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

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.

Increased intrathecal pressure after traumatic spinal cord injury: an illustrative case presentation and a review of the literature

PURPOSE

Early surgical management after traumatic spinal cord injury (SCI) is nowadays recommended. Since posttraumatic ischemia is an important sequel after SCI, maintenance of an adequate mean arterial pressure (MAP) within the first week remains crucial in order to warrant sufficient spinal cord perfusion. However, the contribution of raised intraparenchymal and consecutively increased intrathecal pressure has not been implemented in treatment strategies.

METHODS

Case report and review of the literature.

RESULTS

Here we report a case of a 54-year old man who experienced a thoracic spinal cord injury after a fall. CT-examination revealed complex fractures of the thoracic spine. The patient underwent prompt surgical intervention. Intraoperatively, fractured parts of the ascending Th5 facet joint were displaced into the spinal cord itself. Upon removal, excessive protruding of medullary tissue was observed over several minutes. This demonstrates the clinical relevance of increased intrathecal pressure in some patients.

CONCLUSION

Monitoring and counteracting raised intrathecal pressure should guide clinical decision-making in the future in order to ensure optimal spinal cord perfusion pressure for every affected individual.

Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

OBJECTIVE

A novel technique for monitoring intraspinal pressure and spinal cord perfusion pressure in patients with traumatic spinal cord injury was recently described. This is analogous to monitoring intracranial pressure and cerebral perfusion pressure in patients with traumatic brain injury. Because intraspinal pressure monitoring is a new technique, its safety profile and impact on early patient care and long-term outcome after traumatic spinal cord injury are unknown. The object of this study is to review all patients who had intraspinal pressure monitoring to date at the authors' institution in order to define the accuracy of intraspinal pressure probe placement and the safety of the technique.

METHODS

At the end of surgery to fix spinal fractures, a pressure probe was inserted intradurally to monitor intraspinal pressure at the injury site. Postoperatively, CT scanning was performed within 48 hours and MRI at 2 weeks and 6 months. Neurointensive care management and complications were reviewed. The American Spinal Injury Association Impairment Scale (AIS) grade was determined on admission and at 2 to 4 weeks and 12 to 18 months postoperation.

RESULTS

To date, 42 patients with severe traumatic spinal cord injuries (AIS Grades A–C) had undergone intraspinal pressure monitoring. Monitoring started within 72 hours of injury and continued for up to a week. Based on postoperative CT and MRI, the probe position was acceptable in all patients, i.e., the probe was located at the site of maximum spinal cord swelling. Complications were probe displacement in 1 of 42 patients (2.4%), CSF leakage that required wound resuturing in 3 of 42 patients (7.1%), and asymptomatic pseudomeningocele that was diagnosed in 8 of 42 patients (19.0%). Pseudomeningocele was diagnosed on MRI and resolved within 6 months in all patients. Based on the MRI and neurological examination results, there were no serious probe-related complications such as meningitis, wound infection, hematoma, wound breakdown, or neurological deterioration. Within 2 weeks postoperatively, 75% of patients were extubated and 25% underwent tracheostomy. Norepinephrine was used to support blood pressure without complications. Overall, the mean intraspinal pressure was around 20 mm Hg, and the mean spinal cord perfusion pressure was around 70 mm Hg. In laminectomized patients, the intraspinal pressure was significantly higher in the supine than lateral position by up to 18 mm Hg after thoracic laminectomy and 8 mm Hg after cervical laminectomy. At 12 to 18 months, 11.4% of patients had improved by 1 AIS grade and 14.3% by at least 2 AIS grades.

CONCLUSIONS

These data suggest that after traumatic spinal cord injury intradural placement of the pressure probe is accurate and intraspinal pressure monitoring is safe for up to a week. In patients with spinal cord injury who had laminectomy, the supine position should be avoided in order to prevent rises in intraspinal pressure.

Higher Mean Arterial Pressure Values Correlate with Neurologic Improvement in Patients with Initially Complete Spinal Cord Injuries

BACKGROUND

Traumatic spinal cord injury (SCI) guidelines recommend to maintain mean arterial pressures (MAPs) above 85 mm Hg for 7 days following SCI to minimize spinal cord ischemia. Some physicians doubt that patients with initially complete injuries benefit.

OBJECTIVE

To assess the relationship between MAP augmentation and neurologic improvement in SCI patients stratified by initial American Spinal Injury Association Impairment Scale (AIS) score.

METHODS

High-frequency MAP values of acute SCI patients admitted over a 6-year period were recorded, and values were correlated with degree of neurologic recovery in an analysis stratified by postresuscitation AIS score.

