An evaluation of the factors affecting neurological recovery following spinal cord injury

Appendicular fracture and polytrauma correlate with outcome of spinal cord injury (SCI): A TRACK-SCI study

Spinal cord injuries (SCIs) frequently occur in combination with other major organ injuries, such as traumatic brain injury (TBI) and injuries to the chest, abdomen, and musculoskeletal system (e.g., extremity, pelvic, and spine fractures). However, the effects of appendicular fractures on SCI recovery are poorly understood. We investigated whether the presence of SCI-concurrent appendicular fractures is predictive of a less robust SCI recovery. Patients enrolled in the Transforming Research And Clinical Knowledge in SCI (TRACK-SCI) prospective cohort study were identified and included in this secondary analysis study. Inclusion criteria resulted in 147 patients consisting of 120 isolated SCIs and 27 with concomitant appendicular fracture. The primary outcome was ASIA Impairment Scale (AIS) neurological grades at hospital discharge. Secondary outcomes included hospital length of stay, ICU length of stay, and AIS grade improvement during hospitalization. Multivariable binomial logistic regression analyses assessed whether SCI-concomitant appendicular fractures associate with SCI function and secondary outcomes. These analyses were adjusted for age, gender, injury severity, and non-fracture polytrauma. Appendicular fractures were associated with more severe AIS grades at hospital discharge, though covariate adjustments diminished statistical significance of this effect. Notably, non-fracture injuries to the chest and abdomen were influential covariates. Secondary analyses suggested that appendicular fractures also increased hospital length of stay. Our study indicated that SCI-associated polytrauma is important for predicting SCI functional outcomes. Further statistical evaluation is required to disentangle the effects of appendicular fractures, non-fracture solid organ injury, and SCI physiology to improve health outcomes amongst SCI patients.

A Fully Immersive Virtual Reality Method for Upper Limb Rehabilitation in Spinal Cord Injury

Objective

To determine whether a fully immersive virtual reality (VR) intervention combined with conventional rehabilitation (CR) can improve upper limb function more than CR alone in patients with spinal cord injury (SCI), we conducted a prospective, randomized, controlled clinical trial.

Methods

Participants were randomly assigned to either the control group (CG; n=10) or experimental group (EG; n=10). The participants in the CG received 60 minutes of conventional therapy per day, 4 days per week for 4 weeks, whereas those in the EG received 30 minutes of VR training and 30 minutes of conventional therapy per day, 4 days per week for 4 weeks. The clinical outcome measures included Medical Research Council grade, the American Spinal Injury Association upper extremity motor score (ASIA-UEMS), and scores in the Hand Strength Test, Box and Block Test, Nine-Hole Peg Test, Action Research Arm Test, and Korean version of the Spinal Cord Independence Measure (K-SCIM). The assessments were performed at the beginning (T0) and end of the intervention (T1).

Results

Grip power and K-SCIM score significantly improved in the EG after the intervention. When comparing differences between the groups, elbow extensor, wrist extensor, ASIA-UEMS, grip power, lateral pinch power, and palmar pinch power were all significantly improved.

Conclusion

VR training of upper limb function after SCI can provide an acceptable adjunctive rehabilitation method without significant adverse effects.

[Funtional tenodesis as a predictor of functional outcome in patients with cervical tetraplegia]

AIM

To determine the value of functional tenodesis (FT) of the hand as a predictor of the degree of disability in patients with cervical tetraplegia (CT) at different periods after a spinal injury.

MATERIAL AND METHODS

We examined 190 patients (79% - men) with CT (92.5% of cases of traumatic origin) at the age of 27 [21.0; 36.0] years with a neurological level of C_ІІІ-D_І, and a share of complete motor damage (A - B according to AIS) 70%. The examination included determination of neurological, motor levels and completeness of spinal cord injury (according to ISNSCI), assessment of functional independence (FIM motor domain), FT of the hand, and the severity of contractures of the joints of the hand. Using logit-regression analysis, creation of contingency tables, ROC analysis, depending on the timing of spinal injury, 4 classification models were studied: Disease duration less than 6 months, assessment of the functional outcome 6 months after spinal injury (model A); disease duration less than 6 months, assessment after 12 months (model B); disease duration less than 12 months, assessment after 12 months (model C); disease duration more than 12 months, evaluation after more than 12 months (model D, primary one).

