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Lambrechts MJ, Issa TZ, Hilibrand AS. Updates in the Early Management of Acute Spinal Cord Injury. J Am Acad Orthop Surg 2023; 31:e619-e632. [PMID: 37432977 DOI: 10.5435/jaaos-d-23-00281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future.
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Affiliation(s)
- Mark J Lambrechts
- From the Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
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Batchelor P, Bernard S, Gantner D, Udy A, Board J, Fitzgerald M, Skeers P, Battistuzzo C, Stephenson M, Smith K, Nunn A. Immediate Cooling and Early Decompression for the Treatment of Cervical Spinal Cord Injury: A Safety and Feasibility Study. Ther Hypothermia Temp Manag 2023. [PMID: 36779969 DOI: 10.1089/ther.2022.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
Cervical spinal cord injury (SCI) usually results in severe, long-term disability. Early therapeutic hypothermia (33-34°C) has been used to improve outcomes in preclinical studies, but previous clinical studies have commenced cooling after arrival at hospital. The objective of the study is to determine the feasibility and safety of early therapeutic hypothermia initiated by paramedics and maintained for up to 24 hours in hospital in patients with SCI. This is a pilot clinical study. The study was undertaken at Ambulance Victoria and The Alfred Hospital, Victoria, Australia. A total of 17 consecutive patients with suspected acute traumatic cervical SCI were enrolled. Patients with suspected cervical SCI were administered a bolus (up to 20 mL/kg) intravenous (IV) cold (4°C) normal saline in the prehospital phase of care. After hospital admission and spinal imaging, further cooling used IV catheter temperature control or surface cooling. Major complications and long-term outcomes were compared with historical controls admitted to the same center before the study. A decrease in core temperature of 1.1°C was achieved during prehospital care and the target temperature was achieved in 6 hours with mechanical temperature management devices in the hospital. There were no major safety concerns. Patients with motor complete SCI who underwent early decompressive surgery had a favorable rate of partial spinal cord recovery compared with historical controls. Therapeutic hypothermia induced using bolus, large-volume, ice-cold saline prehospital and maintained for 24 hours using mechanical devices appears to be feasible and safe in patients with SCI. Larger trials need to be undertaken to determine whether prehospital cooling combined with early decompressive surgery improves outcomes in patients with complete cervical SCI. Australian and New Zealand Clinical Trials Registry (ACTRN12616001086459).
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Affiliation(s)
- Peter Batchelor
- Department of Neurology, University Hospital Geelong, Geelong, Australia
| | - Stephen Bernard
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Ambulance Victoria, Doncaster, Australia.,Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dashiell Gantner
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care-Research Center, Melbourne, Australia
| | - Andrew Udy
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care-Research Center, Melbourne, Australia
| | - Jasmin Board
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care-Research Center, Melbourne, Australia
| | - Mark Fitzgerald
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Peta Skeers
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | - Camila Battistuzzo
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia.,Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mick Stephenson
- Ambulance Victoria, Doncaster, Australia.,Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,School of Primary and Allied Health Care, Monash University Peninsula Campus, Frankston, Australia
| | - Karen Smith
- Prehospital, Emergency and Trauma Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Nunn
- Victorian Spinal Cord Service, Austin Hospital, Heidelberg, Australia
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Lima R, Monteiro A, Salgado AJ, Monteiro S, Silva NA. Pathophysiology and Therapeutic Approaches for Spinal Cord Injury. Int J Mol Sci 2022; 23:ijms232213833. [PMID: 36430308 PMCID: PMC9698625 DOI: 10.3390/ijms232213833] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 11/12/2022] Open
Abstract
Spinal cord injury (SCI) is a disabling condition that disrupts motor, sensory, and autonomic functions. Despite extensive research in the last decades, SCI continues to be a global health priority affecting thousands of individuals every year. The lack of effective therapeutic strategies for patients with SCI reflects its complex pathophysiology that leads to the point of no return in its function repair and regeneration capacity. Recently, however, several studies started to uncover the intricate network of mechanisms involved in SCI leading to the development of new therapeutic approaches. In this work, we present a detailed description of the physiology and anatomy of the spinal cord and the pathophysiology of SCI. Additionally, we provide an overview of different molecular strategies that demonstrate promising potential in the modulation of the secondary injury events that promote neuroprotection or neuroregeneration. We also briefly discuss other emerging therapies, including cell-based therapies, biomaterials, and epidural electric stimulation. A successful therapy might target different pathologic events to control the progression of secondary damage of SCI and promote regeneration leading to functional recovery.
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Affiliation(s)
- Rui Lima
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
| | - Andreia Monteiro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
| | - António J. Salgado
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
| | - Susana Monteiro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
| | - Nuno A. Silva
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
- Correspondence:
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Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury. J Pers Med 2022; 12:jpm12071126. [PMID: 35887623 PMCID: PMC9323191 DOI: 10.3390/jpm12071126] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 12/25/2022] Open
Abstract
The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a spinal cord injury (SCI), supraspinal influences on the spinal segmental control system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, pain and dysesthesia, sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of traumatic SCI, current and emerging methods of classification, and its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue.
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