Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study

Perfusion imaging metrics after acute traumatic spinal cord injury are associated with injury severity in rats and humans

Traumatic spinal cord injury (tSCI) causes an immediate loss of neurological function, and the prediction of recovery is difficult in the acute phase. In this study, we used contrast-enhanced ultrasound imaging to quantify intraspinal vascular disruption acutely after tSCI. In a rodent thoracic tSCI model, contrast-enhanced ultrasound revealed a perfusion area deficit that was positively correlated with injury severity and negatively correlated with hindlimb locomotor function at 8 weeks after injury. The spinal perfusion index was calculated by normalizing the contrast inflow at the injury center to the contrast inflow in the injury periphery. The spinal perfusion index decreased with increasing injury severity and positively correlated with hindlimb locomotor function at 8 weeks after injury. The feasibility of intraoperative contrast-enhanced ultrasound imaging was further tested in a cohort of 27 patients with acute tSCI of varying severity and including both motor-complete and motor-incomplete tSCIs. Both the perfusion area deficit and spinal perfusion index were different between motor-complete and motor-incomplete patients. Moreover, the perfusion area deficit and spinal perfusion index correlated with the injury severity at intake and exhibited a correlation with extent of functional recovery at 6 months. Our data suggest that intraoperative contrast-enhanced, ultrasound-derived metrics are correlated with injury severity and chronic functional outcome after tSCI. Larger clinical studies are required to better assess the reliability of the proposed contrast-enhanced ultrasound biomarkers and their prognostic capacity.

Pharmacologic Therapy for Spinal Cord Injury

Neuroprotective strategies aimed at preventing secondary neurologic injury following acute spinal cord injury remain an important area of clinical, translational, and basic science research. Despite recent advancement in the understanding of basic mechanisms of primary and secondary neurologic injury, few pharmacologic agents have shown consistent promise in improving neurologic outcomes following SCI in large randomized clinical trials. The authors review the existing literature and clinical guidelines for pharmacologic therapy investigated for managing acute SCI, including corticosteroids, GM-1 ganglioside (Sygen), Riluzole, opioid antagonists, Cethrin, minocycline, and vasopressors for mean arterial pressure augmentation. Therapies for managing secondary effects of SCI, such as bradycardia, are discussed. Current clinical trials for pharmacotherapy and cellular transplantation following acute SCI are also reviewed. Despite the paucity of current evidence for clinically beneficial post-SCI pharmacotherapy, future research efforts will hopefully elucidate promising therapeutic agents to improve neurologic function.

"White Cord Syndrome" as clinical manifestation of the spinal cord reperfusion syndrome: a systematic review of risk factors, treatments, and outcome

OBJECTIVE

Paralysis subsequent to spinal cord decompression in the cervical or thoracic region is infrequent, with White Cord Syndrome (WCS) being among its several causes. Due to WCS's infrequency, there exists a paucity of high-level evidence concerning its manifestations. Our primary objective is to systematically collate all documented WCS cases, discern prevalent risk and prognostic factors, appraise available treatment modalities, and evaluate patient outcomes.

METHODS

A systematic review was conducted following PRISMA guidelines. The search included PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria required studies to be written in English, be case reports, and contain data on clinical features, management, and treatment outcomes. Exclusion criteria excluded meta-analyses, reviews, editorials, letters, books, studies with insufficient clinical data, and studies not in English or with unavailable full texts. Grey literature was not actively pursued due to identification challenges, potentially introducing selection bias. Two authors independently evaluated papers based on criteria. Disagreements were resolved with a third author. Additionally, the included articles' references were screened for additional relevant articles.

RESULTS

We found a total of 580 articles through our electronic search. After removing duplicates, 399 articles were screened. Out of the remaining 51 studies, 27 were included in the final quantitative analysis. The average age was 54 (3-79 years) with a male-to-female ratio of 2:1, 33% had OPLL, and Common medical histories were hypertension (30%), diabetes mellitus (20%), and previous ACDF surgery (8%). Of all Surgeries, 70% were done with a posterior approach and 30% with the anterior approach. 48% of cases used Intraoperative NeuroMonitoring(IONM), and Loss of Motor Evoked Potentials (MEP) occurred in 37% of cases. Patients received high-dose intravenous steroids. In 26% of cases, additional posterior cervical decompression was performed, and efforts were made to maintain mean arterial pressure above 85 mmHg in 37% of cases. Other medications were administered in 30% of cases. Over an average 26-week follow-up, 37% of patients had good recovery, 40% had partial recovery, and 23% showed no recovery. The average final Nurick grade was 3.2.

CONCLUSIONS

WCS is a rare cause of postoperative neurological deficit following spinal cord decompression surgery. Risk factors for WCS include advanced age, extensive surgery, posterior approach for decompression, and the presence of OPLL. Treatment includes high-dose steroids, posterior cervical decompression, maintaining MAP over 85mmHg, rehabilitation, and sometimes neurotrophic drugs. Most patients can walk with or without assistance during follow-up, but around a quarter never regain neurological function. The only preoperative factor impacting outcomes is the preoperative neurological status (Nurick Grade).

Evaluation of traumatic spinal injuries: a pediatric perspective

PURPOSE

The aim of the present study is to provide information about pediatric patients with spinal trauma.

METHODS

A single-center retrospective chart review was carried out. Children who arrived at the pediatric emergency department due to trauma and those with spinal pathology confirmed by radiological assessment were included. Demographics, mechanisms of trauma, clinical findings, radiological investigations, applied treatments, hospital stay and prognosis were recorded.

RESULTS

A total of 105 patients [59 (56.2%) boys; mean age: 12.9 ± 3.8 years (mean ± SD)] were included. The most common age group was that of 14-18 years (58.1%). The three most common trauma mechanisms were road traffic collisions (RTCs) (60.0%), falls (32.4%), and diving into water (2.9%). A fracture of the spine was detected in 97.1% patients, vertebral dislocation in 10.7%, and spinal cord injury in 16.3%. Of the patients, 36.9% were admitted to the ward and 18.4% to the pediatric intensive care unit; 17.1% were discharged with severe complications and 2.9% cases resulted in death. While 34.3% of the patients had a clinically isolated spine injury, the remaining cases entailed an injury to at least one other body part; the most common associated injuries were to the head (39.8%), abdomen (36.1%), and external areas (28.0%).

CONCLUSION

Spinal trauma was found to have occurred mostly in adolescent males, and the majority of those cases were due to RTCs. Data on the incidence and demographic factors of pediatric spinal trauma are crucial in furthering preventive measures, allowing for the identification of at-risk populations and treatment modalities.

Riluzole is Effective on Spinal Decompression for Treating Acute Spinal Injury When Compared With Methylprednisolone and the Combination of Two Drugs: In Vivo Rat Model

STUDY DESIGN

Randomized controlled animal experiment.

OBJECTIVES

To determine and compare the efficacy of riluzole, MPS and the combination of two drugs in a rat model with acute spinal trauma, electrophysiologically and histopathologically.

METHODS

59 rats were divided into 4 groups as control, riluzole (6 mg/kg, every 12 hours for 7 days), MPS (30 mg/kg, 2nd and 4th hours after injury) and riluzole + MPS. Spinal trauma was created and the subjects were followed for 7 days. Electrophysiological recordings were made via neuromonitoring. The subjects were sacrificed and histopathological examination was made.

RESULTS

For the amplitude values, mean alteration in the period from the spinal cord injury to the end of the 7th day is 15.89 ± 20.00%, 210.93 ± 199.44%, 24.75% ± 10.13% increase and 18.91 ± 30.01% decrease for the control, riluzole, riluzole + MPS and MPS groups, respectively. Although the riluzole treatment group produced the greatest increase in amplitude, it was observed that no treatment provided a significant improvement compared to the control group, in terms of latency and amplitude. It was observed that there was significantly less cavitation area in the riluzole treatment group compared to the control group (P = .020). (P < .05).

CONCLUSIONS

Electrophysiologically, no treatment was found to provide significant improvement. Histopathologically, it was observed that riluzole provided significant neural tissue protection.