RESULTS

FT developed in the first 6 months after spinal injury in 12 (24%) patients, in 6-12 months - in 15 patients (20%), in more than 12 months - in 1 (less than 1%) patient. The incidence of joint contractures of the hand in group A (20%) and C (24%) did not have a statistical difference (χ²=0.22; p=0.64). Hand contractures in the first 6 months were observed in 20% of patients, in the first 12 months - in 24%, more than 12 months after spinal injury - in 28% of patients. In model A, the FT sensitivity was 80%, specificity was 64%, AUC - 0.65; in model B - 85%, 36%, 0.36, respectively; in model C (log-regression χ²=19.1; p was not determined) - 69%, 100%, 0.59, respectively; in model D (log-regression χ²=55.3; p was not determined) - 65%, 100%, 0.71, respectively.

CONCLUSION

FT and contracture of the joints of the hand form during the first year after the debut of CT. As a predictor of a pronounced limitation of self-care, the sensitivity of FT in the first 6 months after spinal injury was 80-85%, in the later period, the specificity of FT was 100%, and sensitivity was 65-69%; in general, the predictive power of FT was low (AUC 0.36-0.71) and increased with the assessment of the functional outcome in the period of more than 12 months after the injury.

The Investigation of the Cox-2 Selective Inhibitor Parecoxib Effects in Spinal Cord Injury in Rat

Aim: Today, spinal cord injury (SCI) can be rehabilitated but cannot be treated adequately. This experimental study was conducted to investigate possible beneficial effects of methylprednisolone and parecoxib in treatment of SCI. Materials and methods: Forty-eight male Wistar albino rats were assigned into CONTROL, acute (MP-A, PX-A, and PXMP-A), and subacute (MP-S, PX-S, and PXMP-S) stage groups. Then, to induce SCI, a temporary aneurysm clip was applied to the spinal cord following T7-8 laminectomy, except in the CONTROL group. Four hours later parecoxib, methylprednisolone, or their combination was administered to rats intraperitoneally except CONTROL, SHAM-A, and SHAM-S groups. Rats in the acute stage group were sacrificed 72 h later, and whereas rats in the subacute stage were sacrificed 7 days later for histopathological and biochemical investigation and for gene-expression analyses. Results: Parecoxib and methylprednisolone and their combination could not improve histopathological grades in any stage. They also could not decrease malondialdehyde or caspase-3, myeloperoxidase levels in any stage. Parecoxib and methylprednisolone could decrease the TNF-α gene expression in subacute stage. Methylprednisolone could increase TGF-1β gene-expression level in acute stage. Conclusion: Neither of the experimental drugs, either alone or in combination, did not show any beneficial effects in SCI model in rats.

A simplified clinical prediction rule for prognosticating independent walking after spinal cord injury: a prospective study from a Canadian multicenter spinal cord injury registry

BACKGROUND CONTEXT

Traumatic spinal cord injury (SCI) is a debilitating condition with limited treatment options for neurologic or functional recovery. The ability to predict the prognosis of walking post injury with emerging prediction models could aid in rehabilitation strategies and reintegration into the community.

PURPOSE

To revalidate an existing clinical prediction model for independent ambulation (van Middendorp et al., 2011) using acute and long-term post-injury follow-up data, and to investigatethe accuracy of a simplified model using prospectively collected data from a Canadian multicenter SCI database, the Rick Hansen Spinal Cord Injury Registry (RHSCIR).

STUDY DESIGN

Prospective cohort study.

PARTICIPANT SAMPLE

The analysis cohort consisted of 278 adult individuals with traumatic SCI enrolled in the RHSCIR for whom complete neurologic examination data and Functional Independence Measure (FIM) outcome data were available.

OUTCOME MEASURES

The FIM locomotor score was used to assess independent walking ability (defined as modified or complete independence in walk or combined walk and wheelchair modality) at 1-year follow-up for each participant.

METHODS

A logistic regression (LR) model based on age and four neurologic variables was applied to our cohort of 278 RHSCIR participants. Additionally, a simplified LR model was created. The Hosmer-Lemeshow goodness of fit test was used to check if the predictive model is applicable to our data set. The performance of the model was verified by calculating the area under the receiver operating characteristic curve (AUC). The accuracy of the model was tested using a cross-validation technique. This study was supported by a grant from The Ottawa Hospital Academic Medical Organization ($50,000 over 2 years). The RHSCIR is sponsored by the Rick Hansen Institute and is supported by funding from Health Canada, Western Economic Diversification Canada, and the provincial governments of Alberta, British Columbia, Manitoba, and Ontario. ET and JP report receiving grants from the Rick Hansen Institute (approximately $60,000 and $30,000 per year, respectively). DMR reports receiving remuneration for consulting services provided to Palladian Health, LLC and Pacira Pharmaceuticals, Inc ($20,000-$30,000 annually), although neither relationship presents a potential conflict of interest with the submitted work. KEH received a grant for involvement in the present study from the Government of Canada as part of the Canada Summer Jobs Program ($3,000). JP reports receiving an educational grant from Medtronic Canada outside of the submitted work ($75,000 annually). TM reports receiving educational fellowship support from AO Spine, AO Trauma, and Medtronic; however, none of these relationships are financial in nature. All remaining authors have no conflicts of interest to disclose.

