Traumatic Spinal Cord Injury

Omega-3 polyunsaturated fatty acids alleviate endoplasmic reticulum stress-induced neuroinflammation by protecting against traumatic spinal cord injury through the histone deacetylase 3/ peroxisome proliferator-activated receptor-γ coactivator pathway

Omega-3 polyunsaturated fatty acids (ω-3 PUFAs) attenuate inflammatory responses in the central nervous system, leading to neuroprotective effects. Inhibition of histone deacetylase 3 (HDAC3) has neuroprotective effects after spinal cord injury (SCI) through the SIRT1 pathway, but the pathophysiological mechanisms of SCI are complex and the interactions between ω-3 PUFAs and organelles remain largely unknown. This study aimed to investigate the effect of ω-3 PUFAs on endoplasmic reticulum (ER) stress-induced neuroinflammation through the HDAC3/peroxisome proliferator-activated receptor-γ coactivator (PGC)-1ɑ pathway after SCI. To this end, a contusion-induced SCI rat model was established to evaluate the effects of ω-3 PUFAs on ER stress-mediated inflammation in SCI. ER stress was rapidly induced in spinal cord lesions after SCI and was significantly reduced after ω-3 PUFA treatment. Consistent with reduced ER stress, HDAC3 expression levels and inflammatory responses were decreased, and PGC-1ɑ expression levels were increased after SCI. We found that ω-3 PUFA treatment attenuated ER stress through HDAC3 inhibition, thereby reducing SCI-induced inflammation. Taken together, these results suggest a role for ω-3 PUFA in protecting against SCI-induced neuroinflammation and promoting neurological functional recovery by regulating the histone deacetylase 3/ peroxisome proliferator-activated receptor-γ coactivator pathway.

Clinical risk factors associated with the need for tracheostomy in traumatic cervical and high thoracic spinal cord injury

BACKGROUND

Our objective was to assess the association of completeness and level of spinal cord injury (SCI) with the need for tracheostomy and identify additional risk factors predictive of tracheostomy.

METHODS

This was a retrospective review of patients with SCI between January 2017 and December 2022.

RESULTS

Patients with complete SCI were roughly thirty-three times more likely to have a tracheostomy when compared to incomplete injury (82 ​% vs 12 ​%, p ​< ​0.001, OR ​= ​32.9). The rate of tracheostomy did not differ between spinal cord levels for complete (p ​= ​0.68) or incomplete (p ​= ​0.08) injuries. Penetrating injury, low GCS, high ISS, and polytrauma were associated with tracheostomy need in incomplete SCI.

CONCLUSION

Complete injury was statistically significantly associated with the need for tracheostomy while level of injury failed to reach significance. Patients with incomplete SCI that have certain clinical risk factors should be considered for early tracheostomy.

Care needs of adults with spinal trauma in the prehospital and hospital setting from the perspective of patient care team: A qualitative research

BACKGROUND

Appropriate care of patients with definite spinal cord injury or at risk of it in the prehospital and hospital stages requires comprehensive planning in the health system. It is also the requirement of any successful program to explain the needs from the perspective of its stakeholders. Thus, this study aimed to discover the care needs of adults with spinal trauma in prehospital and hospital settings from the perspective of the patient care team.

MATERIALS AND METHODS

This qualitative study was conducted with the participation of urban and rural prehospital emergency personnel and emergency departments of educational and therapeutic hospitals affiliated to Isfahan, Tehran, Shiraz, Kermanshah, Ahvaz, and Yasuj Universities of Medical Sciences, through conducting 36 in-depth semi-structured interviews from September to December 2021. Using purposive sampling method, the participants were selected considering the maximum variation. The data saturation was reached after conducting interviews and group discussions with 36 subjects. Data were analyzed using conventional content analysis approach. Lundman and Graneheim approach were used for the study rigour. Data were simultaneously analyzed using MAXQDA software version 10.

RESULT

During the data analysis, two themes of prehospital care with two main categories (emergency care and management of secondary complications of spinal trauma) and hospital care with two main categories (emergency care and management of secondary complications of spinal trauma) emerged.

CONCLUSION

Emergency care and management of secondary complications of spinal cord injury in the prehospital and hospital stages can affect treatment results, improve quality of life, and reduce mortality rate, secondary injuries, and healthcare costs. Thus, identification of the care needs of the adults with spinal trauma from the perspective of the patient care team can help the authorities to plan appropriate interventions.

