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Zhu H, Guest JD, Dunlop S, Xie JX, Gao S, Luo Z, Springer JE, Wu W, Young W, Poon WS, Liu S, Gao H, Yu T, Wang D, Zhou L, Wu S, Zhong L, Niu F, Wang X, Liu Y, So KF, Xu XM. Surgical intervention combined with weight-bearing walking training promotes recovery in patients with chronic spinal cord injury: a randomized controlled study. Neural Regen Res 2024; 19:2773-2784. [PMID: 38595294 PMCID: PMC11168509 DOI: 10.4103/nrr.nrr-d-23-01198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/09/2023] [Accepted: 11/24/2023] [Indexed: 04/11/2024] Open
Abstract
JOURNAL/nrgr/04.03/01300535-202412000-00032/figure1/v/2024-04-08T165401Z/r/image-tiff For patients with chronic spinal cord injury, the conventional treatment is rehabilitation and treatment of spinal cord injury complications such as urinary tract infection, pressure sores, osteoporosis, and deep vein thrombosis. Surgery is rarely performed on spinal cord injury in the chronic phase, and few treatments have been proven effective in chronic spinal cord injury patients. Development of effective therapies for chronic spinal cord injury patients is needed. We conducted a randomized controlled clinical trial in patients with chronic complete thoracic spinal cord injury to compare intensive rehabilitation (weight-bearing walking training) alone with surgical intervention plus intensive rehabilitation. This clinical trial was registered at ClinicalTrials.gov (NCT02663310). The goal of surgical intervention was spinal cord detethering, restoration of cerebrospinal fluid flow, and elimination of residual spinal cord compression. We found that surgical intervention plus weight-bearing walking training was associated with a higher incidence of American Spinal Injury Association Impairment Scale improvement, reduced spasticity, and more rapid bowel and bladder functional recovery than weight-bearing walking training alone. Overall, the surgical procedures and intensive rehabilitation were safe. American Spinal Injury Association Impairment Scale improvement was more common in T7-T11 injuries than in T2-T6 injuries. Surgery combined with rehabilitation appears to have a role in treatment of chronic spinal cord injury patients.
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Affiliation(s)
- Hui Zhu
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - James D. Guest
- Neurological Surgery, and the Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Sarah Dunlop
- School of Biological Sciences, The University of Western Australia, Perth, WA, Australia
- Minderoo Foundation, Perth, WA, Australia
| | - Jia-Xin Xie
- Clinical Center for Spinal Cord Injury, Kunming General Hospital of Chengdu Military Command, Kunming, Yunnan Province, China
| | - Sujuan Gao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Zhuojing Luo
- Department of Orthopedic Spinal Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi Province, China
| | - Joe E. Springer
- Spinal Cord and Brain Injury Research Center, Department of Physical Medicine and Rehabilitation, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Wutian Wu
- Guangdong-HongKong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, Guangdong Province, China
| | - Wise Young
- W. M. Keck Center for Collaborative Neuroscience, Rutgers University, Piscataway, NJ, USA
| | - Wai Sang Poon
- Neurosurgery Department, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administration Region, China
| | - Song Liu
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Hongkun Gao
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Tao Yu
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Dianchun Wang
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Libing Zhou
- Guangdong-HongKong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, Guangdong Province, China
| | - Shengping Wu
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Lei Zhong
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Fang Niu
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Xiaomei Wang
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Yansheng Liu
- Kunming Tongren Hospital, Kunming, Yunnan Province, China
| | - Kwok-Fai So
- Guangdong-HongKong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, Guangdong Province, China
| | - Xiao-Ming Xu
- Spinal Cord and Brain Injury Research Group, Stark Neurosciences Research Institute, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Ariji Y, Hayashi T, Ideta R, Koga R, Murai S, Naka T, Ifuku R, Towatari F, Sakai H, Kurata H, Maeda T. Identification of a reliable sacral-sparing examination to assess the ASIA impairment scale in patients with traumatic spinal cord injury. J Spinal Cord Med 2024; 47:286-292. [PMID: 35352975 PMCID: PMC10885764 DOI: 10.1080/10790268.2022.2047548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES We evaluated the time course of the American Spinal Cord Injury Association (ASIA) impairment scale (AIS) for up to three months in participants within 72 h after traumatic spinal cord injury (TSCI) with complete paralysis. We aimed to determine the most useful sacral-sparing examination (deep anal pressure [DAP], voluntary anal contraction [VAC], S4-5 light touch [LT], or pin prick [PP] sensation) in determining AIS grades. DESIGN Retrospective cohort study. SETTING Spinal Injuries Center, Fukuoka, Japan. PARTICIPANTS Among 668 TSCI participants registered in the Japan Single Center study for Spinal Cord Injury Database (JSSCI-DB) between January 2012 and May 2020, we extracted the data of 80 patients with AIS grade A within 72 h after injury and neurological level of injury (NLI) at T12 or higher. INTERVENTIONS None. OUTCOME MEASURES The sacral-sparing examination at the time of the change to incomplete paralysis was compared to the AIS determination using a standard algorithm and with each assessment including the VAC, DAP, S4-5LT, and S4-5PP examinations at the time of AIS functional change. Agreement among assessments was evaluated using weighted kappa coefficients. The relationship was evaluated using Spearman's rank correlation coefficients. RESULTS Fifteen participants (18.8%) improved to incomplete paralysis (AIS B to D) within three months after injury. The single assessment among the sacral-sparing examinations with the highest agreement and strongest correlation with AIS determination was the S4-5LT examination (k = 0.89, P < 0.01, r = 0.84, P < 0.01). CONCLUSIONS The S4-5LT examination is key in determining complete or incomplete paralysis due to its high discriminatory power.
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Affiliation(s)
- Yuto Ariji
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Tetsuo Hayashi
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryosuke Ideta
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryuichiro Koga
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Satoshi Murai
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Tomoki Naka
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryusei Ifuku
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Fumihiro Towatari
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Hiroaki Sakai
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Hiroyuki Kurata
- Department of Bioscience and Bioinformatics, Kyushu Institute of Technology - Iizuka Campus, Fukuoka, Japan
| | - Takeshi Maeda
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
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Mputu PM, Beauséjour M, Richard-Denis A, Dionne A, Mac-Thiong JM. Does Improvement in American Spinal Injury Association Impairment Scale Grade Correlate With Functional Recovery in All Patients With a Traumatic Spinal Cord Injury? Am J Phys Med Rehabil 2024; 103:117-123. [PMID: 37408130 DOI: 10.1097/phm.0000000000002313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The aim of the study is to determine what improvement on the American Spinal Injury Impairment Scale correlates with functional status after a traumatic spinal cord injury. DESIGN We performed an observational cohort study, analyzing prospective data from 168 patients with traumatic spinal cord injury admitted to a single level 1 trauma center. A multivariable analysis was performed to assess the relationship between functional status (from the Spinal Cord Independence Measure) at 1-year follow-up and American Spinal Injury Impairment Scale grade (baseline and 1-yr follow-up), while taking into account covariables describing the sociodemographic status, trauma severity, and level of neurological injury. RESULTS Individuals improving to at least American Spinal Injury Impairment Scale grade D had significantly higher Spinal Cord Independence Measure score compared with those not reaching American Spinal Injury Impairment Scale D (89.3 ± 15.2 vs. 52.1 ± 20.4) and were more likely to reach functional independence (68.5% vs. 3.6%), regardless of the baseline American Spinal Injury Impairment Scale grade. Higher final Spinal Cord Independence Measure was more likely with an initial American Spinal Injury Impairment Scale grade D (β = 1.504; 95% confidence interval = 0.46-2.55), and a final American Spinal Injury Impairment Scale grade D (β = 3.716; 95% CI = 2.77-4.66) or E (β = 4.422; 95% CI = 2.91-5.93). CONCLUSIONS Our results suggest that reaching American Spinal Injury Impairment Scale grade D or better 1 yr after traumatic spinal cord injury is highly predictive of significant functional recovery, more so than the actual improvement in American Spinal Injury Impairment Scale grade from the injury to the 1-yr follow-up.
