Intraspinal Pressure Monitoring in a Patient with Spinal Cord Injury Reveals Different Intradural Compartments: Injured Spinal Cord Pressure Evaluation (ISCoPE) Study

Invasive devices to monitor the intraspinal perfusion pressure in the hemodynamic management of acute spinal cord injury: A systematic scoping review

BACKGROUND

Various methods for measuring intrathecal pressure (ITP) after spinal cord injury (SCI) to guide hemodynamic management have been investigated. To synthesize the current literature, this current study conducted a scoping review of the use of intrathecal devices to monitor ITP during acute management of SCI with the aim of understanding the association between ITP monitoring with physiological and clinical outcomes.

METHODS

A systematic review of literature following the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. All eligible studies were screened for inclusion and exclusion criteria. Data extracted included number of patients included, severity of injury, characteristics of the intervention-intrathecal device used to record the ITP, outcomes -hemodynamic parameters observed, changes in the American Spinal Injury Association (ASIA) Impairment Scale (AIS), total motor scores, association of ITP with other physiological variables.

RESULTS

The search yielded a total of 1,698 articles, of which 30 observational studies and 2 randomized clinical trials were deemed eligible based on their use of an intrathecal invasive device to monitor spinal cord perfusion pressure (SCPP) in patients with SCI. Of these, 9 studies used a lumbar drain, 23 a Codman pressure probe and 1 study that used both. These studies underscore the crucial interplay between ITP, the SCPP and physiological variables, with neurological outcome. It is still unclear whether monitoring from a lumbar drain is accurate enough to highlight what is occurring at the site of SCI, which is the main advantage of Codman Probe, however, the latter requires specialized personnel that may not be available in most settings. Minor adverse effects were associated with lumbar drain catheters, while cerebrospinal fluid leak requiring repair (~ 7%) is the main concern with Codman Probes.

CONCLUSION

Future investigation of SCPP protocols via lumbar drains and Codman probes ought to involve multi-centered randomized controlled trials and continued translational investigation with animal models.

Role of durotomy on function outcome, tissue sparing, inflammation, and tissue stiffness after spinal cord injury in rats

Currently, there is a lack of effective treatments for spinal cord injury (SCI), a debilitating medical condition associated with enduring paralysis and irreversible neuronal damage. Extradural decompression of osseous as well as soft tissue components has historically been the principal objective of surgical procedures. Nevertheless, this particular surgical procedure fails to tackle the intradural compressive alterations that contribute to secondary SCI. Here, we propose an early intrathecal decompression strategy and evaluate its role on function outcome, tissue sparing, inflammation, and tissue stiffness after SCI. Durotomy surgery significantly promoted recovery of hindlimb locomotor function in an open-field test. Radiological analysis suggested that lesion size and tissue edema were significantly reduced in animals that received durotomy. Relative to the group with laminectomy alone, the animals treated with a durotomy had decreased cavitation, scar formation, and inflammatory responses at 4 weeks after SCI. An examination of the mechanical properties revealed that durotomy facilitated an expeditious restoration of the injured tissue's elastic rigidity. In general, early decompressive durotomy could serve as a significant strategy to mitigate the impairments caused by secondary injury and establish a more conducive microenvironment for prospective cellular or biomaterial transplantation.

Adverse Effect of Neurogenic, Infective, and Inflammatory Fever on Acutely Injured Human Spinal Cord

This study aims to determine the effect of neurogenic, inflammatory, and infective fevers on acutely injured human spinal cord. In 86 patients with acute, severe traumatic spinal cord injuries (TSCIs; American Spinal Injury Association Impairment Scale (AIS), grades A-C) we monitored (starting within 72 h of injury, for up to 1 week) axillary temperature as well as injury site cord pressure, microdialysis (MD), and oxygen. High fever (temperature ≥38°C) was classified as neurogenic, infective, or inflammatory. The effect of these three fever types on injury-site physiology, metabolism, and inflammation was studied by analyzing 2864 h of intraspinal pressure (ISP), 1887 h of MD, and 840 h of tissue oxygen data. High fever occurred in 76.7% of the patients. The data show that temperature was higher in neurogenic than non-neurogenic fever. Neurogenic fever only occurred with injuries rostral to vertebral level T4. Compared with normothermia, fever was associated with reduced tissue glucose (all fevers), increased tissue lactate to pyruvate ratio (all fevers), reduced tissue oxygen (neurogenic + infective fevers), and elevated levels of pro-inflammatory cytokines/chemokines (infective fever). Spinal cord metabolic derangement preceded the onset of infective but not neurogenic or inflammatory fever. By considering five clinical characteristics (level of injury, axillary temperature, leukocyte count, C-reactive protein [CRP], and serum procalcitonin [PCT]), it was possible to confidently distinguish neurogenic from non-neurogenic high fever in 59.3% of cases. We conclude that neurogenic, infective, and inflammatory fevers occur commonly after acute, severe TSCI and are detrimental to the injured spinal cord with infective fever being the most injurious. Further studies are required to determine whether treating fever improves outcome. Accurately diagnosing neurogenic fever, as described, may reduce unnecessary septic screens and overuse of antibiotics in these patients.

Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

OBJECTIVE

This study aims to determine the relationship between spinal cord perfusion pressure (SCPP) and breathing function in patients with acute cervical traumatic spinal cord injuries.

METHODS

We included 8 participants without cervical TSCI plus 13 patients with cervical traumatic spinal cord injuries, American Spinal Injury Association Impairment Scale grades A-C. In the TSCI patients, we monitored intraspinal pressure from the injury site for up to a week and computed the SCPP as mean arterial pressure minus intraspinal pressure. Breathing function was quantified by diaphragmatic electromyography using an EDI (electrical activity of the diaphragm) nasogastric tube as well as by ultrasound of the diaphragm and the intercostal muscles performed when sitting at 20°-30°.

RESULTS

We analysed 106 ultrasound examinations (total 1370 images/videos) and 198 EDI recordings in the patients with cervical traumatic spinal cord injuries. During quiet breathing, low SCPP (< 60 mmHg) was associated with reduced EDI-peak (measure of inspiratory effort) and EDI-min (measure of the tonic activity of the diaphragm), which increased and then plateaued at SCPP 60-100 mmHg. During quiet and deep breathing, the diaphragmatic thickening fraction (force of diaphragmatic contraction) plotted versus SCPP had an inverted-U relationship, with a peak at SCPP 80-90 mmHg. Diaphragmatic excursion (up and down movement of the diaphragm) during quiet breathing did not correlate with SCPP, but diaphragmatic excursion during deep breathing plotted versus SCPP had an inverse-U relationship with a peak at SCPP 80-90 mmHg. The thickening fraction of the intercostal muscles plotted versus SCPP also had inverted-U relationship, with normal intercostal function at SCPP 80-100 mmHg, but failure of the upper and middle intercostals to contract during inspiration (i.e. abdominal breathing) at SCPP < 80 or > 100 mmHg.