Resident immune responses to spinal cord injury: role of astrocytes and microglia

Spinal cord injury can be traumatic or non-traumatic in origin, with the latter rising in incidence and prevalence with the aging demographics of our society. Moreover, as the global population ages, individuals with co-existent degenerative spinal pathology comprise a growing number of traumatic spinal cord injury cases, especially involving the cervical spinal cord. This makes recovery and treatment approaches particularly challenging as age and comorbidities may limit regenerative capacity. For these reasons, it is critical to better understand the complex milieu of spinal cord injury lesion pathobiology and the ensuing inflammatory response. This review discusses microglia-specific purinergic and cytokine signaling pathways, as well as microglial modulation of synaptic stability and plasticity after injury. Further, we evaluate the role of astrocytes in neurotransmission and calcium signaling, as well as their border-forming response to neural lesions. Both the inflammatory and reparative roles of these cells have eluded our complete understanding and remain key therapeutic targets due to their extensive structural and functional roles in the nervous system. Recent advances have shed light on the roles of glia in neurotransmission and reparative injury responses that will change how interventions are directed. Understanding key processes and existing knowledge gaps will allow future research to effectively target these cells and harness their regenerative potential.

Targeted-delivery of nanomedicine-enabled methylprednisolone to injured spinal cord promotes neuroprotection and functional recovery after acute spinal cord injury in rats

To date, no therapy has been proven to be efficacious in fully restoring neurological functions after spinal cord injury (SCI). Systemic high-dose methylprednisolone (MP) improves neurological recovery after acute SCI in both animal and human. MP therapy remains controversial due to its modest effect on functional recovery and significant adverse effects. To overcome the limitation of MP therapy, we have developed a N-(2-hydroxypropyl) methacrylamide copolymer-based MP prodrug nanomedicine (Nano-MP) that can selectively deliver MP to the SCI lesion when administered systemically in a rat model of acute SCI. Our in vivo data reveal that Nano-MP is significantly more effective than free MP in attenuating secondary injuries and neuronal apoptosis. Nano-MP is superior to free MP in improving functional recovery after acute SCI in rats. These data support Nano-MP as a promising neurotherapeutic candidate, which may provide potent neuroprotection and accelerate functional recovery with improved safety for patients with acute SCI.

Concomitant traumatic brain injury as a determinant of survival, and neurological and functional outcomes after traumatic spinal cord injury: A retrospective cohort study

BACKGROUND

Although concomitant traumatic brain injury (TBI) is not infrequently associated with spinal cord injury (SCI), there is relatively scarce information about the effects of concomitant TBI on outcomes after SCI.

OBJECTIVE

To assess the impact of concomitant mild-to-moderate TBI on survival, and neurological and functional outcomes within the first year after acute traumatic SCI.

DESIGN

Retrospective cohort study.

SETTING

Acute spine trauma centers in the United States.

PARTICIPANTS

This study includes all individuals who were enrolled into the Third National Spinal Cord Injury Study (NASCIS-3). The study population was classified into SCI + TBI group and SCI-alone group. TBI was defined as a Glasgow Coma Scale score <15 on admission.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Both groups were compared regarding their survival and neurological outcomes (ie, NASCIS motor, sensory and pain scores) and functional outcome (ie, Functional Independence Measure score) within the first year following SCI. Data analyses were adjusted for major potential confounders.

RESULTS

There were 413 individuals in the SCI-alone group and 86 individuals in the SCI + TBI group (17.2%). Both groups were comparable regarding gender distribution (p = .621). However, the SCI + TBI group was older (p < .001), had a higher proportion of complete (p = .006) and cervical SCI (p = .003), and had a higher blood alcohol level (p < .001) than the SCI-alone group. The SCI + TBI group did not significantly differ from the SCI-alone group regarding survival within the first year after SCI (p = .768). Among the survivors, concomitant mild-to-moderate TBI did not significantly affect neurological and functional outcomes at 1 year after SCI in the multiple regression analyses after adjusting for major potential confounders.

CONCLUSIONS

The results of this study suggest that concomitant mild-to-moderate TBI did not have a significant impact on survival, neurological recovery, and functional outcomes at 1 year after SCI, even though there were some epidemiological differences between SCI-alone and SCI + TBI groups.

Weaning failure due to isolated residual diaphragmatic paralysis after cervical spinal cord ischemia following aortic surgery- a case report

BACKGROUND

Bilateral diaphragmatic dysfunction can lead to dyspnea and recurrent respiratory failure. In rare cases, it may result from high cervical spinal cord ischemia (SCI) due to anterior spinal artery syndrome (ASAS). We present a case of a patient experiencing persistent isolated diaphragmatic paralysis after SCI at level C3/C4 following thoracic endovascular aortic repair (TEVAR) for Kommerell's diverticulum. This is, to our knowledge, the first documented instance of a patient fully recovering from tetraplegia due to SCI while still exhibiting ongoing bilateral diaphragmatic paralysis.

CASE PRESENTATION

The patient, a 67-year-old male, presented to the Vascular Surgery Department for surgical treatment of symptomatic Kommerell's diverticulum in an aberrant right subclavian artery. After successful surgery in two stages, the patient presented with respiratory insufficiency and flaccid tetraparesis consistent with anterior spinal artery syndrome with maintained sensibility of all extremities. A computerized tomography scan (CT) revealed a high-grade origin stenosis of the left vertebral artery, which was treated by angioplasty and balloon-expandable stenting. Consecutively, the tetraparesis immediately resolved, but weaning remained unsuccessful requiring tracheostomy. Abdominal ultrasound revealed a residual bilateral diaphragmatic paralysis. A repeated magnetic resonance imaging (MRI) 14 days after vertebral artery angioplasty confirmed SCI at level C3/C4. The patient was transferred to a pulmonary clinic with weaning center for further recovery.

CONCLUSIONS

This novel case highlights the need to consider diaphragmatic paralysis due to SCI as a cause of respiratory failure in patients following aortic surgery. Diaphragmatic paralysis may remain as an isolated residual in these patients.

Neuroprotective macromolecular methylprednisolone prodrug nanomedicine prevents glucocorticoid-induced muscle atrophy and osteoporosis in a rat model of spinal cord injury

To address the adverse side effects associated with systemic high-dose methylprednisolone (MP) therapy for acute spinal cord injury (SCI), we have developed a N-2-hydroxypropyl methacrylamide copolymer-based MP prodrug nanomedicine (Nano-MP). Intravenous Nano-MP selectively targeted to the inflamed SCI lesion and significantly improved neuroprotection and functional recovery after acute SCI. In the present study, we comprehensively assessed the potential adverse side effects associated with the treatment in the SCI rat models, including reduced body weight and food intake, impaired glucose metabolism, and reduced musculoskeletal mass and integrity. In contrast to free MP treatment, intravenous Nano-MP after acute SCI not only offered superior neuroprotection and functional recovery but also significantly mitigated or even eliminated the aforementioned adverse side effects. The superior safety features of Nano-MP observed in this study further confirmed the clinical translational potential of Nano-MP as a highly promising drug candidate for better clinical management of patients with acute SCI.

Corticosteroids in critically ill patients: A narrative review

Corticosteroids have been utilized in modern medicine for decades. Many indications have been investigated across various treatment settings with both benefit and harm observed. Given the instability of critically ill patients, the increased risk of corticosteroid-related complications, and the pervasive comorbidities, patients who receive corticosteroids must be carefully managed. Common critical care disease states in which corticosteroids have been studied and are routinely utilized include acute respiratory distress syndrome, adrenal insufficiency, angioedema, asthma, chronic obstructive pulmonary disease, community-acquired pneumonia, coronavirus disease 2019, septic shock, and spinal cord injury. Benefits of corticosteroids include an improvement in disease state-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality. The harm of corticosteroids is well documented through adverse effects that include, but are not limited to, hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness. Furthermore, corticosteroids are associated with increased health care costs through adverse effects as well as drug acquisition and administration costs. Given the assortment of agents, dosing, benefits, risks, and utilization in the critical care setting, there may be difficulty with identifying the appropriate places for use of corticosteroids in therapy. There currently exists no comprehensive report detailing the use of corticosteroids in the aforementioned disease states within the critical care setting. This narrative review sets out to describe these in detail.

Clinical application and potential pluripotent effects of hepatocyte growth factor in spinal cord injury regeneration

INTRODUCTION

Spinal cord injury (SCI) is a condition in which the spinal cord parenchyma is damaged by various factors. The mammalian central nervous system has been considered unable to regenerate once damaged, but recent progress in basic research has gradually revealed that injured neural cells can indeed regenerate. Drug therapy using novel agents is being actively investigated as a new treatment for SCI. One notable treatment method is regeneration therapy using hepatocyte growth factors (HGF).

