.

Add glycopyrrolate as needed

D.

Add inhaled corticosteroids

E.

Add oral systemic corticosteroids

Regarding states of impaired consciousness, which of the following statements regarding arousal and awareness is correct?A.

Coma: intact arousal, but impaired awareness

B.

Minimally conscious state: impaired arousal and impaired awareness

C.

Persistent vegetative state: intact arousal, but impaired awareness

D.

Locked-in state: intact arousal, but impaired awareness

E.

All of the above are correct

A 62-year-old female is currently in the ICU following craniotomy for clipping of a cerebral aneurysm. Postoperatively, she is noted to have an oxygen saturation of 92% on 50% non-rebreather face mask, and her respiratory rate is 32 breaths/min. She denies chest pain. Her blood pressure is 96/72 mmHg and heart rate is 120 beats/min. Nimodipine has been held according to blood pressure parameters. A portable chest x-ray shows hazy opacities bilaterally, and bedside echocardiogram shows decreased left ventricular systolic function with apical, septal, lateral, anterior, anteroseptal and inferolateral wall akinesis, along with apical ballooning. Which of the following should be performed next?A.

Intubate the patient and begin mechanical ventilation

B.

Call urgent cardiology consult for cardiac catheterization

C.

Start noninvasive positive airway pressure ventilation

D.

Administer broad spectrum antibiotics

E.

Administer albuterol and systemic corticosteroids

Which of the following is the most common etiology of acute spinal cord ischemia and infarction?A.

Atherosclerotic disease

B.

Rupture of an abdominal aortic aneurysm

C.

Degenerative spine disease

D.

Cardioembolic events

E.

Systemic hypotension in the setting of other disease processes

A 62-year-old female with a history of coronary artery disease has just been admitted to the ICU with a left-sided spontaneous basal ganglia hemorrhage. The patient takes 325 mg of aspirin daily at home, and you are considering platelet transfusion. Which of the following has been demonstrated regarding platelet transfusion in this setting?A.

Improved chances of survival to hospital discharge

B.

Decreased hospital length-of-stay

C.

Improved chances of survival at 3 months

D.

Improved modified Rankin scale at 3 months

E.

None of the above

Which of the following therapies has been shown to decrease the incidence of delayed cerebral ischemia (DCI) in the setting of subarachnoid hemorrhage (SAH)?A.

Atorvastatin

B.

Magnesium

C.

Methylprednisolone

D.

Nicardipine

E.

None of the above

A 70-year-old male with a history of diabetes, hypertension, and cigarette smoking (one pack per day for the last 40 years) is currently in the ICU with a COPD exacerbation. This is his third exacerbation this year, and was discharged from the hospital only 3 weeks prior. On your examination, he is alert, his breathing is labored, and he has rales at the right lung base. His vital signs are as follows: blood pressure 90/60 mmHg, heart rate 120 beats per minute, respirations 28 per minute, and temperature 38.3 °C. His oxygen saturation on 50% face mask is 93%, and his most recent PCO₂ is 55 mmHg. Labs are notable for the following: white blood cell count 14.4 × 10⁹/L with 90% neutrophils, blood urea nitrogen (BUN) 30 mg/dL, serum creatinine 1.2 mg/dL, and glucose 240 mg/dL. Ketones are negative. He is currently on noninvasive positive pressure ventilation at 10/5 cm H₂O and 50% FiO₂, and broad spectrum antibiotics have been administered. An hour later, the nurse pages you because his heart rate is now 140 beats per minute and irregular, blood pressure is 85 systolic, oxygen saturation is 85%, and he is minimally responsive. You now hear bilateral rales, most prominently in the right lung base, and scattered wheezes. Which of the following should be performed next?A.

Increase inspiratory pressure to 15 and FiO₂ to 100%

B.

Start a continuous diltiazem infusion and give intravenous furosemide

C.

Start a continuous phenylephrine infusion targeting a mean arterial pressure (MAP) > 65

D.

Give 125 mg of solumedrol and administer albuterol via nebulizer

E.

Intubate the patient and initiate mechanical ventilation

A 57-year-old male with a history of epilepsy is currently in the stroke unit following a large right middle cerebral artery infarction. A nasogastric tube has been inserted, and 24 h continuous enteral feeds have been initiated. The patient is currently on 100 mg of phenytoin every 8 h for seizure prophylaxis. Which of the following measures should be taken to prevent the patient from developing subtherapeutic phenytoin levels?A.

Change to 18 h tube feeds, and only administer phenytoin at night

B.

Change to 18 h tube feeds, and only administer phenytoin twice daily

C.