CONCLUSIONS

After acute, cervical traumatic spinal cord injuries, breathing function depends on the SCPP. SCPP 80-90 mmHg correlates with optimum diaphragmatic and intercostal muscle function. Our findings raise the possibility that intervention to maintain SCPP in this range may accelerate ventilator liberation which may reduce stay in the neuro-intensive care unit.

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.

Case report: Continuous spinal cord physiologic monitoring following traumatic spinal cord injury-A report from the Winnipeg Intraspinal Pressure Study (WISP)

Introduction

Acute traumatic spinal cord injury is routinely managed by surgical decompression and instrumentation of the spine. Guidelines also suggest elevating mean arterial pressure to 85 mmHg to mitigate secondary injury. However, the evidence for these recommendations remains very limited. There is now considerable interest in measuring spinal cord perfusion pressure by monitoring mean arterial pressure and intraspinal pressure. Here, we present our first institutional experience of using a strain gauge pressure transducer monitor to measure intraspinal pressure and subsequent derivation of spinal cord perfusion pressure.

Case presentation

The patient presented to medical attention after a fall off of scaffolding. A trauma assessment was completed at a local emergency room. He did not have any motor strength or sensation to the lower extremities. A computed tomography (CT) scan of the thoracolumbar spine confirmed a T12 burst fracture with retropulsion of bone fragments into the spinal canal. He was taken to surgery for urgent decompression of the spinal cord and instrumentation of the spine. A subdural strain gauge pressure monitor was placed at the site of injury through a small dural incision. Mean arterial pressure and intraspinal pressure were then monitored for 5 days after surgery. Spinal cord perfusion pressure was derived. The procedure was performed without complication and the patient underwent rehabilitation for 3 months where he regained some motor and sensory function in his lower extremities.

Conclusion

The first North American attempt at insertion of a strain gauge pressure monitor into the subdural space at the site of injury following acute traumatic spinal cord injury was performed successfully and without complication. Spinal cord perfusion pressure was derived successfully using this physiological monitoring. Further research efforts to validate this technique are required.

Time is spine: What's over the horizon

The overarching theme in the early treatment of acute spinal cord injury (SCI) is to reduce the extent of secondary damage to facilitate early neurological and functional recovery. Although multiple studies have brought us innovative and potential new therapies to treat SCI, ameliorating neural damage remains a formidable challenge. Knowledge translation of clinical and basic research studies has shown that surgical intervention is a valuable treatment modality; however, the role, timing and optimal technique in surgery remains a topic of great controversy. While evidence to support the concept of ultra-early surgery for acute SCI continues to emerge, current protocols and international guidelines that encourage reducing time from trauma to surgery support the concept of "Time is Spine". The present article provides a critical narrative review of the current best practice, with a particular focus on the timing of surgical intervention, which shapes our understanding of how time is of the essence in the management of acute SCI.

Multimodal interventions to optimize spinal cord perfusion in patients with acute traumatic spinal cord injuries: a systematic review

OBJECTIVE

The authors systematically reviewed current evidence for the utility of mean arterial pressure (MAP), intraspinal pressure (ISP), and spinal cord perfusion pressure (SCPP) as predictors of outcomes after traumatic spinal cord injury (SCI).

METHODS

PubMed, Cochrane Reviews Library, EMBASE, and Scopus databases were queried in December 2020. Two independent reviewers screened articles using Covidence software. Disagreements were resolved by a third reviewer. The inclusion criteria for articles were 1) available in English; 2) full text; 3) clinical studies on traumatic SCI interventions; 4) involved only human participants; and 5) focused on MAP, ISP, or SCPP. Exclusion criteria were 1) only available in non-English languages; 2) focused only on the brain; 3) described spinal diseases other than SCI; 4) interventions altering parameters other than MAP, ISP, or SCPP; and 5) animal studies. Studies were analyzed qualitatively and grouped into two categories: interventions increasing MAP or interventions decreasing ISP. The Scottish Intercollegiate Guidelines Network level of evidence was used to assess bias and the Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate confidence in the anticipated effects of each outcome.

RESULTS

A total of 2540 unique articles were identified, of which 72 proceeded to full-text review and 24 were included in analysis. One additional study was included retrospectively. Articles that went through full-text review were excluded if they were a review paper (n = 12), not a full article (n = 12), a duplicate paper (n = 9), not a human study (n = 3), not in English (n = 3), not pertaining to traumatic SCI (n = 3), an improper intervention (n = 3), without intervention (n = 2), and without analysis of intervention (n = 1). Although maintaining optimal MAP levels is the current recommendation for SCI management, the published literature supports maintenance of SCPP as a stronger indicator of favorable outcomes. Studies also suggest that laminectomy and durotomy may provide better outcomes than laminectomy alone, although higher-level studies are needed. Current evidence is inconclusive on the effectiveness of CSF drainage for reducing ISP.

CONCLUSIONS

This review demonstrates the importance of assessing how different interventions may vary in their ability to optimize SCPP.

Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

This scoping review systematically reviewed relevant research to summarize the literature addressing the significance of monitoring spinal cord perfusion pressure (SCPP) in acute traumatic spinal cord injury (SCI). The objectives of the review were to (1) examine the nature of research in the field of SCPP monitoring in SCI, (2) summarize the key research findings in the field, and (3) identify research gaps in the existing literature and future research priorities. Primary literature searches were conducted using databases (Medline and Embase) and expanded searches were conducted by reviewing the references of eligible articles and searches of Scopus, Web of Science core collection, Google Scholar, and conference abstracts. Relevant data were extracted from the studies and synthesis of findings was guided by the identification of patterns across studies to identify key themes and research gaps within the literature. Following primary and expanded searches, a total of 883 articles were screened. Seventy-three articles met the review inclusion criteria, including 34 original research articles. Other articles were categorized as conference abstracts, literature reviews, systematic reviews, letters to the editor, perspective articles, and editorials. Key themes relevant to the research question that emerged from the review included the relationship between SCPP and neurological recovery, the safety of monitoring pressures within the intrathecal space, and methods of intervention to enhance SCPP in the setting of acute traumatic SCI. Original research that aims to enhance SCPP by targeting increases in mean arterial pressure or reducing pressure in the intrathecal space is reviewed. Further discussion regarding where pressure within the intrathecal space should be measured is provided. Finally, we highlight research gaps in the literature such as determining the feasibility of invasive monitoring at smaller centers, the need for a better understanding of cerebrospinal fluid physiology following SCI, and novel pharmacological interventions to enhance SCPP in the setting of acute traumatic SCI. Ultimately, despite a growing body of literature on the significance of SCPP monitoring following SCI, there are still a number of important knowledge gaps that will require further investigation.