AREA COVERED

HGF has pluripotent neuroregenerative actions, as indicated by its neuroprotective and regenerative effects on the microenvironment and damaged cells, respectively. This review examines these effects in various phases of SCI, from basic research to clinical studies, and the application of this treatment to other diseases.

EXPERT OPINION

In regenerative medicine for SCI, drug therapies have tended to be more likely to be developed compared to cell replacement treatment. Nevertheless, there are still challenges to be addressed for these clinical applications due to a wide variety of pathology and animal experimental models of basic study, but HGF could be an effective treatment for SCI with expanded application.

Paediatric Spinal Cord Injury: A Review of Current Management

Spinal cord injury (SCI) in the paediatric population is considered a separate entity from the same injury in adults due to the unique anatomical, physiological, and biomechanical properties of the pediatric spine. No comprehensive, standardized, international guidelines currently exist for physicians to follow regarding the management of paediatric spinal cord injuries. Therefore, a narrative literature review approach was employed to explore the management of paediatric spinal cord injuries. The review adhered to the methodological frameworks that entailed identifying a curated selection of pertinent articles on the topic, rather than an exhaustive comprehensive search that is utilised in systematic reviews, this was followed by a reflective interpretation of their content. Using the electronic databases, PubMed and Google Scholar, a search of peer-reviewed studies conducted only in the English language was included. Only studies in which the full article was available were included. Paediatric populations are defined as individuals aged between 0 and 18 years. In total, 26 studies were included in our review. We conclude that it is necessary to factor in specific paediatric considerations, such as disproportionate head size, increased ligament laxity, increased prevalence of upper cervical injury, and future development of scoliosis, in the prehospital, medical, and surgical management of paediatric spinal cord injuries. Clinicians should be made aware of these considerations, as they can improve the outcomes in the paediatric population who suffer from this devastating injury. There is a lack of high-quality studies and data concerning the paediatric population who have sustained SCIs. This literature review highlights the available data and calls for more studies to be conducted in this field.

Management of traumatic spinal cord injury: A current concepts review of contemporary and future treatment

Spinal Cord Injury (SCI) is a condition leading to inflammation, edema, and dysfunction of the spinal cord, most commonly due to trauma, tumor, infection, or vascular disturbance. Symptoms include sensory and motor loss starting at the level of injury; the extent of damage depends on injury severity as detailed in the ASIA score. In the acute setting, maintaining mean arterial pressure (MAP) higher than 85 mmHg for up to 7 days following injury is preferred; although caution must be exercised when using vasopressors such as phenylephrine due to serious side effects such as pulmonary edema and death. Decompression surgery (DS) may theoretically relieve edema and reduce intraspinal pressure, although timing of surgery remains a matter of debate. Methylprednisolone (MP) is currently used due to its ability to reduce inflammation but more recent studies question its clinical benefits, especially with inconsistency in recommending it nationally and internationally. The choice of MP is further complicated by conflicting evidence for optimal timing to initiate treatment, and by the reported observation that higher doses are correlated with increased risk of complications. Thyrotropin-releasing hormone may be beneficial in less severe injuries. Finally, this review discusses many options currently being researched and have shown promising pre-clinical results.

The supraclavicular approach in the management of cervicothoracic-junction benign neurogenic tumors: A real-world analysis

Objectives

The study objectives were to evaluate the safety, feasibility, and risk of neurologic complications with the supraclavicular approach in the operative management of cervicothoracic-junction benign neurogenic tumors.

Methods

Between January 2012 and April 2023, 115 patients who underwent surgical resection for cervicothoracic-junction benign neurogenic tumors were retrospectively enrolled. Patients were divided into 3 groups based on the surgical approach: supraclavicular alone (Supraclav-Alone), n = 16; Transthoracic-Alone (video-assisted thoracoscopic surgery/Open), n = 87; and supraclavicular combined with transthoracic (Supraclav + video-assisted thoracoscopic surgery/open), n = 12. Clinicopathologic variables and postoperative morbidity including neurologic complications were summarized among the groups. Logistic regression analysis was performed to identify predictors for long-term (>6 months) brachial plexus injuries.

Results

The cohort comprised 28 patients (24.3%) who underwent surgical resection using a supraclavicular approach. The Supraclav-Alone group portended the most cephalad location of tumor, the smallest pathologic tumor size, the shortest operative time, the least blood loss, and the least postoperative pain. The incidence of surgical complications, phrenic nerve neuropraxia, recurrent laryngeal nerve neuropraxia, or Horner's syndrome was similar among the groups postoperatively. However, use of the supraclavicular-alone approach (adjusted odds ratio, 0.165; 95% CI, 0.017-0.775) was a predictor for long-term brachial plexus injury complications. Among patients who experienced brachial plexus injury complications, the proportion of patients achieving complete resolution was higher among those undergoing a supraclavicular approach group (Supraclav-Alone: 80.0% vs Supraclav + video-assisted thoracoscopic surgery/Open: 60.0% vs video-assisted thoracoscopic surgery/Open: 25.8%).

Conclusions

The supraclavicular approach may be a safe and feasible strategy in the management of cervicothoracic-junction benign neurogenic tumors that does not increase surgical complications and minimizes the severity of brachial plexus injury.

Neurocritical care and neuromonitoring considerations in acute pediatric spinal cord injury

Management of pediatric spinal cord injury (SCI) is an essential skill for all pediatric neurocritical care physicians. In this review, we focus on the evaluation and management of pediatric SCI, highlight a novel framework for the monitoring of such patients in the intensive care unit (ICU), and introduce advancements in critical care techniques in monitoring and management. The initial evaluation and characterization of SCI is crucial for improving outcomes as well as prognostication. While physical examination and imaging are the main stays of the work-up, we propose the use of somatosensory evoked potentials (SSEPs) and transcranial magnetic stimulation (TMS) for challenging clinical scenarios. SSEPs allow for functional evaluation of the dorsal columns consisting of tracts associated with hand function, ambulation, and bladder function. Meanwhile, TMS has the potential for informing prognostication as well as response to rehabilitation. Spine stabilization, and in some cases surgical decompression, along with respiratory and hemodynamic management are essential. Emerging research suggests that targeted spinal cerebral perfusion pressure may provide potential benefits. This review aims to increase the pediatric neurocritical care physician's comfort with SCI while providing a novel algorithm for monitoring spinal cord function in the ICU.

An updated systematic review of neuroprotective agents in the treatment of spinal cord injury

This systematic review aims to summarize the findings from all clinical randomized trials assessing the efficacy of potential neuroprotective agents in influencing the outcomes of acute spinal cord injuries (SCI). Following the PRISMA guidelines, we conducted comprehensive searches in four electronic databases (PubMed, Scopus, Cochrane Library, and Web of Science) up to September 5th, 2023. Our analysis included a total of 30 studies. We examined the effects of 15 substances/drugs: methylprednisolone, tirilazad mesylate, erythropoietin, nimodipine, naloxone, Sygen, Rho protein antagonist, granulocyte colony-stimulating factor, autologous macrophages, autologous bone marrow cells, vitamin D, progesterone, riluzole, minocycline, and blood alcohol concentration. Notable improvements in neurological outcomes were observed with progesterone plus vitamin D and granulocyte colony-stimulating factor. In contrast, results for methylprednisolone, erythropoietin, Sygen, Rho Protein, and Riluzole were inconclusive, primarily due to insufficient sample size or outdated evidence. No significant differences were found in the remaining evaluated drugs. Progesterone plus vitamin D, granulocyte colony-stimulating factor, methylprednisolone, Sygen, Rho Protein, and Riluzole may enhance neurological outcomes in acute SCI cases. It is worth noting that different endpoints or additional subgroup analyses may potentially alter the conclusions of individual trials. Therefore, certain SCI grades may benefit more from these treatments than others, while the overall results may remain inconclusive.

Current Practice of Acute Spinal Cord Injury Management: A Global Survey of Members from the AO Spine

STUDY DESIGN

Cross-sectional, international survey.

OBJECTIVES

To examine current international practices as well as knowledge, adoption, and barriers to guideline implementation for acute spinal cord injury (SCI) management.

METHODS

A survey was distributed to members of AO Spine. The questionnaire was structured to obtain demographic data and preferred acute SCI practices surrounding steroid use, hemodynamic management, and timing of surgical decompression.