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Affiliation(s)
- Pascal Mputu Mputu
- From the Hôpital du Sacré-Cœur de Montréal, Montreal, Canada (PMM, AR-D, AD, J-MM-T); Department of Biomedical Sciences, Faculty of Medicine, University of Montreal, Montreal, Canada (PMM, AD); Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, Canada (MB, J-MM-T); Department of Community Health Sciences, University of Sherbrooke, Longueuil, Canada (MB); Sainte-Justine University Hospital Research Center, Montréal, Canada (MB, J-MM-T); and Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Canada (AR-D)
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Kelly-Hedrik M, Abd-El-Barr MM, Aarabi B, Curt A, Howley SP, Harrop JS, Kirshblum S, Neal CJ, Noonan V, Park C, Ugiliweneza B, Tator C, Toups EG, Fehlings MG, Williamson T, Guest JD. Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care. J Neurotrauma 2023; 40:1834-1848. [PMID: 36576020 DOI: 10.1089/neu.2022.0450] [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: 12/29/2022] Open
Abstract
Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.
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Affiliation(s)
| | | | - Bizhan Aarabi
- University of Maryland School of Medicine, Maryland, USA
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Susan P Howley
- Christopher & Dana Reeve Foundation, Short Hills, New Jersey, USA
| | - James S Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Kirshblum
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Christopher J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Vanessa Noonan
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Christine Park
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Charles Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G Toups
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James D Guest
- Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami, Miami, USA
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Saadoun S, Grassner L, Belci M, Cook J, Knight R, Davies L, Asif H, Visagan R, Gallagher MJ, Thomé C, Hutchinson PJ, Zoumprouli A, Wade J, Farrar N, Papadopoulos MC. Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial. Trials 2023; 24:497. [PMID: 37550727 PMCID: PMC10405486 DOI: 10.1186/s13063-023-07454-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/13/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Cervical traumatic spinal cord injury is a devastating condition. Current management (bony decompression) may be inadequate as after acute severe TSCI, the swollen spinal cord may become compressed against the surrounding tough membrane, the dura. DISCUS will test the hypothesis that, after acute, severe traumatic cervical spinal cord injury, the addition of dural decompression to bony decompression improves muscle strength in the limbs at 6 months, compared with bony decompression alone. METHODS This is a prospective, phase III, multicenter, randomized controlled superiority trial. We aim to recruit 222 adults with acute, severe, traumatic cervical spinal cord injury with an American Spinal Injury Association Impairment Scale grade A, B, or C who will be randomized 1:1 to undergo bony decompression alone or bony decompression with duroplasty. Patients and outcome assessors are blinded to study arm. The primary outcome is change in the motor score at 6 months vs. admission; secondary outcomes assess function (grasp, walking, urinary + anal sphincters), quality of life, complications, need for further surgery, and mortality, at 6 months and 12 months from randomization. A subgroup of at least 50 patients (25/arm) also has observational monitoring from the injury site using a pressure probe (intraspinal pressure, spinal cord perfusion pressure) and/or microdialysis catheter (cord metabolism: tissue glucose, lactate, pyruvate, lactate to pyruvate ratio, glutamate, glycerol; cord inflammation: tissue chemokines/cytokines). Patients are recruited from the UK and internationally, with UK recruitment supported by an integrated QuinteT recruitment intervention to optimize recruitment and informed consent processes. Estimated study duration is 72 months (6 months set-up, 48 months recruitment, 12 months to complete follow-up, 6 months data analysis and reporting results). DISCUSSION We anticipate that the addition of duroplasty to standard of care will improve muscle strength; this has benefits for patients and carers, as well as substantial gains for health services and society including economic implications. If the addition of duroplasty to standard treatment is beneficial, it is anticipated that duroplasty will become standard of care. TRIAL REGISTRATION IRAS: 292031 (England, Wales, Northern Ireland) - Registration date: 24 May 2021, 296518 (Scotland), ISRCTN: 25573423 (Registration date: 2 June 2021); ClinicalTrials.gov number : NCT04936620 (Registration date: 21 June 2021); NIHR CRN 48627 (Registration date: 24 May 2021).
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Affiliation(s)
- Samira Saadoun
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK.
| | - Lukas Grassner
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
- Institute of Molecular Regenerative Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Maurizio Belci
- National Spinal Injury Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, Bucks, UK
| | - Jonathan Cook
- Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Ruth Knight
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Lucy Davies
- Surgical Intervention Trials Unit, University of Oxford, Oxford, UK
| | - Hasan Asif
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Ravindran Visagan
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Mathew J Gallagher
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Claudius Thomé
- Department of Neurosurgery, Innsbruck Medical University, Innsbruck, Austria
| | | | - Argyro Zoumprouli
- Neuro-Intensive Care Unit, Atkinson Morley Wing, St. George's Hospital NHS Foundation Trust, London, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Farrar
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
- Neurosurgery, Atkinson Morley Wing, St. George's Hospital NHS Foundation Trust, London, UK
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Liam H, Kody B, Kevin R. Sensory sparing does not change long-term outcomes in motor complete spinal cord injuries. Spine J 2022; 22:1169-1177. [PMID: 35123047 DOI: 10.1016/j.spinee.2022.01.021] [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: 06/08/2021] [Revised: 01/23/2022] [Accepted: 01/27/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In the acute postinjury setting, the prognostic value of sensory sparing among motor complete spinal injury patients has been well demonstrated. However, once final AIS grade is achieved 1 year postinjury, the value of sensory sparing alone has not been elucidated. We hypothesized that sensory sparing would lead to better outcomes in AIS B over AIS A patients at long-term, postrecovery follow-up. PURPOSE To evaluate for differences in medical, Physical and Social outcomes between AIS A and B patients at least 1 year postinjury. STUDY DESIGN Retrospective Cohort. PATIENT SAMPLE Adults over the age of 18 with AIS A or B spinal cord injury sustained between January 1, 1995 and September 13, 2019. Data Collected from the Spinal Cord Injury Model Systems Database. OUTCOME MEASURES Self-reported Measures: PHQ-9 score; SCI-QOL Resilience Short Form score; VAS pain score; Life Satisfaction Score; Self-reported depression and sleep disturbances. Physiologic Measures: Body Mass Index, Diabetes Mellitus, Hypertension, Hyperlipidemia, Mortality, Incidence of Pressure Sores. Functional Measures: Bowel and Bladder Management; Illicit Substance use; Level of Education; Marital Status; Rehospitalization Rate. METHODS Patient data from the Spinal Cord Injury Model Systems Database were extracted for patients with a final, recovered American Spinal Injury Association Impairment Scale (AIS) grade of A or B at 1-year postinjury. Variables related to physical, mental and social functioning were compared between the two groups. RESULTS A total of 2,562 AIS A and 675 AIS B patient met inclusion criteria. Occurrence of pressure ulcers was 7% less in AIS B versus A (34.5% vs. 41.9%, p=.003). There were no statistical differences between groups in pain, bowel or bladder accidents, urinary tract infections, or the level of assistance for bowel or bladder management. There was no statistical difference for PHQ-9 depression scores, SCI-QOL Resilience Scores, rates of suicidality or sleep disturbance. There was no difference for illicit drug or alcohol abuse, life satisfaction scores, perceived health, and marriage or divorce rates. CONCLUSIONS Except for a 7% reduction in pressure ulcer occurrence, there is no apparent long-term outcome advantage for motor complete spinal cord injury patients with AIS B sensory sparing over AIS A sensory complete. All other physical function domains were not different, nor were mental and social outcomes.