The Winnipeg Intraspinal Pressure Monitoring Study (WISP): A protocol for validation of fiberoptic pressure monitoring for acute traumatic spinal cord injury

Background

Research efforts have been focused on limiting secondary injury after traumatic spinal cord injury by performing spinal decompression and early optimization of spinal cord perfusion. The Winnipeg Intraspinal Pressure Monitoring Study (WISP) was designed to validate the technique of intraspinal pressure monitoring at the site of injury using a fiberoptic pressure monitor placed at the site of injury.

Objectives

To describe the design of the WISP study.

Study design

Descriptive.

Methods

We explain the current limitations in the available scientific literature around the topic of blood pressure management for acute traumatic spinal cord injury and rational for the WISP study. Then, we describe the design of WISP including the patient selection criteria, study interventions, follow up schedules and outcome measurements. A multitude of future research avenues are also discussed.

Results

The WISP study is a single center pilot study designed to validate the technique of intraspinal pressure monitoring following acute traumatic spinal cord injury. The study involves the measurement of intraspinal pressure from within the subarachnoid space at the site of injury to derive a number of physiological parameters including spinal cord perfusion pressure, spinal cord blood volume, measures of spinal cord compliance and vascular reactivity indices. Twenty eligible patients will be recruited and followed for a period of 12 months with visits scheduled for the first 5 days and 1, 3, 6, and 12 months following surgical intervention.

Conclusions

The WISP study will provide the first attempt in North America at validation of intraspinal pressure monitoring with a fiberoptic pressure monitor at the site of injury. Successful validation will lead to future studies to define optimal spinal cord perfusion pressure, relationships of neural injury biomarkers and outcomes as well as epigenetic studies.

Trial registration

This study has been registered at clinicaltrials.gov (registration# NCT04550117).

Early expansive single sided laminoplasty decompression treatment severe traumatic cervical spinal cord injury

Background

Severe traumatic cervical spinal cord injury (tcSCI) is a disastrous event for patients and families. Maximizing spinal cord function recovery has become the primary therapeutic goal. This study investigated the effect of early extensive posterior decompression on spinal cord function improvement after severe tcSCI.

Methods

A retrospective review of 83 consecutive patients who underwent extensive open-door laminoplasty decompression within 24 h after severe tcSCI (American Spinal Injury Association (ASIA) impairment scale (AIS) grade A to C) between 2009 and 2017 at our institution was performed. The patient clinical and demographic data were collected. Neurological functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) score system, ASIA motor score (AMS) and AIS grade.

Results

Among the 83 patients initially included, the baseline AIS grade was A in 12, B in 28, and C in 43. Twenty-three patients (27.7%) had a high cervical injury. Cervical spinal stenosis (CSS) was identified in 37 patients (44.6%). The mean intramedullary lesion length was 59.6 ± 20.4 mm preoperatively and 34.2 ± 13.3 mm postoperatively (p < 0.0001). At the final follow-up visit, an improvement of at least one and two AIS grades was found in 75 (90.4%) and 41 (49.4%) patients, respectively. 24 (64.9%) patients with an improvement of least two AIS grades had CSS. The mean AMS and JOA score were significantly improved at discharge and the final follow-up visit compared with on admission (p < 0.0001).

Conclusions

Our results suggest that early expansive laminoplasty decompression may improve neurological outcomes after severe tcSCI, especially in patients with CSS. Larger and prospective controlled studies are needed to validate these findings.

Elevated intraspinal pressure in traumatic spinal cord injury is a promising therapeutic target

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.

Monitoring Spinal Cord Tissue Oxygen in Patients With Acute, Severe Traumatic Spinal Cord Injuries

Objectives

To determine the feasibility of monitoring tissue oxygen tension from the injury site (psctO2) in patients with acute, severe traumatic spinal cord injuries.

Design

We inserted at the injury site a pressure probe, a microdialysis catheter, and an oxygen electrode to monitor for up to a week intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), tissue glucose, lactate/pyruvate ratio (LPR), and psctO2. We analyzed 2,213 hours of such data. Follow-up was 6-28 months postinjury.

Setting

Single-center neurosurgical and neurocritical care units.

Subjects

Twenty-six patients with traumatic spinal cord injuries, American spinal injury association Impairment Scale A-C. Probes were inserted within 72 hours of injury.

Interventions

Insertion of subarachnoid oxygen electrode (Licox; Integra LifeSciences, Sophia-Antipolis, France), pressure probe, and microdialysis catheter.

Measurements and Main Results

psctO2 was significantly influenced by ISP (psctO2 26.7 +/- 0.3 mm Hg at ISP > 10 mmHg vs psctO2 22.7 +/- 0.8 mm Hg at ISP <= 10 mm Hg), SCPP (psctO2 26.8 +/- 0.3 mm Hg at SCPP < 90 mm Hg vs psctO2 32.1 +/- 0.7 mm Hg at SCPP >= 90 mm Hg), tissue glucose (psctO2 26.8 +/- 0.4 mm Hg at glucose < 6 mM vs 32.9 +/- 0.5 mm Hg at glucose >= 6 mM), tissue LPR (psctO2 25.3 +/- 0.4 mm Hg at LPR > 30 vs psctO2 31.3 +/- 0.3 mm Hg at LPR <= 30), and fever (psctO2 28.8 +/- 0.5 mm Hg at cord temperature 37-38[degrees]C vs psctO2 28.7 +/- 0.8 mm Hg at cord temperature >= 39[degrees]C). Tissue hypoxia also occurred independent of these factors. Increasing the FIO2 by 0.48 increases psctO2 by 71.8% above baseline within 8.4 minutes. In patients with motor-incomplete injuries, fluctuations in psctO2 correlated with fluctuations in limb motor score. The injured cord spent 11% (39%) hours at psctO2 less than 5 mm Hg (< 20 mm Hg) in patients with motor-complete outcomes, compared with 1% (30%) hours at psctO2 less than 5 mm Hg (< 20 mm Hg) in patients with motor-incomplete outcomes. Complications were cerebrospinal fluid leak (5/26) and wound infection (1/26).

