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Guimbard-Pérez JH, Camino-Willhuber G, Romero-Muñoz LM, Peral-Alarma M, Brocca ME, Barriga-Martín A. [Translated article] Efficacy of early versus delayed spinal cord decompression in neurological recovery after traumatic spinal cord injury: Systematic review and meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00116-4. [PMID: 38971564 DOI: 10.1016/j.recot.2024.07.003] [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: 02/13/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 07/08/2024] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To compare early (<24h) versus late (>24h) spinal cord decompression on neurological recovery in patients with acute spinal cord injury. METHODS A systematic review was performed according to the PRISMA protocol to identify studies published up to December 2022. Prospective cohort studies and controlled trials comparing early versus delayed decompression on neurological recovery were included. Variables included number of patients, level of injury, treatment time, ASIA grade, neurological recovery, use of corticosteroids, and complications. For the meta-analysis, the "forest plot" graph was developed. The risk of bias of the included studies was assessed using the ROBINS-I22 and Rob223 tools. RESULTS Six of the seven studies selected for our review were included in the meta-analysis, with a total of 1188 patients (592 patients in the early decompression group and 596 in the delayed decompression group), the mean follow-up was 8 months, in 5 studies used methylprednisolone, the most reported complications were thromboembolic cardiopulmonary events. Five studies showed significant differences in favour of early decompression (risk difference 0.10, 95% confidence interval 0.07-0.14, heterogeneity 46%). The benefit was greatest in cervical and incomplete injuries. CONCLUSION There is scientific evidence to recommend early decompression in the first 24h after traumatic spinal cord injury, as it improves final neurological recovery, and it should be recommended whenever the patient and hospital conditions allow it to be safely done.
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Affiliation(s)
- J H Guimbard-Pérez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, Spain; Centro de Biotecnología e Innovación Científica (CEBIC), Toledo, Spain.
| | - G Camino-Willhuber
- Spine Care Institute, Hospital for Special Surgery, New York, United States
| | - L M Romero-Muñoz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, Spain
| | - M Peral-Alarma
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, Spain
| | - M E Brocca
- Laboratorio de Biología de Membranas y Reparación Axonal, Hospital Nacional de Parapléjicos, Toledo, Spain
| | - A Barriga-Martín
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, Spain
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2
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Guimbard-Pérez JH, Camino-Willhuber G, Romero-Muñoz LM, Peral-Alarma M, Brocca ME, Barriga-Martín A. Efficacy of early versus delayed spinal cord decompression in neurological recovery after traumatic spinal cord injury: Systematic review and meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023:S1888-4415(23)00200-X. [PMID: 37805026 DOI: 10.1016/j.recot.2023.09.009] [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: 02/13/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/09/2023] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To compare early (<24h) versus late (>24h) spinal cord decompression on neurological recovery in patients with acute spinal cord injury. METHODS A systematic review was performed according to the PRISMA protocol to identify studies published up to December 2022. Prospective cohort studies and controlled trials comparing early versus delayed decompression on neurological recovery were included. Variables included number of patients, level of injury, treatment time, ASIA grade, neurological recovery, use of corticosteroids, and complications. For the meta-analysis, the «forest plot» graph was developed. The risk of bias of the included studies was assessed using the ROBINS-I22 and Rob223 tools. RESULTS Six of the seven studies selected for our review were included in the meta-analysis, with a total of 1188 patients (592 patients in the early decompression group and 596 in the delayed decompression group), the mean follow-up was 8 months, in 5 studies used methylprednisolone, the most reported complications were thromboembolic cardiopulmonary events. Five studies showed significant differences in favor of early decompression (risk difference 0.10, 95% confidence interval 0.07-0.14, heterogeneity 46%). The benefit was greatest in cervical and incomplete injuries. CONCLUSION There is scientific evidence to recommend early decompression in the first 24h after traumatic spinal cord injury, as it improves final neurological recovery, and it should be recommended whenever the patient and hospital conditions allow it to be safely done.
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Affiliation(s)
- J H Guimbard-Pérez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, España; Centro de Biotecnología e Innovación Científica (CEBIC), Toledo, España.
| | | | - L M Romero-Muñoz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, España
| | - M Peral-Alarma
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, España
| | - M E Brocca
- Laboratorio de Biología de Membranas y Reparación Axonal, Hospital Nacional de Parapléjicos, Toledo, España
| | - Andrés Barriga-Martín
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, España
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Hosman AJF, Barbagallo G, van Middendorp JJ. Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury. Bone Joint J 2023; 105-B:400-411. [PMID: 36924174 DOI: 10.1302/0301-620x.105b4.bjj-2022-0947.r2] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research.