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Affiliation(s)
- Harris Liam
- Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Box 422, 1000 W. Carson St, Torrance, CA, 90509, USA.
| | - Barrett Kody
- Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Box 422, 1000 W. Carson St, Torrance, CA, 90509, USA
| | - Rolfe Kevin
- Department of Orthopaedic Surgery, Rancho Los Amigos National Rehabilitation Center, 7601 East Imperial Highway, Downey, CA, 90242, USA
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Kim KD, Lee KS, Coric D, Harrop JS, Theodore N, Toselli RM. Acute Implantation of a Bioresorbable Polymer Scaffold in Patients With Complete Thoracic Spinal Cord Injury: 24-Month Follow-up From the INSPIRE Study. Neurosurgery 2022; 90:668-675. [PMID: 35442254 PMCID: PMC9067089 DOI: 10.1227/neu.0000000000001932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/24/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Based on 6-month data from the InVivo Study of Probable Benefit of the Neuro-Spinal Scaffold for Safety and Neurological Recovery in Patients with Complete Thoracic Spinal Cord Injury (INSPIRE) study (NCT02138110), acute implantation of an investigational bioresorbable polymer device (Neuro-Spinal Scaffold [NSS]) appeared to be safe in patients with complete thoracic spinal cord injury (SCI) and was associated with an ASIA Impairment Scale (AIS) conversion rate that exceeded historical controls. OBJECTIVE To evaluate outcomes through 24 months postimplantation. METHODS INSPIRE was a prospective, open-label, multicenter, single-arm study. Eligible patients had traumatic nonpenetrating SCI with a visible contusion on MRI, AIS A classification, neurological level of injury at T2-T12, and requirement for open spine surgery ≤96 hours postinjury. RESULTS Nineteen patients underwent NSS implantation. Three patients had early death determined by investigators to be unrelated to the NSS or its implantation procedure. Seven of 16 evaluable patients (44%) had improvement of ≥1 AIS grade at 6 months (primary end point) to AIS B (n = 5) or AIS C (n = 2). Three patients with AIS B at 6 months had further neurological improvement to AIS C by 12 (n = 2) and 24 (n = 1) months, respectively; none have deteriorated per latest available follow-up. No unanticipated or serious adverse device effects were reported. CONCLUSION In this small group of patients with complete thoracic SCI, acute NSS implantation within the spinal cord appeared to be safe with no long-term neurological issues identified during the 24-month follow-up. Patients remain stable, with additional AIS conversions observed in some patients at 12 months and beyond. These data further support the safety and probable benefit of NSS implantation in this patient population.
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Affiliation(s)
- Kee D. Kim
- Department of Neurological Surgery, UC Davis, Sacramento, California, USA;
| | - K. Stuart Lee
- Division of Neurosurgery, Vidant Health, Greenville, North Carolina, USA;
| | - Domagoj Coric
- Department of Neurosurgery, Atrium Healthcare, Charlotte, North Carolina, USA;
- Spine Division, Atrium Musculoskeletal Institute, Charlotte, North Carolina, USA;
- Carolina NeuroSurgery and Spine Associates, Charlotte, North Carolina, USA;
| | - James S. Harrop
- Department of Neurological and Orthopedic Surgery, Division of Spine and Peripheral Nerve Surgery, and Delaware Valley SCI Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA;
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA;
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Kumar R, Htwe O, Baharudin A, Rhani SA, Ibrahim K, Nanra JS, Gsangaya M, Harun H, Kandar K, Balan M, Peh S, Pokharkar Y, Ingole A, Hisam Ariffin M. Spinal cord injury - assessing tolerability and use of combined rehabilitation and NeuroAiD (SATURN) study - primary results of an exploratory study. J Spinal Cord Med 2022:1-5. [PMID: 35604343 DOI: 10.1080/10790268.2022.2067972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE MLC601/MLC901 has demonstrated neuroprotective and neuroregenerative properties that enhance neurological recovery in stroke and traumatic brain injury. We aimed to evaluate its safety and potential efficacy in patients with severe spinal cord injury. METHODS Patients with American Spinal Injury Association (ASIA) Impairment Scale (AIS) A and B were included in an open-label cohort study. Each received a course of MLC601/MLC901 for 6 months in addition to standard care and rehabilitation. Key endpoints were safety, AIS grade and motor scores at month 6 (M6). RESULTS Among 30 patients included (mean age 42.2 ± 17.6 years, 24 men), 20 patients had AIS A while 10 patients had AIS B at baseline. Ten patients experienced 14 adverse events including one serious adverse event and six deaths, none were considered treatment-related. AIS improved in 25% of AIS A and 50% of AIS B. Improvement in ASIA motor score was seen most with cervical injury (median change from baseline 26.5, IQR: 6-55). These findings appear to be better than reported rates of spontaneous recovery for SCI AIS A and B. CONCLUSION MLC601/MLC901 is safe and may have a role in the treatment of patients with SCI. A controlled trial is justified.