RESULTS

Sixty-two patients with SCI were analyzed. Thirty-three patients were determined to have complete injuries, and of those 11 improved at least 1 AIS grade by discharge. The average MAP of initially AIS A patients who improved versus those who did not was significantly higher (96.6 ± 0.07 mm Hg vs. 94.4 ± 0.06 mm Hg, respectively; P < 0.001), and the proportion of MAP values <85 mm Hg was significantly lower (13.5% vs. 25.6%, respectively; P < 0.001). A positive correlation between MAP values and outcome was also observed in AIS B and C patients but was not observed in patients who were initially AIS D.

CONCLUSION

A positive correlation was observed between MAP values and neurologic recovery in AIS A, B, and C patients but not AIS D patients. These data raise the possibility that patients with an initially complete SCI may derive greater benefit from MAP augmentation than patients with initial AIS D injuries.

Timing of Surgery in Spinal Cord Injury

STUDY DESIGN

A systematic review of the literature for clinical and preclinical evidence related to timing of decompression following spinal cord injury (SCI).

OBJECTIVE

A review of the literature in search of consensus on what constitutes the ideal time frame for surgical management of SCI.

SUMMARY OF BACKGROUND DATA

Optimal timing for surgical management of SCI remains poorly defined. Despite multiple preclinical and clinical studies, there is still lack of consensus on the optimal time for surgery in SCI.

METHODS

We systematically reviewed the literature for clinical and preclinical evidence related to timing of decompression following SCI. For clinical studies, our review included papers published in English after January 1, 1990. For preclinical studies, we limited our review to papers published after January 2001. The OVID-Medline and Web of Science databases were reviewed for preclinical studies, and the OVID-Medline, Cochrane, and Embase databases were reviewed for clinical studies.

RESULTS

A total of 8792 preclinical articles were identified. Of those, only 14 met our inclusion criteria and were included in the analysis. A total of 25,190 clinical articles were identified. Of those, only 30 studies met our inclusion criteria and were included for analysis. Clinical studies reported on a total of 5236 patients, of whom 1665 underwent early decompression and 3571 underwent late decompression. There was significant variability in the definition of early and late decompression in both clinical and preclinical studies. Preclinical data were in favor of early decompression. From a clinical standpoint, there was only level II evidence proving safety and feasibility of early decompression with no definite evidence of improved outcome for any of the two groups.

CONCLUSION

There is growing evidence in favor of early decompression following SCI. Early decompression was proven to be clinically safe and feasible, but there is still no definite proof that early decompression leads to improved outcomes.

LEVEL OF EVIDENCE

5.

Elevated Serum Insulin-Like Growth Factor 1 Levels in Patients with Neurological Remission after Traumatic Spinal Cord Injury

After traumatic spinal cord injury, an acute phase triggered by trauma is followed by a subacute phase involving inflammatory processes. We previously demonstrated that peripheral serum cytokine expression changes depend on neurological outcome after spinal cord injury. In a subsequent intermediate phase, repair and remodeling takes place under the mediation of growth factors such as Insulin-like Growth Factor 1 (IGF-1). IGF-1 is a promising growth factor which is thought to act as a neuroprotective agent. Since previous findings were taken from animal studies, our aim was to investigate this hypothesis in humans based on peripheral blood serum. Forty-five patients after traumatic spinal cord injury were investigated over a period of three months after trauma. Blood samples were taken according to a fixed schema and IGF-1 levels were determined. Clinical data including AIS scores at admission to the hospital and at discharge were collected and compared with IGF-1 levels. In our study, we could observe distinct patterns in the expression of IGF-1 in peripheral blood serum after traumatic spinal cord injury regardless of the degree of plegia. All patients showed a marked increase of levels seven days after injury. IGF-1 serum levels were significantly different from initial measurements at four and nine hours and seven and 14 days after injury, as well as one, two and three months after injury. We did not detect a significant correlation between fracture and the IGF-1 serum level nor between the quantity of operations performed after trauma and the IGF-1 serum level. Patients with clinically documented neurological remission showed consistently higher IGF-1 levels than patients without neurological remission. This data could be the base for the establishment of animal models for further and much needed research in the field of spinal cord injury.

[Spinaltrauma : Clinical diagnosis and initial care]

DIAGNOSTIC WORK-UP

The rescue, treatment and transport of patients with an injured spine require a systematic scheme with the subsequent rating of the findings and suspected diagnoses. In addition to the assessment of temporal urgency, the available resources and personnel, the duration and complexity of any possible technical measures that might be anticipated, the rational selection of immobilisation tools also plays a significant role. The most important medical rescue aids are the scoop stretcher and the spine board; the spine board, vacuum mattress and cervical collar are used to immobilise the patient.