Switch from standard to hydrolyzed tube feeds

D.

Switch from standard to glycemic control tube feeds

E.

Hold tube feeds for 2 h before and after phenytoin administration

A 37-year-old female presents to the emergency department with approximately 2 weeks of progressively worsening clumsiness and drastic mood swings. Her past medical history is significant only for Crohn’s disease, for which she takes both natalizumab and infliximab. A contrast-enhanced CT scan of her head is performed, revealing hypodense, non-enhancing lesions in the cortical white matter of the frontal and parietal lobes. Despite treatment, the patient expires 1 month later. Which of the following is true regarding the most likely diagnosis?A.

The diagnosis may be confirmed via CSF analysis

B.

The pathologic process spares oligodendrocytes

C.

It is a prion-based disease

D.

The condition is universally fatal despite treatment

E.

All of the above

A 58-year-old female presents to the emergency department with dry cough, fever and rapidly progressive dyspnea over 1 week. She has a history of rheumatoid arthritis (RA) and is maintained on weekly methotrexate and daily prednisone (which was increased to 30 mg starting 1 month ago for an acute flare). She takes no other medications. Her vital signs are as follows: blood pressure 100/70 mmHg, heart rate 110 beats/min, respiratory rate 20 breaths/min, and temperature 38.0 °C. In the ED she develops progressive hypoxemia with oxygen saturation 92% on 100% nonrebreather, and is increasingly diaphoretic. She is emergently intubated, and a chest x-ray post intubation shows extensive bilateral lung opacities. Which of the following should be administered at this time?A.

Ceftriaxone and azithromycin

B.

Vancomycin and piperacillin-tazobactam

C.

Vancomycin, cefepime, and fluconzole

D.

Ceftriaxone, levofloxacin, and trimethoprim-sulfamethoxazole

E.

Tigecycline only

A 45-year-old woman undergoes uncomplicated transsphenoidal resection of a pituitary macroadenoma. She appears well hydrated and is not complaining of excessive thirst. Post-operatively, she is noted to have increased urine output. Serum sodium is 137 mEq/L, and serum osmolarity is 275 mOsm/kg. What is the most likely cause of her polyuria?A.

Syndrome of inappropriate antidiuretic hormone

B.

Diabetes insipidus

C.

Cerebral salt wasting

D.

Fluid mobilization

E.

All of the above are equally likely

A 36-year-old female with a recent lumbar puncture to rule out subarachnoid hemorrhage is now complaining of a severe headache unlike anything she has experienced previously. She reports her headache is worse when standing, and better upon lying flat. She is otherwise neurologically intact. All of the following medications may be beneficial in this scenario except:A.

Acetaminophen

B.

Ibuprofen

C.

Caffeine

D.

Aminophylline

E.

Methylprednisolone

Which of the following is the most common overall cause of acute myocardial infarction?A.

Coronary dissection

B.

Plaque rupture

C.

Imbalance between oxygen demand and supply across a fixed obstruction

D.

Coronary vasospasm

E.

Ischemia related to hypotension and decreased perfusion

A 78-year-old male is in the ICU recovering from sepsis and pneumonia. He was just recently extubated after 2 days of mechanical ventilation and sedation with a fentanyl infusion. Over the ensuing days, he develops worsening abdominal distention, poor bowel sounds, and no stool output. CT scan reveals significant colonic distention, but no mass or obstruction. Records demonstrate a normal routine colonoscopy performed 6 weeks ago. You have appropriately hydrated the patient, corrected any electrolyte abnormalities, placed a rectal tube, withheld all opiates, and given intravenous erythromycin, but to no avail. Abdominal x-rays continue to demonstrate marked cecal dilatation greater than 12 cm in diameter. What is the next best appropriate therapy for this patient?A.

Neostigmine

B.

Naloxone

C.

Metoclopromide

D.

Surgical consultation for hemicolectomy

E.

Endoscopic percutaneous cecostomy tube placement

Which of the following is the most common cerebral vascular malformation in the general population?A.

AV malformation

B.

Dural AV fistula

C.

Developmental venous anomaly

D.

Cavernous malformation

E.

Vein of Galen malformation

A 49-year-old female with a history of acute lymphoblastic leukemia and recent subcutaneous cerebrospinal fluid (CSF) reservoir placement presents to the emergency department with fever, chills, and increased confusion for the past 3 days. Her CSF reservoir was last accessed 1 week ago. A thorough work-up reveals no other obvious infectious source, and there is concern for CSF reservoir-associated meningitis. Which of the following is the most likely causative organism?A.