The Clinical Relevance of Autonomic Dysfunction, Cerebral Hemodynamics, and Sleep Interactions in Individuals Living With SCI

A myriad of physiological impairments is seen in individuals after a spinal cord injury (SCI). These include altered autonomic function, cerebral hemodynamics, and sleep. These physiological systems are interconnected and likely insidiously interact leading to secondary complications. These impairments negatively influence quality of life. A comprehensive review of these systems, and their interplay, may improve clinical treatment and the rehabilitation plan of individuals living with SCI. Thus, these physiological measures should receive more clinical consideration. This special communication introduces the under investigated autonomic dysfunction, cerebral hemodynamics, and sleep disorders in people with SCI to stakeholders involved in SCI rehabilitation. We also discuss the linkage between autonomic dysfunction, cerebral hemodynamics, and sleep disorders and some secondary outcomes are discussed. Recent evidence is synthesized to make clinical recommendations on the assessment and potential management of important autonomic, cerebral hemodynamics, and sleep-related dysfunction in people with SCI. Finally, a few recommendations for clinicians and researchers are provided.

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

Acute Emergent Airway Issues in Sports

Emergent airway issues are rare in competitive sports. However, when airway compromise occurs, the sideline physician will be relied upon to manage the situation and the airway. . The sideline physician is tasked with not only the evaluation of the airway, but also management until the athlete can get to a higher level of care. Familiarity with the assessment of the airway and the various techniques for the management of airway compromise on the sideline are of the utmost importance in the unlikely event that an airway emergency should occur.

Systemic and Pulmonary Inflammation/Oxidative Damage: Implications of General and Respiratory Muscle Training in Chronic Spinal-Cord-Injured Patients

Chronic spinal cord injury affects several respiratory-function-related parameters, such as a decrease in respiratory volumes associated with weakness and a tendency to fibrosis of the perithoracic muscles, a predominance of vagal over sympathetic action inducing airway obstructions, and a difficulty in mobilizing secretions. Altogether, these changes result in both restrictive and obstructive patterns. Moreover, low pulmonary ventilation and reduced cardiovascular system functionality (low venous return and right stroke volume) will hinder adequate alveolar recruitment and low O₂ diffusion, leading to a drop in peak physical performance. In addition to the functional effects described above, systemic and localized effects on this organ chronically increase oxidative damage and tissue inflammation. This narrative review describes both the deleterious effects of chronic spinal cord injury on the functional effects of the respiratory system as well as the role of oxidative damage/inflammation in this clinical context. In addition, the evidence for the effect of general and respiratory muscular training on the skeletal muscle as a possible preventive and treatment strategy for both functional effects and underlying tissue mechanisms is summarized.

Noninvasive respiratory assistance as aid for respiratory care in neuromuscular disorders

Chronic respiratory failure is a common complication of neuromuscular disease. The use of noninvasive ventilation and mechanically assisted cough can reduce symptoms of hypoventilation, slow lung function decline, improve sleep quality, and in some cases prolong survival in patients with neuromuscular disease. In this article, we review indications for the initiation of noninvasive ventilation and mechanically assisted cough as well as provide recommendations for settings and titration. We discuss the evidence supporting the use of noninvasive ventilation as an adjunct to rehabilitation in patients with neuromuscular disease. Lastly, we review the ethical considerations that are relevant to decisions regarding initiation and cessation of noninvasive ventilation. While noninvasive ventilation and mechanically assisted cough have become standards of care in many forms of neuromuscular disease, most current recommendations are based on expert opinion rather than much-needed data from prospective clinical trials and we emphasize topics requiring future research.

Cervical spinal cord injury leads to injury and altered metabolism in the lungs

High-cervical spinal cord injury often disrupts respiratory motor pathways and disables breathing in the affected population. Moreover, cervically injured individuals are at risk for developing acute lung injury, which predicts substantial mortality rates. While the correlation between acute lung injury and spinal cord injury has been found in the clinical setting, the field lacks an animal model to interrogate the fundamental biology of this relationship. To begin to address this gap in knowledge, we performed an experimental cervical spinal cord injury (N = 18) alongside sham injury (N = 3) and naïve animals (N = 15) to assess lung injury in adult rats. We demonstrate that animals display some early signs of lung injury two weeks post-spinal cord injury. While no obvious histological signs of injury were observed, the spinal cord injured cohort displayed significant signs of metabolic dysregulation in multiple pathways that include amino acid metabolism, lipid metabolism, and N-linked glycosylation. Collectively, we establish for the first time a model of lung injury after spinal cord injury at an acute time point that can be used to monitor the progression of lung damage, as well as identify potential targets to ameliorate acute lung injury.