Conclusions

This study lays the foundation for measuring and altering spinal cord oxygen at the injury site. Future studies are required to investigate whether this is an effective new therapy.

Acute, severe traumatic spinal cord injury: improving urinary bladder function by optimizing spinal cord perfusion

OBJECTIVE

The authors sought to investigate the effect of acute, severe traumatic spinal cord injury on the urinary bladder and the hypothesis that increasing the spinal cord perfusion pressure improves bladder function.

METHODS

In 13 adults with traumatic spinal cord injury (American Spinal Injury Association Impairment Scale grades A-C), a pressure probe and a microdialysis catheter were placed intradurally at the injury site. We varied the spinal cord perfusion pressure and performed filling cystometry. Patients were followed up for 12 months on average.

RESULTS

The 13 patients had 63 fill cycles; 38 cycles had unfavorable urodynamics, i.e., dangerously low compliance (< 20 mL/cmH2O), detrusor overactivity, or dangerously high end-fill pressure (> 40 cmH2O). Unfavorable urodynamics correlated with periods of injury site hypoperfusion (spinal cord perfusion pressure < 60 mm Hg), hyperperfusion (spinal cord perfusion pressure > 100 mm Hg), tissue glucose < 3 mM, and tissue lactate to pyruvate ratio > 30. Increasing spinal cord perfusion pressure from 67.0 ± 2.3 mm Hg (average ± SE) to 92.1 ± 3.0 mm Hg significantly reduced, from 534 to 365 mL, the median bladder volume at which the desire to void was first experienced. All patients with dangerously low average initial bladder compliance (< 20 mL/cmH2O) maintained low compliance at follow-up, whereas all patients with high average initial bladder compliance (> 100 mL/cmH2O) maintained high compliance at follow-up.

CONCLUSIONS

We conclude that unfavorable urodynamics develop within days of traumatic spinal cord injury, thus challenging the prevailing notion that the detrusor is initially acontractile. Urodynamic studies performed acutely identify patients with dangerously low bladder compliance likely to benefit from early intervention. At this early stage, bladder function is dynamic and is influenced by fluctuations in the physiology and metabolism at the injury site; therefore, optimizing spinal cord perfusion is likely to improve urological outcome in patients with acute severe traumatic spinal cord injury.

Medical Communication Services after Traumatic Spinal Cord Injury

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).

A review of spinal cord perfusion pressure guided interventions in traumatic spinal cord injury

PURPOSE

To evaluate the causality between interventions on spinal cord perfusion pressure and neurological outcome in traumatic spinal cord injury.

METHODS

A systematic review was conducted in concordance with PRISMA guidelines. The literature was found in the EMBASE, PUBMED, SCOPUS, and WEB OF SCIENCE. Eligible studies included those that reported measurements and interventions on the spinal cord perfusion pressure in either animals or patients suffering from spinal cord injury. Only studies that reported a clinical or relevant clinical outcome measure (i.e., neurophysiology) were included.

RESULTS

The search yielded 795 unique records, and six studies were included after careful review. These studies suggested a positive correlation between spinal cord perfusion pressure and neurological outcome, but conclusions on causality could not be made.

CONCLUSION

In spite of growing indications that neurological outcomes are related to the spinal cord perfusion pressure in traumatic spinal cord injuries, a solid conclusion cannot be made due to the limited literature available. Additional well-designed studies are needed to address this issue.

Duraplasty in Traumatic Thoracic Spinal Cord Injury: Impact on Spinal Cord Hemodynamics, Tissue Metabolism, Histology, and Behavioral Recovery Using a Porcine Model

After acute traumatic spinal cord injury (SCI), the spinal cord can swell to fill the subarachnoid space and become compressed by the surrounding dura. In a porcine model of SCI, we performed a duraplasty to expand the subarachnoid space around the injured spinal cord and evaluated how this influenced acute intraparenchymal hemodynamic and metabolic responses, in addition to histological and behavioral recovery. Female Yucatan pigs underwent a T10 SCI, with or without duraplasty. Using microsensors implanted into the spinal cord parenchyma, changes in blood flow (ΔSCBF), oxygenation (ΔPO₂), and spinal cord pressure (ΔSCP) during and after SCI were monitored, alongside metabolic responses. Behavioral recovery was tested weekly using the Porcine Injury Behavior Scale (PTIBS). Thereafter, spinal cords were harvested for tissue sparing analyses. In both duraplasty and non-animals, the ΔSCP increased ∼5 mm Hg in the first 6 h post-injury. After this, the SCP appeared to be slightly reduced in the duraplasty animals, although the group differences were not statistically significant after controlling for injury severity in terms of impact force. During the first seven days post-SCI, the ΔSCBF or ΔPO₂ values were not different between the duraplasty and control animals. Over 12 weeks, there was no improvement in hindlimb locomotion as assessed by PTIBS scores and no reduction in tissue damage at the injury site in the duraplasty animals. In our porcine model of SCI, duraplasty did not provide any clear evidence of long-term behavioral or tissue sparing benefit after SCI.

Spinal Cord Perfusion Pressure Correlates with Anal Sphincter Function in a Cohort of Patients with Acute, Severe Traumatic Spinal Cord Injuries

Background

Acute, severe traumatic spinal cord injury often causes fecal incontinence. Currently, there are no treatments to improve anal function after traumatic spinal cord injury. Our study aims to determine whether, after traumatic spinal cord injury, anal function can be improved by interventions in the neuro-intensive care unit to alter the spinal cord perfusion pressure at the injury site.

Methods

We recruited a cohort of patients with acute, severe traumatic spinal cord injuries (American Spinal Injury Association Impairment Scale grades A–C). They underwent surgical fixation within 72 h of the injury and insertion of an intrathecal pressure probe at the injury site to monitor intraspinal pressure and compute spinal cord perfusion pressure as mean arterial pressure minus intraspinal pressure. Injury-site monitoring was performed at the neuro-intensive care unit for up to a week after injury. During monitoring, anorectal manometry was also conducted over a range of spinal cord perfusion pressures.