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Affiliation(s)
- Ramesh Kumar
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Ohnmar Htwe
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Azmi Baharudin
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | | | - Kamalnizat Ibrahim
- Department of Orthopaedic, KPJ Ampang Puteri Specialist Hospital, Selangor, Malaysia
| | | | - Muhindra Gsangaya
- Department of Orthopaedics and Traumatology, Hospital Serdang, Selangor, Malaysia
| | - Hezery Harun
- Department of Orthopaedics and Traumatology, Hospital Pengajar Universiti Putra Malaysia, Selangor, Malaysia
| | - Khairrudin Kandar
- Department of Orthopaedic, Avisena Specialist Hospital, Selangor, Malaysia
| | - Maatharasi Balan
- Department of Orthopaedics and Traumatology, Hospital Serdang, Selangor, Malaysia
| | - Shawn Peh
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | | | - Abhinay Ingole
- Singapore Clinical Research Institute, Singapore, Singapore
| | - Mohammad Hisam Ariffin
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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Cell-based and stem-cell-based treatments for spinal cord injury: evidence from clinical trials. Lancet Neurol 2022; 21:659-670. [DOI: 10.1016/s1474-4422(21)00464-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/01/2021] [Accepted: 12/17/2021] [Indexed: 12/22/2022]
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10
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Hejrati N, Fehlings MG. Commentary: Acute Implantation of a Bioresorbable Polymer Scaffold in Patients With Complete Thoracic Spinal Cord Injury: 24-Month Follow-up From the INSPIRE Study. Neurosurgery 2022; 90:e140-e141. [PMID: 35442942 DOI: 10.1227/neu.0000000000001945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Nader Hejrati
- Division of Neurosurgery and Spine Program, Krembil Brain Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Krembil Brain Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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11
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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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12
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Clinical Trials Using Mesenchymal Stem Cells for Spinal Cord Injury: Challenges in Generating Evidence. Cells 2022; 11:cells11061019. [PMID: 35326470 PMCID: PMC8946989 DOI: 10.3390/cells11061019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022] Open
Abstract
Spinal cord injury (SCI) remains an important public health problem which often causes permanent loss of muscle strength, sensation, and function below the site of the injury, generating physical, psychological, and social impacts throughout the lives of the affected individuals, since there are no effective treatments available. The use of stem cells has been investigated as a therapeutic approach for the treatment of SCI. Although a significant number of studies have been conducted in pre-clinical and clinical settings, so far there is no established cell therapy for the treatment of SCI. One aspect that makes it difficult to evaluate the efficacy is the heterogeneity of experimental designs in the clinical trials that have been published. Cell transplantation methods vary widely among the trials, and there are still no standardized protocols or recommendations for the therapeutic use of stem cells in SCI. Among the different cell types, mesenchymal stem/stromal cells (MSCs) are the most frequently tested in clinical trials for SCI treatment. This study reviews the clinical applications of MSCs for SCI, focusing on the critical analysis of 17 clinical trials published thus far, with emphasis on their design and quality. Moreover, it highlights the need for more evidence-based studies designed as randomized controlled trials and potential challenges to be addressed in context of stem cell therapies for SCI.
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13
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Zhang H, Xu J, Saijilafu. The effects of GelMA hydrogel on nerve repair and regeneration in mice with spinal cord injury. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1147. [PMID: 34430588 PMCID: PMC8350630 DOI: 10.21037/atm-21-2874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/15/2021] [Indexed: 12/02/2022]
Abstract
Background To determine the effects of gelatin methacryloyl (GelMA) hydrogel on nerve repair and regeneration in mice with spinal cord injury (SCI). Methods A total of 30 ICR mice (6–8 weeks old) were randomly assigned into the control group, the model group, and the experimental group via the random digits table method. There were 10 mice in each group. All mice underwent a T8 laminectomy. For mice in the experimental group and the model group, after the T8 laminectomy, SCI models were constructed by clamping the mice spinal cord tissue for 1 minute using an aneurysm clip (25 g). Additionally, the SCI area of each mouse in the experimental group was locally injected with 0.05–0.7 mL GelMA hydrogel [10% (w/v)] and photocrosslinking was initiated under a blue light source with a wavelength of 405 nm. The exercise performance of each mouse was tested via the bedside mobility scale (BMS) on post-operative days 1, 3, 7, and 14. After 14 days, mice were sacrificed and the dorsal root ganglion (DRG) sensory neurons were isolated and cultured for 3 days in vitro. The axon lengths of the neurons were then evaluated. Immunohistochemical staining was performed to assess the development of syringomyelia in the area. Western blots (WB) and immunofluorescence staining were performed to quantify the expression of glial fibrillary acidic protein (GFAP), growth associated protein (GAP)43, and nestin in the DRG neurons from each group of mice. Results Compared with mice in the control group, mice in the SCI model group showed a notable decrease in exercise ability, while the exercise ability of mice in the experimental group recovered markedly after treatment with GelMA hydrogel. Administration of GelMA hydrogel lengthened the axon of DRG neurons in mice and reduced the area of syringomyelia. Furthermore, GelMA hydrogel inhibited scar formation and promoted the recovery of neurological function by upregulating GAP43 and nestin expression and downregulating GFAP expression. Conclusions In mice with SCI, local injection of GelMA hydrogel strongly inhibited scar formation, reduced the area of syringomyelia, and promoted nerve regeneration and recovery of limb movement function.
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Affiliation(s)
- Hongcheng Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jinhui Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Shanghai, China
| | - Saijilafu
- Department of Orthopaedics, the First Affiliated Hospital of Soochow University, Suzhou, China.,Orthopaedic Institute, Medical College, Soochow University, Suzhou, China
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14
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Badhiwala JH, Lebovic G, Balas M, da Costa L, Nathens AB, Fehlings MG, Wilson JR, Witiw CD. Variability in time to surgery for patients with acute thoracolumbar spinal cord injuries. Sci Rep 2021; 11:13312. [PMID: 34172757 PMCID: PMC8233434 DOI: 10.1038/s41598-021-92310-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
There are limited data pertaining to current practices in timing of surgical decompression for acute thoracolumbar spinal cord injury (SCI). We conducted a retrospective cohort study to evaluate variability in timing between- and within-trauma centers in North America; and to identify patient- and hospital-level factors associated with treatment delay. Adults with acute thoracolumbar SCI who underwent decompressive surgery within five days of injury at participating trauma centers in the American College of Surgeons Trauma Quality Improvement Program were included. Mixed-effects regression with a random intercept for trauma center was used to model the outcome of time to surgical decompression and assess risk-adjusted variability in surgery timeliness across centers. 3,948 patients admitted to 214 TQIP centers were eligible. 28 centers were outliers, with a significantly shorter or longer time to surgery than average. Case-mix and hospital characteristics explained < 1% of between-hospital variability in surgical timing. Moreover, only 7% of surgical timing variability within-centers was explained by case-mix characteristics. The adjusted intraclass correlation coefficient of 12% suggested poor correlation of surgical timing for patients with similar characteristics treated at the same center. These findings support the need for further research into the optimal timing of surgical intervention for thoracolumbar SCI.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Gerald Lebovic
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, TorontoToronto, ON, M5W 1W8, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Michael Balas
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Healthsciences Center, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Avery B Nathens
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Healthsciences Center, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Medical Director, Trauma Quality Improvement Program, American College of Surgeons, Chicago, IL, USA
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spine Program, Krembil Brain Institute, Toronto Western Hospital, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, TorontoToronto, ON, M5W 1W8, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, TorontoToronto, ON, M5W 1W8, Canada. .,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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15
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Zhong G, Yang Y, Huang X, Chen J, Feng D, Wei K, Chen J, Chen H. The Serum SIRT1 Protein is Associated with the Severity of Injury and Neurological Recovery in Mice with Traumatic Spinal Cord Injury. Neuroscience 2021; 469:103-109. [PMID: 34171408 DOI: 10.1016/j.neuroscience.2021.06.025] [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: 03/18/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
The present study aimed to investigate the association between the serum SIRT1 protein and the severity of spinal cord injury (SCI) as well as the neurological recovery in mice. In this study, the wild-type (WT), Mx1-Cre+ SIRT1loxP/loxP (Mx1), and LCK-Cre+SIRT1loxP/loxP (LCK) mice were subjected to sham surgery, mild, moderate, or severe SCI, respectively. The serum was collected at intervals of 12 h, 1 day (d), 3 d, 5 d, 7 d, 10 d, 14 d, and 21 d after the injury. The locomotor function of all the animals was assessed using the Basso mouse scale (BMS) and the serum SIRT1 proteins were analyzed using enzyme-linked immunosorbent assay (ELISA). The results demonstrated that about 7-10 d after SCI, the levels of SIRT1 protein in the serum correlated significantly with the severity of the injury and at 28 d post-injury, there was a distant neurological recovery (BMS score). The serum SIRT1 concentration in both the Mx1 and LCK mice in the sham group was significantly reduced compared to that in the WT mice, and there was a delayed increase in the serum SIRT1 levels after injury. These findings indicate that the SIRT1 concentrations in the serum of the SCI mice closely correlated with the acute severity and neurological outcome.