PRACTICAL RECOMMENDATIONS

This article is focused on the diagnosis and initial treatment of isolated spinal injuries. The prehospital care of polytraumatised patients and/or those with multiple injuries differs significantly and has different priorities.

Development of a new Emergency Medicine Spinal Immobilization Protocol for trauma patients and a test of applicability by German emergency care providers

Background

In order to match the challenges of quickly recognizing and treating any life-threatening injuries, the ABCDE principles were established for the assessment and treatment of trauma patients. The high priority of spine protection is emphasized by the fact that immobilization of the cervical spine is performed at the very first step in the ABCDE principles. Immobilization is typically performed to prevent or minimize secondary damage to the spinal cord if instability of the spinal column is suspected. Due to increasing reports about disadvantages of spinal immobilization, the indications for performing spinal immobilization must be refined.

The aim of this study was (i) to develop a protocol that supports decision-making for spinal immobilization in adult trauma patients and (ii) to carry out the first applicability test by emergency medical personnel.

Methods

A structured literature search considering the literature from 1980 to 2014 was performed. Based on this literature and on the current guidelines, a new protocol that supports on scene decision-making for spinal immobilization has been developed. Parameters found in the literature concerning mechanisms and factors increasing the likelihood of spinal injury have been included in the new protocol. In order to test the applicability of the new protocol two surveys were performed on German emergency care providers by means of a questionnaire focused on correct decision-making if applying the protocol.

Results

Based on the current literature and guidelines, the Emergency Medicine Spinal Immobilization Protocol (E.M.S. IMMO Protocol) for adult trauma patients was developed. Following a fist applicability test involving 21 participants, the first version of the E.M.S. IMMO Protocol has to be graphically re-organized. A second applicability test comprised 50 participants with the current version of the protocol confirmed good applicability. Questions regarding immobilization of trauma patients could be answered properly using the E.M.S. IMMO Protocol.

Discussion

Current literature increasingly reports of disadvantages that may be associated with immobilization. Based on the requirements of the current guidelines, a new protocol that supports decision-making for indications for out-of-hospital spinal immobilization has been developed in this study. In contrast to established protocols, the new protocol offers different options for immobilization as well as a decicion-support.

Conclusions

The E.M.S. IMMO protocol provides a decision-support tool for indications for spinal immobilization in adult trauma patients that permits variable decision-making depending on the current condition of the trauma patient and the pattern of injuries for immobilization in general and for immobilization method in particular.

A Practical Methodological Approach Towards Identifying Core Competencies in Medical Education Based on Literature Trends: A Feasibility Study Based on Vestibular Schwannoma Science

BACKGROUND

Competency-based medical education (CBME) is gaining momentum in postgraduate residency and fellowship training. While randomized trials, consensus statements, and practice guidelines can help delineate some of the core competencies for CBME, they are not applicable to all clinical scenarios.

OBJECTIVE

To propose and assess the feasibility of a practical methodology for addressing this issue using radiosurgery for vestibular schwannoma (VS) science as an example.

METHODS

The Web of Science electronic database was searched using relevant terms. A 3-step review of titles and abstracts was used. Studies were classified independently and in duplicate as either efficacy or effectiveness analyses. Cohen's kappa score was used to assess inter-rater agreement.

RESULTS

Overall, 1818 surgical and 943 radiosurgical publications were identified. The number of effectiveness studies surpassed that of efficacy studies in the late 1980s for surgical studies, and in the early-to-mid 1990s among radiosurgical studies. The publication rate was higher for radiosurgery in the mid 1990s, but it paralleled that of surgical studies beyond the early 2000s. Variations in this overall trend corresponded to the emergence of studies that assessed the role of endoscopy and the utility of dose reduction in radiosurgery.

CONCLUSION

We have confirmed the feasibility and accuracy of this objective methodological approach. By understanding how the peer-reviewed literature reflects actual practice interests, educators can tailor curricula to ensure that trainees remain current. While further validation studies are needed, this methodology can serve as a supplemental strategy for identifying additional core competencies in CBME.

Safety of peripheral administration of phenylephrine in a neurologic intensive care unit: A pilot study

Integral to the management of the neurocritically injured patient are the prevention and treatment of hypotension, maintenance of cerebral perfusion pressure, and occasionally blood pressure augmentation. When adequate volume resuscitation fails to meet perfusion needs, vasopressors are often used to restore end-organ perfusion. This has historically necessitated central venous access given well-documented incidence of extravasation injuries associated with peripheral administration of vasopressors. In this pilot study, we report our 6-month experience with peripheral administration of low-concentration phenylephrine (40 μg/mL) in our neurocritical care unit. We were able to administer peripheral phenylephrine, up to a dose of 2 μg/(kg min), for an average of 14.29hours (1-54.3) in 20 patients with only 1 possible minor complication and no major complications. This was achieved by adding additional safety measures in our computerized physician order entry system and additional nurse-driven safety protocols. Thus, with careful monitoring and safety precautions, peripheral administration of phenylephrine at an optimized concentration appears to have an acceptable safety profile for use in the neurocritical care unit up to a mean infusion time of 14hours.

