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Foster N, Martin L, Raby E, Wood FM, Fear M, Pavlos N, Edgar DW. Trauma patient heterotopic ossification diagnosis is associated with increased hospital length of stay. Injury 2024; 55:111328. [PMID: 38428100 DOI: 10.1016/j.injury.2024.111328] [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] [Received: 05/02/2023] [Revised: 12/21/2023] [Accepted: 01/14/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Traumatic heterotopic ossification (tHO) refers to the development of extra-skeletal bone in muscle and soft tissues following tissue insult secondary to surgery or trauma. This presents a persistent clinical concern associated with significant patient morbidity and expense to diagnose and treat. Traumatic HO is a substantial barrier to rehabilitation for trauma-injured patients. As such, the development of tHO after burn and other trauma is hypothesised to prolong inpatient length of stay (LOS) and thus increase health care costs. OBJECTIVE To investigate the association between an inpatient tHO diagnosis and hospital LOS in trauma patients. METHODS A retrospective audit of trauma patients over a 14-year period was completed using data from four WA hospitals. Burn and neurological trauma patients diagnosed with tHO as an inpatient (tHO+) and control subjects (tHO-), matched (1:3) by age, gender, and injury severity factors, were identified using medical diagnostic codes. Data relating to patient and injury-related determinants of LOS from tHO+ and tHO- subjects were analysed to model the association of tHO on total hospital length of stay. RESULTS 188 identified patients were hospitalised due to traumatic injury; 47 patients with tHO following burn injury (n = 17), spinal cord injury (n = 13) and traumatic brain injury (n = 17), and 141 control patients. Those who developed tHO during hospitalisation had a significantly higher median LOS than matched trauma patients who did not develop tHO (142 days vs. 61 days). Multivariate regression analyses identified the following independent predictive factors of a prolonged hospital LOS: tHO diagnosis, mechanical ventilation hours, injury to the hip region and thigh area, other ossification disorder, pressure injury, admission to intensive care unit and deep vein thrombosis. Trauma patients diagnosed with tHO during their hospital admission stayed 1.6 times longer than trauma patients matched for injury severity without a tHO diagnosis (IRR 1.56, 95% CI 1.35-1.79, p<0.001). CONCLUSION Traumatic heterotopic ossification is an independent explanatory factor for increased hospital LOS in patients following burns, spinal cord, and traumatic brain injury. Early diagnosis may assist in reducing the impact of tHO on acute hospital stay after trauma.
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Affiliation(s)
- Nichola Foster
- Burn Injury Research Node, Institute for Health Research, School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia 6160, Australia; Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia; Physiotherapy Department, Sir Charles Gairdner Osborne Park Health Care Group, North Metropolitan Health Service, Nedlands, Western Australia 6009, Australia.
| | - Lisa Martin
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Edward Raby
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Mark Fear
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Nathan Pavlos
- School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia 6009, Australia
| | - Dale W Edgar
- Burn Injury Research Node, Institute for Health Research, School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia 6160, Australia; Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia; Safety and Quality Unit, Armadale Kalamunda Group Health Service, East Metropolitan Health Service, Mt Nasura, Western Australia 6112, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
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Franz S, Rust L, Heutehaus L, Rupp R, Schuld C, Weidner N. Impact of Heterotopic Ossification on Functional Recovery in Acute Spinal Cord Injury. Front Cell Neurosci 2022; 16:842090. [PMID: 35221928 PMCID: PMC8864137 DOI: 10.3389/fncel.2022.842090] [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: 12/23/2021] [Accepted: 01/17/2022] [Indexed: 12/14/2022] Open
Abstract
Objective: In spinal cord injury (SCI), heterotopic ossification is a frequent secondary complication, commonly associated with limited range of motion of affected joints, which could lead to secondary disability in activities of daily living. Additionally, heterotopic ossifications might challenge the effect of regeneration-promoting therapies on neurological and functional recovery. This study evaluated the impact of heterotopic ossification on clinical recovery within the first year after SCI. Methods: The study was conducted as a monocentric longitudinal paired cohort study. Recruitment was based on consecutive sampling in the framework of the European Multicenter about Spinal Cord Injury (EMSCI). Recovery profiles were determined using standardized neurological and functional clinical assessments within the 1st year following SCI. All study participants underwent at least two comprehensive standardized neurological and functional clinical examinations according to the International Standards for Neurological Classification of SCI and the Spinal Cord Independence Measure, respectively. Data regarding the diagnosis and treatment of heterotopic ossification were obtained by reviewing the patient medical records. The most similar “digital twin” from the entire EMSCI database were matched in terms of age, acute neurological and functional status to each individual with SCI, and heterotopic ossification. Results: Out of 25 participants diagnosed with heterotopic ossification, 13 individuals were enrolled and matched to control individuals. Most individuals presented with motor complete injury (75%). Ossifications were most frequently located at the hip joints (92%) and mainly occurred within the first 3 months after SCI. Individuals with heterotopic ossification achieved around 40% less functional improvement over time compared to their matched counterparts, whereas neurological recovery was not altered in individuals with SCI and heterotopic ossification. Conclusion: Heterotopic ossification—a common complication of SCI—unfavorably affects functional recovery, which in the end is most relevant for the best possible degree of independence in activities of daily living. Upon presentation with heterotopic ossification, neurological improvement achieved through potential restorative therapies might not translate into clinically meaningful functional improvement. Diagnostic algorithms and effective early prevention/treatment options for heterotopic ossification need to be established to ensure the best possible functional outcome. Clinical Trial Registration: NCT01571531 (https://clinicaltrials.gov).
