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Hu X, Xu W, Ren Y, Wang Z, He X, Huang R, Ma B, Zhao J, Zhu R, Cheng L. Spinal cord injury: molecular mechanisms and therapeutic interventions. Signal Transduct Target Ther 2023; 8:245. [PMID: 37357239 DOI: 10.1038/s41392-023-01477-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/22/2023] [Accepted: 05/07/2023] [Indexed: 06/27/2023] Open
Abstract
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.
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Affiliation(s)
- Xiao Hu
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Wei Xu
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Yilong Ren
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Zhaojie Wang
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Xiaolie He
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Runzhi Huang
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Bei Ma
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Jingwei Zhao
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Rongrong Zhu
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China.
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China.
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China.
| | - Liming Cheng
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China.
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China.
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China.
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Yang CH, Quan ZX, Wang GJ, He T, Chen ZY, Li QC, Yang J, Wang Q. Elevated intraspinal pressure in traumatic spinal cord injury is a promising therapeutic target. Neural Regen Res 2022; 17:1703-1710. [PMID: 35017417 PMCID: PMC8820714 DOI: 10.4103/1673-5374.332203] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The currently recommended management for acute traumatic spinal cord injury aims to reduce the incidence of secondary injury and promote functional recovery. Elevated intraspinal pressure (ISP) likely plays an important role in the processes involved in secondary spinal cord injury, and should not be overlooked. However, the factors and detailed time course contributing to elevated ISP and its impact on pathophysiology after traumatic spinal cord injury have not been reviewed in the literature. Here, we review the etiology and progression of elevated ISP, as well as potential therapeutic measures that target elevated ISP. Elevated ISP is a time-dependent process that is mainly caused by hemorrhage, edema, and blood-spinal cord barrier destruction and peaks at 3 days after traumatic spinal cord injury. Duraplasty and hypertonic saline may be promising treatments for reducing ISP within this time window. Other potential treatments such as decompression, spinal cord incision, hemostasis, and methylprednisolone treatment require further validation.
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Affiliation(s)
- Chao-Hua Yang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province; Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng-Xue Quan
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gao-Ju Wang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Tao He
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhi-Yu Chen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiao-Chu Li
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jin Yang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Qing Wang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
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Alshorman J, Wang Y, Zhu F, Zeng L, Chen K, Yao S, Jing X, Qu Y, Sun T, Guo X. Medical Communication Services after Traumatic Spinal Cord Injury. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:4798927. [PMID: 34512936 PMCID: PMC8424255 DOI: 10.1155/2021/4798927] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 12/28/2022]
Abstract
It is difficult to assess and monitor the spinal cord injury (SCI) because of its pathophysiology after injury, with different degrees of prognosis and various treatment methods, including laminectomy, durotomy, and myelotomy. Medical communication services with different factors such as time of surgical intervention, procedure choice, spinal cord perfusion pressure (SCPP), and intraspinal pressure (ISP) contribute a significant role in improving neurological outcomes. This review aims to show the benefits of communication services and factors such as ISP, SCPP, and surgical intervention time in order to achieve positive long-term outcomes after an appropriate treatment method in SCI patients. The SCPP was found between 90 and 100 mmHg for the best outcome, MAP was found between 110 and 130 mmHg, and mean ISP is ≤20 mmHg after injury. Laminectomy alone cannot reduce the pressure between the dura and swollen cord. Durotomy and duroplasty considered as treatment choices after severe traumatic spinal cord injury (TSCI).