A survey of blood pressure parameters after aneurysmal subarachnoid hemorrhage

Purpose/aim: Blood pressure (BP) regulation is recommended following aneurysmal subarachnoid hemorrhage (aSAH) to prevent re-bleeding and to treat delayed cerebral ischemia. However, optimal BP thresholds are not well established. There is also variation with regard to the BP component (e.g. systolic vs. mean) that is targeted or manipulated.

MATERIALS AND METHODS

An 18-question survey was distributed to physicians and advanced practitioner members of the Neurocritical Care Society. Respondents were asked which BP parameter they manipulated and what their thresholds were in different clinical scenarios. They were also asked whether they were influenced by the presence of incidental aneurysms. Answers were analyzed for differences in training background and treatment setting.

RESULTS

There were 128 responses. The majority were neurointensivists (47 neurology and 37 non-neurology) and treated patients in dedicated neurointensive care units (n = 98). Systolic BP (SBP) was preferred over mean arterial pressure (MAP). Prior to aneurysm treatment, SBP limits ranged from 140 to 180 mm Hg. After aneurysm treatment, SBP limits ranged from 160 to 240 mm Hg. The maximum and minimum MAPs varied by as much as 50%. Nearly two-thirds of the respondents were influenced by the presence of incidental aneurysms. Training background influenced tolerance to BP limits with neurology-trained neurointensivists accepting higher BP limits when treating delayed ischemia ( p = .018). They were also more likely to follow SBP ( p = .018) and have a limit of 140 mm Hg prior to aneurysm treatment ( p = .001).

CONCLUSIONS

There is large practice variability in BP management following aSAH. There is also uncertainty over the importance of incidental aneurysms. Further research could evaluate whether this variability has clinical significance.

Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle-C1 interval

OBJECT

Atlantooccipital dislocation (AOD) in adults cannot be diagnosed with adequate specificity and sensitivity using only CT or plain radiography, and the spine literature offers no guidelines. In children, the most sensitive and specific radiographic measurement for the diagnosis of AOD is the CT-based occipital condyle-C1 interval (CCI). The goal of the current study was to identify the normal CCI in healthy adults and compare it with the CCI in adults with AOD to establish a highly sensitive and specific cutoff value for the neuroimaging diagnosis of AOD.

METHODS

A total of 81 patients, 59 without AOD and 22 with AOD, were included in this study. Measurements obtained from thin-slice CT scans of the craniovertebral joint to assess atlantooccipital dislocation included the CCI, condylar sum, the Wholey and Harris intervals, Powers and Sun ratios, Wackenheim line, and Lee X-lines.

RESULTS

The group of patients without AOD included 30 men (50.8%) and 29 women (49.2%) with a mean age of 42.4 ± 16 years (range 19-87 years). The group of patients with AOD included 10 men (45.5%) and 12 women (54.5%) with a mean age of 38.2 ± 9.7 years (range 20-56 years). Interrater reliabilities within a 95% CI were all greater than 0.98 for CCI measurements. A total of 1296 measurements of the CCI were made in 81 patients. The mean CCI for non-AOD patients was 0.89 ± 0.12 mm, the single largest CCI measurement was 1.4 mm, and the largest mean for either right or left CCI was 1.2 mm. The mean condylar sum was 1.8 ± 0.2 mm, and the largest condylar sum value was 2.2 mm. Linear regression with age predicted an increase in CCI of 0.001 mm/year (p < 0.05). The mean CCI in AOD patients was 3.35 ± 0.18 mm (range 1.5 mm-6.4 mm). The shortest single CCI measurements in the AOD patients were 1.1 mm and 1.2 mm. The mean condylar sum for all 22 AOD patients was 6.7 ± 2.7 mm and the shortest condylar sums were 3.0 mm. Cutoff values for AOD were set at 1.5 mm for the CCI and 3.0 mm for the condylar sum, both with a sensitivity of 1 and false-negative rate of 0. Sensitivity for the Powers, Wholey, Harris, Sun, Wackenheim, and Lee criteria were determined to be 0.55, 0.46, 0.27, 0.23, 0.41, and 0.41, respectively.