RESULTS

The fitted prediction model generated 85% overall classification accuracy, 79% sensitivity, and 90% specificity. The prediction model was able to accurately classify independent walking ability (AUC 0.889, 95% confidence interval [CI] 0.846-0.933, p<.001) compared with the existing prediction model, despite the use of a different outcome measure (FIM vs. Spinal Cord Independence Measure) to qualify walking ability. A simplified, three-variable LR model based on age and two neurologic variables had an overall classification accuracy of 84%, with 76% sensitivity and 90% specificity, demonstrating comparable accuracy with its five-variable prediction model counterpart. The AUC was 0.866 (95% CI 0.816-0.916, p<.01), only marginally less than that of the existing prediction model.

CONCLUSIONS

A simplified predictive model with similar accuracy to a more complex model for predicting independent walking was created, which improves utility in a clinical setting. Such models will allow clinicians to better predict the prognosis of ambulation in individuals who have sustained a traumatic SCI.

The current role of steroids in acute spinal cord injury

BACKGROUND

Acute spinal cord injury (ASCI) is a catastrophic event that can profoundly affect the trajectory of a patient's life. Debate continues over the pharmacologic management of ASCI, specifically, the widespread but controversial use of the steroid methylprednisolone (MP). Treatment efforts are impeded because of limitations in understanding of the pathobiology of ASCI and the difficulty in proving the efficacy of therapies.

METHODS

This review presents the pathophysiology of ASCI and the laboratory and clinical findings on the use of MP.

RESULTS

The use of MP remains a contentious issue in part because of the catastrophic nature of ASCI, the paucity of treatment options, and the legal ramifications. Although historical data on the use of MP in ASCI have been challenged, more recent studies have been used both to support and to oppose treatment of ASCI with steroids.

CONCLUSIONS

ASCI is a devastating event with a complex aftermath of secondary damaging processes that worsen the initial injury. Although the results of NASCIS (National Acute Spinal Cord Injury Study) II and III trials led to the widespread adoption of a high-dose MP regimen for patients treated within 8 hours of injury, subsequent studies have called into question the validity of NASCIS conclusions. Further evidence of the ineffectiveness of the MP protocol has led to declining confidence in the treatment over the last decade. At the present time, high-dose MP cannot be recommended as a standard of care, but it remains an option until supplanted by future evidence-based therapies.

Spinal cord transection modifies neuronal nitric oxide synthase expression in medullar reticular nuclei and in the spinal cord and increases parvalbumin immunopositivity in motoneurons below the site of injury in experimental rabbits

Using immunohistochemistry, we detected the expression of neuronal nitric oxide synthase (nNOS) in ventral medullary gigantocellular reticular nuclei and in the lumbosacral spinal cord 10 days after thoracic transection in experimental rabbits. We tried to determine whether neurons located below the site of injury are protected by the calcium binding protein parvalbumin (PV). Changes of nNOS immunoreactivity (IR) in spinal cord were correlated with the level of nNOS protein in dorsal and ventral horns. Ten days after transection, nNOS was upregulated predominantly in lateral gigantocellular nuclei. In the spinal cord, we revealed a significant increase of nNOS protein in the dorsal horn. This is consistent with a higher density of punctate and fiber-like immunostaining for nNOS in laminae III-IV and the up-regulation of nNOS-IR in neurons of the deep dorsal horn. After surgery, the perikarya of motoneurons remained nNOS immunonegative. Contrary to nNOS, the PV-IR was upregulated in α-motoneurons and small-sized neurons of the ventral horn. However, its expression was considerably reduced in neurons of the deep dorsal horn. The findings indicate that spinal transection affects nNOS and PV in different neuronal circuits.

A review: the role of high dose methylprednisolone in spinal cord trauma in children

BACKGROUND

The use of steroids in traumatic spinal cord injury (SCI) in children is controversial. There is a paucity of literature on its usage. To help clarify recommendations on steroid use in children, we reviewed the current literature on the administration of high dose methylprednisolone (MP) use in traumatic spinal cord injuries with an emphasis in pediatric spinal cord trauma.