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Affiliation(s)
- Jamal Alshorman
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yulong Wang
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Fengzhao Zhu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Lian Zeng
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Kaifang Chen
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Sheng Yao
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xirui Jing
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yanzhen Qu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Tingfang Sun
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xiaodong Guo
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Saadoun S, Jeffery ND. Acute Traumatic Spinal Cord Injury in Humans, Dogs, and Other Mammals: The Under-appreciated Role of the Dura. Front Neurol 2021; 12:629445. [PMID: 33613434 PMCID: PMC7887286 DOI: 10.3389/fneur.2021.629445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/04/2021] [Indexed: 01/16/2023] Open
Abstract
We review human and animal studies to determine whether, after severe spinal cord injury (SCI), the cord swells against the inelastic dura. Evidence from rodent models suggests that the cord swells because of edema and intraparenchymal hemorrhage and because the pia becomes damaged and does not restrict cord expansion. Human cohort studies based on serial MRIs and measurements of elevated intraspinal pressure at the injury site also suggest that the swollen cord is compressed against dura. In dogs, SCI commonly results from intervertebral disc herniation with evidence that durotomy provides additional functional benefit to conventional (extradural) decompressive surgery. Investigations utilizing rodent and pig models of SCI report that the cord swells after injury and that durotomy is beneficial by reducing cord pressure, cord inflammation, and syrinx formation. A human MRI study concluded that, after extensive bony decompression, cord compression against the dura may only occur in a small number of patients. We conclude that the benefit of routinely opening the dura after SCI is only supported by animal and level III human studies. Two randomized, controlled trials, one in humans and one in dogs, are being set up to provide Level I evidence.
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Affiliation(s)
- Samira Saadoun
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
| | - Nicolas D Jeffery
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, TX, United States
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Telemacque D, Zhu FZ, Ren ZW, Chen KF, Drepaul D, Yao S, Yang F, Qu YZ, Sun TF, Guo XD. Effects of durotomy versus myelotomy in the repair of spinal cord injury. Neural Regen Res 2020; 15:1814-1820. [PMID: 32246622 PMCID: PMC7513969 DOI: 10.4103/1673-5374.280304] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/08/2019] [Accepted: 09/03/2019] [Indexed: 11/04/2022] Open
Abstract
Current management for spinal cord injury aims to reduce secondary damage and recover sensation and movement. Acute spinal cord injury is often accompanied by spinal cord compartment syndrome. Decompression by durotomy and/or myelotomy attempts to relieve secondary damage by completelyrelieving the compression of the spinal cord, removing the necrotic tissue, decreasing edema, reducing hemorrhage, and improving blood circulation in the spinal cord. However, it is controversial whether durotomy and/or myelotomy after spinal cord injury are beneficial to neurological recovery. This review compares the clinical effects of durotomy with those of myelotomy in the treatment of spinal cord injury. We found that durotomy has been performed more than myelotomy in the clinic, and that durotomy may be safer and more effective than myelotomy. Durotomy performed in humans had positive effects on neurological function in 92.3% of studies in this review, while durotomy in animals had positive effects on neurological function in 83.3% of studies. Myelotomy procedures were effective in 80% of animal studies, but only one clinical study of myelotomy has reported positive results, of motor and sensory improvement, in humans. However, a number of new animal studies have reported that durotomy and myelotomy are ineffective for spinal cord injury. More clinical data, in the form of a randomized controlled study, are needed to understand the effectiveness of durotomy and myelotomy.