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Affiliation(s)
- Guibin Zhong
- Medical Department, Baoshan Branch Ren Ji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai 200444, China; Department of Orthopedics, Ren Ji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai 200127, China
| | - Yanqiu Yang
- Medical Department, Baoshan Branch Ren Ji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai 200444, China
| | - Xiaodong Huang
- Department of Orthopedics, The Third Affiliated Hospital of Guangzhou Medical University, Guangdong 510150, China
| | - Junling Chen
- Medical Department, Baoshan Branch Ren Ji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai 200444, China
| | - Daming Feng
- Medical Department, Baoshan Branch Ren Ji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai 200444, China
| | - Ke Wei
- Medical Department, Baoshan Branch Ren Ji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai 200444, China
| | - Jianwei Chen
- Department of Orthopedics, Ren Ji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai 200127, China.
| | - Haihong Chen
- Orthopedic Department, Minhang Center Hospital, Fudan University, Shanghai 201100, China.
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16
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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: 98] [Impact Index Per Article: 32.7] [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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17
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Perrouin-Verbe B, Lefevre C, Kieny P, Gross R, Reiss B, Le Fort M. Spinal cord injury: A multisystem physiological impairment/dysfunction. Rev Neurol (Paris) 2021; 177:594-605. [PMID: 33931244 DOI: 10.1016/j.neurol.2021.02.385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 12/24/2022]
Abstract
Spinal cord injury (SCI) is a complex disease that affects not only sensory and motor pathways below the neurological level of injury (NLI) but also all the organs and systems situated below this NLI. This multisystem impairment implies comprehensive management in dedicated SCI specialized centers, by interdisciplinary and multidisciplinary teams, able to treat not only the neurological impairment, but also all the systems and organs affected. After a brief history of the Spinal Cord Medicine, the author describes how to determine the level and severity of a SCI based on the International Standards for Neurological Classification of Spinal Cord Injury and the prognosis factors of recovery. This article provides also a review of the numerous SCI-related impairments (except for urinary, sexual problems and pain treated separately in this issue), their principles of management and related complications.
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Affiliation(s)
- B Perrouin-Verbe
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France.
| | - C Lefevre
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - P Kieny
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - R Gross
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - B Reiss
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - M Le Fort
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
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18
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Updated Review: The Steroid Controversy for Management of Spinal Cord Injury. World Neurosurg 2021; 150:1-8. [PMID: 33684579 DOI: 10.1016/j.wneu.2021.02.116] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute spinal cord injury (ASCI) is a devastating event that can have a profound impact on the lives of patients and their families. While no definitive medical treatment exists, the role of methylprednisolone (MP) in the management of ASCI and other spinal cord pathologies has been investigated in depth; however, its use remains contentious. While MP initially showed promise in the efficacy of ASCI treatment, more recent studies have questioned its use citing numerous systemic adverse effects. Pharmacologic treatments in this area are poorly understood due to the scarcity of knowledge surrounding the pathophysiology and heterogeneity of patients presenting with these conditions. Despite these shortcomings and due to the lack of alternative treatment options, MP is still widely used by physicians. METHODS We review prior and current literature on the use of MP treatment for ASCI patients with a discussion of novel drug delivery systems that have demonstrated the potential to improve MP's bioavailability at the site of injury while minimizing systemic side effects. In addition, current views on the role of MP and dexamethasone in metastatic spinal cord compression and postoperative infection are reviewed. RESULTS While some data support benefits in the use of steroids on spinal cord pathology, extensive research suggests at best limited effects and an unresolvable risk/benefit problem. CONCLUSIONS At present, evidence regarding use of dexamethasone for MSCC is contentious, especially regarding dose regiments. Ultimately, further investigation into the use of steroids is required to determine its utility in treating patients with spinal cord pathology.
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19
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Kim KD, Lee KS, Coric D, Chang JJ, Harrop JS, Theodore N, Toselli RM. A study of probable benefit of a bioresorbable polymer scaffold for safety and neurological recovery in patients with complete thoracic spinal cord injury: 6-month results from the INSPIRE study. J Neurosurg Spine 2021:1-10. [PMID: 33545674 DOI: 10.3171/2020.8.spine191507] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether the investigational Neuro-Spinal Scaffold (NSS), a highly porous bioresorbable polymer device, demonstrates probable benefit for safety and neurological recovery in patients with complete (AIS grade A) T2-12 spinal cord injury (SCI) when implanted ≤ 96 hours postinjury. METHODS This was a prospective, open-label, multicenter, single-arm study in patients with a visible contusion on MRI. The NSS was implanted into the epicenter of the postirrigation intramedullary spinal cord contusion cavity with the intention of providing structural support to the injured spinal cord parenchyma. The primary efficacy endpoint was the proportion of patients who had an improvement of ≥ 1 AIS grade (i.e., conversion from complete paraplegia to incomplete paraplegia) at the 6-month follow-up visit. A preset objective performance criterion established for the study was defined as an AIS grade conversion rate of ≥ 25%. Secondary endpoints included change in neurological level of injury (NLI). This analysis reports on data through 6-month follow-up assessments. RESULTS Nineteen patients underwent NSS implantation. There were 3 early withdrawals due to death, which were all determined by investigators to be unrelated to the NSS or the implantation procedure. Seven of 16 patients (43.8%) who completed the 6-month follow-up visit had conversion of neurological status (AIS grade A to grade B [n = 5] or C [n = 2]). Five patients showed improvement in NLI of 1 to 2 levels compared with preimplantation assessment, 3 patients showed no change, and 8 patients showed deterioration of 1 to 4 levels. There were no unanticipated or serious adverse device effects or serious adverse events related to the NSS or the implantation procedure as determined by investigators. CONCLUSIONS In this first-in-human study, implantation of the NSS within the spinal cord appeared to be safe in the setting of surgical decompression and stabilization for complete (AIS grade A) thoracic SCI. It was associated with a 6-month AIS grade conversion rate that exceeded historical controls. The INSPIRE study data demonstrate that the potential benefits of the NSS outweigh the risks in this patient population and support further clinical investigation in a randomized controlled trial.Clinical trial registration no.: NCT02138110 (clinicaltrials.gov).