METHODS

A retrospective review of the current literature on traumatic spinal cord injuries was conducted. Outcomes were critically reviewed from the National Acute Spinal Cord Injury Studies (NASCIS) II and III and Cochrane review; as well as, other randomized and retrospective studies. Papers describing objective neurological outcomes were only included.

RESULTS

The outcomes of neurological improvement following steroid infusion have not been reproducible outside of the NASCIS and one single Japanese trial. High dose steroids significantly increase the risk of infections leading to prolonged hospital stay and ventilator dependence.

CONCLUSION

Data from adult studies remains controversial with insufficient data to support administration of MP for treatment of traumatic spinal cord injuries. Randomized controlled trials are needed in the pediatric population to assess the advantages of steroid use after SCI in children. On the basis of the current evidence, the use of steroids in patients is associated with increased infectious risks and no neurological improvements.

Current management review of thoracolumbar cord syndromes

BACKGROUND CONTEXT

Injuries to the thoracolumbar spine may lead to a complex array of clinical syndromes that result from dysfunction of the anterior motor units, lumbosacral nerve roots, and/or spinal cord. Neurologic dysfunction may manifest in the lower extremities as loss of fine and gross motor function, touch, pain, temperature, and proprioceptive and vibratory sense deficits. Two clinical syndromes sometimes associated with these injuries are conus medullaris syndrome (CMS) and cauda equina syndrome (CES).

PURPOSE

To review the current management of thoracolumbar spinal cord injuries.

STUDY DESIGN

Literature review.

METHODS

Index Medicus was used to search the primary literature for articles on thoracolumbar injuries. An emphasis was placed on the current management, controversies, and newer treatment options.

RESULTS/CONCLUSIONS

After blunt trauma, these syndromes may reflect a continuum of dysfunction rather than a distinct clinical entity. The transitional anatomy at the thoracolumbar junction, where the conus medullaris is present, makes it less likely that a "pure" CMS or CES syndrome will occur and more likely that a "mixed" injury will. Surgical decompression is the mainstay of treatment for incomplete spinal cord injury (SCI) and incomplete CMS and CES. The value of timing of surgical intervention in the setting of incomplete SCI is unclear at this time. This review summarizes the recent information on epidemiology, pathophysiology, diagnosis, and controversies in the management of thoracolumbar neurologic injury syndromes.

Chemical priming for spinal cord injury: a review of the literature part II-potential therapeutics

INTRODUCTION

Spinal cord injury is a complex cascade of reactions secondary to the initial mechanical trauma that puts into action the innate properties of the injured cells, the circulatory, inflammatory, and chemical status around them, into a non-permissive and destructive environment for neuronal function and regeneration. Priming means putting a cell, in a state of "arousal" towards better function. Priming can be mechanical as trauma is known to enhance activity in cells.

MATERIALS AND METHODS

A comprehensive review of the literature was performed to better understand the possible chemical primers used for spinal cord injuries.

CONCLUSIONS

Taken together, many studies have shown various promising results using the substances outlined herein for treating SCI.

Chemical priming for spinal cord injury: a review of the literature. Part I-factors involved

INTRODUCTION

There are significant differences between the propensity of neural regeneration between the central and peripheral nervous systems.

MATERIALS AND METHODS

Following a review of the literature, we describe the role of growth factors, guiding factors, and neurite outgrowth inhibitors in the physiology and development of the nervous system as well as the pathophysiology of the spinal cord. We also detail their therapeutic role as well as those of other chemical substances that have recently been found to modify regrowth following cord injury.

CONCLUSIONS

Multiple factors appear to have promising futures for the possibility of improving spinal cord injury following injury.

Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature

BACKGROUND CONTEXT

Methylprednisolone has evolved during the 1990s, through the results obtained from the National Acute Spinal Cord Injury Studies NASCIS II and III, as a standard treatment in acute spinal injury.

PURPOSE

To evaluate the scientific basic for the use of methylprednisolone in acute spinal cord injury.

STUDY DESIGN

Systematic review of the accumulated literature.

METHODS

Critical evaluation of the data obtained in the NASCIS II and III studies plus other accumulated literature.

RESULTS

Analyses have been made on subgroups of the study populations, and the results were based on statistical artefacts. Furthermore, improved functional recovery shown by these studies was not clinically significant.

CONCLUSION

There is insufficient evidence to support the use of methylprednisolone as a standard treatment in acute spinal cord injury.