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Affiliation(s)
- Dionne Telemacque
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Feng-Zhao Zhu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Zheng-Wei Ren
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Kai-Fang Chen
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Deepak Drepaul
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Sheng Yao
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Fan Yang
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Yan-Zheng Qu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Ting-Fang Sun
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Xiao-Dong Guo
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
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Nakamoto Y, Uemura T, Hasegawa H, Nakamoto M, Ozawa T. Outcomes of dogs with progressive myelomalacia treated with hemilaminectomy or with extensive hemilaminectomy and durotomy. Vet Surg 2020; 50:81-88. [PMID: 33280138 DOI: 10.1111/vsu.13514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 05/29/2020] [Accepted: 08/16/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the ability of extensive hemilaminectomy and durotomy (EHLD) to control progressive myelomalacia (PMM) in dogs. STUDY DESIGN Retrospective clinical study. ANIMALS Twenty-eight client owned dogs that underwent EHLD (n = 10) or HL alone (n = 18). METHODS After diagnosis by MRI, dogs were immediately treated with HL alone or EHLD at the site of intramedullary hyperintensity on T2-weighted (T2W)-MRI. Medical records were retrospectively reviewed. Follow-up data were collected via telephone interviews with the referring veterinarian and a standardized questionnaire. Postoperative survival outcome between groups was compared (log-rank test) by using Cox's proportional hazard analysis with baseline characteristics entered as covariates. RESULTS The survival rate was higher in the EHLD group (P = .03) compared with the HL-alone group. Eleven of 18 dogs treated with HL survived, while seven of 18 dogs died (median, 5 days after surgery). In the EHLD group, 10 of 10 dogs survived postoperatively. Baseline characteristics were not associated with postoperative survival outcomes. According to multivariate analysis, EHLD was the independent factor associated with an increase in survival rate (P = .0002). CONCLUSION EHLD durotomy at the intramedullary hyperintense region on T2W-MRI improved the survival rate of dogs with PMM compared with dogs treated with standard HL. CLINICAL SIGNIFICANCE This study provides evidence that supports treatment with EHLD in dogs with PMM. Additional prospective studies are required.
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Affiliation(s)
- Yuya Nakamoto
- Kyoto Animal Referral Medical Center, Kyoto, Kuze-gun, Japan.,Neuro Vets Animal Neurology Clinic, 4th floor, 550-4, Bishamon-cho, Nakgyo-ku, Japan
| | - Takashi Uemura
- Kyoto Animal Referral Medical Center, Kyoto, Kuze-gun, Japan
| | - Hiroki Hasegawa
- Kyoto Animal Referral Medical Center, Kyoto, Kuze-gun, Japan
| | - Miwa Nakamoto
- Kyoto Animal Referral Medical Center, Kyoto, Kuze-gun, Japan.,Neuro Vets Animal Neurology Clinic, 4th floor, 550-4, Bishamon-cho, Nakgyo-ku, Japan
| | - Tsuyoshi Ozawa
- Kyoto Animal Referral Medical Center, Kyoto, Kuze-gun, Japan
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Grassner L, Grillhösl A, Griessenauer CJ, Thomé C, Bühren V, Strowitzki M, Winkler PA. Spinal Meninges and Their Role in Spinal Cord Injury: A Neuroanatomical Review. J Neurotrauma 2017; 35:403-410. [PMID: 28922957 DOI: 10.1089/neu.2017.5215] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Current recommendations support early surgical decompression and blood pressure augmentation after traumatic spinal cord injury (SCI). Elevated intraspinal pressure (ISP), however, has probably been underestimated in the pathophysiology of SCI. Recent studies provide some evidence that ISP measurements and durotomy may be beneficial for individuals suffering from SCI. Compression of the spinal cord against the meninges in SCI patients causes a "compartment-like" syndrome. In such cases, intentional durotomy with augmentative duroplasty to reduce ISP and improve spinal cord perfusion pressure (SCPP) may be indicated. Prior to performing these procedures routinely, profound knowledge of the spinal meninges is essential. Here, we provide an in-depth review of relevant literature along with neuroanatomical illustrations and imaging correlates.