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Affiliation(s)
- Kee D Kim
- 1Department of Neurological Surgery, UC Davis, Sacramento, California
| | - K Stuart Lee
- 2Division of Neurosurgery, Vidant Health, Greenville, North Carolina
| | - Domagoj Coric
- 3Atrium Musculoskeletal Institute, Carolina NeuroSurgery & Spine Associates, Charlotte, North Carolina
| | - Jason J Chang
- 4Department of Neurological Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - James S Harrop
- 5Department of Neurological and Orthopedic Surgery, Division of Spine and Peripheral Nerve Surgery, and Delaware Valley SCI Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicholas Theodore
- 6Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
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20
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Niemeyer MJS, Lokerman RD, Sadiqi S, van Heijl M, Houwert RM, van Wessem KJP, Post MWM, van Koppenhagen CF. Epidemiology of Traumatic Spinal Cord Injury in the Netherlands: Emergency Medical Service, Hospital, and Functional Outcomes. Top Spinal Cord Inj Rehabil 2021; 26:243-252. [PMID: 33536729 DOI: 10.46292/sci20-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Evaluating treatment of traumatic spinal cord injuries (TSCIs) from the prehospital phase until postrehabilitation is crucial to improve outcomes of future TSCI patients. Objective To describe the flow of patients with TSCI through the prehospital, hospital, and rehabilitation settings and to relate treatment outcomes to emergency medical services (EMS) transport locations and surgery timing. Method Consecutive TSCI admissions to a level I trauma center (L1TC) in the Netherlands between 2015 and 2018 were retrospectively identified. Corresponding EMS, hospital, and rehabilitation records were assessed. Results A total of 151 patients were included. Their median age was 58 (IQR 37-72) years, with the majority being male (68%) and suffering from cervical spine injuries (75%). In total, 66.2% of the patients with TSCI symptoms were transported directly to an L1TC, and 30.5% were secondarily transferred in from a lower level trauma center. Most injuries were due to falls (63.0%) and traffic accidents (31.1%), mainly bicycle-related. Most patients showed stable vital signs in the ambulance and the emergency department. After hospital discharge, 71 (47.0%) patients were admitted to a rehabilitation hospital, and 34 (22.5%) patients went home. The 30-day mortality rate was 13%. Patients receiving acute surgery (<12 hours) compared to subacute surgery (>12h, <2 weeks) showed no significance in functional independence scores after rehabilitation treatment. Conclusion A surge in age and bicycle-injuries in TSCI patients was observed. A substantial number of patients with TSCI were undertriaged. Acute surgery (<12 hours) showed comparable outcomes results in subacute surgery (>12h, <2 weeks) patients.
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Affiliation(s)
- Menco J S Niemeyer
- University Medical Center Utrecht, Department of Trauma Surgery, Utrecht, the Netherlands
| | - R D Lokerman
- University Medical Center Utrecht, Department of Trauma Surgery, Utrecht, the Netherlands
| | - S Sadiqi
- University Medical Center Utrecht, Department of Orthopedics, Utrecht, the Netherlands
| | - M van Heijl
- Diakonessenhuis Hospital, Department of Surgery, Utrecht, the Netherlands
| | - R M Houwert
- University Medical Center Utrecht, Department of Trauma Surgery, Utrecht, the Netherlands
| | - K J P van Wessem
- University Medical Center Utrecht, Department of Trauma Surgery, Utrecht, the Netherlands
| | - M W M Post
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Groningen, the Netherlands.,University Medical Center Utrecht, Department of Rehabilitation, Physical Therapy Science and Sports, UMCU Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - C F van Koppenhagen
- University Medical Center Utrecht, Center of Excellence for Rehabilitation Medicine, UMCU Brain Center and De Hoogstraat Rehabilitation, Utrecht, the Netherlands
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21
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Santamaria AJ, Benavides FD, Saraiva PM, Anderson KD, Khan A, Levi AD, Dietrich WD, Guest JD. Neurophysiological Changes in the First Year After Cell Transplantation in Sub-acute Complete Paraplegia. Front Neurol 2021; 11:514181. [PMID: 33536992 PMCID: PMC7848788 DOI: 10.3389/fneur.2020.514181] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/05/2020] [Indexed: 12/15/2022] Open
Abstract
Neurophysiological testing can provide quantitative information about motor, sensory, and autonomic system connectivity following spinal cord injury (SCI). The clinical examination may be insufficiently sensitive and specific to reveal evolving changes in neural circuits after severe injury. Neurophysiologic data may provide otherwise imperceptible circuit information that has rarely been acquired in biologics clinical trials in SCI. We reported a Phase 1 study of autologous purified Schwann cell suspension transplantation into the injury epicenter of participants with complete subacute thoracic SCI, observing no clinical improvements. Here, we report longitudinal electrophysiological assessments conducted during the trial. Six participants underwent neurophysiology screening pre-transplantation with three post-transplantation neurophysiological assessments, focused on the thoracoabdominal region and lower limbs, including MEPs, SSEPs, voluntarily triggered EMG, and changes in GSR. We found several notable signals not detectable by clinical exam. In all six participants, thoracoabdominal motor connectivity was detected below the clinically assigned neurological level defined by sensory preservation. Additionally, small voluntary activations of leg and foot muscles or positive lower extremity MEPs were detected in all participants. Voluntary EMG was most sensitive to detect leg motor function. The recorded MEP amplitudes and latencies indicated a more caudal thoracic level above which amplitude recovery over time was observed. In contrast, further below, amplitudes showed less improvement, and latencies were increased. Intercostal spasms observed with EMG may also indicate this thoracic “motor level.” Galvanic skin testing revealed autonomic dysfunction in the hands above the injury levels. As an open-label study, we can establish no clear link between these observations and cell transplantation. This neurophysiological characterization may be of value to detect therapeutic effects in future controlled studies.
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Affiliation(s)
- Andrea J Santamaria
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Francisco D Benavides
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Pedro M Saraiva
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Kimberly D Anderson
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Aisha Khan
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,Miller School of Medicine, The Interdisciplinary Stem Cell Institute, The University of Miami, Miami, FL, United States
| | - Allan D Levi
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - W Dalton Dietrich
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - James D Guest
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
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22
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Toluse AM, Adeyemi TO. Epidemiology and clinical outcomes of spinal cord injuries at a level II trauma centre in Nigeria: a longitudinal five year study. INTERNATIONAL ORTHOPAEDICS 2021; 45:665-671. [PMID: 33443597 DOI: 10.1007/s00264-020-04898-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 12/03/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Spinal cord injuries (SCIs) are devastating consequences of traumatic injuries with far-reaching health and socioeconomic implications. The objectives of this study were to describe the epidemiological characteristics of traumatic SCI and to analyse these epidemiological and clinical characteristics. METHODS This study was a retrospective observational study. We extracted data from the medical records of all cases of acute traumatic SCI that presented at the hospital between January 2013 and December 2017. RESULTS We recorded 99 cases of traumatic SCI over the study period. The patients' mean age was 37.15 ± 13.5 years with a male predominance (68.7%). Working age group accounted for 83.9% of cases. Motor vehicular accident (MVA) and falls accounted for 62.6% and 22.2% respectively. About a third of the cases (32.3%) presented within 24 hours of injury. The most frequently affected level was the cervical spine (63.6%), and complete tetraplegia was the most prevalent clinical pattern (31.3%). American Spinal Injury Association impairment scale (AIS) improved in 31.3% of cases. Twenty-nine patients (30.2%) had morbidity, with 21.2% developing pressure sores. Mortality accounted for 3%. CONCLUSIONS Motor vehicular crash and fall-related traumatic SCI affected mostly males and the working age group with complete tetraplegia as the predominating clinical pattern. There is a need for strategic interventions to reduce MVA and improve pre-hospital care and health policies to ensure early definitive care.