Apport de l’imagerie par résonance magnétique dans les traumatismes médullaires

PURPOSE

To describe MR features of spinal trauma and assess the value of MR imaging in the prognosis.

MATERIAL AND METHODS

Retrospective confrontation between initial and follow up MRI findings and clinical features in 7 young patients with spinal cord injury.

RESULTS

Five lesions were due to motor vehicle accidents and 2 lesions were secondary to falls. Five patients had multiple associated injuries, 1 patient had associated spinal vertebrae injury, the last had Spinal Cord injury Without Radiological Abnormalities (SCIWRA). A motor deficit was noted in 5 cases of paraplegia, a case of monoplegia and a case of tetraparesia. The initial MRI showed in 3 cases intramedullary hemorrhage, cord edema in 2 cases and spinal cord compression and contusion in 1 case. Initial MRI was not done in the remaining case. No cord transection was noted. Outcomes were marked by lack of significant neurological recovery with complications due to bed confinement in 5 cases, and complete neurolgical recovery in two cases. In follow up, MR findings included post traumatic cystic lesion (2 cases), "ad integrum" restitution (1 case), segmental atrophy with gliosis (2 cases) and myelomalacia in the 2 other cases.

CONCLUSION

MR may offer new possibilities in establishing the prognosis for neurological recovery. Our study demonstrated a good correlation between imaging findings, clinical features and outcomes. A hemorrhagic contusion in the acute stage indicated a poor prognosis while a focal hyperintense area on T2-weighted images may resolve.

Effect of postinjury intravenous or intrathecal methylprednisolone on spinal cord excitatory amino-acid release, nitric oxide generation, PGE2 synthesis, and myeloperoxidase content in a pig model of acute spinal cord injury

STUDY DESIGN

Prospective, randomized, in vivo acute spinal cord injury in pigs.

SETTING

Department of Anesthesiology, University of Washington, Seattle, WA, USA.

OBJECTIVES

To determine whether postinjury methylprednisolone could reduce the generation of known mediators of secondary neurological injury.

METHODS

Intrathecal microdialysis probes were used to sample cerebrospinal fluid (CSF) for measurement of PGE(2), glutamate, and citrulline (a byproduct of nitric oxide generation), before and after spinal cord injury in anesthetized pigs. The spinal cord was removed at the end of the study for measurement of myeloperoxidase and methylprednisolone concentrations. Animals were randomly allocated to receive intravenous methylprednisolone (30 mg/kg bolus then 3.4 mg/kg/h), intrathecal methylprednisolone (5 mg bolus then 5 mg/h), or saline, beginning 30 min after the spinal cord was injured by using a modification of the Allen weight drop technique.

RESULTS

Spinal cord injury significantly increased the amount of glutamate, PGE(2), myeloperoxidase, and citrulline, recovered from the CSF dialysates. However, neither intravenous nor intrathecal methylprednisolone administered after injury had any effect on the magnitude of the increase in any of the measured biochemicals. Intrathecal methylprednisolone administration produced a spinal cord methylprednisolone concentration that was eight times greater, and a plasma concentration that was 32 times less, than that achieved with intravenous administration.

CONCLUSIONS

Contrary to earlier animal studies in which methylprednisolone was administered either before or immediately after spinal cord injury, we found no effect of intravenous or intrathecal methylprednisolone on any of the parameters measured when administered 30 min postinjury.

Motor neurone excitability in back muscles assessed using mechanically evoked reflexes in spinal cord injured patients

OBJECTIVE

The clinical and functional assessment of back muscles in human spinal cord injury (SCI) has received little attention. The aim of this study was to develop a method to assess the level of a thoracic spinal cord lesion based on the reflex activation of back muscles.

METHODS

In 11 control subjects and in 12 subjects with clinically complete thoracic SCI (T2-T12), either a spinous process or an erector spinae muscle was prodded to elicit short latency reflexes recorded electromyographically at the spinal level of stimulation. An electromagnetic servo, attached to a blunt probe, applied stimuli at a frequency of 1 Hz and amplitude of 3 mm. Two trials of 50 mechanical prods were conducted at each site.

RESULTS

Reflexes were evoked in control subjects in 82% of trials when the spinous process was prodded, and in 80% of trials when the muscle was prodded. In contrast, reflexes in SCI subjects could be elicited in 90-100% of trials two segments either above or below the lesion. Reflex responses in control subjects had a mean (SEM) latency of 5.72 (0.53) ms when the spinous process was prodded, and 5.42 (0.42) ms when the muscle was prodded. In the SCI subjects, responses had slightly (but insignificantly) longer latencies both above and below the lesion to either stimulus. The amplitude of reflex responses, expressed as a percentage of the background EMG, was on average 2-3 times larger at the three vertebral levels spanning the lesion in SCI subjects than at sites above or below the lesion or at any level in control subjects.