Acute Management of Cervical Spinal Cord Injuries

Traumatic cervical spinal cord injury can cause significant neurologic disability. A cervical spine injury impacts not only the neurologic system but also numerous other organ systems of the body. This complex injury requires a systematic approach to assessment and care aimed at preventing, recognizing, and treating potentially devastating secondary spinal cord injury and multisystem complications. This article focuses on the pathophysiology, initial presentation, and treatment of cervical spinal cord injury by body system.

Respiratory Complications and Weaning Considerations for Patients with Spinal Cord Injuries: A Narrative Review

Respiratory complications following traumatic spinal cord injury are common and are associated with high morbidity and mortality. The inability to cough and clear secretions coupled with weakened respiratory and abdominal muscles commonly leads to respiratory failure, pulmonary edema, and pneumonia. Higher level and severity of the spinal cord injury, history of underlying lung pathology, history of smoking, and poor baseline health status are potential predictors for patients that will experience respiratory complications. For patients who may require prolonged intubation, early tracheostomy has been shown to lead to improved outcomes. Prediction models to aid clinicians with the decision and timing of tracheostomy have been shown to be successful but require larger validation studies in the future. Mechanical ventilation weaning strategies also require further investigation but should focus on a combination of optimizing ventilator setting, pulmonary toilet techniques, psychosocial well-being, and an aggressive bowel regimen.

Translation and validation into Portuguese of the international spinal cord injury pulmonary function basic data set

INTRODUCTION

Spinal cord injury (SCI) is a serious disabling syndrome, and the clinical picture depends on the level and extent of the injury. The International Spinal Cord Society (ISCoS) and the American Spinal Cord Association (ASIA) have developed instruments (Data Sets) to assess the various aspects of the SCI. In 2012, the International SCI Pulmonary Function Basic Data Set was elaborated. It is composed of four questions and spirometry for the collection of lung function basic data.

OBJECTIVE

The objective was to translate and validate the International SCI Pulmonary Function Basic Data Set to the Portuguese language.

METHODS

The entire methodology followed the recommendations of the ISCoS and ASIA. Two translations of the original version into Portuguese were performed, and after consensus among the translators, the Portuguese version was sent for back-translation. After back-translation and comparison with the original version, the final Portuguese version was obtained. For the second phase of the study, 30 SCI individuals were selected. Two interviewers applied the questionnaire in two distinct moments.

RESULTS

All results presented constant, excellent, or perfectly concordant data, except for the third question in the inter-rater comparison, where the Kappa coefficient showed value reasonable in the first interview and good in the second.

CONCLUSION

The translation into Brazilian Portuguese of the "International SCI Pulmonary Function Basic Data Set" created a valid and highly reliable instrument, like the original without linguistic and cultural disagreements that allow its use in the evaluation of patients with SCI in Brazil.

Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury

The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a spinal cord injury (SCI), supraspinal influences on the spinal segmental control system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, pain and dysesthesia, sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of traumatic SCI, current and emerging methods of classification, and its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue.

Autonomic Dysfunction and Management after Spinal Cord Injury: A Narrative Review

The autonomic nervous system (ANS), composed of the sympathetic and parasympathetic nervous systems, acts to maintain homeostasis in the body through autonomic influences on the smooth muscle, cardiac muscles, blood vessels, glands and organs of the body. The parasympathetic nervous system interacts via the cranial and sacral segments of the central nervous system, and the sympathetic nervous system arises from the T1–L2 spinal cord segments. After a spinal cord injury (SCI), supraspinal influence on the ANS is disrupted, leading to sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. Further, afferent signals to the sympathetic cord elicit unabated reflex sympathetic outflow in response to noxious stimuli below the level of SCI. This article outlines the pathophysiology of SCI on the ANS, clinical ramifications of autonomic dysfunction, and the potential long-term sequelae of these influences following SCI.

Treadmill training improves respiratory function in rats after spinal cord injury by inhibiting the HMGB1/TLR-4/NF-κB signaling pathway

OBJECTIVE

To investigate the effects of treadmill training on lung injury and HMGB1/TLR4/NF-κB after spinal cord injury (SCI) in rats.