Results

Data were collected from 14 patients with consecutive traumatic spinal cord injury aged 22–67 years. The mean resting anal pressure was 44 cmH₂O, which is considerably lower than the average for healthy patients, previously reported at 99 cmH₂O. Mean resting anal pressure versus spinal cord perfusion pressure had an inverted U-shaped relation (Ȓ² = 0.82), with the highest resting anal pressures being at a spinal cord perfusion pressure of approximately 100 mmHg. The recto-anal inhibitory reflex (transient relaxation of the internal anal sphincter during rectal distension), which is important for maintaining fecal continence, was present in 90% of attempts at high (90 mmHg) spinal cord perfusion pressure versus 70% of attempts at low (60 mmHg) spinal cord perfusion pressure (P < 0.05). During cough, the rise in anal pressure from baseline was 51 cmH₂O at high (86 mmHg) spinal cord perfusion pressure versus 37 cmH₂O at low (62 mmHg) spinal cord perfusion pressure (P < 0.0001). During anal squeeze, higher spinal cord perfusion pressure was associated with longer endurance time and spinal cord perfusion pressure of 70–90 mmHg was associated with stronger squeeze. There were no complications associated with anorectal manometry.

Conclusions

Our data indicate that spinal cord injury causes severe disruption of anal sphincter function. Several key components of anal continence (resting anal pressure, recto-anal inhibitory reflex, and anal pressure during cough and squeeze) markedly improve at higher spinal cord perfusion pressure. Maintaining too high of spinal cord perfusion pressure may worsen anal continence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12028-021-01232-1.

Current practices and goals for mean arterial pressure and spinal cord perfusion pressure in acute traumatic spinal cord injury: Defining the gaps in knowledge

Context: The mainstay of treatment for acute traumatic spinal cord injury (SCI) is to artificially elevate the patient's mean arterial pressure (MAP) to >85 mmHg to increase blood flow to the injured spinal cord for 7 days. However, the literature supporting these recommendations are only Class III evidence. In fact, the critical time window in which to elevate MAP after SCI and the optimal vasopressor to use are largely unknown, as is whether cerebrospinal fluid diversion has a role, and this leads to variability among practitioners. Also undefined is whether manipulating these parameters improves neurological outcome.Objective: Our goal is to better delineate current clinical practice and identify gaps in knowledge surrounding the care of patients with traumatic SCI.Methods: We undertook a systematic review of the current literature identified from PubMed on MAP elevation and spinal cord parenchymal pressure in acute SCI.Results: The 8 articles (6 human; 2 porcine) that met our inclusion criteria were all published within the last 6 years. Four were prospective, 1 was retrospective, and 3 were review articles. Only one study was randomized. All of these studies involved small sample sizes and varying lengths of MAP elevation. Choice of vasopressor was variable as well.Conclusions: From our literature review, we posit that norepinephrine may be the vasopressor of choice, that spinal parenchymal pressure monitors can be safely placed at the injury site, and that the combination of MAP elevation and cerebrospinal fluid drainage may improve neurologic outcome more than either intervention alone.

Acute Traumatic Spinal Cord Injury in Humans, Dogs, and Other Mammals: The Under-appreciated Role of the Dura

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.

Effect of Durotomy versus Myelotomy on Tissue Sparing and Functional Outcome after Spinal Cord Injury

Various surgical strategies have been developed to alleviate elevated intraspinal pressure (ISP) following acute traumatic spinal cord injury (tSCI). Surgical decompression of either the dural (durotomy) or the dural and pial (myelotomy) lining of the spinal cord has been proposed. However, a direct comparison of these two strategies is lacking. Here, we compare the histological and functional effects of durotomy alone and durotomy plus myelotomy in a rodent model of acute thoracic tSCI. Our results indicate that tSCI causes local tissue edema and significantly elevates ISP (7.4 ± 0.3 mmHg) compared with physiological ISP (1.7 ± 0.4 mmHg; p < 0.001). Both durotomy alone and durotomy plus myelotomy effectively mitigate elevated local ISP (p < 0.001). Histological examination at 10 weeks after tSCI revealed that durotomy plus myelotomy promoted spinal tissue sparing by 13.7% compared with durotomy alone, and by 25.9% compared with tSCI-only (p < 0.0001). Both types of decompression surgeries elicited a significant beneficial impact on gray matter sparing (p < 0.01). Impressively, durotomy plus myelotomy surgery increased preservation of motor neurons by 174.3% compared with tSCI-only (p < 0.05). Durotomy plus myelotomy surgery also significantly promoted recovery of hindlimb locomotor function in an open-field test (p < 0.001). Interestingly, only durotomy alone resulted in favorable recovery of bladder and Ladder Walk performance. Combined, our data suggest that durotomy plus myelotomy following acute tSCI facilitates tissue sparing and recovery of locomotor function. In the future, biomarkers identifying spinal cord injuries that can benefit from either durotomy alone or durotomy plus myelotomy need to be developed.

Implantable Osmotic Transport Device Can Reduce Edema After Severe Contusion Spinal Cord Injury

Recent findings from the ISCoPe study indicate that, after severe contusion to the spinal cord, edema originating in the spinal cord accumulates and compresses the tissue against the surrounding dura mater, despite decompressive laminectomy. It is hypothesized that this compression results in restricted flow of cerebrospinal fluid (CSF) in the subarachnoid space and central canal and ultimately collapses local vasculature, exacerbating ischemia and secondary injury. Here we developed a surgically mounted osmotic transport device (OTD) that rests on the dura and can osmotically remove excess fluid at the injury site. Tests were performed in 4-h studies immediately following severe (250 kD) contusion at T8 in rats using the OTD. A 3-h treatment with the OTD after 1-h post injury significantly reduced spinal cord edema compared to injured controls. A first approximation mathematical interpretation implies that this modest reduction in edema may be significant enough to relieve compression of local vasculature and restore flow of CSF in the region. In addition, we determined the progression of edema up to 28 days after insult in the rat for the same injury model. Results showed peak edema at 72 h. These preliminary results suggest that incorporating the OTD to operate continuously at the site of injury throughout the critical period of edema progression, the device may significantly improve recovery following contusion spinal cord injury.

Acute Spinal Cord Injury: Monitoring Lumbar Cerebrospinal Fluid Provides Limited Information about the Injury Site

In some centers, monitoring lumbar cerebrospinal fluid (CSF) is used to guide management of patients with acute traumatic spinal cord injuries (TSCI) and draining lumbar CSF to improve spinal cord perfusion. Here, we investigate whether the lumbar CSF provides accurate information about the injury site and the effect of draining lumbar CSF on injury site perfusion. In 13 TSCI patients, we simultaneously monitored lumbar CSF pressure (CSFP) and intraspinal pressure (ISP) from the injury site. Using CSFP or ISP, we computed spinal cord perfusion pressure (SCPP), vascular pressure reactivity index (sPRx) and optimum SCPP (SCPP_opt). We also assessed the effect on ISP of draining 10 mL CSF. Metabolites at the injury site were compared with metabolites in the lumbar CSF. We found that ISP was pulsatile, but CSFP had low pulse pressure and was non-pulsatile 21% of the time. There was weak or no correlation between CSFP versus ISP (R = -0.11), SCPP_(csf) versus SCPP_(ISP) (R = 0.39), and sPRx_(csf) versus sPRx_(ISP) (R = 0.45). CSF drainage caused no significant change in ISP in 7/12 patients and a significant drop of <5 mm Hg in 4/12 patients and of ∼8 mm Hg in 1/12 patients. Metabolite concentrations in the CSF versus the injury site did not correlate for lactate (R = 0.00), pyruvate (R = -0.12) or lactate-to-pyruvate ratio (R = -0.05) with weak correlations noted for glucose (R = 0.31), glutamate (R = 0.61), and glycerol (R = 0.56). We conclude that, after a severe TSCI, monitoring from the lumbar CSF provides only limited information about the injury site and that lumbar CSF drainage does not effectively reduce ISP in most patients.