CONCLUSION

We propose that the size of these mechanically evoked reflexes may be useful in determining the level of thoracic SCI. Furthermore, the reflexes might provide a valuable tool with which to monitor recovery after an intervention to repair or improve function of a damaged spinal cord.

Course of Gross Mechanical Efficiency in Handrim Wheelchair Propulsion During Rehabilitation of People With Spinal Cord Injury: A Prospective Cohort Study

OBJECTIVE

To investigate the course of mechanical efficiency of handrim wheelchair propulsion during rehabilitation of subjects with (in)complete paraplegia and tetraplegia.

DESIGN

Subjects were tested at the start of active rehabilitation (t1), 3 months later (t2), and when discharged from inpatient rehabilitation (t3). They performed two 3-minute submaximal treadmill exercise blocks in a wheelchair.

SETTING

Eight rehabilitation centers in the Netherlands.

PARTICIPANTS

Ninety-two people with (in)complete paraplegia and tetraplegia.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mechanical efficiency values were calculated for each block. The course of mechanical efficiency was investigated using test occasions (t1 -t3), completeness and level (paraplegia or tetraplegia) of the lesion, and power output as independent variables in a multilevel regression analysis.

RESULTS

Mechanical efficiency significantly increased between t1 and t2 only. After adding level and completeness of the lesion and their interactions with time to the model, block 2 showed that subjects with paraplegia had a significantly higher mechanical efficiency than subjects with tetraplegia. Subjects with tetraplegia improved more between t1 and t2 . Differences in mechanical efficiency between subjects with paraplegia and tetraplegia could not be explained by differences in absolute and relative power output levels.

CONCLUSIONS

Results showed a significant improvement in mechanical efficiency during the first 3 months of active rehabilitation. Subjects with paraplegia showed a higher mechanical efficiency than did subjects with tetraplegia, whereas the latter showed more improvement between t1 and t2 .

The effects of gender on clinical and neurological outcomes after acute cervical spinal cord injury

The potential clinical relevance of gender on clinical and neurological outcome after spinal cord injury (SCI) has received little attention. In order to address this issue, we examined all consecutive cases of acute traumatic cervical SCI admitted to our institution from 1998 to 2000. There were 38 males (ages 17-89 years, mean of 51.6) and 17 females (ages 18-84 years, mean of 63.2). Both groups were comparable regarding level (C1 to C7) and severity of SCI (ASIA A to D) at admission. Age differences between the groups approached significance (p = 0.057), and thus this factor was treated as a covariate in the analysis. Co-morbidities were as frequent in men (86.8%) as in women (76.5%). The therapeutic approaches, length-of-stay in the acute care unit, mortality, and discharge disposition were similar in men and women. During hospitalization, 44.7% of men and 52.9% of women developed post-SCI secondary complications without any significant gender-related differences. Both groups showed a similar incidence of infections, cardiovascular complications, thromboembolism, and pressure sores. Univariate analysis revealed a trend for higher incidence of psychiatric complications (p = 0.054) and deep venous thrombosis (p = 0.092) in women, which was confirmed by multivariate analysis. Neurological outcome was not correlated with gender. A similar number of males and females (42.1%, 47.1%) showed evidence of neurological recovery as revealed by an improvement in ASIA scores. Moreover, 18.4% of males and 29.4% of females recovered to ASIA E status. Our data suggest a shift in the demographics of acute SCI with an increasing incidence in elderly women. Although neurological outcomes were not significantly related to gender, we observed a trend for higher rates of reactive depression and deep venous thrombosis in women. These issues may be of key clinical importance in developing improved management protocols for SCI so as to maximize functional recovery and quality-of-life.

Iatrogenic paraplegia in spinal surgery

INTRODUCTION

Paraplegia as a result of a surgical spinal procedure is a rare complication. The risk cannot be precisely quantified due to the lack of current data. The aim of this study was to record a sufficiently large number of major spinal operations, especially extended methods in scoliosis surgery. Hereby, a reliable statement regarding the risk of severe neurological complications with these surgical techniques should be possible. First, a retrospective analysis of patients from a German spine centre (spinal fusion) and a survey of 17 German centres of spinal surgery were conducted for the retrospective acquisition of severe iatrogenic neurological complications.