METHODS

A total of 108 female SD rats were randomly divided into three groups: sham operation group, SCI brake group, and SCI exercise group. The rats in the SCI exercise group began treadmill running training on the 3rd day after the operation. The rats in the SCI brake group underwent braking treatment. The lung tissues were obtained on the 3rd, 7th, and 14th days after exercise. Locomotor functional recovery was determined using the BBB scores and inclined plane test. Respiratory function was determined via abdominal aortic blood gas analysis. HE staining was used to detect pathological changes in rat lung tissue. RNA sequencing was used to identify differentially expressed genes at different phases in each group of lung tissues. HMGB1, TLR4, and NF-κB in lung tissue were detected using immunohistochemistry and immunofluorescence. Detection of HMGB1 levels in serum, spinal cord tissues and lung tissues by ELISA. HMGB1, TLR4, NF-κB, IL-1β, IL-6, TNF-α mRNA, and protein expression levels were detected via qRT PCR and western blot.

RESULTS

Motor and respiratory functions significantly decreased after SCI (P<0.05). However, locomotion and respiratory functions were significantly improved after treadmill training intervention (P < 0.05). HE staining showed that interstitial thickening, inflammatory cells, and erythrocyte infiltration occurred in lung tissue of rats after SCI (P<0.05). Moreover, inflammatory reaction in lung tissue was significantly reduced after treadmill training intervention (P<0.05). A total of 428 differentially expressed mRNAs [(|log2(FC)| > 2, P < 0.05)] were identified in the intersection of the three groups. KEGG analysis identified five enriched signal pathways, including NF-kappa B. ELISA results showed that treadmill training could significantly reduce the levels of HMGB1 in serum, spinal cord tissue and lung tissue that were elevated after SCI (P < 0.05). Immunohistochemistry, immunofluorescence, qRT PCR, and Western blot showed that HMGB1, TLR4, IL-1β, IL-6, TNF-α, and NF-κB expressions were significantly up-regulated at the 3rd, 7th and 14th days after SCI, compared with the sham operation group. Besides, inflammatory cytokines were significantly lower in the SCI exercise group than in the SCI brake group at all time points after intervention (P < 0.05).

CONCLUSION

Treadmill training alleviates lung tissue inflammation and promotes recovery of motor and respiratory functions by inhibiting the HMGB1/TLR4/NF-κB signaling pathway after SCI in rats.

Inflammation and Oxidative Stress as Common Mechanisms of Pulmonary, Autonomic and Musculoskeletal Dysfunction after Spinal Cord Injury

Simple Summary

When a spinal cord injury occurs, the neurons that regulate our voluntary movements, those involved in environment and somatic perception and those that regulate vegetative functions are affected. Once neuronal damage is established, the cells of other tissues are also affected in their functions, altering the interaction between organs and altering the proper functioning of the organism. Multiple studies in animal models, as well as in humans, have recognized as factors involved in organ damage the imbalance between the formation of highly reactive molecules called pro-oxidants and defensive mechanisms called antioxidants. Closely associated with this phenomenon, the inflammatory response is also pathologically activated. In this narrative review, we have analyzed the information involving these pathological processes at the level of the lung, the autonomic nervous system and the skeletal musculature after spinal cord injury. Knowing the abnormal functioning mechanisms that occur after a spinal cord injury not only offers a better understanding of the organic events but also offers future possibilities for therapeutic interventions that may benefit the thousands of patients suffering this pathology.

Abstract

One of the etiopathogenic factors frequently associated with generalized organ damage after spinal cord injury corresponds to the imbalance of the redox state and inflammation, particularly of the respiratory, autonomic and musculoskeletal systems. Our goal in this review was to gain a better understanding of this phenomenon by reviewing both animal and human studies. At the respiratory level, the presence of tissue damage is notable in situations that require increased ventilation due to lower thoracic distensibility and alveolar inflammation caused by higher levels of leptin as a result of increased fatty tissue. Increased airway reactivity, due to loss of sympathetic innervation, and levels of nitric oxide in exhaled air that are similar to those seen in asthmatic patients have also been reported. In addition, the loss of autonomic control efficiency leads to an uncontrolled release of catecholamines and glucocorticoids that induce immunosuppression, as well as a predisposition to autoimmune reactions. Simultaneously, blood pressure regulation is altered with vascular damage and atherogenesis associated with oxidative damage. At the muscular level, chronically elevated levels of prooxidants and lipoperoxidation associated with myofibrillar atrophy are described, with no reduction or reversibility of this process through antioxidant supplementation.

