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Wang Y, Zhang J, Yuan J, Li Q, Zhang S, Wang C, Wang H, Wang L, Zhang B, Wang C, Sun Y, Lu X. Application of a novel nested ensemble algorithm in predicting motor function recovery in patients with traumatic cervical spinal cord injury. Sci Rep 2024; 14:17403. [PMID: 39075134 PMCID: PMC11286788 DOI: 10.1038/s41598-024-65755-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/24/2024] [Indexed: 07/31/2024] Open
Abstract
Traumatic cervical spinal cord injury (TCSCI) often causes varying degrees of motor dysfunction, common assessed by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale. Accurate prediction of motor function recovery is extremely important for formulating effective diagnosis, therapeutic and rehabilitation programs. The aim of this study is to investigate the validity of a novel nested ensemble algorithm that uses the very early ASIA motor score (AMS) of ISNCSCI examination to predict motor function recovery 6 months after injury in TCSCI patients. This retrospective study included complete data of 315 TCSCI patients. The dataset consisting of the first AMS at ≤ 24 h post-injury and follow-up AMS at 6 months post-injury was divided into a training set (80%) and a test set (20%). The nested ensemble algorithm was established in a two-stage manner. Support Vector Classification (SVC), Adaboost, Weak-learner and Dummy were used in the first stage, and Adaboost was selected as second-stage model. The prediction results of the first stage models were uploaded into second-stage model to obtain the final prediction results. The model performance was evaluated using precision, recall, accuracy, F1 score, and confusion matrix. The nested ensemble algorithm was applied to predict motor function recovery of TCSCI, achieving an accuracy of 80.6%, a F1 score of 80.6%, and balancing sensitivity and specificity. The confusion matrix showed few false-negative rate, which has crucial practical implications for prognostic prediction of TCSCI. This novel nested ensemble algorithm, simply based on very early AMS, provides a useful tool for predicting motor function recovery 6 months after TCSCI, which is graded in gradients that progressively improve the accuracy and reliability of the prediction, demonstrating a strong potential of ensemble learning to personalize and optimize the rehabilitation and care of TCSCI patients.
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Affiliation(s)
- Yijin Wang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jianjun Zhang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jincan Yuan
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Qingyuan Li
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
| | - Shiyu Zhang
- UCSI University, No. 1, Jalan UCSI, UCSI Heights, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Chenfeng Wang
- Zhejiang University, No. 866 Yuhangtang Road, Xihu District, Hangzhou, 310058, Zhejiang, People's Republic of China
| | - Haibing Wang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Liang Wang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Bangke Zhang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Can Wang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Yuling Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
| | - Xuhua Lu
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
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Juszczak M, Shem K, Elliott CS. The Role of Upper Extremity Motor Function in the Choice of Bladder Management in Those Unable to Volitionally Void due to Neurologic Dysfunction. Urol Clin North Am 2024; 51:263-275. [PMID: 38609198 DOI: 10.1016/j.ucl.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
It is estimated that 425,000 individuals with neurologic bladder dysfunction (spinal cordinjury, spina bifida and multiple sclerosis) are unable to volitionally void and must rely oncatheter drainage. Upper extremity (UE) motor function is one of the most important factors indetermining the type of bladder management chosen in individuals who cannot volitionally void. Novel bladder management solutions for those with impaired UE motor function and concurrent impairments involitional voiding continue to be an area of need. Those with poor UE motor function more often choose an indwelling catheter, whereas those with normal UE motor function more often choose clean intermittent catheterization.
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Affiliation(s)
- Michael Juszczak
- Department of Physical Medicine and Rehabilitation, Tower Health, Reading Hospital Rehabilitation at Wyomissing, Reading, PA 19610, USA
| | - Kazuko Shem
- Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA 95128, USA
| | - Christopher S Elliott
- Division of Urology, Department of Urology, Stanford University Medical Center, Santa Clara Valley Medical Center, Valley Specialties Center-Division of Urology, 4th Floor, 751 South Bascom Avenue, San Jose, CA 95128, USA.
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Zipser CM, Curt A. Disease-specific interventions using cell therapies for spinal cord disease/injury. HANDBOOK OF CLINICAL NEUROLOGY 2024; 205:263-282. [PMID: 39341658 DOI: 10.1016/b978-0-323-90120-8.00007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Traumatic spinal cord injury (SCI) may occur across the lifespan and is of global relevance. Damage of the spinal cord results in para- or tetraplegia and is associated with neuropathic pain, spasticity, respiratory, and autonomic dysfunction (i.e., control of bladder-bowel function). While the acute surgical treatment aims at stabilizing the spine and decompressing the damaged spinal cord, SCI patients require neurorehabilitation to restore neural function and to compensate for any impairments including motor disability, pain treatment, and bladder/bowel management. However, the spinal cord has a limited capacity to regenerate and much of the disability may persist, depending on the initial lesion severity and level of injury. For this reason, and the lack of effective drug treatments, there is an emerging interest and urgent need in promoting axonal regeneration and remyelination after SCI through cell- and stem-cell based therapies. This review briefly summarizes the state-of the art management of acute SCI and its neurorehabilitation to critically appraise phase I/II trials from the last two decades that have investigated cell-based therapies (i.e., Schwann cells, macrophages, and olfactory ensheathing cells) and stem cell-based therapies (i.e., neural stem cells, mesenchymal, and hematopoietic stem cells). Recently, two large multicenter trials provided evidence for the safety and feasibility of neural stem cell transplantation into the injured cord, whilst two monocenter trials also showed this to be the case for the transplantation of Schwann cells into the posttraumatic cord cavity. These are milestone studies that will facilitate further interventional trials. However, the clinical adoption of such approaches remains unproven, as there is only limited encouraging data, often in single patients, and no proven trial evidence to support regulatory approval.
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Affiliation(s)
- Carl Moritz Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.
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Mackenzie L, Tan E, Benad L. Computer-assisted robotic device for upper limb interventions for a patient with an incomplete cervical level spinal cord injury. BMJ Case Rep 2023; 16:e253570. [PMID: 37802598 PMCID: PMC10565334 DOI: 10.1136/bcr-2022-253570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
A man in his 50s with an incomplete cervical spinal cord injury underwent a 3-week occupational therapy programme using a computer-assisted robotic device for the upper limbs (Diego) in an acute care spinal injury unit. The patient and their partner reported their experience. Range of motion (ROM), muscle strength, pain, fatigue, independence and occupational performance are reported. Improvements occurred in upper limb ROM (shoulder and elbow), muscle strength (right elbow extensors), fatigue and functional status. Whether the results in this patient with the Diego were the same or better than standard care could not be determined. Preliminary findings suggest that the Diego was feasible for rehabilitation in an acute setting in our patient. However, it may not be suitable for all patients and a large comparative study with other therapies is needed. A limitation in the use of the Diego relates to the initial cost of the device ($A150 000).
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Affiliation(s)
- Lynette Mackenzie
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Emma Tan
- Occupational Therapy Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Lisa Benad
- Occupational Therapy Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Garside T, Stanford R, Flower O, Li T, Dababneh E, Hammond N, Bass F, Middleton J, Tang J, Ball J, Delaney A. Acute assessment of spinal cord injury in New South Wales: A retrospective study of current practice in two spinal cord injury referral centers. J Spinal Cord Med 2023:1-8. [PMID: 37707355 DOI: 10.1080/10790268.2023.2247625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Interventions provided in the early phases after spinal cord injury (SCI) may improve neurological recovery and provide for best possible functional outcomes. Knowing this relies on early and clear documentation of the level and grade of the spinal cord injury. Guidelines advocate for early documentation of neurological status within 72 h of injury to allow early prognostication and to help guide initial management. It is unclear whether this is current practice in New South Wales (NSW). METHODS Patients with acute SCI who were admitted to two SCI referral centers during 2018-2019 in NSW were included. Data relating to documentation of neurological status, timing of imaging, surgery and transfer to spinal cord injury center were collected and summarized using descriptive statistics. RESULTS Only 18 percent of patients had an acceptable neurological examination according to the International Standards for Classification of Spinal Cord Injury (ISNCSCI) within 72 h of injury (either not done, or unable to determine the neurological level of injury). At the first neurological examination, the neurological level of injury and grade was unable to be determined in 26.8% of patients and 29.9% of patients respectively. At discharge from acute care and transfer to rehabilitation, the neurological level was undetermined in 28.9% of patients and grade undetermined in 26.8%. ISNCSCI examination was most commonly performed by spinal rehabilitation doctors after patients were discharged from the intensive care unit (ICU). CONCLUSIONS Documentation of neurological level and grade of SCI within 72 h of injury is not being performed in the large majority of this cohort, which may impede evaluation of neurological improvement in response to acute treatment, and hinder prognostication.
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Affiliation(s)
- Tessa Garside
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - Ralph Stanford
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Oliver Flower
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Trent Li
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Edward Dababneh
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - Frances Bass
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - James Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and The University of Sydney, Sydney, Australia
| | - Jonathan Tang
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Jonathan Ball
- Department of Neurosurgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
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Rose Hill EJ, Bertelli JA. Spinal Cord Injury: Epidemiology, Spontaneous Recovery, and Hand Therapy for the Reconstructive Hand Surgeon. J Hand Surg Am 2023:S0363-5023(23)00031-X. [PMID: 36963997 DOI: 10.1016/j.jhsa.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/13/2022] [Accepted: 01/08/2023] [Indexed: 03/26/2023]
Abstract
People with spinal cord injury (SCI) prioritize hand function above all else as a reconstructive goal, yet remain a markedly undertreated population by hand surgeons. This review article provides an overview of the epidemiology of SCI and the unmet clinical need of these patients. Further, this article outlines the natural history of SCI, including the expected spontaneous recovery over time and the expectations of hand function when treated with hand therapy alone. This review aims to equip reconstructive hand surgeons with a sound understanding of the basic principles of SCI and recovery and provide a rationale for when to intervene with surgery. In the last decade, this field has changed dramatically with the advent of reliable nerve transfers, making referral and surgical intervention time-sensitive. Therefore this review aims to highlight the expectations from hand therapy alone in this group, the urgent need for early referral to allow nerve transfer options to be viable, and the strategies for overcoming the barriers to these referrals. This offers the opportunity for surgeons to expand their tetraplegia practices while maximizing the considerable contributions to the hand function and quality of life of these patients.