RESULTS

593 members completed the survey including orthopaedic surgeons (54.3%), neurosurgeons (35.6%), and traumatologists (8.4%). Most (61.2%) respondents were from low and middle-income countries (LMICs). 53.6% of physicians used steroids for the treatment of acute SCIs. Respondents from LMICs were more likely to administer steroids than HICs (178 vs. 78; P < .001). 331 respondents (81.5%) answered that patients would receive mean arterial pressure (MAP) targeted treatment. In LMICs, SCI patients were less likely to be provided with MAP-targeted treatment (76.9%) as compared to HICs (89%; P < .05). The majority of respondents (87.8%) reported that patients would benefit from early decompression. Despite overwhelming evidence and surgeons' responses that would offer early surgery, 62.4% of respondents stated they encounter logistical barriers in their institutions. This was particularly evident in LMICs, where 57.9% of respondents indicated that early intervention was unlikely to be accomplished, while only 21.1% of respondents from HICs stated the same (P < .001).

CONCLUSION

This survey highlights challenges in the implementation of standardized global practices in the management of acute SCI. Future research efforts will need to refine SCI guidelines and address barriers to guideline implementation.

Our experience with the surgical management of lower cervical spine fractures: fifty case series

PURPOSE

Trauma to the lower cervical spine is a serious lesion due to its neurological consequences which jeopardize the vital and functional prognosis. They constitute a public health problem due to their frequency and seriousness requiring rapid and adequate treatment. The aim of our study is to (1) describe the epidemiological, clinical, and radiological characteristics of lower cervical spine trauma patients; (2) support the therapeutic management of these patients and show our experience in surgery for lower cervical spine trauma; and (3) analyze the anatomical and functional results and discuss them with literature data.

METHODS

This is a retrospective descriptive study of 50 patients with lower cervical spine trauma treated surgically over a period of five years from January 1, 2016, to December 2020.

RESULTS

The average age of our patients was 34.5 years, with a sex ratio of 1.7. The etiologies are dominated by accidents on public roads (58%). They show neurological disorders such as spinal cord damage in 30% of cases and root damage in 20% of cases. The radiological assessment revealed eight tear drops, ten comminuted fractures, 12 severe sprains, 12 biarticular dislocations, six uniarticular dislocations, and two herniated discs. Treatment was surgical in all patients with an anterolateral approach and anterior arthrodesis. The evolution was favourable in 21 patients and stationary in 29 patients.

CONCLUSION

Our study concluded that dislocations and fracture dislocations were the predominant type of injury in cases of AVP. Tetraplegia was mainly observed with uni- and biarticular dislocations. The variation in consolidation time was not correlated with trauma-to-surgery time. Better neurological recovery was observed with mild initial neurological damage than with initially severe damage. The appearance of an adjacent syndrome is less frequent with monosegmental arthrodesis than with multisegmental arthrodesis. Cage arthrodesis was an alternative to iliac harvesting with similar results.

Comprehensive and Visualized Analysis of Interventional Clinical Trials of Spinal Cord Injury in the Past Two Decades: A Bibliometric Study

OBJECTIVE

The aim of this study was to provide a bibliometric analysis of reported clinical trials of interventional spinal cord injury (SCI) and present the current status, global trends, and scholars' knowledge in this field.

METHODS

Data were obtained from PubMed and Web of Science (WOS) Core Collection. A literature screening process was conducted to select reports of interventional SCI clinical trials. Qualitative and quantitative analysis was performed based on information from the WOS database. Co-occurrence analysis of keywords, collaboration analysis, and co-citation analysis were performed using VOSviewer.

RESULTS

A total of 849 articles were selected for analysis. Therapeutic strategies in the articles were classified into 10 subgroups. Locomotor training, local complication-related treatments, and neuromodulation are the top 3 subgroups. Spinal Cord was the most productive and most frequently cited journal in SCI clinical trials. The most productive country, institution, and author are the United States, the University of Miami, and Harvey LA, respectively. The collaboration network analysis shows that researchers and institutions from the United States, Canada, the United Kingdom, and Australia were the pivotal driving forces in this field. Spinal cord injury, rehabilitation, individuals, electrical stimulation, and exercise are the top 5 most frequent keywords. The co-citation analysis shows that the most frequently cited references are all international standards and guidelines of SCI clinical trials.

CONCLUSIONS

There is a broad research collaboration network, although it is distributed unevenly worldwide. International standards and guidelines are needed to conduct high-quality clinical trials in the future.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS)

BACKGROUND

The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies.

METHODS

A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted.

RESULTS

A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak).

CONCLUSIONS

This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Pharmacological interventions targeting the microcirculation following traumatic spinal cord injury

Traumatic spinal cord injury is a devastating disorder characterized by sensory, motor, and autonomic dysfunction that severely compromises an individual's ability to perform activities of daily living. These adverse outcomes are closely related to the complex mechanism of spinal cord injury, the limited regenerative capacity of central neurons, and the inhibitory environment formed by traumatic injury. Disruption to the microcirculation is an important pathophysiological mechanism of spinal cord injury. A number of therapeutic agents have been shown to improve the injury environment, mitigate secondary damage, and/or promote regeneration and repair. Among them, the spinal cord microcirculation has become an important target for the treatment of spinal cord injury. Drug interventions targeting the microcirculation can improve the microenvironment and promote recovery following spinal cord injury. These drugs target the structure and function of the spinal cord microcirculation and are essential for maintaining the normal function of spinal neurons, axons, and glial cells. This review discusses the pathophysiological role of spinal cord microcirculation in spinal cord injury, including its structure and histopathological changes. Further, it summarizes the progress of drug therapies targeting the spinal cord microcirculation after spinal cord injury.

Biodegradable nanoparticles targeting circulating immune cells reduce central and peripheral sensitization to alleviate neuropathic pain following spinal cord injury

ABSTRACT

Neuropathic pain is a critical source of comorbidity following spinal cord injury (SCI) that can be exacerbated by immune-mediated pathologies in the central and peripheral nervous systems. In this article, we investigate whether drug-free, biodegradable, poly(lactide- co -glycolide) (PLG) nanoparticle treatment mitigates the development of post-SCI neuropathic pain in female mice. Our results show that acute treatment with PLG nanoparticles following thoracic SCI significantly reduces tactile and cold hypersensitivity scores in a durable fashion. Nanoparticles primarily reduce peripheral immune-mediated mechanisms of neuropathic pain, including neuropathic pain-associated gene transcript frequency, transient receptor potential ankyrin 1 nociceptor expression, and MCP-1 (CCL2) chemokine production in the subacute period after injury. Altered central neuropathic pain mechanisms during this period are limited to reduced innate immune cell cytokine expression. However, in the chronic phase of SCI, nanoparticle treatment induces changes in both central and peripheral neuropathic pain signaling, driving reductions in cytokine production and other immune-relevant markers. This research suggests that drug-free PLG nanoparticles reprogram peripheral proalgesic pathways subacutely after SCI to reduce neuropathic pain outcomes and improve chronic central pain signaling.

A review of dorsal root ganglia and primary sensory neuron plasticity mediating inflammatory and chronic neuropathic pain

Pain is a sensory state resulting from complex integration of peripheral nociceptive inputs and central processing. Pain consists of adaptive pain that is acute and beneficial for healing and maladaptive pain that is often persistent and pathological. Pain is indeed heterogeneous, and can be expressed as nociceptive, inflammatory, or neuropathic in nature. Neuropathic pain is an example of maladaptive pain that occurs after spinal cord injury (SCI), which triggers a wide range of neural plasticity. The nociceptive processing that underlies pain hypersensitivity is well-studied in the spinal cord. However, recent investigations show maladaptive plasticity that leads to pain, including neuropathic pain after SCI, also exists at peripheral sites, such as the dorsal root ganglia (DRG), which contains the cell bodies of sensory neurons. This review discusses the important role DRGs play in nociceptive processing that underlies inflammatory and neuropathic pain. Specifically, it highlights nociceptor hyperexcitability as critical to increased pain states. Furthermore, it reviews prior literature on glutamate and glutamate receptors, voltage-gated sodium channels (VGSC), and brain-derived neurotrophic factor (BDNF) signaling in the DRG as important contributors to inflammatory and neuropathic pain. We previously reviewed BDNF's role as a bidirectional neuromodulator of spinal plasticity. Here, we shift focus to the periphery and discuss BDNF-TrkB expression on nociceptors, non-nociceptor sensory neurons, and non-neuronal cells in the periphery as a potential contributor to induction and persistence of pain after SCI. Overall, this review presents a comprehensive evaluation of large bodies of work that individually focus on pain, DRG, BDNF, and SCI, to understand their interaction in nociceptive processing.