Preliminary Study of an Adjustable, Wearable, Noninvasive Vest Providing Chest Compression to Assist with Breathing

Respiratory muscle paralysis caused by acute cervical spinal cord injury usually leads to pulmonary ventilation dysfunction and even death from respiratory failure. In addition to invasive treatments such as mechanical ventilation, the utilization of noninvasive respiratory support equipment plays an important role in long-term assisted breathing. In this study, we describes a wearable, noninvasive vest with adjustable pressure that enables assisted breathing and with an automatic alarm, and we aims to explore its safety and effectiveness on healthy adult participants. The vest monitors the human heart rate and the blood oxygen index data in real time, the alarm is automatically activated when the data is abnormal. Eight healthy participants had no obvious discomfort during the test while wearing the vest. Lung volumes, antero-posterior diameters, and left-right diameters at the second, fourth, and sixth ribs levels were acquired before and after inflation of the vest airbag, the data acquired by the imaging analysis using chest computed tomography showed significant differences before and after the inflation (p < 0.05). Thus, The vest designed for this study can achieve uniform and effective compression of the thorax, significantly changed the size of the thorax and lungs. It is expected to be applied as noninvasive support for patients with respiratory dysfunction.

Soft Exoskeleton Mimics Human Cough for Assisting the Expectoration Capability of SCI Patients

OBJECTIVE

This paper describes the design of a bionic soft exoskeleton and demonstrates its feasibility for assisting the expectoration function rehabilitation of patients with spinal cord injury (SCI).

METHODS

A human-robot coupling respiratory mechanic model is established to mimic human cough, and a synergic inspire-expire assistance strategy is proposed to maximize the peak expiratory flow (PEF), the key metric for promoting cough intensity. The negative pressure module of the exoskeleton is a soft "iron lung" using layer-jamming actuation. It assists inspiration by increasing insufflation to mimic diaphragm and intercostal muscle contraction. The positive pressure module exploits soft origami actuators for assistive expiration; it pressures human abdomen and bionically "pushes" the diaphragm upward.

RESULTS

The maximum increase in PEF ratios for mannequins, healthy participants, and patients with SCI with robotic assistance were 57.67%, 278.10%, and 124.47%, respectively. The soft exoskeleton assisted one tetraplegic SCI patient to cough up phlegm successfully.

CONCLUSION

The experimental results suggest that the proposed soft exoskeleton is promising for assisting the expectoration ability of SCI patients in everyday life scenarios.

SIGNIFICANCE

The proposed soft exoskeleton is promising for advancing the application field of rehabilitation exoskeletons from motor functions to respiratory functions.

Cystectomy and ileal conduit for neurogenic bladder: Comparison of the open, laparoscopic and robotic approaches

AIM

The objective of the present study was to compare the outcomes of open versus laparoscopic versus robotic cystectomy and ileal conduit for neurogenic lower urinary tract dysfunction (NLUTD).

METHODS

The charts of all patients who underwent cystectomy and ileal conduit for NLUTD between January 2004 and November 2020 in an academic center were retrospectively reviewed. The approach was either open, laparoscopic or robot-assisted depending on the period (i.e., three consecutive era). For the robotic approach, the diversion was done either intracorporeally or extracorporeally. We compared the perioperative and late postoperative outcomes between the three groups.

RESULTS

After exclusion of 10 patients with non-neurogenic benign conditions, 126 patients were included over the study period. The most frequent neurological conditions were multiple sclerosis (36.5%) and spinal cord injury (25.4%). The approach was open, laparoscopic or robot-assisted in 31 (24.6%), 26 (20.6%) and 69 (54.7%) cases respectively. Seventy-two patients experienced a 90-day postoperative complication (57.1%) of which 22 had a major complication (Clavien 3 or higher, 17.5%) including one death (0.8%). The rate of major postoperative complications was significantly lower in the robotic group (23% vs. 23% vs. 10%; p = 0.049) while the rate of overall complications was comparable across the three groups (58.1% vs. 53.9% vs. 60.6%; p = 0.84). After a median follow-up of 23 months, 22 patients presented a late complication (17.6%), mainly incisional hernia (5; 4%) and uretero-ileal stricture (9; 7.2%). The rate of late complications did not differ significantly between the three approaches.

CONCLUSION

Cystectomy and ileal conduit for neurogenic bladder is associated with a relatively high perioperative morbidity. The robot-assisted approach may decrease the risk of major postoperative complications.