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Affiliation(s)
- Elspeth Jane Rose Hill
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT.
| | - Jayme Augusto Bertelli
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil; Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Brazil; Department of Plastic Surgery, Joana de Gusmão Children's Hospital, Florianópolis, Santa Catarina, Brazil
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Zou Z, Kang S, Hou Y, Chen K. Pediatric spinal cord injury with radiographic abnormality: the Beijing experience. Spine J 2023; 23:403-411. [PMID: 36064092 DOI: 10.1016/j.spinee.2022.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal cord injury (SCI) without radiographic abnormality (SCIWORA) is a syndrome that usually occurs in children primarily because of the unique biomechanics of the pediatric spine. We recently found that the histopathological and behavioral effects of SCI with radiographic abnormality (SCIWRA) and SCIWORA are very different from each other in animal models. Although numerous studies were conducted to understand the epidemiological and clinical characteristics of the overall pediatric SCI population and the pediatric SCIWORA population, the characteristics of the pediatric SCIWRA population and their differences from those of the SCIWORA population are poorly understood. PURPOSE To describe the epidemiology and clinical outcomes of pediatric patients with SCIWRA and their differences from those with SCIWORA. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE A total of 47 pediatric SCIWRA patients. OUTCOME MEASURES Epidemiological characteristics, injury severities, functional deficits, and management and recovery outcomes. METHODS Review of all cases with SCIWRA at Beijing Children's Hospital between July 2007 and December 2019 and comparison between the present data and our previous SCIWORA data. RESULTS Of the 187 pediatric SCI patients, 47 had SCIWRA (age: 7.06 ± 3.75 years, male-to-female ratio: 3:2). Main causes of SCIWRA were fall (38%) and traffic accidents (38%). Lesions were often located at multiple levels (62%). Incubation period was 3 ± 18 hours. According to the American Spinal Injury Association impairment scale (AIS), many SCIWRA patients had incomplete impairment (AIS B, 9%; AIS C, 9%; AIS D, 32%). Specifically, many of them had abnormal upper and lower limb muscle powers (55% and 60%), upper and lower limb muscle tones (34% and 49%), sensation (38%), and knee, ankle, and abdominal reflexes (47%, 34%, and 36%). 72% of SCIWRA patients were treated with methylprednisolone, dexamethasone, or both. 81% of them showed neurological improvement before discharge. There was no association between corticosteroid therapy and neurological improvement. Moreover, functional outcomes of their upper and lower limb muscle powers were significantly associated with functional outcomes of their upper and lower limb muscle tones (p < 0.01), respectively. In comparison to the SCIWRA population, the SCIWORA population had a higher ratio of younger and female patients of sports-related thoracic injuries with long incubation period leading to lower-body deficits and complete impairment (p<0.05 or p<0.01). Despite all the differences, their neurological improvement was similar (p>0.05). CONCLUSIONS Demographic differences exist in the SCIWRA population. Corticosteroids do not appear to be effective in the different types of pediatric SCI. Limb muscle tone may be used to evaluate the functional status of limb muscle power. The epidemiological and clinical characteristics of SCIWRA and SCIWORA are very different from each other. It is important to formulate tailor-made prevention, evaluation, and management strategies for the pediatric population to optimize the SCI outcomes.
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Affiliation(s)
- Zhewei Zou
- Department of Neurology, Beijing Children's Hospital, 56 Nanlishi Road, Xicheng, Beijing, 100045, China
| | - Shaoyang Kang
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Yifu Science Hall, 37 Xueyuan Road, Haidian, Beijing, 100191, China
| | - Yuxin Hou
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Yifu Science Hall, 37 Xueyuan Road, Haidian, Beijing, 100191, China
| | - Kinon Chen
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Yifu Science Hall, 37 Xueyuan Road, Haidian, Beijing, 100191, China.
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Balbinot G, Li G, Kalsi-Ryan S, Abel R, Maier D, Kalke YB, Weidner N, Rupp R, Schubert M, Curt A, Zariffa J. Segmental motor recovery after cervical spinal cord injury relates to density and integrity of corticospinal tract projections. Nat Commun 2023; 14:723. [PMID: 36759606 PMCID: PMC9911610 DOI: 10.1038/s41467-023-36390-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Cervical spinal cord injury (SCI) causes extensive impairments for individuals which may include dextrous hand function. Although prior work has focused on the recovery at the person-level, the factors determining the recovery of individual muscles are poorly understood. Here, we investigate the muscle-specific recovery after cervical spinal cord injury in a retrospective analysis of 748 individuals from the European Multicenter Study about Spinal Cord Injury (NCT01571531). We show associations between corticospinal tract (CST) sparing and upper extremity recovery in SCI, which improves the prediction of hand muscle strength recovery. Our findings suggest that assessment strategies for muscle-specific motor recovery in acute spinal cord injury are improved by accounting for CST sparing, and complement person-level predictions.
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Affiliation(s)
- Gustavo Balbinot
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.
- Krembil Research Institute, University Health Network, Toronto, ON, Canada.
- Center for Advancing Neurotechnological Innovation to Application - CRANIA, University Health Network, Toronto, ON, Canada.
| | - Guijin Li
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Sukhvinder Kalsi-Ryan
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Jose Zariffa
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.
- Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, Canada.
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Clinical Prediction Rule Validation for Ambulation Outcome After Traumatic Spinal Cord Injury in a Spanish Population. J Trauma Nurs 2022; 29:201-209. [DOI: 10.1097/jtn.0000000000000662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mohammadzada F, Zipser CM, Easthope CA, Halliday DM, Conway BA, Curt A, Schubert M. Mind your step: Target walking task reveals gait disturbance in individuals with incomplete spinal cord injury. J Neuroeng Rehabil 2022; 19:36. [PMID: 35337335 PMCID: PMC8957135 DOI: 10.1186/s12984-022-01013-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Walking over obstacles requires precise foot placement while maintaining balance control of the center of mass (CoM) and the flexibility to adapt the gait patterns. Most individuals with incomplete spinal cord injury (iSCI) are capable of overground walking on level ground; however, gait stability and adaptation may be compromised. CoM control was investigated during a challenging target walking (TW) task in individuals with iSCI compared to healthy controls. The hypothesis was that individuals with iSCI, when challenged with TW, show a lack of gait pattern adaptability which is reflected by an impaired adaptation of CoM movement compared to healthy controls. Methods A single-center controlled diagnostic clinical trial with thirteen participants with iSCI (0.3–24 years post injury; one subacute and twelve chronic) and twelve healthy controls was conducted where foot and pelvis kinematics were acquired during two conditions: normal treadmill walking (NW) and visually guided target walking (TW) with handrail support, during which participants stepped onto projected virtual targets synchronized with the moving treadmill surface. Approximated CoM was calculated from pelvis markers and used to calculate CoM trajectory length and mean CoM Euclidean distance TW-NW (primary outcome). Nonparametric statistics, including spearman rank correlations, were performed to evaluate the relationship between clinical parameter, outdoor mobility score, performance, and CoM parameters (secondary outcome). Results Healthy controls adapted to TW by decreasing anterior–posterior and vertical CoM trajectory length (p < 0.001), whereas participants with iSCI reduced CoM trajectory length only in the vertical direction (p = 0.002). Mean CoM Euclidean distance TW-NW correlated with participants’ neurological level of injury (R = 0.76, p = 0.002) and CoM trajectory length (during TW) correlated with outdoor mobility score (R = − 0.64, p = 0.026). Conclusions This study demonstrated that reduction of CoM movement is a common strategy to cope with TW challenge in controls, but it is impaired in individuals with iSCI. In the iSCI group, the ability to cope with gait challenges worsened the more rostral the level of injury. Thus, the TW task could be used as a gait challenge paradigm in ambulatory iSCI individuals. Trial registration Registry number/ ClinicalTrials.gov Identifier: NCT03343132, date of registration 2017/11/17. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-022-01013-7.
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Affiliation(s)
- Freschta Mohammadzada
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Carl Moritz Zipser
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Chris A Easthope
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.,Cereneo Foundation, Center for Interdisciplinary Research, 6354, Vitznau, Switzerland
| | - David M Halliday
- Department of Electronic Engineering, University of York, York, YO10 5DD, UK.,York Biomedical Research Institute, University of York, York, UK
| | - Bernard A Conway
- Biomedical Engineering, University of Strathclyde, Glasgow, G4 0NW, UK
| | - Armin Curt
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
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Perioperative major neurologic deficits as a complication of spine surgery. Spinal Cord Ser Cases 2021; 7:81. [PMID: 34518513 DOI: 10.1038/s41394-021-00444-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN Retrospective review of spine surgery patients with new major neurologic complication. OBJECTIVE To define the causes and severity of new neurologic damage to the spinal cord or cauda equina caused by spinal surgery. MATERIALS AND METHODS Consult records were reviewed for all postoperative spine surgery patients referred to a tertiary spinal cord injury rehabilitation center over a 12-year period. Any patients with a new perioperative surgery-related decrement in American Spinal Injury Association (ASIA) Impairment Scale (AIS), loss of bowel or bladder function, or loss of ability to ambulate were examined and final 1-year gaps for neurologic loss reported. RESULTS 64 patients had a new perioperative major neurologic event with: 41% thoracic, 39% cervical, and 20% lumbar; 61% intraoperative, 31% in the immediate 2-week postoperative period, 8% unknown. Chronic myelopathy (44%) was the most common indication. The causes of neurologic injury were postoperative fluid collection (25%), malposition of instrumentation (14%), traumatic decompression (14%), cord infarct (11%), deformity correction (2%), and unknown (34%). Overall, 87% lost the ability to ambulate and 66% lost volitional bowel-bladder control. AIS decrement and loss of ambulation and bowel-bladder function did not differ statistically significantly by surgical indication. However, among the main root causes, traumatic decompressions and cord infarcts had significantly worse neurologic deterioration than fluid collections or malposition of instrumentation. CONCLUSION The relative rate of major neurologic injury in spine surgery is higher in thoracic and cervical cases at spinal cord levels, especially when done for myelopathy, even though lumbar surgeries are most common. The most common causes of neurologic injury were potentially avoidable postoperative fluid collections, malposition of instrumentation, and traumatic decompression.