Targeted Perfusion Therapy in Spinal Cord Trauma

We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets. Key concepts are discussed such as intraspinal pressure and spinal cord perfusion pressure (SCPP) at the injury site, respectively, analogous to intracranial pressure and cerebral perfusion pressure for traumatic brain injury. The concept of spinal cord autoregulation is introduced and quantified using spinal pressure reactivity index (sPRx), which is analogous to pressure reactivity index for traumatic brain injury. The U-shaped relationship between sPRx and SCPP defines the optimum SCPP as the SCPP that minimizes sPRx (i.e., maximizes autoregulation), and suggests that not only ischemia but also hyperemia at the injury site may be detrimental. The observation that optimum SCPP varies between patients and temporally in each patient supports individualized management. We discuss multimodality monitoring, which revealed strong correlations between SCPP and injury site metabolism (tissue glucose, lactate, pyruvate, glutamate, glycerol), monitored by surface microdialysis. Evidence is presented that the dura is a major, but unappreciated, cause of spinal cord compression after TSCI; we thus propose expansion duroplasty as a novel treatment. Monitoring spinal cord blood flow at the injury site has revealed novel phenomena, e.g., 3 distinct blood flow patterns, local steal, and diastolic ischemia. We conclude that monitoring from the injured spinal cord in the intensive care unit is a safe technique that appears to enable optimized and individualized spinal cord perfusion.

Efficacy of Ultra-Early (< 12 h), Early (12-24 h), and Late (>24-138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12-24 h), and 15 underwent decompressive surgery late (> 24-138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862-0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.

Transcutaneous contrast-enhanced ultrasound imaging of the posttraumatic spinal cord

STUDY DESIGN

Experimental animal study.

OBJECTIVE

The current study aims to test whether the blood flow within the contused spinal cord can be assessed in a rodent model via the acoustic window of the laminectomy utilizing transcutaneous ultrasound.

SETTING

Department of Neurological Surgery, University of Washington, Seattle WA.

METHODS

Long-Evans rats (n = 12) were subjected to a traumatic thoracic spinal cord injury (SCI). Three days and 10 weeks after injury, animals underwent imaging of the contused spinal cord using ultrafast contrast-enhanced ultrasound with a Vantage ultrasound research system in combination with a 15 MHz transducer. Lesion size and signal-to-noise ratios were estimated via transcutaneous, subcutaneous, or epidural ultrasound acquisition through the acoustic window created by the original laminectomy.

RESULTS

Following laminectomy, transcutaneous and subcutaneous contrast-enhanced ultrasound imaging allowed for assessment of perfusion and vascular flow in the contused rodent spinal cord. An average loss of 7.2 dB from transcutaneous to subcutaneous and the loss of 5.1 dB from subcutaneous to epidural imaging in signal-to-noise ratio (SNR) was observed. The hypoperfused injury center was measured transcutaneously, subcutaneously and epidurally (5.78 ± 0.86, 5.91 ± 0.53, 5.65 ± 1.07 mm²) at 3 days post injury. The same animals were reimaged again at 10 weeks following SCI, and the area of hypoperfusion had decreased significantly compared with the 3-day measurements detected via transcutaneous, subcutaneous, and epidural imaging respectively (0.69 ± 0.05, 1.09 ± 0.11, 0.95 ± 0.11 mm², p < 0.001).

CONCLUSIONS

Transcutaneous ultrasound allows for measurements and longitudinal monitoring of local hemodynamic changes in a rodent SCI model.

Predictors of Intraspinal Pressure and Optimal Cord Perfusion Pressure After Traumatic Spinal Cord Injury

Background/Objectives

We recently developed techniques to monitor intraspinal pressure (ISP) and spinal cord perfusion pressure (SCPP) from the injury site to compute the optimum SCPP (SCPP_opt) in patients with acute traumatic spinal cord injury (TSCI). We hypothesized that ISP and SCPP_opt can be predicted using clinical factors instead of ISP monitoring.

Methods

Sixty-four TSCI patients, grades A–C (American spinal injuries association Impairment Scale, AIS), were analyzed. For 24 h after surgery, we monitored ISP and SCPP and computed SCPP_opt (SCPP that optimizes pressure reactivity). We studied how well 28 factors correlate with mean ISP or SCPP_opt including 7 patient-related, 3 injury-related, 6 management-related, and 12 preoperative MRI-related factors.

Results

All patients underwent surgery to restore normal spinal alignment within 72 h of injury. Fifty-one percentage had U-shaped sPRx versus SCPP curves, thus allowing SCPP_opt to be computed. Thirteen percentage, all AIS grade A or B, had no U-shaped sPRx versus SCPP curves. Thirty-six percentage (22/64) had U-shaped sPRx versus SCPP curves, but the SCPP did not reach the minimum of the curve, and thus, an exact SCPP_opt could not be calculated. In total 5/28 factors were associated with lower ISP: older age, excess alcohol consumption, nonconus medullaris injury, expansion duroplasty, and less intraoperative bleeding. In a multivariate logistic regression model, these 5 factors predicted ISP as normal or high with 73% accuracy. Only 2/28 factors correlated with lower SCPP_opt: higher mean ISP and conus medullaris injury. In an ordinal multivariate logistic regression model, these 2 factors predicted SCPP_opt as low, medium–low, medium–high, or high with only 42% accuracy. No MRI factors correlated with ISP or SCPP_opt.

Conclusions

Elevated ISP can be predicted by clinical factors. Modifiable factors that may lower ISP are: reducing surgical bleeding and performing expansion duroplasty. No factors accurately predict SCPP_opt; thus, invasive monitoring remains the only way to estimate SCPP_opt.

Electronic supplementary material

The online version of this article (10.1007/s12028-018-0616-7) contains supplementary material, which is available to authorized users.