Challenges in Translating Regenerative Therapies for Spinal Cord Injury

Regenerating the injured spinal cord is a substantial challenge with many obstacles that need to be overcome to achieve robust functional benefits. This abundance of hurdles can partly explain the limited success when applying regenerative intervention treatments in animal models and/or people. In this article, we elaborate on a few of these obstacles, starting with the applicability of animal models and how they compare to the clinical setting. We then discuss the requirement for combinatorial interventions and the associated problems in experimental design, including the addition of rehabilitative training. The article expands on differences in lesion sizes and locations between humans and common animal models, and how this difference can determine the success or failure of an intervention. An additional and frequently overlooked problem in the translation of interventions that applies beyond the field of neuroregeneration is the reporting bias and the lack of transparency in reporting findings. New data mandates are tackling this problem and will eventually result in a more balanced view of the field. Finally, we will discuss strategies to negotiate the challenging course of successful translation to facilitate successful translation of regeneration promoting interventions.

Mesenchymal stem cell-derived extracellular vesicles therapy in traumatic central nervous system diseases: a systematic review and meta-analysis

Although there are challenges in treating traumatic central nervous system diseases, mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) have recently proven to be a promising non-cellular therapy. We comprehensively evaluated the efficacy of mesenchymal stem cell-derived extracellular vesicles in traumatic central nervous system diseases in this meta-analysis based on preclinical studies. Our meta-analysis was registered at PROSPERO (CRD42022327904, May 24, 2022). To fully retrieve the most relevant articles, the following databases were thoroughly searched: PubMed, Web of Science, The Cochrane Library, and Ovid-Embase (up to April 1, 2022). The included studies were preclinical studies of mesenchymal stem cell-derived extracellular vesicles for traumatic central nervous system diseases. The Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE)'s risk of bias tool was used to examine the risk of publication bias in animal studies. After screening 2347 studies, 60 studies were included in this study. A meta-analysis was conducted for spinal cord injury (n = 52) and traumatic brain injury (n = 8). The results indicated that mesenchymal stem cell-derived extracellular vesicles treatment prominently promoted motor function recovery in spinal cord injury animals, including rat Basso, Beattie and Bresnahan locomotor rating scale scores (standardized mean difference [SMD]: 2.36, 95% confidence interval [CI]: 1.96-2.76, P < 0.01, I² = 71%) and mouse Basso Mouse Scale scores (SMD = 2.31, 95% CI: 1.57-3.04, P = 0.01, I² = 60%) compared with controls. Further, mesenchymal stem cell-derived extracellular vesicles treatment significantly promoted neurological recovery in traumatic brain injury animals, including the modified Neurological Severity Score (SMD = -4.48, 95% CI: -6.12 to -2.84, P < 0.01, I² = 79%) and Foot Fault Test (SMD = -3.26, 95% CI: -4.09 to -2.42, P = 0.28, I² = 21%) compared with controls. Subgroup analyses showed that characteristics may be related to the therapeutic effect of mesenchymal stem cell-derived extracellular vesicles. For Basso, Beattie and Bresnahan locomotor rating scale scores, the efficacy of allogeneic mesenchymal stem cell-derived extracellular vesicles was higher than that of xenogeneic mesenchymal stem cell-derived extracellular vesicles (allogeneic: SMD = 2.54, 95% CI: 2.05-3.02, P = 0.0116, I² = 65.5%; xenogeneic: SMD: 1.78, 95%CI: 1.1-2.45, P = 0.0116, I² = 74.6%). Mesenchymal stem cell-derived extracellular vesicles separated by ultrafiltration centrifugation combined with density gradient ultracentrifugation (SMD = 3.58, 95% CI: 2.62-4.53, P < 0.0001, I² = 31%) may be more effective than other EV isolation methods. For mouse Basso Mouse Scale scores, placenta-derived mesenchymal stem cell-derived extracellular vesicles worked better than bone mesenchymal stem cell-derived extracellular vesicles (placenta: SMD = 5.25, 95% CI: 2.45-8.06, P = 0.0421, I² = 0%; bone marrow: SMD = 1.82, 95% CI: 1.23-2.41, P = 0.0421, I² = 0%). For modified Neurological Severity Score, bone marrow-derived MSC-EVs worked better than adipose-derived MSC-EVs (bone marrow: SMD = -4.86, 95% CI: -6.66 to -3.06, P = 0.0306, I² = 81%; adipose: SMD = -2.37, 95% CI: -3.73 to -1.01, P = 0.0306, I² = 0%). Intravenous administration (SMD = -5.47, 95% CI: -6.98 to -3.97, P = 0.0002, I² = 53.3%) and dose of administration equal to 100 μg (SMD = -5.47, 95% CI: -6.98 to -3.97, P < 0.0001, I² = 53.3%) showed better results than other administration routes and doses. The heterogeneity of studies was small, and sensitivity analysis also indicated stable results. Last, the methodological quality of all trials was mostly satisfactory. In conclusion, in the treatment of traumatic central nervous system diseases, mesenchymal stem cell-derived extracellular vesicles may play a crucial role in promoting motor function recovery.

Pharmacotherapeutic Approaches to Treatment of Muscular Dystrophies

Muscular dystrophies are a heterogeneous group of genetic muscle-wasting disorders that are subdivided based on the region of the body impacted by muscle weakness as well as the functional activity of the underlying genetic mutations. A common feature of the pathophysiology of muscular dystrophies is chronic inflammation associated with the replacement of muscle mass with fibrotic scarring. With the progression of these disorders, many patients suffer cardiomyopathies with fibrosis of the cardiac tissue. Anti-inflammatory glucocorticoids represent the standard of care for Duchenne muscular dystrophy, the most common muscular dystrophy worldwide; however, long-term exposure to glucocorticoids results in highly adverse side effects, limiting their use. Thus, it is important to develop new pharmacotherapeutic approaches to limit inflammation and fibrosis to reduce muscle damage and promote repair. Here, we examine the pathophysiology, genetic background, and emerging therapeutic strategies for muscular dystrophies.

Coaxial 3D printing of hierarchical structured hydrogel scaffolds for on-demand repair of spinal cord injury

After spinal cord injury (SCI), endogenous neural stem cells (NSCs) near the damaged site are activated, but few NSCs migrate to the injury epicenter and differentiate into neurons because of the harsh microenvironment. It has demonstrated that implantation of hydrogel scaffold loaded with multiple cues can enhance the function of endogenous NSCs. However, programming different cues on request remains a great challenge. Herein, a time-programmed linear hierarchical structure scaffold is developed for spinal cord injury recovery. The scaffold is obtained through coaxial 3D printing by encapsulating a dual-network hydrogel (composed of hyaluronic acid derivatives and N-cadherin modified sodium alginate, inner layer) into a temperature responsive gelatin/cellulose nanofiber hydrogel (Gel/CNF, outer layer). The reactive species scavenger, metalloporphyrin, loaded in the outer layer is released rapidly by the degradation of Gel/CNF, inhibiting the initial oxidative stress at lesion site to protect endogenous NSCs; while the inner hydrogel with appropriate mechanical support, linear topology structure and bioactive cues facilitates the migration and neuronal differentiation of NSCs at the later stage of SCI treatment, thereby promoting motor functional restorations in SCI rats. This study offers an innovative strategy for fabrication of multifunctional nerve regeneration scaffold, which has potential for clinical treatment of SCI. STATEMENT OF SIGNIFICANCE: Two major challenges facing the recovery from spinal cord injury (SCI) are the low viability of endogenous neural stem cells (NSCs) within the damaged microenvironment, as well as the difficulty of neuronal regeneration at the injured site. To address these issues, a spinal cord-like coaxial scaffold was fabricated with free radical scavenging agent metalloporphyrin Mn (III) tetrakis (4-benzoic acid) porphyrin and chemokine N-cadherin. The scaffold was constructed by 3D bioprinting for time-programmed protection and modulation of NSCs to effectively repair SCI. This 3D coaxially bioprinted biomimetic construct enables multi-factor on-demand repair and may be a promising therapeutic strategy for SCI.

Updates in the Early Management of Acute Spinal Cord Injury

Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future.