Spinal cord injury: A multisystem physiological impairment/dysfunction

Spinal cord injury (SCI) is a complex disease that affects not only sensory and motor pathways below the neurological level of injury (NLI) but also all the organs and systems situated below this NLI. This multisystem impairment implies comprehensive management in dedicated SCI specialized centers, by interdisciplinary and multidisciplinary teams, able to treat not only the neurological impairment, but also all the systems and organs affected. After a brief history of the Spinal Cord Medicine, the author describes how to determine the level and severity of a SCI based on the International Standards for Neurological Classification of Spinal Cord Injury and the prognosis factors of recovery. This article provides also a review of the numerous SCI-related impairments (except for urinary, sexual problems and pain treated separately in this issue), their principles of management and related complications.

Targeting axon guidance cues for neural circuit repair after spinal cord injury

At least two-thirds of spinal cord injury cases are anatomically incomplete, without complete spinal cord transection, although the initial injuries cause complete loss of sensory and motor functions. The malleability of neural circuits and networks allows varied extend of functional restoration in some individuals after successful rehabilitative training. However, in most cases, the efficiency and extent are both limited and uncertain, largely due to the many obstacles of repair. The restoration of function after anatomically incomplete injury is in part made possible by the growth of new axons or new axon branches through the spared spinal cord tissue and the new synaptic connections they make, either along the areas they grow through or in the areas they terminate. This review will discuss new progress on the understanding of the role of axon guidance molecules, particularly the Wnt family proteins, in spinal cord injury and how the knowledge and tools of axon guidance can be applied to increase the potential of recovery. These strategies, combined with others, such as neuroprotection and rehabilitation, may bring new promises. The recovery strategies for anatomically incomplete spinal cord injuries are relevant and may be applicable to traumatic brain injury and stroke.

Clinical guidelines for neurorestorative therapies in spinal cord injury (2021 China version)

Treatment of spinal cord injury (SCI) remains challenging. Considering the rapid developments in neurorestorative therapies for SCI, we have revised and updated the Clinical Therapeutic Guidelines for Neurorestoration in Spinal Cord Injury (2016 Chinese version) of the Chinese Association of Neurorestoratology (Preparatory) and China Committee of International Association of Neurorestoratology. Treatment of SCI is a systematic multimodal process that aims to improve survival and restore neurological function. These guidelines cover real-world comprehensive neurorestorative management of acute, subacute, and chronic SCI and include assessment and diagnosis, pre-hospital first aid, treatment, rehabilitation, and complication management.

Initial assessment and management of respiratory infections in persons with spinal cord injuries and disorders in the COVID-19 era

As the COVID-19 pandemic unfolds, emergency department (ED) personnel will face a higher caseload, including those with special medical needs such as persons living with spinal cord injuries and disorders (SCI/D). Individuals with SCI/D who develop COVID-19 are at higher risk for rapid decompensation and development of acute respiratory failure during respiratory infections due to the combination of chronic respiratory muscle paralysis and autonomic dysregulation causing neurogenic restrictive/obstructive lung disease and chronic immune dysfunction. Often, acute respiratory infections will lead to significant mucus production in individuals with SCI/D, and aggressive secretion management is an important component of successful medical treatment. Secretion management techniques include nebulized bronchodilators, chest percussion/drainage techniques, manually assisted coughing techniques, nasotracheal suctioning, and mechanical insufflation-exsufflation. ED professionals, including respiratory therapists, should be familiar with the significant comorbidities associated with SCI/D and the customized secretion management procedures and techniques required for optimal medical management and prevention of respiratory failure. Importantly, protocols should also be implemented to minimize potential COVID-19 spread during aerosol-generating procedures.

A Primary Care Provider's Guide to Preventive Health After Spinal Cord Injury

Objective: Provide guidance for preventive health and health maintenance after spinal cord injury (SCI) for primary care providers (PCPs). Main message: Individuals with SCI may not receive the same preventive health care as the general population. Additionally, SCI-related secondary conditions may put their health at risk. SCI is considered a complex condition associated with many barriers to receiving quality primary care. Attention to routine preventive care and the unique health considerations of persons with SCI can improve health and quality of life and may prevent unnecessary health care utilization. Conclusion: PCPs are experts in preventive care and continuity of care, however individuals with SCI may not receive the same preventive care due to numerous barriers. This article serves as a quick reference for PCPs.

Respiratory complications during initial rehabilitation and survival following spinal cord injury in Sweden: a retrospective study

Study design

Retrospective study.

Objectives

To determine prevalence of respiratory complications in individuals with spinal cord injury (SCI) during the initial rehabilitation at the spinal cord injury unit (SCU) and to describe the subsequent effect on mortality.