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Affiliation(s)
- Adetunji M Toluse
- Department of Orthopaedic and Trauma Surgery, National Orthopaedic Hospital, PMB 2009, Igbobi, Yaba, Lagos, Nigeria.
| | - Taofeek O Adeyemi
- Department of Orthopaedic and Trauma Surgery, National Orthopaedic Hospital, PMB 2009, Igbobi, Yaba, Lagos, Nigeria
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23
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Pfyffer D, Vallotton K, Curt A, Freund P. Predictive Value of Midsagittal Tissue Bridges on Functional Recovery After Spinal Cord Injury. Neurorehabil Neural Repair 2020; 35:33-43. [PMID: 33190619 PMCID: PMC8350965 DOI: 10.1177/1545968320971787] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The majority of patients with spinal cord injury (SCI) have anatomically incomplete lesions and present with preserved tissue bridges, yet their outcomes vary. Objective To assess the predictive value of the anatomical location (ventral/dorsal) and width of preserved midsagittal tissue bridges for American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion and SCI patient stratification into recovery-specific subgroups. Methods This retrospective longitudinal study includes 70 patients (56 men, age: 52.36 ± 18.58 years) with subacute (ie, 1 month) SCI (45 tetraplegics, 25 paraplegics), 1-month neuroimaging data, and 1-month and 12-month clinical data. One-month midsagittal T2-weighted scans were used to determine the location and width of tissue bridges. Their associations with functional outcomes were assessed using partial correlation and unbiased recursive partitioning conditional inference tree (URP-CTREE). Results Fifty-seven (81.4%) of 70 patients had tissue bridges (2.53 ± 2.04 mm) at 1-month post-SCI. Larger ventral (P = .001, r = 0.511) and dorsal (P < .001, r = 0.546) tissue bridges were associated with higher AIS conversion rates 12 months post-SCI (n = 39). URP-CTREE analysis identified 1-month ventral tissue bridges as predictors of 12-month total motor scores (0.4 mm cutoff, P = .008), recovery of upper extremity motor scores at 12 months (1.82 mm cutoff, P = .002), 12-month pin-prick scores (1.4 mm cutoff, P = .018), and dorsal tissue bridges at 1 month as predictors of 12-month Spinal Cord Independence Measure scores (0.5 mm cutoff, P = .003). Conclusions Midsagittal tissue bridges add predictive value to baseline clinical measures for post-SCI recovery. Based on tissue bridges’ width, patients can be classified into subgroups of clinical recovery profiles. Midsagittal tissue bridges provide means to optimize patient stratification in clinical trials.
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Affiliation(s)
- Dario Pfyffer
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Kevin Vallotton
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick Freund
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Wellcome Trust Center for Neuroimaging, UCL Institute of Neurology, University College London, London, UK.,Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
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24
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Marino RJ, Leff M, Cardenas DD, Donovan J, Chen D, Kirshblum S, Leiby BE. Trends in Rates of ASIA Impairment Scale Conversion in Traumatic Complete Spinal Cord Injury. Neurotrauma Rep 2020; 1:192-200. [PMID: 34223541 PMCID: PMC8240895 DOI: 10.1089/neur.2020.0038] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Recent studies of persons with spinal cord injury (SCI) report higher conversion rates of the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades, especially for complete injuries. We examined the rate of conversion over time after complete SCI, accounting for demographic and injury characteristics. Subjects were 16 years of age and older with a complete SCI injury between 1995 and 2015, enrolled in the National SCI Database as day-1 admissions. We grouped subjects into 3-year intervals and assessed trends in conversion for the total sample and by tetraplegia (Tetra), high paraplegia (levels T1–9, HPara), and low paraplegia (levels T10–12, LPara).We used logistic regression to identify factors related to conversion such as age, sex, etiology, and level of injury. Of 2036 subjects, 1876 subjects had a follow-up examination between 30 and 730 days post-injury. Average age at injury was 34.2 ± 14.6 years; 79.8% were male, 44.6% Tetra, 35.3% HPara, and 20.1% LPara. There was a strong trend toward increased rates of conversion over time (p < 0.01 for all groups), especially for Tetra (to incomplete from 17.6% in 1995–1997 to 50% in 2013–2015, and to motor incomplete from 9.4% to 28.1%). Conversion rates for Para were less dramatic. There were increased odds of converting to incomplete for year of injury, level of injury (Tetra >LPara >HPara), non-violent etiology, and age (older is better). We found similar factors for conversion to motor incomplete, except sex was significant and etiology was not. Conversion rates from complete to incomplete and motor incomplete injury have been increasing, particularly for persons with tetraplegia. This has implications for acute clinical trials and for prognostication early after SCI.
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Affiliation(s)
- Ralph J Marino
- Department of Rehabilitation Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Leff
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Diana D Cardenas
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jayne Donovan
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - David Chen
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steve Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA.,Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Benjamin E Leiby
- Biostatistics Division, Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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25
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Haghnegahdar A, Behjat R, Saadat S, Badhiwala J, Farrokhi MR, Niakan A, Eghbal K, Barzideh E, Shahlaee A, Ghaffarpasand F, Ghodsi Z, Vaccaro AR, Sadeghi-Naini M, Fehlings MG, Guest JD, Derakhshan P, Rahimi-Movaghar V. A Randomized Controlled Trial of Early versus Late Surgical Decompression for Thoracic and Thoracolumbar Spinal Cord Injury in 73 Patients. Neurotrauma Rep 2020; 1:78-87. [PMID: 34223533 PMCID: PMC8240887 DOI: 10.1089/neur.2020.0027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Convincing clinical evidence exists to support early surgical decompression in the setting of cervical spinal cord injury (SCI). However, clinical evidence on the effect of early surgery in patients with thoracic and thoracolumbar (from T1 to L1 [T1–L1]) SCI is lacking and a critical knowledge gap remains. This randomized controlled trial (RCT) sought to evaluate the safety and efficacy of early (<24 h) compared with late (24–72 h) decompressive surgery after T1–L1 SCI. From 2010 to 2018, patients (≥16 years of age) with acute T1–L1 SCI presenting to a single trauma center were randomized to receive either early (<24 h) or late (24–72 h) surgical decompression. The primary outcome was an ordinal change in American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at 12-month follow-up. Secondary outcomes included complications and change in ASIA motor score (AMS) at 12 months. Outcome assessors were blinded to treatment assignment. Of 73 individuals whose treatment followed the study protocol, 37 received early surgery and 36 underwent late surgery. The mean age was 29.74 ± 11.4 years. In the early group 45.9% of patients and in the late group 33.3% of patients had a ≥1-grade improvement in AIS (odds ratio [OR] 1.70, 95% confidence interval [CI]: 0.66-4.39, p = 0.271); significantly more patients in the early (24.3%) than late (5.6%) surgery group had a ≥2-grade improvement in AIS (OR 5.46, 95% CI: 1.09-27.38, p = 0.025). There was no statistically significant difference in the secondary outcome measures. Surgical decompression within 24 h of acute traumatic T1–L1 SCI is safe and is associated with improved neurological outcome, defined as at least a 2-grade improvement in AIS at 12 months.