Coagulase-negative staphylococci

B.

Propionobacterium acnes

C.

Methicillin-resistant Staphylococcus aureus

D.

Klebsiella pneumoniae

E.

Neisseria meningitidis

A 47-year-old woman presents to the emergency department with headache, nausea, and vomiting. Non-contrast head CT is performed, revealing subarachnoid blood in the right Sylvian fissure, and conventional angiography reveals the presents of a large right-sided MCA aneurysm. The patient undergoes successful surgical clipping of her aneurysm, and is being observed in the ICU. On admission, the patient’s serum sodium was 142 mEq/L and the hematocrit was 37%; by the seventh post-operative day, the serum sodium is 127 mEq/L and the hematocrit is 44%. Bedside ultrasonography demonstrates an IVC diameter of approximately 0.9 cm. Which of the following interventions would be least reasonable at this time?A.

Fludrocortisone, 0.2 mg twice a day

B.

2% hypertonic saline, infused peripherally

C.

3% hypertonic saline, infused centrally

D.

Sodium chloride oral tablets

E.

1500 mL daily fluid restriction

Which of the following is true regarding central (non-infectious) fever?A.

Less common in subarachnoid hemorrhage

B.

More common versus infectious fever

C.

Earlier onset versus infectious fever

D.

Easier to confirm versus infectious fever

E.

All of the above

Flaccid paralysis is most commonly associated with which of the following forms of encephalitis?A.

West Nile

B.

Varicella zoster

C.

Rabies

D.

Herpes simplex

E.

Epstein-Barr

Which of the following would not be considered appropriate therapy for heparin-induced thrombocytopenia (HIT)?A.

Discontinuation of heparin products alone

B.

Danaparoid

C.

Fondaparinux

D.

Argatroban

E.

All of the above are acceptable treatment options

A 45-year-old male with severe blunt traumatic brain injury (TBI) from a motor vehicle collision suffered a ventricular fibrillation cardiac arrest at the time of injury with return of spontaneous circulation (ROSC) in the field after endotracheal intubation and one dose of epinephrine. On arrival to the emergency department, no regional wall motion abnormalities were noted on surface echocardiography and no ST segment changes were seen on the presenting EKG. Head CT revealed cerebral contusions but no extra-axial mass lesions. The patient is now in the ICU and found to be comatose without sedation. Mild therapeutic hypothermia to 33° is being considered in the management of this post-arrest patient. Which of the following statements is true?A.

Mild therapeutic hypothermia is contraindicated due to the risk of induced epilepsy

B.

Mild therapeutic hypothermia is contraindicated with any intracranial pathology on CT imaging

C.

Mild therapeutic hypothermia does not induce a clinically significant coagulopathy

D.

Patients who have sustained ROSC after an arrest associated with TBI do not benefit from therapeutic hypothermia

E.

Endovascular cooling is superior to surface cooling in young patients with ROSC

A 35-year-old male is in the intensive care unit following resection of a large right-sided meningioma. He is currently intubated and sedated on a continuous fentanyl infusion. The nurse calls you to the bedside due to concerns over “unusual ventilator waveforms”. Upon arrival, you note the following (see Image 1). What is the best way to describe this phenomenon?A.

Reverse triggering

B.

Double triggering

C.

Breath stacking

D.

Missed triggering

E.

None of the above; normal ventilator waveforms are present

On-scene treatment of spinal injuries in motor sports

Because spinal cord injuries can have fatal consequences for injured race car drivers, prehospital treatment of spinal injuries is a major concern in motor sports. A structured procedure for assessing trauma patients and their treatment should follow established ABCDE principles. Only then, a stable patient could be further examined and appropriate measures can be undertaken. For patients in an acute life-threatening condition, rapid transport must be initiated and should not be delayed by measures that are not indicated. If a competitor must first be extricated from the racing vehicle, the correct method of extrication must be chosen. To avoid secondary injury to the spine after a racing accident, in-line extrication from the vehicle and immobilization of the patient are standard procedures in motor sports and have been used for decades. Since immobilization can be associated with disadvantages and complications, the need for immobilization of trauma patients outside of motor sports medicine has become the subject of an increasing number of reports in the scientific literature. Even in motor sports, where specific safety systems that offer spinal protection are present, the indications for spinal immobilization need to be carefully considered rather than being blindly adopted as a matter of course. The aim of this article is to use recent literature to present an overview about the treatment of spinal injuries in motor sports. Further, we present a new protocol for indications for immobilizing the spine in motor sports that is based on the ABCDE principles and takes into account the condition of the patient.