Clinical profile and visual outcome in patients with traumatic optic neuropathy

Purpose

To analyze the visual outcome in patients with traumatic optic neuropathy (TON) with respect to different treatment modalities, to study the correlation of initial visual loss with the final visual outcome, and to find out the predictor of final visual outcome in patients with indirect TON.

Methods

A retrospective analysis of 36 eyes with TON was done. Data on clinical profile, including demographics, mode of trauma, best corrected visual acuity (BCVA), pupillary reflex examination, and anterior and posterior segment examination, was collected. Presence and location of orbital and cranial fractures were identified from computed tomography scan. Visual outcomes following steroid therapy, optic nerve (ON) decompression, and in untreated patients were analyzed. Pre- and post-treatment BCVA were divided into three groups based on logarithm of the minimum angle of resolution (logMAR) as follows: group A: 3, group B: 2.9-1.3, and group C<1.3. BCVA values at follow-up visits were taken as the primary outcome measure. Association between various risk factors and final visual outcome in patients with indirect TON was also analyzed.

Results

Out of 34 patients whose 36 eyes were studied, three (8.8%) patients were females and 31 (91.2%) patients were males. Most common mode of trauma was road traffic accident (RTA; 91.2%), which was followed by fall (8.8%) and assault (2.9%). Pre- and post-treatment BCVA values of 36 eyes were compared, and improvement in BCVA after treatment was found to be statistically significant. Also, 28.6% of patients with presenting BCVA of no light perception showed improvement compared to 94.1% and 100% in groups B and C, respectively. Orbital wall fractures were seen in 80.5% (n = 29) of the patients, with lateral wall fracture being the most common (58.3%) followed by medial wall (33.3%), roof (27.7%), floor (27.7%), and optic strut (5%).

Conclusion

Baseline BCVA had significant association with final vision improvement. Lateral wall fracture was the most common fracture associated with indirect TON. Patients treated with high-dose corticosteroids, irrespective of the time of presentation, had a better visual outcome.

Therapeutic potential of natural compounds from herbs and nutraceuticals in spinal cord injury: Regulation of the mTOR signaling pathway

Spinal cord injury (SCI) is a disease in which the spinal cord is subjected to various external forces that cause it to burst, shift, or, in severe cases, injure the spinal tissue, resulting in nerve injury. SCI includes not only acute primary injury but also delayed and persistent spinal tissue injury (i.e., secondary injury). The pathological changes post-SCI are complex, and effective clinical treatment strategies are lacking. The mammalian target of rapamycin (mTOR) coordinates the growth and metabolism of eukaryotic cells in response to various nutrients and growth factors. The mTOR signaling pathway has multiple roles in the pathogenesis of SCI. There is evidence for the beneficial effects of natural compounds and nutraceuticals that regulate the mTOR signaling pathways in a variety of diseases. Therefore, the effects of natural compounds on the pathogenesis of SCI were evaluated by a comprehensive review using electronic databases, such as PubMed, Web of Science, Scopus, and Medline, combined with our expertise in neuropathology. In particular, we reviewed the pathogenesis of SCI, including the importance of secondary nerve injury after the primary mechanical injury, the roles of the mTOR signaling pathways, and the beneficial effects and mechanisms of natural compounds that regulate the mTOR signaling pathway on pathological changes post-SCI, including effects on inflammation, neuronal apoptosis, autophagy, nerve regeneration, and other pathways. This recent research highlights the value of natural compounds in regulating the mTOR pathway, providing a basis for developing novel therapeutic strategies for SCI.

Spinal cord injury: molecular mechanisms and therapeutic interventions

Spinal cord injury (SCI) remains a severe condition with an extremely high disability rate. The challenges of SCI repair include its complex pathological mechanisms and the difficulties of neural regeneration in the central nervous system. In the past few decades, researchers have attempted to completely elucidate the pathological mechanism of SCI and identify effective strategies to promote axon regeneration and neural circuit remodeling, but the results have not been ideal. Recently, new pathological mechanisms of SCI, especially the interactions between immune and neural cell responses, have been revealed by single-cell sequencing and spatial transcriptome analysis. With the development of bioactive materials and stem cells, more attention has been focused on forming intermediate neural networks to promote neural regeneration and neural circuit reconstruction than on promoting axonal regeneration in the corticospinal tract. Furthermore, technologies to control physical parameters such as electricity, magnetism and ultrasound have been constantly innovated and applied in neural cell fate regulation. Among these advanced novel strategies and technologies, stem cell therapy, biomaterial transplantation, and electromagnetic stimulation have entered into the stage of clinical trials, and some of them have already been applied in clinical treatment. In this review, we outline the overall epidemiology and pathophysiology of SCI, expound on the latest research progress related to neural regeneration and circuit reconstruction in detail, and propose future directions for SCI repair and clinical applications.

Human amnionic progenitor cell secretome mitigates the consequence of traumatic optic neuropathy in a mouse model

Traumatic optic neuropathy (TON) is a condition in which acute injury to the optic nerve from direct or indirect trauma results in vision loss. The most common cause of TON is indirect injury to the optic nerve caused by concussive forces that are transmitted to the optic nerve. TON occurs in up to 5% of closed-head trauma patients and there is currently no known effective treatment. One potential treatment option for TON is ST266, a cell-free biological solution containing the secretome of amnion-derived multipotent progenitor (AMP) cells. We investigated the efficacy of intranasal ST266 in a mouse model of TON induced by blunt head trauma. Injured mice treated with a 10-day regimen of ST266 showed an improvement in spatial memory and learning, a significant preservation of retinal ganglion cells, and a decrease in neuropathological markers in the optic nerve, optic tract, and dorsal lateral geniculate nucleus. ST266 treatment effectively downregulated the NLRP3 inflammasome-mediated neuroinflammation pathway after blunt trauma. Overall, treatment with ST266 was shown to improve functional and pathological outcomes in a mouse model of TON, warranting future exploration of ST266 as a cell-free therapeutic candidate for testing in all optic neuropathies.

Diagnosis and treatment of transnasal endoscopic optic canal decompression for traumatic optic neuropathy

Objective

To investigate the clinical efficacy and prognostic factors of transnasal endoscopic optic decompression in the treatment of traumatic optic neuropathy (TON).

Methods

A retrospective analysis was performed on 13 TON patients in The Seventh Affiliated Hospital of Sun Yat-sen University and Shenzhen Eye Hospital in Shenzhen City (China) from June 2020 to April 2022. These patients had received transnasal endoscopic optic decompression, and hormonal and neurotrophic drugs were given after surgery. Visual acuity (VA) improvement was used as the criterion to judge clinical efficacy.

Results

In a total of 13 patients, 13 injured eyes (12 men and 1 woman; mean age, 28.0 ± 11.8 years) received transnasal endoscopic optic decompression. After surgery, nine patients had improved VA, whereas four patients failed to show any improvement, resulting in a total effective rate of 69.2%. Of the six patients with no light perception preoperatively, three had effective results after the operation, giving an effective rate of 50.0%. Of the seven patients with residual light sensation preoperatively, six had effective results after the operation, giving an effective rate of 85.7%. Of the 10 patients operated on within 7 days after injury, seven had effective results, giving an effective rate of 70%. Of the three patients injured and operated on after 7 days, two had effective results, giving an effective rate of 66.7%.

Conclusion

Transnasal endoscopic optic nerve decompression is an effective treatment method for TON. The presence of residual light perception and the timing of surgery within 7 days are crucial to the prognosis.

Pharmacological management of acute spinal cord injury: a longitudinal multi-cohort observational study

Multiple types and classes of medications are administered in the acute management of traumatic spinal cord injury. Prior clinical studies and evidence from animal models suggest that several of these medications could modify (i.e., enhance or impede) neurological recovery. We aimed to systematically determine the types of medications commonly administered, alone or in combination, in the transition from acute to subacute spinal cord injury. For that purpose, type, class, dosage, timing, and reason for administration were extracted from two large spinal cord injury datasets. Descriptive statistics were used to describe the medications administered within the first 60 days after spinal cord injury. Across 2040 individuals with spinal cord injury, 775 unique medications were administered within the two months after injury. On average, patients enrolled in a clinical trial were administered 9.9 ± 4.9 (range 0-34), 14.3 ± 6.3 (range 1-40), 18.6 ± 8.2 (range 0-58), and 21.5 ± 9.7 (range 0-59) medications within the first 7, 14, 30, and 60 days post-injury, respectively. Those enrolled in an observational study were administered on average 1.7 ± 1.7 (range 0-11), 3.7 ± 3.7 (range 0-24), 8.5 ± 6.3 (range 0-42), and 13.5 ± 8.3 (range 0-52) medications within the first 7, 14, 30, and 60 days post-injury, respectively. Polypharmacy was commonplace (up to 43 medications per day per patient). Approximately 10% of medications were administered acutely as prophylaxis (e.g., against the development of pain or infections). To our knowledge, this was the first time acute pharmacological practices have been comprehensively examined after spinal cord injury. Our study revealed a high degree of polypharmacy in the acute stages of spinal cord injury, raising the potential to impact neurological recovery. All results can be interactively explored on the R_XSCI web site ( https://jutzelec.shinyapps.io/RxSCI/ ) and GitHub repository ( https://github.com/jutzca/Acute-Pharmacological-Treatment-in-SCI/ ).