Setting

The SCU at the university hospital in Gothenburg, Sweden.

Methods

We reviewed the medical charts of newly injured persons with SCI who were admitted to the SCU between 1/1/2010 and 12/31/2014. Outcome measures were time to death, length of stay, occurrence of respiratory complications, and the use of breathing aids.

Results

A total of 136 consecutive individuals were included; 53% with cervical SCI and 20% with lower SCI suffered from one or several respiratory complications during their initial rehabilitation in the SCU. At follow-up, 10/1/2018, 20% of the individuals were deceased. The most common cause of death was related to respiratory insufficiency. The individuals with respiratory complications during the initial rehabilitation in the SCU had particularly shortened survival compared with those without. The relative risk (RR) of dying if the person suffered from any respiratory complications during their initial rehabilitation in the SCU was 2.1 times higher than for those with no respiratory complications (RR, 2.1; 95% CI, 1.1–3.9).

Conclusions

Having respiratory complications at the SCU provides preliminary data to support the claim that respiratory complications predict premature mortality. Early diagnosis and prophylactic measures seem to be necessary to mitigate the adverse consequences of serious respiratory problems.

A Primary Care Provider's Guide to Managing Respiratory Health in Subacute and Chronic Spinal Cord Injury

Respiratory complications following spinal cord injury (SCI) have remained the leading cause of death across the lifespan and are one of the most common reasons for hospitalization. Complications from altered respiratory physiology after SCI include atelectasis, pneumonia, venous thromboembolic disease, and sleep-disordered breathing. The risk for complications is greater with higher SCI levels and severity, and mortality from pneumonia is heightened compared to the general population. Optimal primary care for individuals with SCI includes appropriate surveillance for SCI-specific respiratory disease, key preventive care including promotion of influenza immunization and respiratory muscle training, and early identification and treatment of pneumonia with institution of aggressive secretion management strategies. The respiratory physiology and specific management of respiratory complications after SCI is reviewed.

Guideline for diagnosis and treatment of spine trauma in the epidemic of COVID-19

Outbreak of COVID-19 is ongoing all over the world. Spine trauma is one of the most common types of trauma and will probably be encountered during the fight against COVID-19 and resumption of work and production. Patients with unstable spine fractures or continuous deterioration of neurological function require emergency surgery. The COVID-19 epidemic has brought tremendous challenges to the diagnosis and treatment of such patients. To coordinate the diagnosis and treatment of infectious disease prevention and spine trauma so as to formulate a rigorous diagnosis and treatment plan and to reduce the disability and mortality of the disease, multidisciplinary collaboration is needed. This expert consensus is formulated in order to (1) prevent and control the epidemic, (2) diagnose and treat patients with spine trauma reasonably, and (3) reduce the risk of cross-infection between patients and medical personnel during the treatment.

Spinal cord injury in infancy: activity-based therapy impact on health, function, and quality of life in chronic injury

Introduction

Spinal cord injury (SCI) in infancy magnifies the complexity of a devastating diagnosis. Children injured so young have high incidences of scoliosis, hip dysplasia, and respiratory complications leading to poor health and outcomes. We report the medical history, progression of rehabilitation, usual care and activity-based therapy, and outcomes for a child injured in infancy. Activity-based therapy (ABT) aims to activate the neuromuscular system above and below the lesion through daily, task-specific training to improve the neuromuscular capacity, and outcomes for children with acquired SCI.

Case presentation

A 3-month-old infant suffered a cervical SCI from a surgical complication with resultant tetraplegia. Until age 3, her medical complications included scoliosis, kyphosis, and pneumonia. Even with extensive physical and occupational therapy, she was fully dependent on caregivers for mobility and unable to roll, come to sit, sit, stand or walk. She initiated ABT at ~3 years old, participating for 8 months. The child’s overall neuromuscular capacity improved significantly, especially for head and trunk control, contributing to major advances in respiratory health, novel engagement with her environment, and improved physical abilities.

Discussion

From injury during infancy until 3 years old, this child’s health, abilities, and complications were consistent with the predicted path of early-onset SCI. Due to her age at injury, severity and chronicity of injury, she demonstrated unexpected, meaningful changes in her neuromuscular capacity during and post-ABT associated with improved health, function and quality of life for herself and her caregivers.