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Affiliation(s)
- Steffen Franz
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Lukas Rust
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Laura Heutehaus
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Schuld
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
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Adegeest CY, van Gent JAN, Stolwijk-Swüste JM, Post MWM, Vandertop WP, Öner FC, Peul WC, Wengel PVT. Influence of severity and level of injury on the occurrence of complications during the subacute and chronic stage of traumatic spinal cord injury: a systematic review. J Neurosurg Spine 2021; 36:632-652. [PMID: 34767527 DOI: 10.3171/2021.7.spine21537] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Secondary health conditions (SHCs) are long-term complications that frequently occur due to traumatic spinal cord injury (tSCI) and can negatively affect quality of life in this patient population. This study provides an overview of the associations between the severity and level of injury and the occurrence of SHCs in tSCI. METHODS A systematic search was conducted in PubMed and Embase that retrieved 44 studies on the influence of severity and/or level of injury on the occurrence of SHCs in the subacute and chronic phase of tSCI (from 3 months after trauma). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS In the majority of studies, patients with motor-complete tSCI (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade A or B) had a significantly increased occurrence of SHCs in comparison to patients with motor-incomplete tSCI (AIS grade C or D), such as respiratory and urogenital complications, musculoskeletal disorders, pressure ulcers, and autonomic dysreflexia. In contrast, an increased prevalence of pain was seen in patients with motor-incomplete injuries. In addition, higher rates of pulmonary infections, spasticity, and autonomic dysreflexia were observed in patients with tetraplegia. Patients with paraplegia more commonly suffered from hypertension, venous thromboembolism, and pain. CONCLUSIONS This review suggests that patients with a motor-complete tSCI have an increased risk of developing SHCs during the subacute and chronic stage of tSCI in comparison with patients with motor-incomplete tSCI. Future studies should examine whether systematic monitoring during rehabilitation and the subacute and chronic phase in patients with motor-complete tSCI could lead to early detection and potential prevention of SHCs in this population.
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Affiliation(s)
- Charlotte Y Adegeest
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden.,2Department of Neurosurgery, Haaglanden Medical Center, The Hague
| | - Jort A N van Gent
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden
| | - Janneke M Stolwijk-Swüste
- 3Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht
| | - Marcel W M Post
- 3Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht.,4Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen
| | - William P Vandertop
- 5Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam
| | - F Cumhur Öner
- 6Department of Orthopedic Surgery, University Medical Center Utrecht; and
| | - Wilco C Peul
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden.,2Department of Neurosurgery, Haaglanden Medical Center, The Hague.,7Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Center Leiden, Haaglanden Medical Center and Haga Teaching Hospital, The Hague, The Netherlands
| | - Paula V Ter Wengel
- 2Department of Neurosurgery, Haaglanden Medical Center, The Hague.,7Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Center Leiden, Haaglanden Medical Center and Haga Teaching Hospital, The Hague, The Netherlands
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Carpentier VT, Salga M, Gatin L, Genêt F, Paquereau J. Early diagnosis of heterotopic ossification among patients admitted to a neurological Post-Intensive Care Rehabilitation Unit. Eur J Phys Rehabil Med 2021; 57:527-534. [PMID: 33448758 DOI: 10.23736/s1973-9087.21.06589-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Heterotopic ossification (HO) is defined as the formation of endochondral bone within soft tissue. Non-genetic forms, mainly corresponding to a consequence of bone, brain or spinal cord injury, are the most common. HO leads to important functional limitations and alteration of quality of life. To our knowledge, the time between brain, bone, or spinal cord injury and clinical suspicion of HO has never been studied. By admitting patients with severe neurological disorders, we hypothesized that the prevalence of HO in neurological post-intensive care rehabilitation units (PICRU) might be significant as these patients have recognized risk factors for HO. AIM This study aimed to investigate HO among patients admitted to a neurological PICRU with two objectives: 1) to describe the prevalence of HO in PICRU; 2) to assess the time between neurological disorder, clinical suspicion of HO and radiological diagnosis. DESIGN A monocentric retrospective cohort study. SETTING PICRU in our public