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 1: Use of High-Dose Corticosteroids

Objective  The aim of the present study was to evaluate the current practice of using of methylprednisolone sodium succinate (MPSS) in acute spinal cord Injuries (ASCIs) among spine surgeons from Iberolatinoamerican countries. Methods  A descriptive cross-sectional study design as a survey was conducted. A questionnaire composed of 2 sections, one on demographic data regarding the surgeons and MPSS administration, was sent by email to members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results  A total of 182 surgeons participated in the study: 65.4% (119) orthopedic surgeons and 24.6% (63) neurosurgeons. Sixty-nine (37.9%) used MPSS in the initial management of ASCIs. There were no significant differences between countries ( p  = 0.451), specialty ( p  = 0.352), or surgeon seniority ( p  = 0.652) for the use of corticosteroids in the initial management of ASCIs. Forty-five (65.2%) respondents reported using an initial high-dose bolus (30 mg/Kg) followed by a perfusion (5.4 mg/kg/h). Forty-six (66.7%) surgeons who used MPSS only prescribed it if the patients presented within 8 hours of the ASCI. Most of the surgeons (50.7% [35]) administered high-dose corticosteroids because of the conviction that it has clinal benefits and improves neurological recovery. Conclusion  Results from the present survey show that MPSS use in ASCI is not widespread within spine surgeons and that the controversy regarding its use remains unresolved. This is probably due to the low level of evidence of the available data, to variations over the years, to inconsistencies in acute care protocols, and to health service pathways.

Predicting the Role of Preoperative Intramedullary Lesion Length and Early Decompressive Surgery in ASIA Impairment Scale Grade Improvement Following Subaxial Traumatic Cervical Spinal Cord Injury

BACKGROUND

 Traumatic cervical spinal cord injury (TCSCI) is a disabling condition with uncertain neurologic recovery. Clinical and preclinical studies have suggested early surgical decompression and other measures of neuroprotection improve neurologic outcome. We investigated the role of intramedullary lesion length (IMLL) on preoperative magnetic resonance imaging (MRI) and the effect of early cervical decompressive surgery on ASIA impairment scale (AIS) grade improvement following TCSCI.

METHODS

 In this retrospective study, we investigated 34 TCSCI patients who were admitted over a 12-year period, from January 1, 2008 to January 31, 2020. We studied the patient demographics, mode of injury, IMLL and timing of surgical decompression. The IMLL is defined as the total length of edema and contusion/hemorrhage within the cord. Short tau inversion recovery (STIR) sequences or T2-weighted MR imaging with fat saturation increases the clarity of edema and depicts abnormalities in the spinal cord. All patients included had confirmed adequate spinal cord decompression with cervical fixation and a follow-up of at least 6 months.

RESULTS

 Of the 34 patients, 16 patients were operated on within 24 hours (early surgery group) and 18 patients were operated on more than 24 hours after trauma (delayed surgery group). In the early surgery group, 13 (81.3%) patients had improvement of at least one AIS grade, whereas in the delayed surgery group, AIS grade improvement was seen in only in 8 (44.5%) patients (early vs. late surgery; odds ratio [OR] = 1.828; 95% confidence interval [CI]: 1.036-3.225). In multivariate regression analysis coefficients, the timing of surgery and intramedullary edema length on MRI were the most significant factors in improving the AIS grade following cervical SCI. Timing of surgery as a unique variance predicted AIS grade improvement significantly (p < 0.001). The mean IMLL was 41.47 mm (standard deviation [SD]: 18.35; range: 20-87 mm). IMLL was a predictor of AIS grade improvement on long-term outcome in bivariate analysis (p < 0.001). This study suggests that patients who had IMLL of less than 30 mm had a better chance of grade conversion irrespective of the timing of surgery. Patients with an IMLL of 31 to 60 mm had chances of better grade conversion after early surgery. A longer IMLL predicts lack of improvement (p < 0.05). If the IMLL is greater than 61 mm, the probability of nonconversion of AIS grade is higher, even if the patient is operated on within 24 hours of trauma.

CONCLUSION

 Surgical decompression within 24 hours of trauma and shorter preoperative IMLL are significantly associated with improved neurologic outcome, reflected by better AIS grade improvement at 6 months' follow-up. The IMLL on preoperative MRI can reliably predict outcome after 6 months. The present study suggests that patients have lesser chances of AIS grade improvement when the IMLL is ≥61 mm.

A critical appraisal of clinical practice guidelines on pharmacological treatments for spinal cord injury

BACKGROUND CONTEXT

Spinal cord injury brings devastating consequences and huge economic burden. Different authoritative organizations have developed different guidelines for pharmacological treatments of spinal cord injury, but there is a lack of a critical appraisal of them.

PURPOSE

To systematically review and appraise guidelines regarding their recommendations for pharmacological treatments for spinal cord injury.

STUDY DESIGN

Systematic review.

METHODS

We searched Medline, Embase, Cochrane, and Web of Science from January 2000 to January 2022 as well as guideline-specific databases (eg, Congress of Neurological Surgeons) and Google Scholar. We included the most updated guideline containing evidence-based recommendations or consensus-based recommendations developed by specific authoritative organizations if multiple versions were available. We appraised guidelines through the Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument consisting of six domains (eg, applicability). With supporting evidence, recommendations were classified as: for, against, neither for nor against. We utilized an evidence assessment system to categorize the quality of supporting evidence as poor, fair, or good.

RESULTS

Eight guidelines developed from 2008 to 2020 were included, but all of them scored lowest in the domain of applicability among all six domains. Twelve pharmacological agents (eg, methylprednisolone) were studied. For methylprednisolone, three guidelines (3/8=37.5%) recommended for (one evidence-based and two consensus-based), three (3/8=37.5%) recommended against (all evidence-based), and two (2/8=25%) recommended neither for nor against. For monosialotetrahexosylganglioside (GM-1), one guideline (1/4=25%) recommended for (consensus-based), one (1/4=25%) recommended against (evidence-based), and two (2/4=50%) recommended neither for nor against. For other agents (eg, minocycline), most guidelines (3/5=60%) recommended neither for nor against, one (1/5=20%) recommended against naloxone (evidence-based) and nimodipine (evidence-based), and one (1/5=20%) recommended for neural growth factor (consensus-based). The quality of most of the supporting evidence was poor, and the rest was fair.

CONCLUSIONS

There were inconsistencies among recommendations for methylprednisolone and GM-1. Evidence-based recommendations tended to recommend against, whereas consensus-based recommendations tended to recommend for.

Spontaneous Hematomyelia Associated with the Use of Non-vitamin K Antagonist

Vitamin K antagonists have been frequently prescribed as anticoagulants with the potential side effect of spontaneous hematomyelia with a poor prognosis. However, to our knowledge, there has been no report of spontaneous hematomyelia combined with the use of a non-vitamin K antagonist. A 63-year-old man presented with left leg weakness, impaired sensation, and urinary retention while taking rivaroxaban (non-vitamin K antagonist) for 4 months for atrial fibrillation. Anticoagulant agents were discontinued. Methylprednisolone pulse therapy was administered without surgical hematoma evacuation. Three months after the initial development of the hematomyelia, the symptoms improved to grade 5 for both lower extremities, and there was complete recovery in sensory and urinary functions. This might be the first description of a complete recovery of neurologic deficits without hematoma evacuation in spontaneous hematomyelia patients caused by non-vitamin K antagonist therapy.

Successful treatment of thoracic myelopathy caused by spontaneous spinal epidural hematoma (SSEH) combined with calcification of the ligamentum flavum (CLF) by posterior percutaneous endoscopic surgery (PPES): A case report

Study Design

A retrospective case report.