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Kirshblum S, Snider B, Eren F, Guest J. Characterizing Natural Recovery after Traumatic Spinal Cord Injury. J Neurotrauma 2021; 38:1267-1284. [PMID: 33339474 PMCID: PMC8080912 DOI: 10.1089/neu.2020.7473] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6-9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersy, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Brittany Snider
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Fatma Eren
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - James Guest
- Neurological Surgery, Miller School of Medicine, Miami, Florida, USA
- The Miami Project to Cure Paralysis, Miami, Florida, USA
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Combined botulinum toxin type A and electrical stimulation in individuals with C5-C6 and C6-C7 tetraplegia: a pilot study. Spinal Cord Ser Cases 2020; 6:70. [PMID: 32753629 DOI: 10.1038/s41394-020-0317-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN Single-blind pilot study. OBJECTIVES (1) To evaluate combined BoNT-A injection of spastic antagonistic muscles and ES of wrist extensors in order to improve hand function in incomplete cervical SCI patients. (2) To identify prognostic indicators of hand improvements, as a function of motor levels of injury. SETTING Ten incomplete asymmetric SCI tetraplegics admitted to San Camillo Hospital (Venezia, Italy), who were not able to perform automatic grasping, were enrolled in the study. A better motor level (BML) C6-C7 and worse motor level (WML) C5-C6 were assigned to take into account asymmetric motor strength. METHODS Administration of 100-200 UI BoNT-A per limb into flexor carpi radialis (FCR), extensor digitorum communis (EDC), brachial biceps (BB), and pectoralis major (PM) was performed. This was in conjunction with 6 weeks of 30-min ES sessions repeated three times a day for 6 days a week in wrist extensor muscles, and 6 weeks of 30-min hand rehabilitation for 6 days a week. Assessments included wrist Range of Motion (w-RoM), Modified Ashworth Score (MAS), Functional Independence Measure motor scores (FIM motor), and Nine Hole Peg Test (NHPT). RESULTS Treatments produced a significant reduction in motor spasticity (MAS) and better dexterity (NHPT) in the C6-C7 BML with respect to the WML cases (p level = 0.007; p = 0.01, respectively). FIM motor scores improved more in BML (median: 20; range 20/22) than in WML (median: 10; range 8/17). CONCLUSIONS Hand function improvement, determined by combined BONT-A and ES, was better in C6-C7 than in C5-C6 SCI patients.
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Adedigba JA, Oremakinde AA, Huang B, Maulucci CM, Malomo AO, Shokunbi TM, Adeolu AA. Preliminary Findings After Nonoperative Management of Traumatic Cervical Spinal Cord Injury on a Background of Degenerative Disc Disease: Providing Optimum Patient Care and Costs Saving in a Nigerian Setting. World Neurosurg 2020; 142:246-254. [PMID: 32668334 DOI: 10.1016/j.wneu.2020.07.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We assessed the hypothesis that nonoperative management would be a viable treatment option for patients with underlying degenerative disease who have traumatic cervical spinal cord injury (TCSI) without neurological deterioration and/or spinal instability during hospitalization. METHODS Data were collected prospectively from 2011 to 2016. All the patients had been treated nonoperatively with hard cervical collar immobilization. The clinical parameters assessed included the Frankel grade at presentation and discharge, the occurrence of deep vein thrombosis, urinary tract infection, sphincter dysfunction, and pressure sores. The radiographic data collected included magnetic resonance imaging signal cord changes. P ≤ 0.05 represented a significant association between the Frankel grade at presentation and the outcome parameters. RESULTS A total of 28 patients were included in the present study. Of the patients who had presented with Frankel grade B, 85.71% had improved to a higher grade, 90.91% of the patients with Frankel grade C had improved to a higher grade, and 14.29% of the patients with Frankel grade D had improved to Frankel grade E. All the patients had satisfactory spinal stability, as evidenced by dynamic radiographs, after treatment. CONCLUSION The findings from the present study have shown that nonoperative management can result in improved neurological outcomes for patients with underlying degenerative disease who have experienced TCSI without evidence of neurological deterioration and spinal instability. The Frankel grade at presentation was significantly associated with outcome parameters such as the neurological outcome on discharge and the occurrence of urinary tract infection. The results from the present study could be helpful to neurological surgeons in rural and other low-resource settings because the cost savings realized by nonoperative treatment will not sacrifice the provision of adequate care to their patients.
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Affiliation(s)
- Joseph A Adedigba
- Deparment of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA.
| | | | - Brendan Huang
- Deparment of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Christopher M Maulucci
- Deparment of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Adefolahan O Malomo
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria; Department of Neurological Surgery, University of Ibadan, Ibadan, Nigeria
| | - Temitayo M Shokunbi
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria; Department of Neurological Surgery, University of Ibadan, Ibadan, Nigeria
| | - Augustine A Adeolu
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria; Department of Neurological Surgery, University of Ibadan, Ibadan, Nigeria
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The Functional Impact of the Absence of a Bulbocavernosus Reflex in the Postoperative Period After a Motor-Complete Traumatic Spinal Cord Injury. Am J Phys Med Rehabil 2020; 99:712-718. [PMID: 32032092 DOI: 10.1097/phm.0000000000001398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the impact of the absence of a bulbocavernosus reflex in the postoperative period on the neurological and functional recovery 6-12 mos after a motor-complete traumatic spinal cord injury. DESIGN A retrospective review of a prospective database was completed among 66 patients. The functional and neurological statuses between individuals with and without a bulbocavernosus reflex were compared. A general linear model was used to investigate the association between the postoperative bulbocavernosus reflex status and the functional outcome, using the Spinal Cord Independence Measure. RESULTS Forty percent of the cohort had no bulbocavernosus reflex 5 days after trauma. Individuals with a bulbocavernosus reflex showed a higher rate of American Spinal Injury Association Impairment Scale grade conversion, improvement of the level of injury, and higher functional scores; however, it did not reach a significant level. The bulbocavernosus reflex status in the postoperative period was not significantly associated with the functional status 6-12 mos after injury. CONCLUSIONS Late recovery of the bulbocavernosus reflex in the postoperative period may be associated with poorer neurological and functional outcome for individuals sustaining a motor-complete traumatic spinal cord injury, for which the prognosis estimation is limited. A prospective study including a larger number of patients is necessary to confirm results of this study.
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Atkinson DA, Mendez L, Goodrich N, Aslan SC, Ugiliweneza B, Behrman AL. Muscle Activation Patterns During Movement Attempts in Children With Acquired Spinal Cord Injury: Neurophysiological Assessment of Residual Motor Function Below the Level of Lesion. Front Neurol 2019; 10:1295. [PMID: 31920919 PMCID: PMC6933608 DOI: 10.3389/fneur.2019.01295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/25/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction: Characterization of residual neuromotor capacity after spinal cord injury (SCI) is challenging. The current gold standard for measurement of sensorimotor function after SCI, the International Society for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam, seeks to determine isolated intentional muscle activation, however many individuals with SCI exhibit intentional movements and muscle activation patterns which are not confined to specific joint or muscle. Further, isolated muscle activation is a feature of the neuromuscular system that emerges during development, and thus may not be an appropriate measurement standard for children younger than 6. Methods: We utilized neurophysiological assessment methodology, long studied in adult SCI populations, to evaluate residual neuromotor capacity in 24 children with SCI, as well as 19 typically developing (TD) children. Surface electromyography (EMG) signals were recorded from 11 muscles bilaterally, representing spinal motor output from all regions (i.e., cervical, thoracic, and lumbosacral), during standardized movement attempts. EMG records were subjectively analyzed based on spatiotemporal muscle activation characteristics, while the voluntary response index (VRI) was utilized for objective analysis of unilateral leg movement tasks. Results: Evidence of intentional leg muscle activation below the level of lesion was found in 11/24 children with SCI, and was classified based on activation pattern. Trace activation, bilateral (generalized) activation, and unilateral or isolated activation occurred in 32, 49, and 8% of movement tasks, respectively. Similarly, VRI analyses objectively identified significant differences between TD and SCI children in both magnitude (p < 0.01) and similarity index (p < 0.05) for all unilateral leg movement tasks. Activation of the erector spinae muscles, recorded at the T10–T12 vertebral level, was observed in all children with SCI, regardless of injury level or severity. Conclusions: Residual descending influence on spinal motor circuits may be present after SCI in children. Assessment of multi-muscle activation patterns during intentional movement attempts can provide objective evidence of the presence and extent of such residual muscle activation, and may provide an indicator of motor recovery potential following injury. The presence of residual intentional muscle activation has important implications for rehabilitation following pediatric-onset SCI.
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Affiliation(s)
- Darryn A Atkinson
- Doctor of Physical Therapy Program, University of St. Augustine for Health Sciences, Austin, TX, United States
| | - Laura Mendez
- Kosair Charities Center for Pediatric NeuroRecovery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Natalie Goodrich
- Kosair Charities Center for Pediatric NeuroRecovery, University of Louisville, Louisville, KY, United States.,Pediatric Neurorecovery Program, Frazier Rehab Institute, Louisville, KY, United States
| | - Sevda C Aslan
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States.,Department of Neurological Surgery, University of Louisville, Louisville, KY, United States
| | - Beatrice Ugiliweneza
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States.,Department of Neurological Surgery, University of Louisville, Louisville, KY, United States
| | - Andrea L Behrman
- Kosair Charities Center for Pediatric NeuroRecovery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States.,Department of Neurological Surgery, University of Louisville, Louisville, KY, United States
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17
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Ulnar nerve integrity predicts 1-year outcome in cervical spinal cord injury. Neurol Res Pract 2019; 1:11. [PMID: 33324877 PMCID: PMC7650063 DOI: 10.1186/s42466-019-0017-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/25/2019] [Indexed: 11/24/2022] Open
Abstract
Background Accurate predictors of neurological recovery after cervical spinal cord injury are needed. Particularly, to tailor adequate rehabilitation plans. However, objective and quantifiable predictors are sparse. Methods Within the prospective European Multicenter Study about Spinal Cord Injury (EMSCI) registry, cervical spinal cord injury patients are monitored at fixed follow up visits (2, 4, 12, 24, and 48 weeks after injury) clinically and with ulnar nerve electroneurography. Associations of ulnar nerve compound muscle action potential amplitudes (CMAP) with American Spinal Cord Injury Association (ASIA) impairment scale (AIS) grades over time were analyzed using linear mixed modeling. Applying logistic regression, the prognostic value of within 4-week ulnar nerve CMAP for 1-year AIS was analyzed. To account for missing data, (1) last observation carried forward and (2) multiple imputation methods were applied. For model derivation, our centers’ cohort (EMSCI-HD) was analyzed. For model validation the cohort of other centers (EMSCI-nonHD) was used. Results In the EMSCI-HD cohort, the median age (interquartile range (IQR)) was 52 (34–67) years. 58% were male. The initial AIS distribution was: A = 31%, B = 17%, C = 30%, and D = 22%). In the EMSCI-nonHD cohort, the median age was 49 (32–65) years. Compared to the EMSCI-HD cohort more patients were male (79%, p = 0.0034). The AIS distribution was: A = 33%, B = 13%, C = 21%, and D = 33%). In complete-case mixed model analyses (EMSCI-HD: n = 114; EMSCI-nonHD: n = 508) higher ulnar nerve CMAP were associated with better AIS grades over the entire follow up period. In complete-case logistic regression (EMSCI-HD: n = 90; EMSCI-nonHD: n = 444) higher ulnar nerve CMAP was an independent predictor of better AIS grades. The odds ratio for within 4-week ulnar nerve CMAP to predict 1-year AIS grade D versus A-C in the EMSCI-HD cohort was 1.24 per millivolt (confidence interval 1.07–1.44). The model was validated in an independent cervical spinal cord injury (EMSCI-nonHD) cohort (odds ratio 1.09, confidence interval 1.03–1.17). Conclusions In cervical spinal cord injury, the consideration of early ulnar nerve CMAP improves prognostic accuracy, which is of particular importance in patients with clinical grading uncertainties. Electronic supplementary material The online version of this article (10.1186/s42466-019-0017-1) contains supplementary material, which is available to authorized users.