Identification of the potential dual inhibitor of protein tyrosine phosphatase sigma and leukocyte common antigen-related phosphatase by virtual screen, molecular dynamic simulations and post-analysis

Owing to their inhibitory role in regulating oligodendrocyte differentiation and apoptosis, protein tyrosine phosphatase sigma (PTPσ) and leukocyte common antigen-related phosphatase (LAR) play a crucial potential role in treating spinal cord injury (SCI) disease. In this research, the computer aided drug design (CADD) methods were applied to discover the potential dual-target drug involving virtual screen, molecular docking and molecular dynamic simulation. Initially, the top 20 compounds with higher docking score than the positive controls (ZINC13749892, ZINC14516161) were virtually screened out from NCI and ZINC databases, and then were submitted in ADMET to predict their drug properties. Among these potential compounds, ZINC72417086 showed a higher docking score and satisfied Lipinski's rule of five. In addition, the post-analysis demonstrated that when ZINC72417086 bound to PTPσ and LAR, it could stable proteins conformations and destroy the residues interactions between P-loop and other loop regions in active pocket. Meanwhile, residue ARG1595 and ARG1528 could play a crucial role in in the inhibition of PTPσ and LAR, respectively. This research offered a novel approach for rapid discovery of dual-target leads compounds to treat SCI.Communicated by Ramaswamy H. Sarma.

Acute Adverse Events After Spinal Cord Injury and Their Relationship to Long-term Neurologic and Functional Outcomes: Analysis From the North American Clinical Trials Network for Spinal Cord Injury

OBJECTIVES

There are few contemporary, prospective multicenter series on the spectrum of acute adverse events and their relationship to long-term outcomes after traumatic spinal cord injury. The goal of this study is to assess the prevalence of adverse events after traumatic spinal cord injury and to evaluate the effects on long-term clinical outcome.

DESIGN

Multicenter prospective registry.

SETTING

Consortium of 11 university-affiliated medical centers in the North American Clinical Trials Network.

PATIENTS

Eight-hundred one spinal cord injury patients enrolled by participating centers.

INTERVENTIONS

Appropriate spinal cord injury treatment at individual centers.

MEASUREMENTS AND MAIN RESULTS

A total of 2,303 adverse events were recorded for 502 patients (63%). Penalized maximum logistic regression models were fitted to estimate the likelihood of neurologic recovery (ASIA Impairment Scale improvement ≥ 1 grade point) and functional outcomes in subjects who developed adverse events at 6 months postinjury. After accounting for potential confounders, the group that developed adverse events showed less neurologic recovery (odds ratio, 0.55; 95% CI, 0.32-0.96) and was more likely to require assisted breathing (odds ratio, 6.55; 95% CI, 1.17-36.67); dependent ambulation (odds ratio, 7.38; 95% CI, 4.35-13.06) and have impaired bladder (odds ratio, 9.63; 95% CI, 5.19-17.87) or bowel function (odds ratio, 7.86; 95% CI, 4.31-14.32) measured using the Spinal Cord Independence Measure subscores.

CONCLUSIONS

Results from this contemporary series demonstrate that acute adverse events are common and are associated with worsened long-term outcomes after traumatic spinal cord injury.

Quantitative changes in perineuronal nets in development and posttraumatic condition

Perineuronal net (PNN) is a highly structured portion of the CNS extracellular matrix (ECM) regulating synaptic plasticity and a range of pathologic conditions including posttraumatic regeneration and epilepsy. Here we studied Wisteria floribunda agglutinin-stained histological sections to quantify the PNN size and enrichment of chondroitin sulfates in mouse brain and spinal cord. Somatosensory cortex sections were examined during the period of PNN establishment at postnatal days 14, 21 and 28. The single cell PNN size and the chondroitin sulfate intensity were quantified for all cortex layers and specifically for the cortical layer IV which has the highest density of PNN-positive neurons. We demonstrate that the chondroitin sulfate proteoglycan staining intensity is increased between P14 and P28 while the PNN size remains unchanged. We then addressed posttraumatic changes of the PNN expression in laminae 6 and 7 of cervical spinal cord following hemisection injury. We demonstrate increase of the chondroitin sulfate content at 1.6-1.8 mm rostrally from the injury site and increase of the density of PNN-bearing cells at 0.4-1.2 mm caudally from the injury site. We further demonstrate decrease of the single cell PNN area at 0.2 mm caudally from the injury site suggesting that the PNN ECM takes part in the posttraumatic tissue rearrangement in the spinal cord. Our results demonstrate new insights on the PNN structure dynamics in the developing and posttraumatic CNS.