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Affiliation(s)
- Allard J F Hosman
- Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Giuseppe Barbagallo
- U.O. di Clinica Neurochirurgia Azienda Ospedaliero, Universitaria Policlinico, Catania, Italy
| | | | - Joost J van Middendorp
- Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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4
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Lee BJ, Jeong JH. Early Decompression in Acute Spinal Cord Injury : Review and Update. J Korean Neurosurg Soc 2023; 66:6-11. [PMID: 36274255 PMCID: PMC9837486 DOI: 10.3340/jkns.2022.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/25/2022] [Accepted: 07/01/2022] [Indexed: 01/25/2023] Open
Abstract
Spinal cord injury (SCI) has a significant negative effect on the quality of life due to permanent neurologic damage and economic burden by continuous treatment and rehabilitation. However, determining the correct approach to ensure optimal clinical outcomes can be challenging and remains highly controversial. In particular, with the introduction of the concept of early decompression in brain pathology, the discussion of the timing of decompression in SCI has emerged. In addition to that, the concept of "time is spine" has been added recently, and the mortality and complications caused by SCI have been reduced by providing timely and professional treatment to patients. However, there are many difficulties in establishing international clinical guidelines for the timing of early decompression in SCI because policies for each country and medical institution differ according to the circumstances of medical infrastructure and economic conditions in the surgical treatment of SCI. Therefore, we aim to provide a current review of timing of early decompression in patient with SCI.
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Affiliation(s)
- Byung-Jou Lee
- Department of Neurosurgery and Neuroscience & Radiosurgery Hybrid Research Center, Inje University Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Korea
| | - Je Hoon Jeong
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Pedro KM, Fehlings MG. Time is spine: What's over the horizon. J Clin Orthop Trauma 2022; 35:102043. [PMID: 36340959 PMCID: PMC9634004 DOI: 10.1016/j.jcot.2022.102043] [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: 08/10/2022] [Revised: 09/13/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
The overarching theme in the early treatment of acute spinal cord injury (SCI) is to reduce the extent of secondary damage to facilitate early neurological and functional recovery. Although multiple studies have brought us innovative and potential new therapies to treat SCI, ameliorating neural damage remains a formidable challenge. Knowledge translation of clinical and basic research studies has shown that surgical intervention is a valuable treatment modality; however, the role, timing and optimal technique in surgery remains a topic of great controversy. While evidence to support the concept of ultra-early surgery for acute SCI continues to emerge, current protocols and international guidelines that encourage reducing time from trauma to surgery support the concept of "Time is Spine". The present article provides a critical narrative review of the current best practice, with a particular focus on the timing of surgical intervention, which shapes our understanding of how time is of the essence in the management of acute SCI.
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Affiliation(s)
- Karlo M. Pedro
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Fehlings MG, Pedro K, Hejrati N. Management of Acute Spinal Cord Injury: Where Have We Been? Where Are We Now? Where Are We Going? J Neurotrauma 2022; 39:1591-1602. [PMID: 35686453 DOI: 10.1089/neu.2022.0009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Michael G Fehlings
- Division of Genetics and Development, Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Karlo Pedro
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nader Hejrati
- Division of Genetics and Development, Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Thomas AX, Riviello JJ, Davila-Williams D, Thomas SP, Erklauer JC, Bauer DF, Cokley JA. Pharmacologic and Acute Management of Spinal Cord Injury in Adults and Children. Curr Treat Options Neurol 2022; 24:285-304. [PMID: 35702419 PMCID: PMC9184374 DOI: 10.1007/s11940-022-00720-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review This review provides guidance for acute spinal cord injury (SCI) management through an analytical assessment of the most recent evidence on therapies available for treating SCI, including newer therapies under investigation. We present an approach to the SCI patient starting at presentation to acute rehabilitation and prognostication, with additional emphasis on the pediatric population when evidence is available. Recent Findings Further studies since the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated a potential functional outcome benefit with ultra-early surgical intervention ≤ 8 h post-SCI. Subsequent analysis of the National Acute Spinal Cord Injury Study (NASCIS) II and NASCIS III trials have demonstrated potentially serious complications from intravenous methylprednisolone with limited benefit. Newer therapies actively being studied have demonstrated limited or no benefit in preclinical and clinical trials with insufficient evidence to support use in acute SCI treatment. Summary Care for SCI patients requires a multi-disciplinary team. Immediate evaluation and management are focused on preventing additional injury and restoring perfusion to the affected cord. Rapid assessment and intervention involve focused neurological examination, targeted imaging, and surgical intervention when indicated. There are currently no evidence-based recommendations for pathomechanistically targeted therapies.
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Affiliation(s)
- Ajay X. Thomas
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston, TX USA
| | - James J. Riviello
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - Daniel Davila-Williams
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - Sruthi P. Thomas
- Division of Pediatric Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX USA
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Jennifer C. Erklauer
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
| | - David F. Bauer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, TX USA
| | - Jon A. Cokley
- Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Department of Pharmacy, Baylor College of Medicine, Houston, TX USA
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8
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Abstract
This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.