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Khorasanizadeh M, Yousefifard M, Eskian M, Lu Y, Chalangari M, Harrop JS, Jazayeri SB, Seyedpour S, Khodaei B, Hosseini M, Rahimi-Movaghar V. Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis. J Neurosurg Spine 2019; 30:683-699. [PMID: 30771786 DOI: 10.3171/2018.10.spine18802] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/11/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance. METHODS A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis. RESULTS A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups. CONCLUSIONS The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.
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Affiliation(s)
| | - Mahmoud Yousefifard
- 2Physiology Research Center and Department of Physiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahsa Eskian
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Yi Lu
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryam Chalangari
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - James S Harrop
- 4Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia
- 5Neurosurgery, Delaware Valley Regional Spinal Cord Injury Center, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | | | - Simin Seyedpour
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Behzad Khodaei
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Mostafa Hosseini
- 6Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Alizadeh A, Dyck SM, Karimi-Abdolrezaee S. Traumatic Spinal Cord Injury: An Overview of Pathophysiology, Models and Acute Injury Mechanisms. Front Neurol 2019; 10:282. [PMID: 30967837 PMCID: PMC6439316 DOI: 10.3389/fneur.2019.00282] [Citation(s) in RCA: 633] [Impact Index Per Article: 126.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/05/2019] [Indexed: 12/11/2022] Open
Abstract
Traumatic spinal cord injury (SCI) is a life changing neurological condition with substantial socioeconomic implications for patients and their care-givers. Recent advances in medical management of SCI has significantly improved diagnosis, stabilization, survival rate and well-being of SCI patients. However, there has been small progress on treatment options for improving the neurological outcomes of SCI patients. This incremental success mainly reflects the complexity of SCI pathophysiology and the diverse biochemical and physiological changes that occur in the injured spinal cord. Therefore, in the past few decades, considerable efforts have been made by SCI researchers to elucidate the pathophysiology of SCI and unravel the underlying cellular and molecular mechanisms of tissue degeneration and repair in the injured spinal cord. To this end, a number of preclinical animal and injury models have been developed to more closely recapitulate the primary and secondary injury processes of SCI. In this review, we will provide a comprehensive overview of the recent advances in our understanding of the pathophysiology of SCI. We will also discuss the neurological outcomes of human SCI and the available experimental model systems that have been employed to identify SCI mechanisms and develop therapeutic strategies for this condition.
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Affiliation(s)
- Arsalan Alizadeh
- Regenerative Medicine Program, Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, Spinal Cord Research Center, University of Manitoba, Winnipeg, MB, Canada
| | - Scott Matthew Dyck
- Regenerative Medicine Program, Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, Spinal Cord Research Center, University of Manitoba, Winnipeg, MB, Canada
| | - Soheila Karimi-Abdolrezaee
- Regenerative Medicine Program, Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, Spinal Cord Research Center, University of Manitoba, Winnipeg, MB, Canada
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Elliott CS, Zlatev D, Crew J, Shem K. Do appreciable changes in the upper extremity motor capability to perform clean intermittent catheterization come about with time after traumatic spinal cord injury? Neurourol Urodyn 2019; 38:975-980. [PMID: 30801799 DOI: 10.1002/nau.23943] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Bladder dysfunction after spinal cord injury (SCI) often requires clean intermittent catheterization (CIC) or other management strategies. A common dilemma in those desiring to perform CIC independently but lacking the appropriate upper extremity (UE) motor function is the timing of reconstructive surgery. METHODS We assessed the National Spinal Cord Injury Data Set for the years 2000-2016. Our cohort consisted of persons with cervical SCI, who underwent complete motor examination upon discharge from rehabilitation and at 1-year follow-up. Using a previously published algorithm, UE motor scores were transformed to predict a patient's ability to independently perform CIC. Improvements in the predicted ability to self-catheterize were evaluated. RESULTS Of the 1428 individuals meeting the inclusion criteria, improvements in the predicted UE motor function necessary to independently self-catheterize were observed in 39%, 42%, and 38% of those deemed possibly able, only able with surgical assistance, or unable to self-catheterize at rehabilitation discharge, respectively. On multivariate analysis, only increasing Association Impairment Scale (AIS) classification and AIS classification improvement over the first year were associated with an increased odds of improving predicted CIC ability (odds ratio [OR] = 1.44 for AIS C and 1.97 for AIS D compared with AIS A, and OR = 1.90 for AIS classification improvement versus stable AIS classification, P < 0.05 for each). CONCLUSION Improvements in UE motor function to independently perform CIC occur in approximately 40% of persons with cervical SCI in the first year after rehabilitation discharge. Those with incomplete injuries are more likely to improve. These findings should enhance patient bladder management counseling and guide surgeons in determining an appropriate timeline for offering reconstruction.
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Affiliation(s)
- Christopher S Elliott
- Department of Urology, Stanford University Medical Center, Palo Alto, California.,Division of Urology, Santa Clara Valley Medical Center, San Jose, California
| | - Dimitar Zlatev
- Department of Urology, Stanford University Medical Center, Palo Alto, California
| | - James Crew
- Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, California
| | - Kazuko Shem
- Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, California
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Evaluation of a ketogenic diet for improvement of neurological recovery in individuals with acute spinal cord injury: a pilot, randomized safety and feasibility trial. Spinal Cord Ser Cases 2018; 4:88. [PMID: 30275980 DOI: 10.1038/s41394-018-0121-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 01/26/2023] Open
Abstract
Study design Longitudinal, randomized study. Objectives (1) Test the safety and feasibility of a ketogenic diet (KD) intervention in the acute stages of spinal cord injury (SCI), (2) assess the effects of a KD on neurological recovery, and (3) identify potential serum biomarkers associated with KD-induced changes in neurological recovery. Setting Acute care and rehabilitation facility. Methods The KD is a high-fat, low-carbohydrate diet that includes ≈70-80% total energy as fat. Seven participants with acute complete and incomplete SCI (AIS A-D) were randomly assigned to KD (n = 4) or standard diet (SD, n = 3). Neurological examinations, resting energy expenditure analysis, and collection of blood for evaluation of circulating ketone levels were performed within 72 h of injury and before discharge. Untargeted metabolomics analysis was performed on serum samples to identify potential serum biomarkers that may explain differential responses between groups. Results Our pilot findings primarily demonstrated that KD is safe and feasible to be administered in acute SCI. Furthermore, upper extremity motor scores were higher (p < 0.05) in the KD vs. SD group and an anti-inflammatory lysophospholipid, lysoPC 16:0, was present at higher levels, and an inflammatory blood protein, fibrinogen, was present at lower levels in the KD serum samples vs. SD serum samples. Conclusion Taken together, these preliminary results suggest that a KD may have anti-inflammatory effects that may promote neuroprotection, resulting in improved neurological recovery in SCI. Future studies with larger sample size are warranted for demonstrating efficacy of KD for improving neurological recovery.
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Hamilton R, Kirshblum S, Sikka S, Callender L, Bennett M, Prajapati P. Sacral examination in spinal cord injury: Is it really needed? J Spinal Cord Med 2018; 41:556-561. [PMID: 29376770 PMCID: PMC6117574 DOI: 10.1080/10790268.2017.1410307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To determine if a self-report measure of S4-5 motor and sensory function in patients with chronic SCI accurately predicts sacral examination results. DESIGN Prospective, single-blinded self-report survey compared with sacral exam. SETTING Outpatient SCI clinic. PARTICIPANTS 116 patients aged 18+ with chronic SCI > 6 months who have undergone sacral exam. INTERVENTIONS The survey included demographic/clinical and sacral function information such as light tough (LT), pinprick sensation (PP), deep anal pressure (DAP) and voluntary anal contraction (VAC). Survey results and sacral exam were compared and stratified by the patient's American Spinal Cord Injury Association Impairment Scale (AIS) category. OUTCOME MEASURES Sacral self-report survey, AIS examination. RESULTS Mean age was 41.3 ± 14.4 years with majority male (69%) and Caucasian (71.6%). Overall, Positive Predictive Value (PPV) ranged between 48% (VAC) to 73% (DAP) and Negative Predictive Value (NPV) between 92% (VAC) to 100% (LT). AIS-A had NPV of 100% across all categories, and AIS-D had PPV of 100% across all categories. CONCLUSION Patient report of sacral sparing can predict negative sensation in patients with AIS-A and predict positive sensation in persons with AIS-D. Overall, the self-report of sacral sparing of motor and sensory function is not predictive enough to rely on for accurate classification.
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Affiliation(s)
- Rita Hamilton
- Baylor Institute for Rehabilitation, Dallas, Texas, USA,Baylor University Medical Center, Dallas, Texas, USA,Correspondence to: Rita Hamilton, 909 North Washington Avenue, Dallas, TX75246, USA; Ph: 214-820-9593.