Practical Application of Recent Advances in Diagnostic, Prognostic, and Therapeutic Modalities for Spinal Cord Injury

OBJECTIVE

Spinal cord injury remains a highly morbid entity, with limited treatment modalities in both acute and chronic settings. Clinical research efforts to improve therapeutic guidelines are confounded by initial evaluation inaccuracies, as presentations are frequently complicated by trauma and objective diagnostic and prognostic methods are poorly defined. The purpose of our study was to review recent practical advances for further delineation of these injuries and how such classification may benefit the development of novel treatments.

METHODS

A review was carried out of recent studies reported within the last 5 years for prognostic and diagnostic modalities of acute spinal cord injury.

RESULTS

Substantial efforts have been made to improve the timeliness and accuracy of the initial assessment, not only for the purpose of enhancing prognostication but also in determining the efficacy of new treatments. Whether it be applying traumatic brain injury principles to limit injury extent, external stimulators used for chronic pain conditions to enhance the effects of physical therapy, or creative algorithms incorporating various nerve or muscle transfer techniques, innovative and practical solutions continue to be developed in lieu of definitive treatment. Further development will benefit from enhanced stratification of injury from accurate and practical assessment modalities.

CONCLUSIONS

Recent advances in accurate, timely, and practical classification methods of acute spinal cord injury will assist in the development of novel treatment approaches for both acute and chronic injury alike.

Monitoring spinal cord hemodynamics and tissue oxygenation: a review of the literature with special focus on the near-infrared spectroscopy technique

STUDY DESIGN

Review.

OBJECTIVES

Clinical studies have shown that the hemodynamic management of patients following acute spinal cord injury (SCI) is an important aspect of their treatment for maintaining spinal cord (SC) perfusion and minimizing ischemic secondary injury to the SC. While this highlights the importance of ensuring adequate perfusion and oxygenation to the injured cord, a method for the real-time monitoring of these hemodynamic measures within the SC is lacking. The purpose of this review is to discuss current and potential methods for SC hemodynamic monitoring with special focus on applications using near-infrared spectroscopy (NIRS).

METHODS

A literature search using the PubMed database. All peer-reviewed articles on NIRS monitoring of SC published from inception to May 2019 were reviewed.

RESULTS

Among 125 papers related to SC hemodynamics monitoring, 26 focused on direct/indirect NIRS monitoring of the SC.

DISCUSSION

Current options for continuous, non-invasive, and real-time monitoring of SC hemodynamics are challenging and limited in scope. As a relatively new technique, NIRS has been successfully used for monitoring human cerebral hemodynamics, and has shown promising results in intraoperative assessment of SC hemodynamics in both human and animal models. Although utilizing NIRS to monitor the SC has been validated, applying NIRS clinically following SCI requires further development and investigation.

CONCLUSIONS

NIRS is a promising non-invasive technique with the potential to provide real-time monitoring of relevant parameters in the SC. Currently, in its first developmental stages, further clinical and experimental studies are mandatory to ensure the validity and safety of NIRS techniques.

Extent of Spinal Cord Decompression in Motor Complete (American Spinal Injury Association Impairment Scale Grades A and B) Traumatic Spinal Cord Injury Patients: Post-Operative Magnetic Resonance Imaging Analysis of Standard Operative Approaches

Although decompressive surgery following traumatic spinal cord injury (TSCI) is recommended, adequate surgical decompression is rarely verified via imaging. We utilized magnetic resonance imaging (MRI) to analyze the rate of spinal cord decompression after surgery. Pre-operative (within 8 h of injury) and post-operative (within 48 h of injury) MRI images of 184 motor complete patients (American Spinal Injury Association Impairment Scale [AIS] grade A = 119, AIS grade B = 65) were reviewed to verify spinal cord decompression. Decompression was defined as the presence of a patent subarachnoid space around a swollen spinal cord. Of the 184 patients, 100 (54.3%) underwent anterior cervical discectomy and fusion (ACDF), and 53 of them also underwent laminectomy. Of the 184 patients, 55 (29.9%) underwent anterior cervical corpectomy and fusion (ACCF), with (26 patients) or without (29 patients) laminectomy. Twenty-nine patients (16%) underwent stand-alone laminectomy. Decompression was verified in 121 patients (66%). The rates of decompression in patients who underwent ACDF and ACCF without laminectomy were 46.8% and 58.6%, respectively. Among these patients, performing a laminectomy increased the rate of decompression (72% and 73.1% of patients, respectively). Twenty-five of 29 (86.2%) patients who underwent a stand-alone laminectomy were found to be successfully decompressed. The rates of decompression among patients who underwent laminectomy at one, two, three, four, or five levels were 58.3%, 68%, 78%, 80%, and 100%, respectively (p < 0.001). In multi-variate logistic regression analysis, only laminectomy was significantly associated with successful decompression (odds ratio 4.85; 95% confidence interval 2.2-10.6; p < 0.001). In motor complete TSCI patients, performing a laminectomy significantly increased the rate of successful spinal cord decompression, independent of whether anterior surgery was performed.

Non-linear Dynamical Analysis of Intraspinal Pressure Signal Predicts Outcome After Spinal Cord Injury

The injured spinal cord is a complex system influenced by many local and systemic factors that interact over many timescales. To help guide clinical management, we developed a technique that monitors intraspinal pressure from the injury site in patients with acute, severe traumatic spinal cord injuries. Here, we hypothesize that spinal cord injury alters the complex dynamics of the intraspinal pressure signal quantified by computing hourly the detrended fluctuation exponent alpha, multiscale entropy, and maximal Lyapunov exponent lambda. 49 patients with severe traumatic spinal cord injuries were monitored within 72 h of injury for 5 days on average to produce 5,941 h of intraspinal pressure data. We computed the spinal cord perfusion pressure as mean arterial pressure minus intraspinal pressure and the vascular pressure reactivity index as the running correlation coefficient between intraspinal pressure and arterial blood pressure. Mean patient follow-up was 17 months. We show that alpha values are greater than 0.5, which indicates that the intraspinal pressure signal is fractal. As alpha increases, intraspinal pressure decreases and spinal cord perfusion pressure increases with negative correlation between the vascular pressure reactivity index vs. alpha. Thus, secondary insults to the injured cord disrupt intraspinal pressure fractality. Our analysis shows that high intraspinal pressure, low spinal cord perfusion pressure, and impaired pressure reactivity strongly correlate with reduced multi-scale entropy, supporting the notion that secondary insults to the injured cord cause de-complexification of the intraspinal pressure signal, which may render the cord less adaptable to external changes. Healthy physiological systems are characterized by edge of chaos dynamics. We found negative correlations between the percentage of hours with edge of chaos dynamics (−0.01 ≤ lambda ≤ 0.01) vs. high intraspinal pressure and vs. low spinal cord perfusion pressure; these findings suggest that secondary insults render the intraspinal pressure more regular or chaotic. In a multivariate logistic regression model, better neurological status on admission, higher intraspinal pressure multi-scale entropy and more frequent edge of chaos intraspinal pressure dynamics predict long-term functional improvement. We conclude that spinal cord injury is associated with marked changes in non-linear intraspinal pressure metrics that carry prognostic information.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Changes in Pressure, Hemodynamics, and Metabolism within the Spinal Cord during the First 7 Days after Injury Using a Porcine Model