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Affiliation(s)
- Stuart Stokes
- Spinal Unit, Department of Neurosurgery, Hull Royal Infirmary, Hull, UK
| | - Martin Drozda
- Spinal Unit, Department of Neurosurgery, Hull Royal Infirmary, Hull, UK
| | - Christopher Lee
- Spinal Unit, Department of Neurosurgery, Hull Royal Infirmary, Hull, UK
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9
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Pursuing More Aggressive Timelines in the Surgical Treatment of Traumatic Spinal Cord Injury (TSCI): A Retrospective Cohort Study with Subgroup Analysis. J Clin Med 2021; 10:jcm10245977. [PMID: 34945273 PMCID: PMC8703655 DOI: 10.3390/jcm10245977] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/07/2021] [Accepted: 12/17/2021] [Indexed: 12/17/2022] Open
Abstract
Background: The optimal timing of surgical therapy for traumatic spinal cord injury (TSCI) remains unclear. The purpose of this study is to evaluate the impact of “ultra-early” (<4 h) versus “early” (4–24 h) time from injury to surgery in terms of the likelihood of neurologic recovery. Methods: The effect of surgery on neurological recovery was investigated by comparing the assessed initial and final values of the American Spinal Injury Association (ASIA) Impairment Scale (AIS). A post hoc analysis was performed to gain insight into different subgroup regeneration behaviors concerning neurological injury levels. Results: Datasets from 69 cases with traumatic spinal cord injury were analyzed. Overall, 19/46 (41.3%) patients of the “ultra-early” cohort saw neurological recovery compared to 5/23 (21.7%) patients from the “early” cohort (p = 0.112). The subgroup analysis revealed differences based on the neurological level of injury (NLI) of a patient. An optimal cutpoint for patients with a cervical lesion was estimated at 234 min. Regarding the prediction of neurological improvement, sensitivity was 90.9% with a specificity of 68.4%, resulting in an AUC (area under the curve) of 84.2%. In thoracically and lumbar injured cases, the estimate was lower, ranging from 284 (thoracic) to 245 min (lumbar) with an AUC of 51.6% and 54.3%. Conclusions: Treatment within 24 h after TSCI is associated with neurological recovery. Our hypothesis that intervention within 4 h is related to an improvement in the neurological outcome was not confirmed in our collective. In a clinical context, this suggests that after TSCI there is a time frame to get the right patient to the right hospital according to advanced trauma life support (ATLS) guidelines.
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Proteomic Portraits Reveal Evolutionarily Conserved and Divergent Responses to Spinal Cord Injury. Mol Cell Proteomics 2021; 20:100096. [PMID: 34129941 PMCID: PMC8260874 DOI: 10.1016/j.mcpro.2021.100096] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/14/2021] [Accepted: 05/11/2021] [Indexed: 01/16/2023] Open
Abstract
Despite the emergence of promising therapeutic approaches in preclinical studies, the failure of large-scale clinical trials leaves clinicians without effective treatments for acute spinal cord injury (SCI). These trials are hindered by their reliance on detailed neurological examinations to establish outcomes, which inflate the time and resources required for completion. Moreover, therapeutic development takes place in animal models whose relevance to human injury remains unclear. Here, we address these challenges through targeted proteomic analyses of cerebrospinal fluid and serum samples from 111 patients with acute SCI and, in parallel, a large animal (porcine) model of SCI. We develop protein biomarkers of injury severity and recovery, including a prognostic model of neurological improvement at 6 months with an area under the receiver operating characteristic curve of 0.91, and validate these in an independent cohort. Through cross-species proteomic analyses, we dissect evolutionarily conserved and divergent aspects of the SCI response and establish the cerebrospinal fluid abundance of glial fibrillary acidic protein as a biochemical outcome measure in both humans and pigs. Our work opens up new avenues to catalyze translation by facilitating the evaluation of novel SCI therapies, while also providing a resource from which to direct future preclinical efforts. • Targeted proteomic analysis of CSF and serum samples from 111 acute SCI patients. • Single- and multiprotein biomarkers of injury severity and recovery. • Parallel proteomic analysis in a large animal model identifies conserved biomarkers. • Evolutionary conservation and divergence of the proteomic response to SCI.
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11
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Wang W, Su Y, Tang S, Li H, Xie W, Chen J, Shen L, Pan X, Ning B. Identification of noncoding RNA expression profiles and regulatory interaction networks following traumatic spinal cord injury by sequence analysis. Aging (Albany NY) 2020; 11:2352-2368. [PMID: 30998503 PMCID: PMC6520015 DOI: 10.18632/aging.101919] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/10/2019] [Indexed: 02/05/2023]
Abstract
Aim: To systematically profile and characterize the noncoding RNA (ncRNA) expression pattern in the lesion epicenter of spinal tissues after traumatic spinal cord injury (TSCI) and predicted the structure and potential functions of the regulatory networks associated with these differentially expressed ncRNAs and mRNAs. Results: A total of 498 circRNAs, 458 lncRNAs, 155 miRNAs and 1203 mRNAs were identified in TSCI mice models to be differentially expressed. The regulatory networks associated with these differentially expressed ncRNAs and mRNAs were constructed. Materials and methods: We used RNA-Seq, Gene ontology (GO), KEGG pathway analysis and co-expression network analyses to profle the expression and regulation patterns of noncoding RNAs and mRNAs of mice models after TSCI. The findings were validated by quantitative real-time PCR (qRT-PCR) and Luciferase assay. Conclusion: noncoding RNAs might play important roles via the competing endogenous RNA regulation pattern after TSCI, further findings arising from this study will not only expand the understanding of potential ncRNA biomarkers but also help guide therapeutic strategies for TSCI.