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Affiliation(s)
- Lukas Grassner
- 1 Department of Neurosurgery, Trauma Center Murnau , Germany .,2 Center for Spinal Cord Injuries, Trauma Center Murnau , Germany .,3 Institute of Molecular Regenerative Medicine, Paracelsus Medical University , Salzburg, Austria .,4 Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University , Salzburg, Austria
| | | | - Christoph J Griessenauer
- 6 Department of Neurosurgery, Geisinger Health System , Danville, Pennsylvania.,7 Neurosurgical Service, Department of Surgery, Harvard Medical School , Boston, Massachusetts
| | - Claudius Thomé
- 8 Department of Neurosurgery, Medical University Innsbruck , Austria
| | - Volker Bühren
- 2 Center for Spinal Cord Injuries, Trauma Center Murnau , Germany
| | | | - Peter A Winkler
- 9 Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University , Salzburg, Austria
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Intraspinal Pressure Monitoring and Extensive Duroplasty in the Acute Phase of Traumatic Spinal Cord Injury: A Systematic Review. World Neurosurg 2017; 105:145-152. [PMID: 28578120 DOI: 10.1016/j.wneu.2017.05.138] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/20/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The prognosis in cervical spinal cord injury is poor, and surgical and neurointensive care management need further improvement. Monitoring of the intraspinal pressure (ISP) at an early stage after traumatic spinal cord injury (tSCI) is useful clinically. MATERIALS AND METHODS Obtaining continuous spinal cord perfusion pressure (SCPP) measurements based on the difference between mean arterial pressure and ISP allows offering best medical and surgical treatment during this critical phase of tSCI. A search was carried out with PubMed, Embase, and Google Scholar up to January 10, 2017. Articles resulting from these searches and relevant references cited in those articles were reviewed. RESULTS The optimal SCPP was found to be between 90 and 100 mm Hg and mean arterial pressure of 110-130. Laminectomy alone was found to be ineffective in the reduction of ISP because it does not lower the pressure exerted by dura on the swollen spinal cord. Therefore, bony decompression with durotomy or duroplasty seems to be the procedure of choice to reduce the ISP less than 20 mm Hg. CONCLUSIONS A randomized controlled trial is required to determine whether laminectomy with durotomy and monitoring of ISP with SCPP optimization improve neurological recovery after tSCI.
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Saadoun S, Papadopoulos MC. Spinal cord injury: is monitoring from the injury site the future? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:308. [PMID: 27716379 PMCID: PMC5050726 DOI: 10.1186/s13054-016-1490-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This paper challenges the current management of acute traumatic spinal cord injury based on our experience with monitoring from the injury site in the neurointensive care unit. We argue that the concept of bony decompression is inadequate. The concept of optimum spinal cord perfusion pressure, which differs between patients, is introduced. Such variability suggests individualized patient treatment. Failing to optimize spinal cord perfusion limits the entry of systemically administered drugs into the injured cord. We conclude that monitoring from the injury site helps optimize management and should be subjected to a trial to determine whether it improves outcome.
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Affiliation(s)
- Samira Saadoun
- Academic Neurosurgery Unit, St. George's, University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery Unit, St. George's, University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK.
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Phang I, Papadopoulos MC. Intraspinal Pressure Monitoring in a Patient with Spinal Cord Injury Reveals Different Intradural Compartments: Injured Spinal Cord Pressure Evaluation (ISCoPE) Study. Neurocrit Care 2016; 23:414-8. [PMID: 26136148 DOI: 10.1007/s12028-015-0153-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND We recently described a technique for monitoring intraspinal pressure (ISP) after traumatic spinal cord injury (TSCI). This is analogous to intracranial pressure monitoring after brain injury. We showed that, after severe TSCI, ISP at the injury site is elevated as the swollen cord is compressed against the dura. METHODS In a patient with complete thoracic TSCI, we sequentially monitored subdural ISP above the injury, at the injury site, and below the injury intraoperatively. Postoperatively, we simultaneously monitored subdural ISP and intraparenchymal ISP at the injury site and compared the two ISP signals as well as their Fast Fourier Transform spectra. RESULTS Subdural ISP recorded from the injury site was higher than subdural ISP recorded from above or below the injury site by more than 10 mmHg. The subdural and intraparenchymal ISP signals recorded from the injury site had comparable amplitudes and Fast Fourier Transform spectra. Intraparenchymal pulse pressure was twofold larger than subdural pulse pressure. CONCLUSION After severe TSCI, three intradural compartments form (space above injury, injury site, space below injury) with different ISPs. At the level of maximum spinal cord swelling (injury site), subdural ISP is comparable to intraparenchymal ISP.