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA,Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Seema Sikka
- Baylor Institute for Rehabilitation, Dallas, Texas, USA,Baylor University Medical Center, Dallas, Texas, USA
| | - Librada Callender
- Baylor Institute for Rehabilitation, Dallas, Texas, USA,Baylor University Medical Center, Dallas, Texas, USA
| | - Monica Bennett
- Baylor Institute for Rehabilitation, Dallas, Texas, USA,Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas, Texas, USA
| | - Purvi Prajapati
- Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas, Texas, USA
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Quality of life in the subacute period following a cervical traumatic spinal cord injury based on the initial severity of the injury: a prospective cohort study. Spinal Cord 2018; 56:1042-1050. [DOI: 10.1038/s41393-018-0178-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 06/06/2018] [Accepted: 06/15/2018] [Indexed: 01/12/2023]
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Rigot S, Worobey L, Boninger ML. Gait Training in Acute Spinal Cord Injury Rehabilitation-Utilization and Outcomes Among Nonambulatory Individuals: Findings From the SCIRehab Project. Arch Phys Med Rehabil 2018; 99:1591-1598. [PMID: 29510092 DOI: 10.1016/j.apmr.2018.01.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 01/05/2018] [Accepted: 01/28/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To investigate the relation of gait training (GT) during inpatient rehabilitation (IPR) to outcomes of people with traumatic spinal cord injury (SCI). DESIGN Prospective observational study using the SCIRehab database. SETTING Six IPR facilities. PARTICIPANTS Patients with new SCI (N=1376) receiving initial rehabilitation. INTERVENTIONS Patients were divided into groups consisting of those who did and did not receive GT. Patients were further subdivided based on their primary mode of mobility as measured by the FIM. MAIN OUTCOME MEASURES Pain rating scales, Patient Health Questionnaire Mood Subscale, Satisfaction With Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART). RESULTS Nearly 58% of all patients received GT, including 33.3% of patients who were primarily using a wheelchair 1 year after discharge from IPR. Those who used a wheelchair and received GT, received significantly less transfer and wheeled mobility training (P<.001). CHART physical independence (P=.002), mobility (P=.024), and occupation (P=.003) scores were significantly worse in patients who used a wheelchair at 1 year and received GT, compared with those who used a wheelchair and did not receive GT in IPR. Older age was also a significant predictor of worse participation as measured by the CHART. CONCLUSIONS A significant percentage of individuals who are not likely to become functional ambulators are spending portions of their IPR stays performing GT, which is associated with less time allotted for other functional interventions. GT in IPR was also associated with participation deficits at 1 year for those who used a wheelchair, implying the potential consequences of opportunity costs, pain, and psychological difficulties of receiving unsuccessful GT. Clinicians should consider these data when deciding to implement GT during initial IPR.
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Affiliation(s)
- Stephanie Rigot
- Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Lynn Worobey
- Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA.
| | - Michael L Boninger
- Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA; Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA
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Facchinello Y, Richard-Denis A, Beauséjour M, Thompson C, Mac-Thiong JM. The use of classification tree analysis to assess the influence of surgical timing on neurological recovery following severe cervical traumatic spinal cord injury. Spinal Cord 2018; 56:687-694. [PMID: 29483585 DOI: 10.1038/s41393-018-0073-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/09/2018] [Accepted: 01/29/2018] [Indexed: 12/27/2022]
Abstract
STUDY DESIGN Post hoc analysis of prospectively collected data. OBJECTIVES Assess the influence of surgical timing on neurological recovery using classification tree analysis in patients sustaining cervical traumatic spinal cord injury. SETTING Hôpital du Sacré-Coeur de Montreal METHODS: 42 patients sustaining cervical SCI were followed for at least 6 months post injury. Neurological status was assessed from the American Spinal Injury Association impairment scale (AIS) and neurological level of injury (NLI) at admission and at follow-up. Age, surgical timing, AIS grade at admission and energy of injury were the four input parameters. Neurological recovery was quantified by the occurrence of improvement by at least one AIS grade, at least 2 AIS grades and at least 2 NLI. RESULTS Proportion of patients that improved at least one ASIA grade was higher in the group that received early surgery (75 vs. 41 %). The proportion of patients that improved two AIS grades was also higher in the group that received early surgery (67 vs. 38 %). Finally, 30 % of the patients that received early decompression improved two NLI as compared with 0% in the other group. Early surgery was also associated with a non-statistically significant improvement in functional recovery. CONCLUSIONS Neurological recovery of patients sustaining cervical traumatic spinal cord injury can be improved by early decompression surgery performed within 19 h post trauma. SPONSORSHIP U.S. Army Medical Research and Material Command, Rick Hansen Institute.
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Affiliation(s)
- Yann Facchinello
- Department of Surgery, Faculty of Medicine, University of Montreal, Pavillon Roger-Gaudry, S-749, C.P. 6128, succ. Centre-ville, Montreal, Quebec, H3C 3J7, Canada.,Hôpital du Sacré-Cœur de Montréal, 5400 Gouin Boul. West, Montreal, Quebec, H4J 1C5, Canada
| | - Andréane Richard-Denis
- Hôpital du Sacré-Cœur de Montréal, 5400 Gouin Boul. West, Montreal, Quebec, H4J 1C5, Canada.,Department of Medicine, Faculty of Medicine, University of Montreal, Pavillon Roger-Gaudry, S-749, C.P. 6128, succ. Centre-ville, Montreal, Quebec, H3C 3J7, Canada
| | - Marie Beauséjour
- Department of Surgery, Faculty of Medicine, University of Montreal, Pavillon Roger-Gaudry, S-749, C.P. 6128, succ. Centre-ville, Montreal, Quebec, H3C 3J7, Canada.,Sainte-Justine University Hospital Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, Quebec, H3T 1C5, Canada
| | - Cynthia Thompson
- Hôpital du Sacré-Cœur de Montréal, 5400 Gouin Boul. West, Montreal, Quebec, H4J 1C5, Canada
| | - Jean-Marc Mac-Thiong
- Department of Surgery, Faculty of Medicine, University of Montreal, Pavillon Roger-Gaudry, S-749, C.P. 6128, succ. Centre-ville, Montreal, Quebec, H3C 3J7, Canada. .,Hôpital du Sacré-Cœur de Montréal, 5400 Gouin Boul. West, Montreal, Quebec, H4J 1C5, Canada. .,Sainte-Justine University Hospital Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, Quebec, H3T 1C5, Canada.
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Ronzi Y, Perrouin-Verbe B, Hamel O, Gross R. Spinal cord injury associated with cervical spinal canal stenosis: Outcomes and prognostic factors. Ann Phys Rehabil Med 2018; 61:27-32. [DOI: 10.1016/j.rehab.2017.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 09/19/2017] [Accepted: 09/25/2017] [Indexed: 10/18/2022]
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Definitions of traumatic conus medullaris and cauda equina syndrome: a systematic literature review. Spinal Cord 2017; 55:886-890. [DOI: 10.1038/sc.2017.54] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 03/31/2017] [Accepted: 04/05/2017] [Indexed: 12/18/2022]
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Oh SK, Choi KH, Yoo JY, Kim DY, Kim SJ, Jeon SR. A Phase III Clinical Trial Showing Limited Efficacy of Autologous Mesenchymal Stem Cell Therapy for Spinal Cord Injury. Neurosurgery 2016; 78:436-47; discussion 447. [PMID: 26891377 DOI: 10.1227/neu.0000000000001056] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In our previous report, 3 of 10 patients with spinal cord injury who were injected with autologous mesenchymal stem cells (MSCs) showed motor improvement in the upper extremities and in activities of daily living. OBJECTIVE To report on the results of a phase III clinical trial of autologous MSCs therapy. METHODS Patients were selected based on the following criteria: chronic American Spinal Injury Association B status patients who had more than 12 months of cervical injury, and no neurological changes during the recent 3 months of vigorous rehabilitation. We injected 1.6 × 10 autologous MSCs into the intramedullary area at the injured level and 3.2 × 10 autologous MSCs into the subdural space. Outcome data were collected over 6 months regarding neurological examination, magnetic resonance imaging with diffusion tensor imaging, and electrophysiological analyses. RESULTS Among the 16 patients, only 2 showed improvement in neurological status (unilateral right C8 segment from grade 1 to grade 3 in 1 patient and bilateral C6 from grade 3 to grade 4 and unilateral right C8 from grade 0 to grade 1 in 1 patient). Both patients with neurological improvement showed the appearance of continuity in the spinal cord tract by diffusion tensor imaging. There were no adverse effects associated with MSCs injection. CONCLUSION Single MSCs application to intramedullary and intradural space is safe, but has a very weak therapeutic effect compared with multiple MSCs injection. Further clinical trials to enhance the effect of MSCs injection are necessary.
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Affiliation(s)
- Sun Kyu Oh
- Departments of *Neurological Surgery,‡Rehabilitation Medicine, and§Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Battistuzzo CR, Smith K, Skeers P, Armstrong A, Clark J, Agostinello J, Cox S, Bernard S, Freeman BJ, Dunlop SA, Batchelor PE. Early Rapid Neurological Assessment for Acute Spinal Cord Injury Trials. J Neurotrauma 2016; 33:1936-1945. [DOI: 10.1089/neu.2015.4360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Camila R. Battistuzzo
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Melbourne, VIC, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University and Ambulance Victoria, Melbourne VIC, Australia
| | - Peta Skeers
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Melbourne, VIC, Australia
| | - Alex Armstrong
- School of Animal Biology, The University of Western Australia, Perth, WA, Australia
| | - Jillian Clark
- Centre for Orthopaedic and Trauma Research, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Jacqui Agostinello
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Melbourne, VIC, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University and Ambulance Victoria, Melbourne VIC, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University and Ambulance Victoria, Melbourne VIC, Australia
| | - Brian J.C. Freeman
- Centre for Orthopaedic and Trauma Research, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sarah A. Dunlop
- School of Animal Biology, The University of Western Australia, Perth, WA, Australia
| | - Peter E. Batchelor
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Melbourne, VIC, Australia
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Oh SK, Jeon SR. Current Concept of Stem Cell Therapy for Spinal Cord Injury: A Review. Korean J Neurotrauma 2016; 12:40-46. [PMID: 27857906 PMCID: PMC5110917 DOI: 10.13004/kjnt.2016.12.2.40] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/10/2016] [Accepted: 04/28/2016] [Indexed: 01/17/2023] Open
Abstract
Spinal cord injury (SCI) is a catastrophic condition associated with significant neurological deficit, social, and financial burdens. Over the past decades, various treatments including medication, surgery, and rehabilitation therapy for SCI have been performed, but there were no definite treatment option to improve neurological function of patients with chronic SCI. Therefore, new treatment trials with stem cells have been studied to regenerate injured spinal cord. Among various types of stem cells, bone marrow derived mesenchymal stem cells is highly expected as candidates for the stem cell therapy. The result of the current research showed that direct intramedullary injection to the injured spinal cord site in subacute phase is most effective. Neurological examination, electrophysiologic studies, and magnetic resonance imaging are commonly used to assess the effectiveness of treatment. Diffusion tensor imaging visualizing white matter tract can be also alternative option to identify neuronal regeneration. Despite various challenging issues, stem cell therapy will open new perspectives for SCI treatment.