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Affiliation(s)
- Wenzhao Wang
- Jinan Central Hospital Affiliated to Shandong University, Jinan, China.,Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Yanlin Su
- Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Shi Tang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hongfei Li
- Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Wei Xie
- Department Emergency Medicine, Affiliated Hospital of Taishan Medical University, Taian, China
| | - Jianan Chen
- Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Lin Shen
- Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Xinda Pan
- Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Bin Ning
- Jinan Central Hospital Affiliated to Shandong University, Jinan, China
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12
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Wilson JR, Witiw CD, Badhiwala J, Kwon BK, Fehlings MG, Harrop JS. Early Surgery for Traumatic Spinal Cord Injury: Where Are We Now? Global Spine J 2020; 10:84S-91S. [PMID: 31934526 PMCID: PMC6947677 DOI: 10.1177/2192568219877860] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE There is a strong biological rationale to perform early decompression after traumatic spinal cord injury (SCI). With an enlarging clinical evidence base, most spine surgeons internationally now favor early decompression for the majority of SCI patients; however, a number of pertinent questions remain surrounding this therapy. METHODS A narrative review evaluating the status of early surgery for SCI. In particular, we addressed the following questions: (1) Which patients stand to benefit most from early surgery? 2) What is the most appropriate time threshold defining early surgery? RESULTS Although heterogeneity exists, the evidence generally seems to support early surgery. While the best evidence exists for cervical SCI, there is insufficient data to support a differential effect for early surgery depending on neurological level or injury severity. When comparing thresholds to define early versus late surgery-including a later threshold (48-72 hours), an earlier threshold (24 hours), and an ultra-early threshold (8-12 hours)-the 2 earlier time points seem to be associated with the greatest potential for improved outcomes. However, existing prehospital and hospital logistics pose barriers to early surgery in a significant proportion of patients. An overview of recommendations from the recent AOSpine guidelines is provided. CONCLUSION In spite of increasing acceptance of early surgery post SCI, further research is needed to (1) identify subgroups of patients who stand to derive particular benefit-in particular to develop more evidence-based approaches for central cord syndrome and (2) investigate the efficacy and feasibility of ultra-early surgery targeting more aggressive timelines.
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Affiliation(s)
- Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,Jefferson R. Wilson, Division of Neurosurgery, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
| | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
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13
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Fiss I, Bettag C, Schatlo B, von Eckardstein K, Tsogkas I, Schwarz A, von der Brelie C, Rohde V. Prophylactic enlargement of the thecal sac volume by spinal expansion duroplasty in patients with unresectable malignant intramedullary tumors and metastases prior to radiotherapy. Neurosurg Rev 2018; 43:273-279. [PMID: 30426355 DOI: 10.1007/s10143-018-1051-0] [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: 08/24/2018] [Revised: 10/14/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
Abstract
Unresectable malignant intramedullary tumors and metastases usually require radiotherapy which intensifies spinal cord edema and might result in neurological decline. Spinal expansion duroplasty before radiotherapy enlarges the intrathecal volume and might thus prevent neurological deficits. The study aims to evaluate the clinical course of patients undergoing expansion duroplasty. This retrospective analysis (2007-2016) included all patients with unresectable intramedullary tumors who underwent spinal expansion duroplasty. To assess the degree of preoperative cord enlargement, we calculated the "diameter ratio": diameter of the spinal cord below and above the tumor / diameter of the tumor × 2. The presence of perimedullary cerebrospinal fluid (CSF) at the affected levels was analyzed on the preoperative magnetic resonance imaging (MRI). We recorded the occurrence of neurological deficits, wound breakdown, and CSF fistula. We screened 985 patients, 11 of which were included. Eight patients had an intramedullary metastasis, three patients a spinal malignant glioma. A diameter ratio ≤ 0.8 representing a significant preoperative intramedullary enlargement was seen in 10 cases (90.9%). Postoperative imaging was available in 9 patients, demonstrating successful decompression in 8 of the 9 patients (88.9%). The postoperative course was uneventful in 9 patients (81.8%). Mean overall survival was 13.4 (SD 16.2) months. Spinal expansion duroplasty prior to radiotherapy is a previously undescribed concept. Despite neoadjuvant radiation, no wound breakdown or CSF fistula occurred. In unresectable intramedullary tumors and metastases, spinal expansion duroplasty seems to be a safe procedure with the potential to prevent neurological decline due to radiation-induced cord swelling.
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Affiliation(s)
- Ingo Fiss
- Department of Neurosurgery, Medical Center, Georg August University of Göttingen, Göttingen, Germany.