Traumatic spinal cord injury (SCI) triggers many perturbations within the injured cord, such as decreased perfusion, reduced tissue oxygenation, increased hydrostatic pressure, and disrupted bioenergetics. While much attention is directed to neuroprotective interventions that might alleviate these early pathophysiologic responses to traumatic injury, the temporo-spatial characteristics of these responses within the injured cord are not well documented. In this study, we utilized our Yucatan mini-pig model of traumatic SCI to characterize intraparenchymal hemodynamic and metabolic changes within the spinal cord for 1 week post-injury. Animals were subjected to a contusion/compression SCI at T10. Prior to injury, probes for microdialysis and the measurement of spinal cord blood flow (SCBF), oxygenation (in partial pressure of oxygen; PaPO₂), and hydrostatic pressure were inserted into the spinal cord 0.2 and 2.2 cm from the injury site. Measurements occurred under anesthesia for 4 h post-injury, after which the animals were recovered and measurements continued for 7 days. Close to the lesion (0.2 cm), SCBF levels decreased immediately after SCI, followed by an increase in the subsequent days. Similarly, PaPO₂ plummeted, where levels remained diminished for up to 7 days post-injury. Lactate/pyruvate (L/P) ratio increased within minutes. Further away from the injury site (2.2 cm), L/P ratio also gradually increased. Hydrostatic pressure remained consistently elevated for days and negatively correlated with changes in SCBF. An imbalance between SCBF and tissue metabolism also was observed, resulting in metabolic stress and insufficient oxygen levels. Taken together, traumatic SCI resulted in an expanding area of ischemia/hypoxia, with ongoing physiological perturbations sustained out to 7 days post-injury. This suggests that our clinical practice of hemodynamically supporting patients out to 7 days post-injury may fail to address persistent ischemia within the injured cord. A detailed understanding of these pathophysiological mechanisms after SCI is essential to promote best practices for acute SCI patients.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Continuous Monitoring and Visualization of Optimum Spinal Cord Perfusion Pressure in Patients with Acute Cord Injury

The optimum spinal cord perfusion pressure (SCPP) after traumatic spinal cord injury (TSCI) is unknown. Here, we describe techniques to compute and display the optimum SCPP in real time. We recruited adults within 72 h of severe TSCI (American Spinal Injuries Association [ASIA] grades A-C). A pressure probe and a microdialysis catheter were placed on the injured cord. SCPP was computed as mean arterial pressure (MAP) minus intraspinal pressure (ISP), spinal pressure reactivity index (sPRx) as the running ISP/MAP correlation coefficient, and continuous optimum SCPP (cSCPP_opt) as the SCPP that minimizes sPRx in a moving 4-h window. In 45 patients, we monitored ISP and blood pressure. In 14 patients, we also monitored injury site metabolism. cSCPP_opt could be computed 45% of the time. Mean cSCPP_opt varied by up to 60 mm Hg between patients. Each patient's cSCPP_opt varied with time (standard deviation 10-20 mm Hg). Color-coded maps showing the sPRx/SCPP curve evolution enhanced visualization of cSCPP_opt. Periods when SCPP ≈ cSCPP_opt were associated with low injury site glucose, high pyruvate, and high lactate. Mean SCPP deviation from cSCPP_opt correlated with worse neurological outcome at 9-12 months: ASIA grade improved in 30% of patients with <5 mm Hg deviation, 10% of patients with 5-15 mm Hg deviation, and no one with >15 mm Hg deviation. We conclude that real-time computation and visualization of cSCPP_opt after TSCI are feasible. cSCPP_opt appears to enhance glucose utilization at the injury site and varies widely between and within patients. Our data suggest that targeting cSCPP_opt after TSCI might improve neurological outcome.

Surgical Neurostimulation for Spinal Cord Injury

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

Spinal cord injury: is monitoring from the injury site the future?

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.

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

PURPOSE

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

METHODS

Case report and review of the literature.

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The differential effects of norepinephrine and dopamine on cerebrospinal fluid pressure and spinal cord perfusion pressure after acute human spinal cord injury

STUDY DESIGN

Prospective vasopressor cross-over interventional studyObjectives:To examine how two vasopressors used in acute traumatic spinal cord injury (SCI) affect intrathecal cerebrospinal fluid pressure and the corresponding spinal cord perfusion pressure (SCPP).

SETTING

Vancouver, British Columbia, Canada.

METHODS

Acute SCI patients over the age of 17 with cervical or thoracic ASIA Impairment Scale (AIS). A, B or C injuries were enrolled in this study. Two vasopressors, norepinephrine and dopamine, were evaluated in a 'crossover procedure' to directly compare their effect on the intrathecal pressure (ITP). The vasopressor cross-over procedures were performed in the intensive care unit where ITP, mean arterial pressure (MAP) and heart rate were being continuously measured. The SCPP was calculated as the difference between MAP and ITP.

RESULTS

A total of 11 patients were enrolled and included in our analysis. There were 6 patients with AIS A, 3 with AIS B and 2 with AIS C injuries at baseline. We performed 24 cross-over interventions in these 11 patients. There was no difference in MAP with the use of norepinephrine versus dopamine (84±1 mm Hg for both; P=0.33). Conversely, ITP was significantly lower with the use of norepinephrine than with dopamine (17±1 mm Hg vs 20±1 mm Hg, respectively, P<0.001). This decrease in ITP with norepinephrine resulted in an increased SCPP during the norepinephrine infusion when compared with dopamine (67±1 mm Hg vs 65±1 mm Hg respectively, P=0.0049).

CONCLUSION

Norepinephrine was able to maintain MAP with a lower ITP and a correspondingly higher SCPP as compared with dopamine in this study. These results suggest that norepinephrine may be preferable to dopamine if vasopressor support is required post SCI to maintain elevated MAPs in accordance with published guidelines.