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Affiliation(s)
- Sun Kyu Oh
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ryong Jeon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Wang H, Ou L, Zhou Y, Li C, Liu J, Chen Y, Yu H, Wang Q, Zhao Y, Han J, Xiang L. Traumatic upper cervical spinal fractures in teaching hospitals of China over 13 years: A retrospective observational study. Medicine (Baltimore) 2016; 95:e5205. [PMID: 27787377 PMCID: PMC5089106 DOI: 10.1097/md.0000000000005205] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 10/04/2016] [Accepted: 10/04/2016] [Indexed: 01/19/2023] Open
Abstract
To investigate the incidence and pattern of patients managed for traumatic upper cervical spinal fractures (TUCSFs) in teaching hospitals in China over 13 years.We retrospectively reviewed 351 patients with TUCSF admitted to our teaching hospitals. Incidence rates were calculated with respect to age, gender, etiologies of trauma, anatomical distribution, anatomical classification, American spinal injury association impairment scale (ASIA) classification of neurological deficit and associated injuries.There were 260 male and 91 female patients, with a mean age of 44.2 ± 16.3 years. The mean age of the patients significantly increased by year of admission, from 35.2 ± 14.5 years to 47.5 ± 17.2 years (P = 0.005). Motor vehicle accidents (MVAs) (n = 132, 37.6%) and high falls (n = 104, 29.6%) were the 2 most common mechanisms. The number of C2 fractures (n = 300, 85.5%) was significantly higher than that of C1 (n = 99, 28.2%) (P < 0.001). High falls resulted in significantly more Type I C1 fractures than other etiologies (all P < 0.001). MVAs resulted in many more Type II and Type III C1 fractures and Type II and Type III C2 fractures than other etiologies. High falls were the most common injury type (n = 44, 36.4%) resulting in neurological deficits. Patients who presented with Landell classification Type I single C1 fracture (n = 6, 42.9%) had the highest rate of neurological deficits. Eighty-two patients had combined injuries; the most common pattern was cervical + cervical spine (n = 44, 12.5%), followed by cervical + thoracic spine (n = 27, 7.7%). A total of 121 patients (34.5%) suffered neurological deficits. Of all patients with TUCSF without combined injuries, single C2 fractures accounted for the highest rate of neurological deficits (n = 62, 32.0%). Multivariate logistic regression analysis indicated that sex (OR = 1.876, 95% CI: 1.022-3.443, P = 0.042), etiology (MVA pedestrians vs high fall: OR = 0.187, 95% CI: 0.056-0.629, P = 0.007), level (C1 + OFs vs C1: OR = 6.264, 95% CI: 1.152-34.045, P = 0.034), and injury severity scoring (ISS) (OR = 1.186, 95% CI: 1.133-1.242, P < 0.001) were independent risk factors of neurological deficit.The most common causes of TUCSF were MVAs and high falls; single C2 fractures without combined injuries accounted for the most common neurological deficits. Different etiologies resulted in different specific anatomical injuries and neurological deficits. We should make early diagnoses and initiate timely treatment according to different TUCSF patterns.
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Affiliation(s)
- Hongwei Wang
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning
- Correspondence: Hongwei Wang, Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning 110016, China (e-mail: ); Jun Liu, Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning 110016, China (e-mail: )
| | - Lan Ou
- Department of Radiology, Southwest Hospital
| | - Yue Zhou
- Department of Orthopedics, Xinqiao Hospital, the Third Military Medical University, Chongqing
| | - Changqing Li
- Department of Orthopedics, Xinqiao Hospital, the Third Military Medical University, Chongqing
| | - Jun Liu
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning
- Correspondence: Hongwei Wang, Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning 110016, China (e-mail: ); Jun Liu, Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning 110016, China (e-mail: )
| | - Yu Chen
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning
| | - Hailong Yu
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning
| | - Qi Wang
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning
| | - Yiwen Zhao
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of Science, Shenyang, Liaoning, China
| | - Jianda Han
- State Key Laboratory of Robotics, Shenyang Institute of Automation, Chinese Academy of Science, Shenyang, Liaoning, China
| | - Liangbi Xiang
- Department of Orthopedics, General Hospital of Shenyang Military Area Command of Chinese PLA, Shenyang, Liaoning
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Influence of Age Alone, and Age Combined With Pinprick, on Recovery of Walking Function in Motor Complete, Sensory Incomplete Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:1635-41. [DOI: 10.1016/j.apmr.2016.01.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/21/2016] [Accepted: 01/23/2016] [Indexed: 11/20/2022]
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Kumru H, Benito-Penalva J, Valls-Sole J, Murillo N, Tormos JM, Flores C, Vidal J. Placebo-controlled study of rTMS combined with Lokomat® gait training for treatment in subjects with motor incomplete spinal cord injury. Exp Brain Res 2016; 234:3447-3455. [DOI: 10.1007/s00221-016-4739-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/19/2016] [Indexed: 01/28/2023]
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Readdy WJ, Saigal R, Whetstone WD, Mefford AN, Ferguson AR, Talbott JF, Inoue T, Bresnahan JC, Beattie MS, Pan J, Manley GT, Dhall SS. Failure of Mean Arterial Pressure Goals to Improve Outcomes Following Penetrating Spinal Cord Injury. Neurosurgery 2016; 79:708-714. [DOI: 10.1227/neu.0000000000001249] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Increased spinal cord perfusion and blood pressure goals have been recommended for spinal cord injury (SCI). Penetrating SCI is associated with poor prognosis, but there is a paucity of literature examining the role of vasopressor administration for the maintenance of mean arterial pressure (MAP) goals in this patient population.
OBJECTIVE:
To elucidate this topic and to determine the efficacy of vasopressor administration in penetrating SCI by examining a case series of consecutive penetrating SCIs.
METHODS:
We reviewed consecutive patients with complete penetrating SCI who met inclusion and exclusion criteria, including the administration of vasopressors to maintain MAP goals. We identified 14 patients with complete penetrating SCIs with an admission American Spinal Injury Association grade of A from 2005 to 2011. The neurological recovery, complications, interventions, and vasopressor administration strategies were reviewed and compared with those of a cohort with complete blunt SCI.
RESULTS:
In our patient population, only 1 patient with penetrating SCI (7.1%) experienced neurological recovery, as determined by improvement in the American Spinal Injury Association grade, despite the administration of vasopressors for supraphysiological MAP goals for an average of 101.07 ± 34.96 hours. Furthermore, 71.43% of patients with penetrating SCI treated with vasopressors experienced associated cardiogenic complications.
CONCLUSION:
Given the decreased likelihood of neurological improvement in penetrating injuries, it may be important to re-examine intervention strategies in this population. Specifically, the use of vasopressors, in particular dopamine, with their associated complications is more likely to cause complications than to result in neurological improvement. Our experience shows that patients with acute penetrating SCI are unlikely to recover, despite aggressive cardiopulmonary management.
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Affiliation(s)
- William J. Readdy
- Brain and Spinal Injury Center, Departments of Neurological Surgery, San Francisco, San Francisco, California
- Emergency Medicine, San Francisco, California
| | - Rajiv Saigal
- Brain and Spinal Injury Center, Departments of Neurological Surgery, San Francisco, San Francisco, California
- Emergency Medicine, San Francisco, California
| | - William D. Whetstone
- Emergency Medicine, San Francisco, California
- Radiology and Biomedical Imaging, San Francisco, California
| | | | | | - Jason F. Talbott
- Emergency Medicine, San Francisco, California
- Anesthesia, University of California, San Francisco, San Francisco, California
| | - Tomoo Inoue
- Emergency Medicine, San Francisco, California
| | | | | | - Jonathan Pan
- Emergency Medicine, San Francisco, California
- Anesthesia, University of California, San Francisco, San Francisco, California
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Thakkar UG, Vanikar AV, Trivedi HL, Shah VR, Dave SD, Dixit SB, Tiwari BB, Shah HH. Infusion of autologous adipose tissue derived neuronal differentiated mesenchymal stem cells and hematopoietic stem cells in post-traumatic paraplegia offers a viable therapeutic approach. Adv Biomed Res 2016; 5:51. [PMID: 27110548 PMCID: PMC4817398 DOI: 10.4103/2277-9175.178792] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 07/11/2015] [Indexed: 12/18/2022] Open
Abstract
Background: Spinal cord injury (SCI) is not likely to recover by current therapeutic modalities. Stem cell (SC) therapy (SCT) has promising results in regenerative medicine. We present our experience of co-infusion of autologous adipose tissue derived mesenchymal SC differentiated neuronal cells (N-Ad-MSC) and hematopoietic SCs (HSCs) in a set of patients with posttraumatic paraplegia. Materials and Methods: Ten patients with posttraumatic paraplegia of mean age 3.42 years were volunteered for SCT. Their mean age was 28 years, and they had variable associated complications. They were subjected to adipose tissue resection for in vitro generation of N-Ad-MSC and bone marrow aspiration for generation of HSC. Generated SCs were infused into the cerebrospinal fluid (CSF) below injury site in all patients. Results: Total mean quantum of SC infused was 4.04 ml with a mean nucleated cell count of 4.5 × 104/μL and mean CD34+ of 0.35%, CD45−/90+ and CD45−/73+ of 41.4%, and 10.04%, respectively. All of them expressed transcription factors beta-3 tubulin and glial fibrillary acid protein. No untoward effect of SCT was noted. Variable and sustained improvement in Hauser's index and American Spinal Injury Association score was noted in all patients over a mean follow-up of 2.95 years. Mean injury duration was 3.42 years against the period of approximately 1-year required for natural recovery, suggesting a positive role of SCs. Conclusion: Co-infusion of N-Ad-MSC and HSC in CSF is safe and viable therapeutic approach for SCIs.