| | - C Bettag
- Department of Neurosurgery, Medical Center, Georg August University of Göttingen, Göttingen, Germany
| | - B Schatlo
- Department of Neurosurgery, Medical Center, Georg August University of Göttingen, Göttingen, Germany
| | - K von Eckardstein
- Department of Neurosurgery, Medical Center, Georg August University of Göttingen, Göttingen, Germany
| | - I Tsogkas
- Department of Neuroradiology, Medical Center, Georg August University of Göttingen, Göttingen, Germany
| | - A Schwarz
- Department of Neuroradiology, Medical Center, Georg August University of Göttingen, Göttingen, Germany
| | - C von der Brelie
- Department of Neurosurgery, Medical Center, Georg August University of Göttingen, Göttingen, Germany
| | - V Rohde
- Department of Neurosurgery, Medical Center, Georg August University of Göttingen, Göttingen, Germany
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Seif M, Ziegler G, Freund P. Progressive Ventricles Enlargement and Cerebrospinal Fluid Volume Increases as a Marker of Neurodegeneration in Patients with Spinal Cord Injury: A Longitudinal Magnetic Resonance Imaging Study. J Neurotrauma 2018; 35:2941-2946. [PMID: 29993326 PMCID: PMC6306675 DOI: 10.1089/neu.2017.5522] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Next to gray and white matter atrophy, cerebrospinal fluid (CSF) volume and ventricular dilation may be surrogate biomarkers for brain atrophy in spinal cord injury (SCI). We therefore aimed to track brain atrophy by means of CSF volume changes and ventricular enlargements over two years after SCI. Fifteen patients with SCI and 18 healthy controls underwent a series of T1-weighted scans during five time points over two years. Changes of CSF/intracranial volume (CSF/ICV) ratio, CSF volume, and ventricular enlargement rate over time were determined. Sample sizes with 80% power and 5% significance were calculated to detect a range of treatment effects for a two-armed trial. There was a significant cross-sectional increased CSF/ICV ratio in patients compared with controls at each time point (p < 0.02). The rate of CSF/ICV changes, however, was not significantly different between groups over time. CSF volume increased linearly over bilateral sensorimotor cortices (left: p = 0.002, right: p = 0.042) and in the supracerebellar space (p < 0.001) within two years. An acceleration of the enlargement within the third (p = 0.017) and the fourth (p = 0.006) ventricles was observed in patients over time. Sample size estimation for six-month trials with CSF volume requires 25 patients per treatment arm to detect a hypothetical treatment effect in terms of slowing of atrophy rate of 30%. This study shows that SCI-induced changes in CSF/ICV ratio and ventricular expansion rate provide additional information on the neurodegenerative processes after injury. The sensitivity to scoring treatment effects speaks to its potential to serve as a sensitive biomarker in addition to local atrophy measures.
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Affiliation(s)
- Maryam Seif
- 1 Spinal Cord Injury Center, University of Zurich, Zurich, Switzerland.,2 Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Gabriel Ziegler
- 3 Dementia Research, Otto-von-Guericke-University, Magdeburg, Germany.,4 German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany
| | - Patrick Freund
- 1 Spinal Cord Injury Center, University of Zurich, Zurich, Switzerland.,2 Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,5 Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, UCL, London, United Kingdom
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Mapping the continuum of care to surgery following traumatic spinal cord injury. Injury 2018; 49:1552-1557. [PMID: 29934095 DOI: 10.1016/j.injury.2018.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is a devastating injury, frequently resulting in paralysis and a lifetime of medical and social problems. Reducing time to surgery may improve patient outcomes. A vital first step to reduce times is to map current pathways of care from injury to surgery, identify rapid care pathways and factors associated with rapid care pathway times. METHODS A retrospective review of the Alfred Trauma Service records was undertaken for all cases of spinal injury recorded in the Alfred Trauma Registry over a three year period. Patients with an Abbreviated Injury Scale (AIS) code matching 148 codes for spinal injury were included in the study. Information extracted from the Alfred Trauma Registry included demographic, clinical and key care timelines. RESULTS Of the 342 cases identified, 119 had SCI. The average age of SCI patients was 52 years, with 84% male. The vast majority of SCI patients experienced multiple concurrent injuries (87%). Median time from injury to surgery was 17 h r 28 min for SCI patients in comparison to 28 h r 23 min for non-SCI patients. Three pathways to surgery were identified following Trauma Centre presentation- transfer to surgery direct from trauma unit (median time to surgery was 4 h 17 min.), via Intensive Care (median time to surgery was 24 h 33 min) and via the ward (median time to surgery 28 h r 35 min.) SCI was independently associated with the fastest pathway - direct transfer from trauma unit to surgery - with 41% of SCI cases transferred directly to surgery from the trauma unit. CONCLUSION Notwithstanding that the vast majority of SCI patients presented with other traumatic injuries, half of all SCI cases reached surgery within 18 h of injury, with 25% within 9 h. SCI was independently associated with direct transfer to surgery from the trauma unit. SCI patients achieve rapid times to surgery within a complex trauma service. Furthermore, the trauma system is well positioned to implement further time reductions to surgery for SCI patients.