MATERIALS AND METHODS

The study included 1194 patients who underwent a spinal fusion during the period 1992-2002. The incidents of postoperative paraplegia are described in detail, and case studies done. Possible causes, methods of intraoperative monitoring and options of therapy are discussed according to research in relevant publications. Additionally, severe neurological complications of 3115 spinal operations were recorded in a standardised survey conducted throughout major German spinal centres.

RESULTS

Of the 1194 patients surveyed, 7 (0.59%) experienced a postsurgical complete or incomplete paraplegia. In 3 of the recorded cases, the cause could be identified. The survey of 3115 scoliosis surgeries showed that iatrogenic paraplegia occurred with a frequency of 0.55%. The risks associated with short spinal fusions (0.14%), cervical discectomies (0.07%) and lumbar discectomies (0.03%) are considerably less.

CONCLUSION

Operative treatment of scoliosis with a high degree of correction carries a risk of neurological complications of about 0.5%. Mechanical as well as ischaemic damage to the spinal cord can be detected early by means of consistent intraoperative neuromonitoring.

Respostas cardio-respiratórias em pacientes com traumatismo raquimedular

O objetivo desta pesquisa foi investigar as variáveis cardio-respiratórias (Pa, FC, VO2, VCO2 e Ve) durante a Estimulação Elétrica Neuromuscular (EENM) do quadríceps em portadores de lesão medular. Participaram da pesquisa dez pacientes (cinco paraplégicos e cinco tetraplégicos). O protocolo do teste consistiu em 10 minutos de repouso, 20 minutos de EENM dos quadriceps e 10 minutos de recuperação. Durante a EENM foram constatados baixos valores de VO2 e VCO2. Os paraplégicos apresentaram rápida cinética dos gases e os tetraplégicos lenta cinética dos gases. Houve o aumento da Pa sistólica e da FC. Ainda, os valores das variáveis cardio-respiratórias foram inversamente relatadas para o nível de lesão, ou seja, quanto maior o nível de lesão, menor os valores. Portanto, a maioria dos pacientes apresentaram algumas limitações nas respostas cardio-respiratórias, indicando realização de exercício exaustivo, mas apresentaram capacidade de realização de exercício induzido artificialmente, possivelmente devido aos benefícios da EENM.

Response of NADPH-Diaphorase-Exhibiting Neurons in the Medullar Reticular Formation to High Spinal Cord Injury

1. The effect of hemisection of the cervical spinal cord on NADPH-diaphorase staining in the reticular nuclei of the rabbit medulla was investigated using histochemical technique. 2. A quantitative assessment of somal and neuropil NADPH-diaphorase staining was made by an image analyzer in a selected area of each reticular nucleus of the rabbit medulla. 3. On the 7th postsurgery day, the highest up-regulation of somatic NADPH-diaphorase staining was observed in regions regulating cardiorespiratory processes; however, the highest increase of neuropil NADPH-diaphorase staining was found in the reticular nuclei modulating the tonus of postural muscles. 4. The degeneration of non-NADPH-diaphorase-stained neurons was detected throughout the reticular formation of the medulla, but the extent of neuronal death did not correlate with the up-regulation of the NADPH-diaphorase staining in the reticular nuclei of the medulla. 5. The findings provide evidence that NADPH-diaphorase-exhibiting neurons are refractory to the hemisection of the cervical spinal cord and that the neuronal up-regulation of NADPH-diaphorase at the medullar level is probably not a causative factor leading to the death of the reticulospinal neurons.

Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome

STUDY DESIGN

A systematic review of the literature, pertaining surgical treatment of traumatic thoracic and lumbar spine fractures, was performed.

OBJECTIVES

To provide information on surgical techniques for traumatic spine fracture management, their respective performance and complication rates, based on previously published information.

SUMMARY OF BACKGROUND DATA

The treatment of traumatic fractures of the thoracic and lumbar spine remains controversial. There is insufficient evidence in the literature to choose between the various surgical options. In absence of conclusive studies, a systematic review can be an alternative to obtain more convincing information.

METHODS

Full-text papers from 1970 until 2001 were included if strict inclusion criteria were met. Five surgical subgroups were recognized: posterior short-segment (PS), posterior long-segment (PL), reports on both posterior short- and long-segment (PSL), anterior (A), and anterior combined with posterior (AP) techniques. Clearly defined and generally accepted parameters were scored and subsequently analyzed. The preoperative injury severity of the surgical groups was compared. The neurologic, radiologic, and functional outcome and complications of all groups were assessed.