CONCLUSIONS

The CCI is shorter in adult patients as opposed to the pediatric population. The revised CCI (1.5 mm) and condylar sum (3.0 mm) cutoff values have the highest sensitivity and specificity for the diagnosis of AOD in the adult population.

Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Systematic Review and Meta-Analysis

Previous meta-analyses of methylprednisolone (MPS) for patients with acute traumatic spinal cord injuries (TSCIs) have not addressed confidence in the quality of evidence used for pooled effect estimates, and new primary studies have been recently published. We aimed to determine whether MPS improves motor recovery and is associated with increased risks for adverse events. We searched MEDLINE, EMBASE, and The Cochrane Library, and two reviewers independently screened articles, extracted data, and evaluated risk of bias. We pooled outcomes from randomized, controlled trials (RCTs) and controlled observational studies separately and used the Grades of Recommendation, Assessment, Development, and Evaluation approach to evaluate confidence. We included four RCTs and 17 observational studies. MPS was not associated with an increase in long-term motor score recovery (two RCTs: 335 participants; mean difference [MD], −1.11; 95% confidence interval [CI], −4.75 to 2.53; p = 0.55, low confidence; two observational studies: 528 participants; MD, 1.37; 95% CI, −3.08 to 5.83; p = 0.55, very low confidence) or improvement by at least one motor grade (three observational studies: 383 participants; risk ratio [RR], 0.84; 95% CI, 0.53–1.33; p = 0.46, very low confidence). Evidence from two RCTs demonstrated superior short-term motor score improvement if MPS was administered within 8 h of injury (two RCTs: 250 participants; MD, 4.46; 95% CI, 0.97–7.94; p = 0.01, low confidence), but risk of bias and imprecision limit confidence in these findings. Observational studies demonstrated a significantly increased risk for gastrointestinal bleeding (nine studies: 2857 participants; RR, 2.18; 95% CI, 1.13–4.19; p = 0.02, very low confidence), but RCTs did not. Pooled evidence does not demonstrate a significant long-term benefit for MPS in patients with acute TSCIs and suggests it may be associated with increased gastrointestinal bleeding. These findings support current guidelines against routine use, but strong recommendations are not warranted because confidence in the effect estimates is limited.

Magnetic resonance imaging of traumatic injury to the craniovertebral junction: a case-based review

OBJECT

The craniovertebral junction (CVJ) is unique in the spinal column regarding the degree of multiplanar mobility allowed by its bony articulations. A network of ligamentous attachments provides stability to this junction. Although ligamentous injury can be inferred on CT scans through the utilization of craniometric measurements, the disruption of these ligaments can only be visualized directly with MRI. Here, the authors review the current literature on MRI evaluation of the CVJ following trauma and present several illustrative cases to highlight the utility and limitations of craniometric measures in the context of ligamentous injury at the CVJ.

METHODS

A retrospective case review was conducted to identify patients with cervical spine trauma who underwent cervical MRI and subsequently required occipitocervical or atlantoaxial fusion. Craniometric measurements were performed on the CT images in these cases. An extensive PubMed/MEDLINE literature search was conducted to identify publications regarding the use of MRI in the evaluation of patients with CVJ trauma.

RESULTS

The authors identified 8 cases in which cervical MRI was performed prior to operative stabilization of the CVJ. Craniometric measures did not reliably rule out ligamentous injury, and there was significant heterogeneity in the reliability of different craniometric measurements. A review of the literature revealed several case series and descriptive studies addressing MRI in CVJ trauma. Three papers reported the inadequacy of the historical Traynelis system for identifying atlantooccipital dislocation and presented 3 alternative classification schemes with emphasis on MRI findings.

CONCLUSIONS

Recognition of ligamentous instability at the CVJ is critical in directing clinical decision making regarding surgical stabilization. Craniometric measures appear unreliable, and CT alone is unable to provide direct visualization of ligamentous injury. Therefore, while the decision to obtain MR images in CVJ trauma is largely based on clinical judgment with craniometric measures used as an adjunct, a high degree of suspicion is warranted in the care of these patients as a missed ligamentous injury can have devastating consequences.

Application of Cervical Collars - An Analysis of Practical Skills of Professional Emergency Medical Care Providers

Background/Objective

The application of a cervical collar is a standard procedure in trauma patients in emergency medicine. It is often observed that cervical collars are applied incorrectly, resulting in reduced immobilization of the cervical spine. The objective of this study was to analyze the practical skills of trained professional rescue personnel concerning the application of cervical collars.

Material and Methods

Within emergency medical conferences, n = 104 voluntary test subjects were asked to apply a cervical collar to a training doll, wherein each step that was performed received an evaluation. Furthermore, personal and occupational data of all study participants were collected using a questionnaire.