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[Efficacy of intramedullary and extramedullary decompression and lavage therapy under microscope for treatment of chronic cervical spinal cord injury]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38. [PMID: 29502056 PMCID: PMC6743871 DOI: 10.3969/j.issn.1673-4254.2018.02.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To analyze the clinical effect of spinal cord decompression and lavage therapy on chronic cervical spinal cord injury and explore the possible mechanism. METHODS Fifty-seven patients with chronic cervical spinal cord injury treated in our hospital from January, 2008 to January, 2015 were enrolled, including 17 with multilevel cervical disc herniation, 25 with long segmental ossification of the posterior longitudinal ligament, 13 with hypertrophy or calcification of neck ligamentum flavum, and 2 with old cervical fractures. Open-door spinal canal laminoplasty via a posterior approach and decompression in simple extramedullary decompression was performed in 31 cases (group A), and open-door spinal cord incision decompression via a posterior approach, saline irrigation, and spinal canal laminoplasty in intramedullary decompression was performed in 26 cases (group B). The pre-operative cerebrospinal fluid in group B patients was collected to examine the inflammatory factors. All the patients were followed up and evaluated for pre- and postoperative JOA scores to calculate the improvement rate with regular examinations by X-ray, CT or MRI. RESULTS Imaging examinations 2 weeks after the operation showed obvious relief of the primary lesion in both groups, and the improvement of high signals was better in group B than in group A. The mean improvement rate at 12 months after the operation was 52.33% in group A and 61.52% in group B (P<0.05), and the mean JOA score was significantly higher in group B than in group A (14.80∓1.51 vs 13.58∓0.56; P<0.05). Cerebrospinal fluid leakage occurred in 3 cases, epidural hematoma in 2 cases, internal fixation loosening in 1 case in group A; portal shaft fracture and internal fixation loosening occurred in 1 case in group B. Postoperative recovery time was shorter in group B and entered the platform phase in 3 months. The inflammatory factors IFN-γ, IL-17F, IL-6 and sCD40L were all significantly higher than the normal levels after spinal cord injury, and the increment of IL-6 was the most conspicuous (P<0.05). CONCLUSION Intramedullary and extramedullary decompression can achieve better outcomes than extramedullary decompression in patients with chronic cervical cord injury. This may be related not only to relieving adhesions and secondary compression by cutting the dura under the microscope, but also to removal of local inflammatory factors.
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Mattiassich G, Gollwitzer M, Gaderer F, Blocher M, Osti M, Lill M, Ortmaier R, Haider T, Hitzl W, Resch H, Aschauer-Wallner S. Functional Outcomes in Individuals Undergoing Very Early (< 5 h) and Early (5–24 h) Surgical Decompression in Traumatic Cervical Spinal Cord Injury: Analysis of Neurological Improvement from the Austrian Spinal Cord Injury Study. J Neurotrauma 2017; 34:3362-3371. [DOI: 10.1089/neu.2017.5132] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Georg Mattiassich
- Trauma Center Linz, Teaching Hospital of the Paracelsus Medical University Salzburg, Linz, Austria
- Ludwig-Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
- Department of Orthopaedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Vinzenzgruppe Center of Orthopaedic Excellence, Teaching Hospital of the Paracelsus Medical University Salzburg, Linz, Austria
| | - Maria Gollwitzer
- Department of Neurosurgery, Neuromed Campus, Kepler University Linz, Linz, Austria
| | - Franz Gaderer
- Department of Trauma Surgery, Medcampus III, Kepler University Linz, Linz, Austria
| | - Martina Blocher
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Osti
- Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria
| | - Markkus Lill
- Trauma Center Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Reinhold Ortmaier
- Department of Orthopaedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Vinzenzgruppe Center of Orthopaedic Excellence, Teaching Hospital of the Paracelsus Medical University Salzburg, Linz, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, ISAG/UMIT, Hall in Tyrol, Austria
| | - Thomas Haider
- Department of Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Hitzl
- Research Office of Biostatistics, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Herbert Resch
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Stephanie Aschauer-Wallner
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria
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Xin DQ, Hu ZM, Huo HJ, Yang XJ, Han D, Xing WH, Zhao Y, Qiu QH. Schisandrin B attenuates the inflammatory response, oxidative stress and apoptosis induced by traumatic spinal cord injury via inhibition of p53 signaling in adult rats. Mol Med Rep 2017; 16:533-538. [PMID: 28560444 PMCID: PMC5482126 DOI: 10.3892/mmr.2017.6622] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 02/20/2017] [Indexed: 12/14/2022] Open
Abstract
Schisandrin B is an active monomer of the Chinese magnolia vine (Schisandra chinensis) that can reduce transaminase activity in liver cells, inhibit lipid peroxidation, enhance antioxidant status, has protective effects in the liver and has antitumor effects. The present study investigated the potential protective effects of schisandrin B on the p53 signaling pathway in attenuating the inflammatory response, oxidative stress and apoptosis induced by traumatic spinal cord injury (TSCI) in adult rats. Behavioral examination, inclined plate test and spinal cord water content were used to evaluate the protective effect of schisandrin B in TSCI rats. The expression levels of superoxide dismutase (SOD), malondialdehyde (MDA), nuclear factor (NF)-κB subunit p65 and tumor necrosis factor (TNF)-α were examined using ELISA kits. Western blot analysis was performed to analyze the protein expression of caspase-3 and phosphorylated (p)-p53 in TSCI rats. In the present study, schisandrin B improved behavioral examination results and the maximum angle of inclined plate test, and inhibited spinal cord water content in rats with TSCI. Notably, schisandrin B reduced the activation of traumatic injury-associated pathways, including SOD, MDA, NF-κB p65 and TNF-α, in TSCI rats. In addition, schisandrin B suppressed the TSCI-induced expression of caspase-3 and p-p53 in TSCI rats. These results indicated that schisandrin B may attenuate the inflammatory response, oxidative stress and apoptosis in TSCI rats by inhibiting the p53 signaling pathway in adult rats.