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Affiliation(s)
- Umang G Thakkar
- Department of Stem Cell Therapy and Regenerative Medicine, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Aruna V Vanikar
- Department of Stem Cell Therapy and Regenerative Medicine, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India; Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Hargovind L Trivedi
- Department of Stem Cell Therapy and Regenerative Medicine, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India; Department of Nephrology and Transplantation Medicine, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Veena R Shah
- Department of Anesthesiology and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Shruti D Dave
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Satyajit B Dixit
- Department of Stem Cell Therapy and Regenerative Medicine, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Bharat B Tiwari
- Department of Physiotherapy and Rehabilitation, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Harda H Shah
- Department of Physiotherapy and Rehabilitation, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
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Mobility, continence, and life expectancy in persons with Asia Impairment Scale Grade D spinal cord injuries. Am J Phys Med Rehabil 2015; 94:180-91. [PMID: 24919073 DOI: 10.1097/phm.0000000000000140] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Previous research on the life expectancy of persons with American Spinal Injury Association (ASIA) Impairment Scale Grade D spinal cord injury has considered them as a large homogenous group, making no functional or medical distinctions. This study sought to (1) determine how survival in this group depends on ambulatory function and the extent of bowel or bladder dysfunction, (2) compute life expectancies for various subgroups, and (3) examine whether survival has improved over time. DESIGN Data were from 8,206 adults with ASIA Impairment Scale Grade D spinal cord injury in the Spinal Cord Injury Model Systems database who were not ventilator dependent and who survived more than 1 yr after injury. There were a total of 114,739 person-years of follow-up and 1,730 deaths during the 1970-2011 study period. Empirical age- and sex-specific mortality rates were computed. Regression analysis of survival data with time-dependent covariates was used to determine the effect of risk factors, to test for a time trend, and to estimate mortality rates for subgroups. Life expectancies were obtained from life tables constructed for each subgroup. RESULTS The ability to walk, whether independently or with an assistive device, was associated with longer survival than wheelchair dependence. The need for an indwelling catheter, and to a lesser extent intermittent catheterization, was associated with increased mortality risk. Persons who walked unaided and who did not require catheterization had life expectancies roughly 90% of normal. Those who required a wheelchair for locomotion had life expectancies comparable with that in paraplegia, less than 75% of normal. No time trend in survival was found. CONCLUSIONS Life expectancy of persons with ASIA Impairment Scale D spinal cord injury depends strongly on the ability to walk and the need for catheterization.
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Abstract
OPINION STATEMENT Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90 mm Hg should be kept for at least 1 week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72 h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72 h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.
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Scivoletto G, Tamburella F, Laurenza L, Torre M, Molinari M. Who is going to walk? A review of the factors influencing walking recovery after spinal cord injury. Front Hum Neurosci 2014; 8:141. [PMID: 24659962 PMCID: PMC3952432 DOI: 10.3389/fnhum.2014.00141] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 02/26/2014] [Indexed: 12/11/2022] Open
Abstract
The recovery of walking function is considered of extreme relevance both by patients and physicians. Consequently, in the recent years, recovery of locomotion become a major objective of new pharmacological and rehabilitative interventions. In the last decade, several pharmacological treatment and rehabilitative approaches have been initiated to enhance locomotion capacity of SCI patients. Basic science advances in regeneration of the central nervous system hold promise of further neurological and functional recovery to be studied in clinical trials. Therefore, a precise knowledge of the natural course of walking recovery after SCI and of the factors affecting the prognosis for recovery has become mandatory. In the present work we reviewed the prognostic factors for walking recovery, with particular attention paid to the clinical ones (neurological examination at admission, age, etiology gender, time course of recovery). The prognostic value of some instrumental examinations has also been reviewed. Based on these factors we suggest that a reliable prognosis for walking recovery is possible. Instrumental examinations, in particular evoked potentials could be useful to improve the prognosis.
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Affiliation(s)
- Giorgio Scivoletto
- Spinal Cord Unit, IRCCS Fondazione S. Lucia Rome, Italy ; Clinical and Research Movement Analysis Lab, Fondazione S. Lucia Rome, Italy
| | - Federica Tamburella
- Spinal Cord Unit, IRCCS Fondazione S. Lucia Rome, Italy ; Clinical and Research Movement Analysis Lab, Fondazione S. Lucia Rome, Italy
| | | | - Monica Torre
- Spinal Cord Unit, IRCCS Fondazione S. Lucia Rome, Italy
| | - Marco Molinari
- Spinal Cord Unit, IRCCS Fondazione S. Lucia Rome, Italy ; Clinical and Research Movement Analysis Lab, Fondazione S. Lucia Rome, Italy
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Kortelainen J, Vipin A, Mir H, Thakor N, Al-Nashash H, All A. Effect of isoflurane on somatosensory evoked potentials in a rat model. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2014; 2014:4286-4289. [PMID: 25570940 DOI: 10.1109/embc.2014.6944572] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Somatosensory evoked potentials (SEPs) are widely used in the clinic as well as research to study the functional integrity of the different parts of sensory pathways. However, most general anesthetics, such as isoflurane, are known to suppress SEPs, which might affect the interpretation of the signals. In animal studies, the usage of anesthetics during SEP measurements is inevitable due to which detailed effect of these drugs on the recordings should be known. In this paper, the effect of isoflurane on SEPs was studied in a rat model. Both time and frequency properties of the cortical recordings generated by stimulating the tibial nerve of rat's hindlimb were investigated at three different isoflurane levels. While the anesthetic agent is shown to generally suppress the amplitude of the SEP, the effect was found to be nonlinear influencing more substantially the latter part of waveform. This finding will potentially help us in future work aiming at separating the effects of anesthetics on SEP from those due to injury in the ascending neural pathways.
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Leven D, Sadr A, Aibinder WR. Brown-Séquard syndrome after a gun shot wound to the cervical spine: a case report. Spine J 2013; 13:e1-5. [PMID: 24051332 DOI: 10.1016/j.spinee.2013.06.093] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 04/08/2013] [Accepted: 06/24/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Brown-Séquard syndrome is characterized by a hemisection of the spinal cord most commonly after spinal trauma or neoplastic disease. The injury causes ipsilateral hemiplegia and proprioceptive sensory disturbances with contralateral loss of pain and temperature sensation. Patients with Brown-Séquard syndrome have the best prognosis of all spinal cord injury patterns. At this time, the ideal management for Brown-Séquard syndrome after penetrating trauma has yet to be defined. PURPOSE To report a case of a gun shot wound to the upper cervical spine that resulted in Brown-Séquard syndrome and was treated effectively with early cervical spine decompression and fusion. STUDY DESIGN Observational case report. METHODS A 28-year-old woman presented after sustaining a low-velocity gun shot wound in to the upper cervical spine in a civilian assault. On initial presentation, she had 0/5 motor scores in the left upper and lower extremities and normal motor scores on the right. Sensory examination was limited as she was intubated and sedated on admission due to airway compromise. A computed tomography scan revealed a bullet lodged in the vertebral body of C3 with boney fragments and soft tissue encroaching on the spinal cord. Subsequently, she underwent C3 corpectomy, bulletectomy, and anterior cervical decompression with fusion. RESULTS Intraoperatively, no dural disruption or cerebral spinal fluid leak was noted, and her posterior longitudinal ligament was intact. One month postoperatively, her left lower extremity motor score was 5/5 with movement of her left thumb and all fingers. Strength in her biceps, triceps, and wrist extensors and flexors was 3/5. Her functional capacity and strength gradually improved. CONCLUSIONS Reinke et al. support surgical intervention for patients with incomplete paraplegia after the patient is medically stabilized, although their case report discussed lower thoracic injury, which carries a more favorable prognosis. All other prior case reports and prospective studies that reported favorable outcomes after Brown-Séquard syndrome involved the midthoracic, low thoracic, or lumbar spinal levels. This report is the first case of Brown-Séquard syndrome after a high cervical gun shot wound, which was managed with immediate decompression and fusion, where near complete recovery was obtained.
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Affiliation(s)
- Dante Leven
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, 450 Clarkson Ave., Box 30, Brooklyn, NY 11203, USA
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41
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Epidemiology of Traumatic Cervical Spinal Fractures and Risk Factors for Traumatic Cervical Spinal Cord Injury in China. ACTA ACUST UNITED AC 2013; 26:E306-13. [DOI: 10.1097/bsd.0b013e3182886db9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Ashworth-Beaumont J, Nowicky A. P 105. Efficacy of Anodal transcranial direct current stimulation in rehabilitation of motor hand function in chronic incomplete spinal cord injury may depend on sensory impairment: A pilot study. Clin Neurophysiol 2013. [DOI: 10.1016/j.clinph.2013.04.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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van Middendorp JJ, Hosman AJF, Doi SAR. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013; 30:1781-94. [PMID: 23815524 DOI: 10.1089/neu.2013.2932] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Abstract The debate over the effects of the timing of surgical spinal decompression after traumatic spinal cord injury (tSCI) has remained unresolved for over a century. The aim of the current study was to perform a systematic review and quality-adjusted meta-analysis of studies evaluating the effects of the timing of spinal surgery after tSCI. Studies were searched for through the MEDLINE(®) database (1966 to August 2012) and a 15-item, tailored scoring system was used for assessing the included studies' susceptibility to bias. Random effects and quality effects meta-analyses were performed. Models were tested for robustness using one way and criterion-based sensitivity analysis and funnel plots. Results are presented as weighted mean differences (WMDs) and odds ratios (ORs) with 95% confidence intervals (CIs). A total of 18 studies were analyzed. Heterogeneity was evident among the studies included. Quality effects models showed that - when compared with "late" surgery - "early" spinal surgery was significantly associated with a higher total motor score improvement (WMD: 5.94 points, 95% CI:0.74,11.15) in seven studies, neurological improvement rate (OR: 2.23, 95% CI:1.35,3.67) in six studies, and shorter length of hospital stay (WMD: -9.98 days, 95% CI:-13.10,-6.85) in six studies. However, one way and criterion-based sensitivity analyses demonstrated a profound lack of robustness among pooled estimates. Funnel plots showed significant proof of publication bias. In conclusion, despite the fact that "early" spinal surgery was significantly associated with improved neurological and length of stay outcomes, the evidence supporting "early" spinal surgery after tSCI lacks robustness as a result of different sources of heterogeneity within and between original studies. Where the conduct of a surgical, randomized controlled trial seems to be an unfeasible undertaking in acute tSCI, methodological safeguards require the utmost attention in future cohort studies. (Prospero registration number: PROSPERO CRD42012003182. See also http://www.crd.york.ac.uk/NIHR_PROSPERO/ ).