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Affiliation(s)
- Ali Haghnegahdar
- Department of Neurosurgery, Shiraz University of Medical Sciences, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz, Iran
| | - Reza Behjat
- Department of Neurosurgery, Shiraz University of Medical Sciences, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz, Iran
| | - Soheil Saadat
- Department of Emergency Medicine, University of California, Irvine, Irvine, California, USA
| | - Jetan Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Krembil Brain Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Majid Reza Farrokhi
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Niakan
- Department of Neurosurgery, Shiraz University of Medical Sciences, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz, Iran
| | - Keyvan Eghbal
- Department of Neurosurgery, Shiraz University of Medical Sciences, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz, Iran
| | - Ehsan Barzideh
- Department of Neurosurgery, Shiraz University of Medical Sciences, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz, Iran
| | - Abtin Shahlaee
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
| | - Fariborz Ghaffarpasand
- Department of Neurosurgery, Shiraz University of Medical Sciences, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz, Iran
| | - Zahra Ghodsi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alexander R Vaccaro
- Department of Orthopedics and Neurosurgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, Pennsylvania, USA
| | - Mohsen Sadeghi-Naini
- Department of Neurosurgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Krembil Brain Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - James David Guest
- Department of Neurosurgery, The Miami Project to Cure Paralysis, University of Miami, Miami, Florida, USA
| | - Pegah Derakhshan
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Pre-Hospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Tissue Repair Laboratory, Institute of Biochemistry and Biophysics (IBB), University of Tehran, Tehran, Iran
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27
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Curt A, Hsieh J, Schubert M, Hupp M, Friedl S, Freund P, Huber E, Pfyffer D, Sutter R, Jutzeler C, Wüthrich RP, Min K, Casha S, Fehlings MG, Guzman R. The Damaged Spinal Cord Is a Suitable Target for Stem Cell Transplantation. Neurorehabil Neural Repair 2020; 34:758-768. [PMID: 32698674 DOI: 10.1177/1545968320935815] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background. Given individuals with spinal cord injury (SCI) approaching 2 million, viable options for regenerative repair are desperately needed. Human central nervous system stem cells (HuCNS-SC) are self-renewing, multipotent adult stem cells that engraft, migrate, and differentiate in appropriate regions in multiple animal models of injured brain and spinal cord. Preclinical improved SCI locomotor function provided rationale for the first-in-human SCI clinical trial of HuCNS-SC cells. Evidence of feasibility and long-term safety of cell transplantation into damaged human cord is needed to foster translational progression of cellular therapies. Methods. A first-ever, multisite phase I/IIa trial involving surgical transplantation of 20 million HuCNS-SC cells into the thoracic cord in 12 AIS A or B subjects (traumatic, T2-T11 motor-complete, sensory-incomplete), aged 19 to 53 years, demonstrated safety and preliminary efficacy. Six-year follow-up data were collected (sensory thresholds and neuroimaging augmenting clinical assessments). Findings. The study revealed short- and long-term surgical and medical safety (well-tolerated immunosuppression in population susceptible to infections). Preliminary efficacy measures identified 5/12 with reliable sensory improvements. Unfortunately, without thoracic muscles available for manual muscle examination, thoracic motor changes could not be measured. Lower limb motor scores did not change during the study. Cervical cord imaging revealed, no tumor formation or malformation of the lesion area, and secondary supralesional structural changes similar to SCI control subjects. Interpretation. Short- and long-term safety and feasibility support the consideration of cell transplantation for patients with complete and incomplete SCI. This report is an important step to prepare, foster, and maintain the therapeutic development of cell transplantation for human SCI.
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Affiliation(s)
- Armin Curt
- Balgrist University Hospital, Zurich, Switzerland
| | - Jane Hsieh
- Balgrist University Hospital, Zurich, Switzerland
| | | | - Markus Hupp
- Balgrist University Hospital, Zurich, Switzerland
| | | | | | | | | | - Reto Sutter
- Balgrist University Hospital, Zurich, Switzerland
| | | | | | - Kan Min
- Balgrist University Hospital, Zurich, Switzerland
| | - Steve Casha
- University of Calgary, Calgary, Alberta, Canada
| | - Michael G Fehlings
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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28
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The effect of zoledronic acid on attenuation of bone loss at the hip and knee following acute traumatic spinal cord injury: a randomized-controlled study. Spinal Cord 2020; 58:921-929. [DOI: 10.1038/s41393-020-0431-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 11/09/2022]
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29
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Early Decompression (<8 Hours) Improves Functional Bladder Outcome and Mobility After Traumatic Thoracic Spinal Cord Injury. World Neurosurg 2020; 134:e847-e854. [DOI: 10.1016/j.wneu.2019.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/02/2019] [Accepted: 11/04/2019] [Indexed: 12/15/2022]
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30
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Exploration of surgical blood pressure management and expected motor recovery in individuals with traumatic spinal cord injury. Spinal Cord 2019; 58:377-386. [PMID: 31649323 PMCID: PMC7062632 DOI: 10.1038/s41393-019-0370-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/03/2019] [Accepted: 10/08/2019] [Indexed: 02/06/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE To assess the impact of mean arterial blood pressure (MAP) during surgical intervention for spinal cord injury (SCI) on motor recovery. SETTING Level-one Trauma Hospital and Acute Rehabilitation Hospital in San Jose, CA, USA. METHODS Twenty-five individuals with traumatic SCI who received surgical and acute rehabilitation care at a level-one trauma center were included in this study. The Surgical Information System captured intraoperative MAPs on a minute-by-minute basis and exposure was quantified at sequential thresholds from 50 to 104 mmHg. Change in International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor score was calculated based on physiatry evaluations at the earliest postoperative time and at discharge from acute rehabilitation. Linear regression models were used to estimate the rate of recovery across the entire MAP range. RESULTS An exploratory analysis revealed that increased time within an intraoperative MAP range (70-94 mmHg) was associated with ISNCSCI motor score improvement. A significant regression equation was found for the MAP range 70-94 mmHg (F[1, 23] = 5.07, r2 = 0.181, p = 0.034). ISNCSCI motor scores increased 0.039 for each minute of exposure to the MAP range 70-94 mmHg during the operative procedure; this represents a significant correlation between intraoperative time with MAP 70-94 and subsequent motor recovery. Blood pressure exposures above or below this range did not display a positive association with motor recovery. CONCLUSIONS Hypertension as well as hypotension during surgery may impact the trajectory of recovery in individuals with SCI, and there may be a direct relationship between intraoperative MAP and motor recovery.
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