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Affiliation(s)
- D Q Xin
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Z M Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - H J Huo
- Department of Spinal Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia 010030, P.R. China
| | - X J Yang
- Department of Spinal Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia 010030, P.R. China
| | - D Han
- Department of Cardiovascular Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia 010059, P.R. China
| | - W H Xing
- Department of Spinal Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia 010030, P.R. China
| | - Y Zhao
- Department of Spinal Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia 010030, P.R. China
| | - Q H Qiu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
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Blaško J, Szekiova E, Slovinska L, Kafka J, Cizkova D. Axonal outgrowth stimulation after alginate/mesenchymal stem cell therapy in injured rat spinal cord. Acta Neurobiol Exp (Wars) 2017. [DOI: 10.21307/ane-2017-066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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Barbagallo GMV, Raudino G, Visocchi M, Alobaid AA, Al-Mutair AA, Naveen T, Certo F. Restoration of Thoracolumbar Spine Stability and Alignment in Elderly Patients Using Minimally Invasive Spine Surgery (MISS). A Safe and Feasible Option in Degenerative and Traumatic Spine Diseases. ACTA NEUROCHIRURGICA SUPPLEMENT 2017; 124:69-74. [DOI: 10.1007/978-3-319-39546-3_11] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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21
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Kreinest M, Ludes L, Biglari B, Küffer M, Türk A, Grützner PA, Matschke S. Influence of Previous Comorbidities and Common Complications on Motor Function after Early Surgical Treatment of Patients with Traumatic Spinal Cord Injury. J Neurotrauma 2016; 33:2175-2180. [DOI: 10.1089/neu.2016.4416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michael Kreinest
- Department of Trauma Surgery and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Lisa Ludes
- Department of Trauma Surgery and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Bahram Biglari
- Department of Paraplegiology, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | | | - Ansgar Türk
- Department of Paraplegiology, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Paul A. Grützner
- Department of Trauma Surgery and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Stefan Matschke
- Department of Trauma Surgery and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
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22
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Grassner L, Wutte C, Klein B, Mach O, Riesner S, Panzer S, Vogel M, Bühren V, Strowitzki M, Vastmans J, Maier D. Early Decompression (< 8 h) after Traumatic Cervical Spinal Cord Injury Improves Functional Outcome as Assessed by Spinal Cord Independence Measure after One Year. J Neurotrauma 2016; 33:1658-66. [DOI: 10.1089/neu.2015.4325] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lukas Grassner
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
- Department of Neurosurgery, Trauma Center Murnau, Germany
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Austria
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Austria
| | - Christof Wutte
- Department of Neurosurgery, Trauma Center Murnau, Germany
| | - Barbara Klein
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Austria
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Austria
| | - Orpheus Mach
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | - Silvie Riesner
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | - Stephanie Panzer
- Department of Radiology, Trauma Center Murnau, Germany
- Institute of Biomechanics, Trauma Center Murnau and Paracelsus Medical University Salzburg, Murnau, Germany
| | - Matthias Vogel
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | - Volker Bühren
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | | | - Jan Vastmans
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | - Doris Maier
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
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23
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24
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van Middendorp JJ, Hosman AJF, Doi SAR. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013; 30:1781-94. [PMID: 23815524 DOI: 10.1089/neu.2013.2932] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Abstract The debate over the effects of the timing of surgical spinal decompression after traumatic spinal cord injury (tSCI) has remained unresolved for over a century. The aim of the current study was to perform a systematic review and quality-adjusted meta-analysis of studies evaluating the effects of the timing of spinal surgery after tSCI. Studies were searched for through the MEDLINE(®) database (1966 to August 2012) and a 15-item, tailored scoring system was used for assessing the included studies' susceptibility to bias. Random effects and quality effects meta-analyses were performed. Models were tested for robustness using one way and criterion-based sensitivity analysis and funnel plots. Results are presented as weighted mean differences (WMDs) and odds ratios (ORs) with 95% confidence intervals (CIs). A total of 18 studies were analyzed. Heterogeneity was evident among the studies included. Quality effects models showed that - when compared with "late" surgery - "early" spinal surgery was significantly associated with a higher total motor score improvement (WMD: 5.94 points, 95% CI:0.74,11.15) in seven studies, neurological improvement rate (OR: 2.23, 95% CI:1.35,3.67) in six studies, and shorter length of hospital stay (WMD: -9.98 days, 95% CI:-13.10,-6.85) in six studies. However, one way and criterion-based sensitivity analyses demonstrated a profound lack of robustness among pooled estimates. Funnel plots showed significant proof of publication bias. In conclusion, despite the fact that "early" spinal surgery was significantly associated with improved neurological and length of stay outcomes, the evidence supporting "early" spinal surgery after tSCI lacks robustness as a result of different sources of heterogeneity within and between original studies. Where the conduct of a surgical, randomized controlled trial seems to be an unfeasible undertaking in acute tSCI, methodological safeguards require the utmost attention in future cohort studies. (Prospero registration number: PROSPERO CRD42012003182. See also http://www.crd.york.ac.uk/NIHR_PROSPERO/ ).