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Affiliation(s)
- Joost J van Middendorp
- 1 Stoke Mandeville Spinal Foundation, National Spinal Injuries Centre , Stoke Mandeville Hospital, Aylesbury, United Kingdom
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Franke AC, Snoek GJ, de Groot S, Nene AV, Spooren AIF, Post MWM. Arm hand skilled performance in persons with a cervical spinal cord injury--long-term follow-up. Spinal Cord 2013; 51:161-4. [PMID: 22986678 DOI: 10.1038/sc.2012.95] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To assess development of arm hand skilled performance (AHSP) during and after in-patient rehabilitation in persons with cervical spinal cord injury (CSCI) and to determine factors that influence the outcome. SETTING Eight rehabilitation centres in the Netherlands with specialised spinal cord injury departments. METHODS AHSP was assessed using the Van Lieshout test (VLT) in persons admitted with recent CSCI. Assessment was carried out at the beginning (t1), after 3 months (t2), at the end (t3) of in-patient rehabilitation, and 1 and 5 years thereafter (t4, t5). Multilevel regression analysis was performed to determine development of AHSP and associations between AHSP and age, gender, motor completeness, lesion level (high or low CSCI), motor scores of upper extremity (MSUE), and pain in the tested arm. RESULTS Fifty-five participants were included with mean age 38 years (range 18–64). There were 73% male, 80% had high CSCI (C3–C6) and 69% had motor complete lesion. Scores of VLT improved significantly during in-patient rehabilitation (mean: t1=25; t3=33) (P=0.005), scores remained unchanged at 1 year (t4=32) and 5 years (t5=32) (P=0.903) after in-patient rehabilitation. Motor completeness, MSUE and pain were significantly related to the VLT score (P<0.001, P<0.001, P=0.015, respectively). Age, gender and lesion level had no significant relationship. CONCLUSION AHSP improved during in-patient rehabilitation. It was then stable during the next 5 years after discharge. Persons with an incomplete lesion, high MSUE and no pain in the tested arm perform best on the VLT.
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Affiliation(s)
- A C Franke
- Rehabilitation Centre Het Roessingh, Enschede, The Netherlands.
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Kuypers NJ, James KT, Enzmann GU, Magnuson DSK, Whittemore SR. Functional consequences of ethidium bromide demyelination of the mouse ventral spinal cord. Exp Neurol 2013; 247:615-22. [PMID: 23466931 DOI: 10.1016/j.expneurol.2013.02.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/19/2013] [Accepted: 02/25/2013] [Indexed: 02/08/2023]
Abstract
Ethidium bromide (EB) has been extensively used in the rat as a model of spinal cord demyelination. However, this lesion has not been addressed in the adult mouse, a model with unlimited genetic potential. Here we characterize behavioral function, inflammation, myelin status and axonal viability following bilateral injection of 0.20 mg/mL ethidium bromide or saline into the ventral white matter (VWM) of female C57Bl/6 mice. EB-induced VWM demyelination significantly reduced spared VWM and Basso Mouse Scale (BMS) scores persisting out to 2 months. Chronic hindlimb dysfunction was accompanied by a persistent inflammatory response (demonstrated by CD45(+) immunofluorescence) and axonal loss (demonstrated by NF-M immunofluorescence and electron microscopy; EM). These cellular responses differ from the rat where inflammation resolves by 3-4 weeks and axon loss is minimal following EB demyelination. As these data suggest that EB-injection in the mouse spinal cord is a non-remyelinating lesion, we sought to ask whether wheel running could promote recovery by enhancing plasticity of local lumbar circuitry independent of remyelination. This did not occur as BMS and Treadscan assessment revealed no significant effect of wheel running on recovery. However, this study defines the importance of descending ventral motor pathways to locomotor function in the mouse as VWM loss results in a chronic hindlimb deficit.
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Affiliation(s)
- Nicholas J Kuypers
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40292, USA
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Wilson JR, Cadotte DW, Fehlings MG. Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review. J Neurosurg Spine 2013; 17:11-26. [PMID: 22985366 DOI: 10.3171/2012.4.aospine1245] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object of this study was to identify, by means of a systematic review of the literature, the acute clinical predictors of neurological outcome, functional outcome, and survival after traumatic spinal cord injury (SCI). METHODS A comprehensive computerized literature review search was performed, using MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews. Selected articles were classified according to their level of evidence. Articles were then stratified into one of 3 domains depending on whether the primary focus was clinical prediction of 1) neurological outcome, 2) functional status, or 3) survival. For each study selected, clinical predictors related to patient demographic characteristics, injury mechanism, or neurological examination findings were extracted, and the individual relationship to outcome was defined. RESULTS The initial search resulted in 376 citations. After application of the inclusion and exclusion criteria and study review, 51 relevant articles were identified and graded. Of these, 25 provided predictors for neurological outcome, 22 for functional outcome, and 15 for survival, with several of the articles providing information on more than one type of outcome. All of the included studies were designated as providing Class I, II, or III levels of evidence. The severity of neurological injury (as measured by admission Americal Spinal Injury Association Impairment Scale grade, Frankel grade, or injury completeness), level of injury, and the presence of a zone of partial preservation were consistent predictors of neurological outcome. Severity of neurological injury, level of injury, reflex pattern, and age were consistent predictors of functional outcome. Finally, severity of neurological injury, level of injury, age, and the presence of multisystem trauma seen with higher-energy injury mechanisms were consistent predictors of survival. CONCLUSIONS On the basis on this review, the authors have identified a constellation of acute clinical features that may help to define an individual's profile for recovery and survival after SCI. This study will help to facilitate communication in the clinical realm and assist in classifying subsets of patients within future clinical studies.
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Affiliation(s)
- Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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47
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Burns AS, Marino RJ, Flanders AE, Flett H. Clinical diagnosis and prognosis following spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2012; 109:47-62. [PMID: 23098705 DOI: 10.1016/b978-0-444-52137-8.00003-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Spinal cord injury (SCI) is a sudden, life-altering event. Injury severity and accompanying recovery vary considerably from individual to individual. The most important determinant of prognosis is whether an injury is clinically complete or incomplete. While approximately 10-20% of complete injuries convert to incomplete during the first year post-injury, the magnitude of motor recovery following complete SCI is limited or absent. Robust functional motor recovery (e.g., weight-bearing, ambulation) distal to the zone of injury is rare. Recovery following incomplete SCI is particularly variable, and anywhere from 20% to 75% of individuals will recover some degree of walking capacity by 1 year post-injury. This is related to presenting injury severity (American Spinal Injury Association Impairment Scale grade); however, even 20-50% of individuals who present as motor complete, sensory incomplete will walk in some capacity by 1 year post-injury. Regardless, for both complete and incomplete injuries, the majority of recovery is observed during the initial 9-12 months, with a relative plateau reached by 12-18 months post-injury. Magnetic resonance imaging (MRI) provides valuable adjunct information when a bedside clinical assessment cannot be completed. The presence of intramedullary hemorrhage and extended segments of edema have been associated with clinically complete SCI.
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Benito-Penalva J, Edwards DJ, Opisso E, Cortes M, Lopez-Blazquez R, Murillo N, Costa U, Tormos JM, Vidal-Samsó J, Valls-Solé J, Medina J. Gait training in human spinal cord injury using electromechanical systems: effect of device type and patient characteristics. Arch Phys Med Rehabil 2011; 93:404-12. [PMID: 22209475 DOI: 10.1016/j.apmr.2011.08.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 08/14/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report the clinical improvements in spinal cord injury (SCI) patients associated with intensive gait training using electromechanical systems according to patient characteristics. DESIGN Prospective longitudinal study. SETTING Inpatient SCI rehabilitation center. PARTICIPANTS Adults with SCI (n=130). INTERVENTION Patients received locomotor training with 2 different electromechanical devices, 5 days per week for 8 weeks. MAIN OUTCOME MEASURES Lower-extremity motor score, Walking Index for Spinal Cord Injury, and 10-meter walking test data were collected at the baseline, midpoint, and end of the program. Patients were stratified according to the American Spinal Injury Association (ASIA) category, time since injury, and injury etiology. A subgroup of traumatic ASIA grade C and D patients were compared with data obtained from the European Multicenter Study about Human Spinal Cord Injury (EM-SCI). RESULTS One hundred and five patients completed the program. Significant gains in lower-limb motor function and gait were observed for both types of electromechanical device systems, to a similar degree. The greatest rate of improvement was shown in the motor incomplete SCI patients, and for patients <6 months postinjury. The positive response associated with training was not affected by injury etiology, age, sex, or lesion level. The trajectory of improvement was significantly enhanced relative to patients receiving the conventional standard of care without electromechanical systems (EM-SCI). CONCLUSIONS The use of electromechanical systems for intensive gait training in SCI is associated with a marked improvement in lower-limb motor function and gait across a diverse range of patients and is most evident in motor incomplete patients, and for patients who begin the regimen early in the recovery process.
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Affiliation(s)
- Jesús Benito-Penalva
- Department of Spinal Cord Injury, Institut Guttmann, Hospital de Neurorehabilitació, Institut Universitari adscrit a la Universitat Autònoma de Barcelona, Barcelona, Spain.
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Newton D, England M, Doll H, Gardner BP. The case for early treatment of dislocations of the cervical spine with cord involvement sustained playing rugby. ACTA ACUST UNITED AC 2011; 93:1646-52. [DOI: 10.1302/0301-620x.93b12.27048] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The most common injury in rugby resulting in spinal cord injury (SCI) is cervical facet dislocation. We report on the outcome of a series of 57 patients with acute SCI and facet dislocation sustained when playing rugby and treated by reduction between 1988 and 2000 in Conradie Hospital, Cape Town. A total of 32 patients were completely paralysed at the time of reduction. Of these 32, eight were reduced within four hours of injury and five of them made a full recovery. Of the remaining 24 who were reduced after four hours of injury, none made a full recovery and only one made a partial recovery that was useful. Our results suggest that low-velocity trauma causing SCI, such as might occur in a rugby accident, presents an opportunity for secondary prevention of permanent SCI. In these cases the permanent damage appears to result from secondary injury, rather than primary mechanical spinal cord damage. In common with other central nervous system injuries where ischaemia determines the outcome, the time from injury to reduction, and hence reperfusion, is probably important. In order to prevent permanent neurological damage after rugby injuries, cervical facet dislocations should probably be reduced within four hours of injury.
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Affiliation(s)
- D. Newton
- National Spinal Injuries Centre, Stoke
Mandeville Hospital, Aylesbury, Buckinghamshire
HP21 8AL, UK
| | - M. England
- RFU Injured Players Foundation, Rugby
House, 200 Whitton Road, Twickenham
TW2 7BA, UK
| | - H. Doll
- Department of Public Health, University
of Oxford, Old Road Campus, Headington, Oxford
OX3 7LF, UK
| | - B. P. Gardner
- National Spinal Injuries Centre, Stoke
Mandeville Hospital, Aylesbury, Buckinghamshire
HP21 8AL, UK
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Lamothe G, Muller F, Vital JM, Goossens D, Barat M. Evolution of spinal cord injuries due to cervical canal stenosis without radiographic evidence of trauma (SCIWORET): A prospective study. Ann Phys Rehabil Med 2011; 54:213-24. [DOI: 10.1016/j.rehab.2011.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/11/2011] [Accepted: 02/12/2011] [Indexed: 11/28/2022]
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