Results

The test subjects included professional rescue personnel (80.8%) and emergency physicians (12.5%). The average occupational experience of all study participants in pre-clinical emergency care was 11.1±8.9 years. Most study participants had already attended a certified training on trauma care (61%) and felt "very confident" in handling a cervical collar (84%). 11% applied the cervical collar to the training doll without errors. The most common error consisted of incorrect adjustment of the size of the cervical collar (66%). No association was found between the correct application of the cervical collar and the occupational group of the test subjects (trained rescue personnel vs. emergency physicians) or the participation in certified trauma courses.

Conclusion

Despite pronounced subjective confidence regarding the application of cervical collars, this study allows the conclusion that there are general deficits in practical skills when cervical collars are applied. A critical assessment of the current training contents on the subject of trauma care must, therefore, be demanded.

Mean Arterial Blood Pressure Correlates with Neurological Recovery after Human Spinal Cord Injury: Analysis of High Frequency Physiologic Data

Current guidelines for the care of patients with acute spinal cord injuries (SCIs) recommend maintaining mean arterial pressure (MAP) values of 85-90 mm Hg for 7 days after an acute SCI however, little evidence supports this recommendation. We sought to better inform the relationship between MAP values and neurological recovery. A computer system automatically collected and stored q1 min physiological data from intensive care unit monitors on patients with SCI over a 6-year period. Data for 100 patients with acute SCI were collected. 74 of these patients had American Spinal Injury Association Impairment Scale (AIS) grades determined by physical examination on admission and at time of hospital discharge. Average MAP values as well as the proportion of MAP values below thresholds were explored for values from 120 mm Hg to 40 mm Hg in 1 mm Hg increments; the relationship between these measures and outcome was explored at various time points up to 30 days from the time of injury. A total of 994,875 q1 min arterial line blood pressure measurements were recorded for the included patients amid 1,688,194 min of recorded intensive care observations. A large proportion of measures were below 85 mm Hg despite generally acceptable average MAP values. Higher average MAP values correlated with improved recovery in the first 2-3 days after SCI while the proportion of MAP values below the accepted threshold of 85 mm Hg seemed a stronger correlate, decreasing in strength over the first 5-7 days after injury. This study provides strong evidence supporting a correlation between MAP values and neurological recovery. It does not, however, provide evidence of a causal relationship. Duration of hypotension may be more important than average MAP. It provides support for the notion of MAP thresholds in SCI recovery, and the highest MAP values correlated with the greatest degree of neurological recovery. The results are concordant with current guidelines in suggesting that MAP thresholds >85 mm Hg may be appropriate after acute SCI.

Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Propensity Score-Matched Cohort Study from a Canadian Multi-Center Spinal Cord Injury Registry

In prior analyses of the effectiveness of methylprednisolone for the treatment of patients with acute traumatic spinal cord injuries (TSCIs), the prognostic importance of patients' neurological levels of injury and their baseline severity of impairment has not been considered. Our objective was to determine whether methylprednisolone improved motor recovery among participants in the Rick Hansen Spinal Cord Injury Registry (RHSCIR). We identified RHSCIR participants who received methylprednisolone according to the Second National Spinal Cord Injury Study (NASCIS-II) protocol and used propensity score matching to account for age, sex, time of neurological exam, varying neurological level of injury, and baseline severity of neurological impairment. We compared changes in total, upper extremity, and lower extremity motor scores using the Wilcoxon signed-rank test and performed sensitivity analyses using negative binomial regression. Forty-six patients received methylprednisolone and 1555 received no steroid treatment. There were no significant differences between matched participants for each of total (13.7 vs. 14.1, respectively; p=0.43), upper extremity (7.3 vs. 6.4; p=0.38), and lower extremity (6.5 vs. 7.7; p=0.40) motor recovery. This result was confirmed using a multivariate model and, as predicted, only cervical (C1-T1) rather than thoracolumbar (T2-L3) injury levels (p<0.01) and reduced baseline injury severity (American Spinal Injury Association [ASIA] Impairment Scale grades; p<0.01) were associated with greater motor score recovery. There was no in-hospital mortality in either group; however, the NASCIS-II methylprednisolone group had a significantly higher rate of total complications (61% vs. 36%; p=0.02) NASCIS-II methylprednisolone did not improve motor score recovery in RHSCIR patients with acute TSCIs in either the cervical or thoracic spine when the influence of anatomical level and severity of injury were included in the analysis. There was a significantly higher rate of total complications in the NASCIS-II methylprednisolone group. These findings support guideline recommendations against routine administration of methylprednisolone in acute TSCI.

Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study

We recently showed that, after traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression. This is an open label, prospective trial comparing combined bony and dural decompression versus laminectomy. Twenty-one patients with acute severe TSCI had re-alignment of the fracture and surgical fixation; 11 had laminectomy alone (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy+duroplasty group). Primary outcomes were magnetic resonance imaging evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy+duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group. Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. We conclude that, after TSCI, laminectomy+duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy alone.

Neurological Recovery after Traumatic Cervical Spinal Cord Injury Is Superior if Surgical Decompression and Instrumented Fusion Are Performed within 8 Hours versus 8 to 24 Hours after Injury: A Single Center Experience

A prospective study was performed to evaluate the impact of surgical decompression (SD) and instrumented fusion within 8 h versus 8-24 h after injury on neurological recovery after cervical traumatic spinal cord injury (tSCI) in patients operated on in the UMC Ljubljana, Slovenia. Only patients with the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades of A through C and with MRI-confirmed spinal cord compression were enrolled. The primary outcome was the change in AIS grade at the 6-month follow-up. Of the 48 enrolled patients, 22 patients who underwent surgery within 8 h (group 8 h) and 20 patients who underwent surgery between 8 and 24 h (Group 8-24 h) after injury concluded the study. At admission, there was no statistically significant difference in AIS grade between the study groups. At the 6-month follow-up, an improvement of at least two AIS grades was found in 45.5% of patients in group 8 h and in 10% of patients in group 8-24 h (p=0.017). The median improvement in the ASIA motor score was 38.5 (10.0-61.0) motor points in group 8 h and 15.0 (8.8-34.0) motor points in group 8-24 h (p=0.0468). In a multivariate analysis, adjusted for the preoperative AIS grade and the degree of spinal canal compromise, the odds of an at least two-grade AIS improvement were at least 106% higher for patients in group 8 h than for patients in group 8-24 h (odds ratio=11.08, p=0.004). No statistically significant difference was found in the rate of perioperative complications, pneumonia, and the number of ventilator-dependent days or the mortality between the groups. Our results suggest that the patients with tSCI who undergo SD within 8 h after injury have superior neurological outcomes than patients who undergo SD 8-24 h after injury, without any increase in the rate of adverse effects.

Neurologic emergencies in sports

PURPOSE OF REVIEW

Sports neurology is an emerging area of subspecialty. Neurologists and non-neurologists evaluating and managing individuals participating in sports will encounter emergencies that directly or indirectly involve the nervous system. Since the primary specialty of sports medicine physicians and other practitioners involved in the delivery of medical care to athletes in emergency situations varies significantly, experience in recognition and management of neurologic emergencies in sports will vary as well. This article provides a review of information and elements essential to neurologic emergencies in sports for the practicing neurologist, although content may be of benefit to readers of varying background and expertise.

RECENT FINDINGS

Both common neurologic emergencies and less common but noteworthy neurologic emergencies are reviewed in this article. Issues that are fairly unique to sports participation are highlighted in this review. General concepts and principles related to treatment of neurologic emergencies that are often encountered unrelated to sports (eg, recognition and treatment of status epilepticus, increased intracranial pressure) are discussed but are not the focus of this article. Neurologic emergencies can involve any region of the nervous system (eg, brain, spine/spinal cord, peripheral nerves, muscles). In addition to neurologic emergencies that represent direct sports-related neurologic complications, indirect (systemic and generalized) sports-related emergencies with significant neurologic consequences can occur and are also discussed in this article.

SUMMARY

Neurologists and others involved in the care of athletes should consider neurologic emergencies in sports when planning and providing medical care.

Postoperative Mycoplasma hominis infections after neurosurgical intervention

OBJECT

Mycoplasma hominis is a rare cause of infection after neurosurgical procedures. The Mycoplasma genus contains the smallest bacteria discovered to date. Mycoplasma are atypical bacteria that lack a cell wall, a feature that complicates both diagnosis and treatment. The Gram stain and some types of culture media fail to identify these organisms, and typical broad-spectrum antibiotic regimens are ineffective because they act on cell wall metabolism. Mycoplasma hominis commonly colonizes the genitourinary tract in a nonvirulent manner, but it has caused postoperative, postpartum, and posttraumatic infections in various organ systems. The authors present the case of a 17-year-old male with a postoperative intramedullary spinal cord abscess due to M. hominis and report the results of a literature review of M. hominis infections after neurosurgical procedures. Attention is given to time to diagnosis, risk factors for infection, ineffective antibiotic regimens, and final effective antibiotic regimens to provide pertinent information for the practicing neurosurgeon to diagnose and treat this rare occurrence.

METHODS

A PubMed search was performed to identify reports of M. hominis infections after neurosurgical procedures.