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Affiliation(s)
- Isaac Phang
- Academic Neurosurgery Unit, St George's University of London, Room 0.136 Jenner Wing, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery Unit, St George's University of London, Room 0.136 Jenner Wing, Cranmer Terrace, Tooting, London, SW17 0RE, UK.
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Zhang J, Wang H, Zhang C, Li W. Intrathecal decompression versus epidural decompression in the treatment of severe spinal cord injury in rat model: a randomized, controlled preclinical research. J Orthop Surg Res 2016; 11:34. [PMID: 27006005 PMCID: PMC4802628 DOI: 10.1186/s13018-016-0369-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/15/2016] [Indexed: 11/30/2022] Open
Abstract
Background In the setting of severe spinal cord injury (SCI), there is no markedly efficacious clinical therapeutic regimen to improve neurological function. After epidural decompression, as is shown in animal models, the swollen cord against non-elastic dura and elevation of intrathecal pressure may be the main causes of aggravated neurologic function. We performed an intrathecal decompression by longitudinal durotomy to evaluate the neuroprotective effect after severe SCI by comparing with epidural decompression. Methods Eighty-four adult male Sprague-Dawley rats were assigned to three groups: sham group (group S), epidural decompression (group C), and intrathecal decompression group (group D). A weight-drop model was performed at T9. The Basso-Beattie-Bresnahan (BBB) score was used to evaluate neurological function. Animals were sacrificed at corresponding time points, and we performed pathohistological examinations including HE staining and immunohistochemical staining (IHC) of glial fibrillary acidic protein (GFAP), neurocan, and ED1 at the epicenter of injured cords. Finally, the lesions were quantitatively analyzed by SPSS 22.0. Results The mortality rates were, respectively, 5.55 % (2/36) and 13.9 % (5/36) in groups C and D, and there was no significant difference between groups C and D (P = 0.214). Compared with epidural decompression, intrathecal decompression could obviously improve BBB scores after SCI. HE staining indicated that more white matter was spared, and fewer vacuoles and less axon degradation were observed. The expression peak of GFAP, neurocan, and ED1 occurred at an earlier time and was down-regulated in group D compared to group C. Conclusions Our findings based on rat SCI model suggest that intrathecal decompression by longitudinal durotomy can prompt recovery of neurological function, and this neuroprotective mechanism may be related to the down-regulation of GFAP, neurocan, and ED1.
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Affiliation(s)
- Jian Zhang
- No.1 Department of Orthopedic Surgery, Tianjin Baodi Hospital, No.8, Guangchuan Road, Baodi District, Tianjin, 301800, China.
| | - Huili Wang
- No.1 Department of Orthopedic Surgery, Tianjin Baodi Hospital, No.8, Guangchuan Road, Baodi District, Tianjin, 301800, China
| | - Chenggang Zhang
- Institute of Radiation and Radiation Medicine, Academy of Military Medical Sciences, No.27, Taiping Road, Haidian District, Beijing, 100850, China
| | - Weiguang Li
- Institute of Radiation and Radiation Medicine, Academy of Military Medical Sciences, No.27, Taiping Road, Haidian District, Beijing, 100850, China
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Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC. 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. J Neurotrauma 2015; 32:865-74. [PMID: 25705999 PMCID: PMC4492612 DOI: 10.1089/neu.2014.3668] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Isaac Phang
- 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom
| | - Melissa C Werndle
- 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom
| | - Samira Saadoun
- 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom
| | - Georgios Varsos
- 2 Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Marek Czosnyka
- 2 Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Argyro Zoumprouli
- 3 Department of Anaesthesia, St. George's Hospital , London, United Kingdom
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