RESULTS

A total of 132 papers, the majority being retrospective case-series, were included representing 5,748 patients. The preoperative injury severity revealed an inequality between the subgroups. Partial neurologic deficits had the potential to resolve irrespective of treatment choice. None of the five techniques used was able to maintain the corrected kyphosis angle. The functional outcome after surgery seems to be better than generally believed. Complications are relatively rare.

CONCLUSIONS

In general, surgical treatment of traumatic spine fractures is safe and effective. Surgical techniques can only be compared using randomized controlled trials.

High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option

BACKGROUND

A systematic review of the evidence pertaining to methylprednisolone infusion following acute spinal cord injury was conducted in order to address the persistent confusion about the utility of this treatment.

METHODS

A committee of neurosurgical and orthopedic spine specialists, emergency physicians and physiatrists engaged in active clinical practice conducted an electronic database search for articles about acute spinal cord injuries and steroids, from January 1, 1966 to April 2001, that was supplemented by a manual search of reference lists, requests for unpublished additional information, translations of foreign language references and study protocols from the author of a Cochrane systematic review and Pharmacia Inc. The evidence was graded and recommendations were developed by consensus.

RESULTS

One hundred and fifty-seven citations that specifically addressed spinal cord injuries and methylprednisolone were retrieved and 64 reviewed. Recommendations were based on one Cochrane systematic review, six Level I clinical studies and seven Level II clinical studies that addressed changes in neurological function and complications following methylprednisolone therapy.

CONCLUSIONS

There is insufficient evidence to support the use of high-dose methylprednisolone within eight hours following an acute closed spinal cord injury as a treatment standard or as a guideline for treatment. Methylprednisolone, prescribed as a bolus intravenous infusion of 30 mg per kilogram of body weight over fifteen minutes within eight hours of closed spinal cord injury, followed 45 minutes later by an infusion of 5.4 mg per kilogram of body weight per hour for 23 hours, is only a treatment option for which there is weak clinical evidence (Level I- to II-1). There is insufficient evidence to support extending methylprednisolone infusion beyond 23 hours if chosen as a treatment option.

Pharmacological therapy after acute cervical spinal cord injury

CORTICOSTEROIDS

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Treatment with methylprednisolone for either 24 or 48 hours is recommended as an option in the treatment of patients with acute spinal cord injuries that should be undertaken only with the knowledge that the evidence suggesting harmful side effects is more consistent than any suggestion of clinical benefit. GM-1 GANGLIOSIDE:

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Treatment of patients with acute spinal cord injuries with GM-1 ganglioside is recommended as an option without demonstrated clinical benefit.

The role of steroids in acute spinal cord injury: an evidence-based analysis

STUDY DESIGN

Literature review.

OBJECTIVES

The purpose of this article is to review the available literature and formulate evidence-based recommendations for the use of methylprednisone in the setting of acute spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

Since the early 1990s, methylprednisolone has become widely prescribed for the treatment of acute SCI. Arguably, it has become a standard of care.

METHODS

Through an electronic database search strategy and by cross-reference with published literature, appropriate clinical studies were identified. They were reviewed in chronologic order with respect to study design, outcome measures, results, and conclusions.

RESULTS

Nine studies were identified that attempted to evaluate the role of steroids in nonpenetrating (blunt) spinal cord injury. Five of these were Class I clinical trials, and four were Class II studies. All of the studies failed to demonstrate improvement because of steroid administration in any of the a priori hypotheses testing. Although post hoc analyses were interesting, they failed to demonstrate consistent significant treatment effects.

CONCLUSIONS

From an evidence-based approach, methylprednisolone cannot be recommended for routine use in acute nonpenetrating SCI. Prolonged administration of high-dose steroids (48 hours) may be harmful to the patient. Until more evidence is forthcoming, methylprednisolone should be considered to have investigational (unproven) status only.

Spinal cord injury research: review and synthesis

This article provides a substantive review and synthesis of major areas of emphasis in spinal cord injury (SCI) research. Comprehensive examination of the current status and future implications for SCI research includes consideration of investigations from the following arenas: epidemiology, functional classification and prediction, neurophysiologic testing, models of injury and recovery, psychosocial considerations, surgical strategies, animal laboratory research, economic implications, life expectancy, complication rates, gender differences, pharmacological management, and prevention. Synthesis of these research conclusions from a broad spectrum of laboratory, clinical, and scientific domains provides opportunity for improving SCI prevention, treatment, and adaptation.