RESULTS

Eleven cases of postneurosurgical M. hominis infection were found. No other cases of intramedullary spinal cord abscess were found. Initial antibiotic coverage was inadequate in all cases, and diagnosis was delayed in all cases. Multiple surgical interventions were often needed. Once appropriate antibiotics were started, patients typically experienced rapid resolution of their neurological symptoms. In 27% of cases, a suspicious genitourinary source other than urinary catheterization was identified.

CONCLUSIONS

Postoperative M. hominis infections are rarely seen after neurosurgical procedures. They are typically responsive to appropriate antibiotic therapy. Mycoplasma infection may cause prolonged hospitalization and multiple returns to the operating room due to delay in diagnosis. Early clinical suspicion with appropriate antibiotic coverage could help prevent these significant complications.

Efficacy of N-acetylcysteine on neuroclinical, biochemical, and histopathological parameters in experimental spinal cord trauma: comparison with methylprednisolone

BACKGROUND

N-acetylcysteine (NAC) is an antioxidant agent that has been shown to have beneficial effects when treating various diseases. The aim of this study was to investigate the effects of NAC on spinal cord injury in an experimental rat model.

METHODS

A total of 48 adult male wistar albino rats were divided into six groups. Group C included the control rats, group L included the rats that underwent laminectomy, and group T included the rats in which spinal cord trauma was induced by the weight-drop method after laminectomy. Groups M (the methylprednisolone group), N (the NAC group), and MN (the methylprednisolone + NAC group) were the treatment groups. In the fourth group (group M), 30 mg/kg methylprednisolone (MP) was administered as a bolus intraperitoneally (IP), and a standard MP treatmentat a dose of 5.4 mg/kg was applied for 24 h. In the fifth group (group N), only 300 mg/kg NAC was administered as a bolus IP. In the sixth group (group MN), the standard MP treatment and a single 300 mg/kg dose of NAC were administered as a bolus IP. The motor functions of the rats were evaluated on the 1st, 7th, and 14th days using the inclined plane test defined by Rivlin and Tator and the motor scale defined by Gale et al. Spinal cord samples were obtained on the 14th day. The samples were evaluated using pathological and biochemical analysis.

RESULTS

In the neuroclinical assessment, no differences were observed between groups T and M in terms of motor improvement. However, statistically significant differences were observed between group T and groups N and MN (p < 0.001, p = 0.01, respectively). Statistically significant differences were also seen between group M and groups N and MN on the 1st and 7th days (p < 0.017, p < 0.01, respectively). Additionally, when groups N and MN were compared with groups T and M,the pathological and biochemical analyses were found to be statistically different (p < 0.05, p < 0.001, respectively).

CONCLUSION

It was concluded that NAC treatment and the combined NAC + MP treatment may be more useful for healing in rats with experimental spinal cord injury in terms of neuroclinical, pathological, and biochemical results than MP-only therapy.

Comparison of deferoxamine and methylprednisolone: protective effect of pharmacological agents on lipid peroxidation in spinal cord injury in rats

STUDY DESIGN

Experimental study.

OBJECTIVE

To investigate the protective effect of deferoxamine (DFO) administration in comparison with methylprednisolone (MP) on lipid peroxidation and antioxidants after spinal cord injury (SCI) in rats.

SUMMARY OF BACKGROUND DATA

DFO is used for treating an iron-chelating agent, which is also used in the treatment of iron poisoning and thalassaemia. The neuroprotective effect of DFO was evaulated as a therapeutic agent for SCI.

METHODS

Forty Wistar rats were randomly divided into 5 groups as sham laminectomy (n = 8), laminectomy with SCI (n = 8), laminectomy with SCI and 0.9% saline intraperitoneal (i.p.) (n = 8), laminectomy with SCI and 30 mg/kg MP i.p. (n = 8), and laminectomy with SCI and 30 mg/kg DFO i.p. (n = 8). Neurological deficits were examined 24 hours after trauma, and all rats were killed. Spinal cord segments were harvested for both biochemical and histopathological evaluation.

RESULTS

At 24 hours post-SCI, whereas malondialdehyde levels were increased, superoxide dismutase, catalase, and glutathione peroxidase levels were decreased in groups I, II, and III. MP and DFO treatment decreased MDA levels and increased superoxide dismutase CAT, and glutathione peroxidase levels in control and study groups. There was no statistically significant difference between treatment with MP and DFO (P> 0.05). All rats were paraplegic after SCI, except in the sham group. Histopathological improvement was observed in control and study groups.

CONCLUSION

This study indicates that beneficial effects may be provided and further studies need to investigate the dose-dependent beneficial and side effects of DFO in SCI.

LEVEL OF EVIDENCE

N/A.