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Affiliation(s)
- Joost J van Middendorp
- 1 Stoke Mandeville Spinal Foundation, National Spinal Injuries Centre , Stoke Mandeville Hospital, Aylesbury, United Kingdom
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25
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Sjovold SG, Mattucci SF, Choo AM, Liu J, Dvorak MF, Kwon BK, Tetzlaff W, Oxland TR. Histological Effects of Residual Compression Sustained for 60 Minutes at Different Depths in a Novel Rat Spinal Cord Injury Contusion Model. J Neurotrauma 2013; 30:1374-84. [DOI: 10.1089/neu.2013.2906] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Simon G. Sjovold
- Orthopaedic and Injury Biomechanics Group, Departments of Orthopaedics and Mechanical Engineering, University of Pennsylvania, Philadelphia, Pennsylvania
- International Collaboration on Repair Discoveries, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen F.E. Mattucci
- Orthopaedic and Injury Biomechanics Group, Departments of Orthopaedics and Mechanical Engineering, University of Pennsylvania, Philadelphia, Pennsylvania
- International Collaboration on Repair Discoveries, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anthony M. Choo
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jie Liu
- International Collaboration on Repair Discoveries, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcel F. Dvorak
- International Collaboration on Repair Discoveries, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Spine, Department of Orthopaedics, University of British Columbia, British Columbia, Canada
| | - Brian K. Kwon
- International Collaboration on Repair Discoveries, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Spine, Department of Orthopaedics, University of British Columbia, British Columbia, Canada
| | - Wolfram Tetzlaff
- International Collaboration on Repair Discoveries, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas R. Oxland
- Orthopaedic and Injury Biomechanics Group, Departments of Orthopaedics and Mechanical Engineering, University of Pennsylvania, Philadelphia, Pennsylvania
- International Collaboration on Repair Discoveries, University of Pennsylvania, Philadelphia, Pennsylvania
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Cristante AF, Filho TEPB, Oliveira RP, Marcon RM, Ferreira R, Santos GB. Effects of antidepressant and treadmill gait training on recovery from spinal cord injury in rats. Spinal Cord 2013; 51:501-7. [PMID: 23567756 DOI: 10.1038/sc.2013.18] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
STUDY DESIGN Experimental, controlled, animal study. OBJECTIVES To evaluate the influences of antidepressant treatment, treadmill gait training and a combination of these therapies in rats with experimental, acute spinal cord injury (SCI). SETTING Brazil. METHODS 48 Wistar rats were given standardized SCI; rats were then randomly assigned to four treatment groups: (1) motor rehabilitation therapy for 1 hour daily (gait training); (2) daily treatment with the antidepressant, fluoxetine (0.3 ml per 100 g intraperitoneally), beginning 24 h after the trauma; (3) combined fluoxetine treatment and gait training, or (4) untreated (controls). Neurological recovery was tested with the Basso, Beattie and Bresnahan (BBB) scale at 2, 7, 14, 21, 28 ,35 and 42 days after injury. Moreover, on day 42, all rats underwent a motor-evoked potential test (MEP); then, after euthanasia, histopathological evaluation was conducted in the area of SCI. RESULTS Based on the BBB scale, the combined treatment group showed significantly greater improvement compared with the other three groups, from the 14th to the 42nd day of observation. The MEP revealed that all treated groups showed significant improvement compared with the control group (P<0.02 for latency and P<0.01 for amplitude). CONCLUSION Our results indicated that a combination of antidepressant and treadmill gait training was superior to either treatment alone for improving functional deficits in rats with experimental, acute SCI.
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Affiliation(s)
- A F Cristante
- Department of Orthopaedics and Traumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Pauloo, São Paulo, Brazil.
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Cristante AF, Barros Filho TEPD, Marcon RM, Letaif OB, Rocha IDD. Therapeutic approaches for spinal cord injury. Clinics (Sao Paulo) 2012; 67:1219-24. [PMID: 23070351 PMCID: PMC3460027 DOI: 10.6061/clinics/2012(10)16] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 08/23/2012] [Indexed: 01/02/2023] Open
Abstract
This study reviews the literature concerning possible therapeutic approaches for spinal cord injury. Spinal cord injury is a disabling and irreversible condition that has high economic and social costs. There are both primary and secondary mechanisms of damage to the spinal cord. The primary lesion is the mechanical injury itself. The secondary lesion results from one or more biochemical and cellular processes that are triggered by the primary lesion. The frustration of health professionals in treating a severe spinal cord injury was described in 1700 BC in an Egyptian surgical papyrus that was translated by Edwin Smith; the papyrus reported spinal fractures as a "disease that should not be treated." Over the last biological or pharmacological treatment method. Science is unraveling the mechanisms of cell protection and neuroregeneration, but clinically, we only provide supportive care for patients with spinal cord injuries. By combining these treatments, researchers attempt to enhance the functional recovery of patients with spinal cord injuries. Advances in the last decade have allowed us to encourage the development of experimental studies in the field of spinal cord regeneration. The combination of several therapeutic strategies should, at minimum, allow for partial functional recoveries for these patients, which could improve their quality of life.
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Affiliation(s)
- Alexandre Fogaça Cristante
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Instituto de Ortopedia e Traumatologia (IOT), Grupo de Coluna, São Paulo/SP, Brazil
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