Objective

To report a case who developed deteriorated paraplegia by spontaneous spinal epidural hematoma (SSEH) based on calcification of the ligamentum flavum (CLF) at the T10-11 level, achieved full neurological recovery following posterior percutaneous endoscopic surgery (PPES).

Summary of Background Data

CLF rarely occurs at the thoracic spine, and the symptom usually progress slowly. SSEH is another rare spinal lesion that might progress rapidly and cause emergent severe spinal cord compression syndrome. Coexistence of SSEH and CLF at the same thoracic level was rarely reported in English literature.

Methods

A 65-year-old man presented to our hospital with the complaint of sensorimotor loss on the lower limbs and dysfunction of bladder for 1 day after a progressive weakness and numbness of the lower limbs for 3 months. MR examination found a dorsal protruding mass at the T10-11 level, while computed tomography (CT) found the protruding mass contained scattered calcified deposits. The patient was diagnosed with thoracic CLF. Decompression via PPES was carried out to realize bilateral decompression through a unilateral approach.

Results

During the operation, the protruding mass was found to be composed of SSEH and CLF together. After the operation, the patient's neurological function recovered quickly. One week later, the patient could walk by himself. After 3 months, complete neurological function had recovered.

Conclusion

SSEH could develop based on CLF at thoracic level and cause serious neurological dysfunction. PPES might be an advisable method to remove CLF and evacuate SSEH with good clinical results.

Immune response following traumatic spinal cord injury: Pathophysiology and therapies

Traumatic spinal cord injury (SCI) is a devastating condition that is often associated with significant loss of function and/or permanent disability. The pathophysiology of SCI is complex and occurs in two phases. First, the mechanical damage from the trauma causes immediate acute cell dysfunction and cell death. Then, secondary mechanisms of injury further propagate the cell dysfunction and cell death over the course of days, weeks, or even months. Among the secondary injury mechanisms, inflammation has been shown to be a key determinant of the secondary injury severity and significantly worsens cell death and functional outcomes. Thus, in addition to surgical management of SCI, selectively targeting the immune response following SCI could substantially decrease the progression of secondary injury and improve patient outcomes. In order to develop such therapies, a detailed molecular understanding of the timing of the immune response following SCI is necessary. Recently, several studies have mapped the cytokine/chemokine and cell proliferation patterns following SCI. In this review, we examine the immune response underlying the pathophysiology of SCI and assess both current and future therapies including pharmaceutical therapies, stem cell therapy, and the exciting potential of extracellular vesicle therapy.

The role of immune cells and associated immunological factors in the immune response to spinal cord injury

Spinal cord injury (SCI) is a devastating neurological condition prevalent worldwide. Where the pathological mechanisms underlying SCI are concerned, we can distinguish between primary injury caused by initial mechanical damage and secondary injury characterized by a series of biological responses, such as vascular dysfunction, oxidative stress, neurotransmitter toxicity, lipid peroxidation, and immune-inflammatory response. Secondary injury causes further tissue loss and dysfunction, and the immune response appears to be the key molecular mechanism affecting injured tissue regeneration and functional recovery from SCI. Immune response after SCI involves the activation of different immune cells and the production of immunity-associated chemicals. With the development of new biological technologies, such as transcriptomics, the heterogeneity of immune cells and chemicals can be classified with greater precision. In this review, we focus on the current understanding of the heterogeneity of these immune components and the roles they play in SCI, including reactive astrogliosis and glial scar formation, neutrophil migration, macrophage transformation, resident microglia activation and proliferation, and the humoral immunity mediated by T and B cells. We also summarize findings from clinical trials of immunomodulatory therapies for SCI and briefly review promising therapeutic drugs currently being researched.

Pedicle Screw Fixation for Hemiplegia and Bilateral Hypoesthesia Due to C2-C3 Spinal Fracture Dislocation: A Case Report

CASE

A 48-year-old man fell from a tree and presented to the emergency department with right-sided full hemiplegia and C3 bilateral hypoesthesia. Imaging was remarkable for a C2-C3 fracture-dislocation. The patient was effectively managed surgically with a posterior decompression and 4-level posterior cervical fixation/fusion that included pedicle screws in the axis fixation and lateral mass screws. The reduction/fixation remained stable, and the patient regained full lower extremity function and demonstrated functional upper-extremity recovery at three-year follow-up.

CONCLUSIONS

C2-C3 fracture-dislocation is a rare but potentially fatal injury due to concomitant spinal cord injury, and its surgical management can be challenging because of the proximity of vascular and nerve structures. Posterior cervical fixation that includes axis pedicle screws can be an effective fixation option in select patients with this condition.

Sex-Related Discrepancies in the Access to Optimal Care and Outcomes After Traumatic Spinal Cord Injury: A Retrospective Cohort Study Using Data From a Canadian Registry

OBJECTIVE

To compare males and females who were stratified into subgroups corresponding to premenopausal, perimenopausal, and postmenopausal ages, regarding access to optimal care and their outcomes after traumatic spinal cord injury (tSCI).

STUDY DESIGN

Retrospective cohort study.

SETTING

Eighteen acute care centers and 13 rehabilitation facilities across Canada.

PARTICIPANTS

This study included 5571 individuals with tSCI at C1-L2 who were enrolled in the Rick Hansen Spinal Cord Injury Registry from July 2004 to September 2019 (N=5571). Females were compared with males in the younger (aged ≤40 years), middle-aged (ages 41-50), and older (aged >50 years) subgroups.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Females were compared with males in each subgroup with regard to their demographic data, pre-existing comorbidities, injury characteristics, management choices, access to optimal care, and clinical, neurologic, and functional outcomes after tSCI.

RESULTS

In the younger subgroups, females (n=408) were significantly younger, had a greater proportion of aboriginals and transportation-related tSCIs, underwent surgical treatment more often, and had a greater sensory score change than males (n=1613). In the middle-aged subgroups, females (n=174) had a greater proportion of high-thoracic tSCIs than males (n=666). In the older subgroups, females (n=660) were significantly older, had more fall-related and less severe tSCIs, had a shorter stay at the rehabilitation center, had less spasticity, and were discharged home less often than males (n=2050).

CONCLUSIONS

The results of this study suggest some sex-related differences in individuals' demographics and injury characteristics, but fewer discrepancies between females and males regarding their access to optimal care and outcomes after tSCI. Overall, future clinical trials could consider inclusion of males and females of all age groups to enhance recruitment and augment generalizability.

Application of Robotic Recovery Techniques to Stroke Survivors-Bibliometric Analysis

Stroke is a significant disability and death cause worldwide and is conventionally defined as a neurological impairment relating to the intense focal harm of the central nervous system (CNS) by vascular causative components. Although the applicability of robotic rehabilitation is a topic with considerable practical significance because it has produced noticeably higher improvements in motor function than regular (physical and occupational) therapy and exempted the therapists, most of the existing bibliometric papers were not focused on stroke survivors. Additionally, a modular system is designed by joining several medical end-effector devices to a single limb segment, which addresses the issue of potentially dangerous pathological compensatory motions. Searching the Web of Science database, 31,930 papers were identified, and using the VOSviewer software and science mapping technology, data were extracted on the most prolific countries, the connections between them, the most valuable journals according to certain factors, their average year of publication, the most influential papers, and the most relevant topical issues (bubble map of term occurrence). The most prolific country in the analyzed field and over the entire period evaluated (1975-2022) is the United States, and the most prolific journal is Neurorehabilitation and Neural Repair, observing a marked increase in the three periods of scientific interest for this field. The present paper assesses numerous scientific publications to provide, through statistical interpretation of the data, a detailed description of the use of robotic rehabilitation in stroke survivors. The findings may aid scientists, academics, and clinicians in establishing precise goals in the optimization of the management of stroke survivors via robotic rehabilitation, but also through easier access to scientifically validated literature.

Secondary damage management of acute traumatic spinal cord injury in low and middle-income countries: A survey on a global scale (Part III)

•In LMICs, several factor may affect the applicability of guidelines for secondary damage control of spinal cord injury.•In LMICs, the use of steroids for spinal cord injury is heterogeneous and admissions to an intensive care units are limited.•The delays for surgical decompression of spinal cord injury can be significan and vary across income and geographic region.•Transfer times seem to be the most common reason for surgical delay in all income and geographic regions.•Costs for surgery for spinal trauma may be a significant barrier to guideline adherence, especially in low-resource settings.