university teaching hospital. This inpatient referral department is specifically dedicated to the early discharge from Intensive Care Units (ICU) of patients with severe neurological impairment who need rehabilitation. POPULATION We study all patients admitted between April 2016 and January 2019. One hundred twenty-five subjects were admitted for a rehabilitation program after neuro-trauma or stroke. We included all first-time stays in PICRU lasting 7 days or longer. METHODS Retrospective data extraction using administrative data from an electronic patient management program was done to select eligible subjects. Included subjects were then identified by a retrospective review of electronic inpatient medical records after patient discharge. Data of interest were collected from these same medical records. RESULTS Forty-four HO were diagnosed in 24 subjects (24/125; 19%), with a median number of 2 [1; 2] HO per subject. Neurological trauma was the main reason for admission to ICU (89/125; 71%) and half of patients had a traumatic brain injury (TBI) (67/125; 54%). The diagnosis of HO was made in PICRU in 75% of cases. Clinical suspicion of HO (autonomic dysfunction, local inflammatory signs, pain, or reduced joint range of motion) was made 6 [5; 7] weeks after admission to ICU. Radiological confirmation of clinical suspicion or fortuitous diagnosis by imaging (50% of the cases) occurred 8 [7; 12] weeks after admission to ICU. The median time of clinical suspicion or radiological diagnosis was 1 week after admission to PICRU. CONCLUSIONS HO is a sub-acute complication which develops in patients admitted to ICU for severe central nervous system disorders as clinical suspicion or radiological confirmation of diagnosis was made within the first week after admission in neurological PICRU (i.e. 6 to 8 weeks after ICU admission). CLINICAL REHABILITATION IMPACT As treatment for HO may at least partially improves rehabilitation and quality of life, we recommend a systematic screening in PICRU patients for HO by clinical examination supplemented by imaging in case of suspicion.
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Affiliation(s)
- Vincent T Carpentier
- Department of Physical Medicine and Rehabilitation, CIC-IT 1429, Raymond-Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France.,Faculty of Medicine, University of Paris, Paris, France.,Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France
| | - Marjorie Salga
- Department of Physical Medicine and Rehabilitation, CIC-IT 1429, Raymond-Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France.,Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France.,U1179 END-ICAP, Inserm, UFR Simone Veil - Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), Paris Saclay University, Montigny-le-Bretonneux, France
| | - Laure Gatin
- Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France.,U1179 END-ICAP, Inserm, UFR Simone Veil - Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), Paris Saclay University, Montigny-le-Bretonneux, France.,Department of Orthopedic Surgery, Raymond-Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France
| | - François Genêt
- Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France.,U1179 END-ICAP, Inserm, UFR Simone Veil - Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), Paris Saclay University, Montigny-le-Bretonneux, France
| | - Julie Paquereau
- Department of Physical Medicine and Rehabilitation, CIC-IT 1429, Raymond-Poincaré Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Garches, France - .,Garches Neuro-Orthopedics Research Group (GRENOG), Garches, France
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Yolcu YU, Wahood W, Goyal A, Alvi MA, Reeves RK, Qu W, Gerberi DJ, Goncalves S, Bydon M. Factors Associated with Higher Rates of Heterotopic Ossification after Spinal Cord Injury: A Systematic Review and Meta-Analysis. Clin Neurol Neurosurg 2020; 195:105821. [PMID: 32388145 DOI: 10.1016/j.clineuro.2020.105821] [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: 02/10/2020] [Revised: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
Abstract
Heterotopic Ossification (HO) refers to the formation of bone within soft tissue. Traumatic spinal cord injury (SCI) has been shown to be associated with development of HO. However, risk factors for HO following SCI are unknown. In light of this knowledge gap, we performed a systematic review and meta-analysis to summarize available evidence and elucidate risk factors associated with heterotopic ossification. An electronic literature search was conducted using five databases. Studies containing SCI patients, with a proportion diagnosed with HO, were included. Meta-analyses were performed to assess the association between following risk factors and development of HO: sex, type of injury, spasticity, pressure ulcer, injury level, urinary tract infection (UTI), deep vein thrombosis (DVT), number of smokers, and pneumonia. Nine studies with 2,115 patients were included. It was found that males (Odds Ratio [95% Confidence Interval]: 2.25 [1.61, 3.13]), smokers (2.88 [1.62, 5.11]), patients with complete injury (3.61 [2.29, 5.71]), pneumonia (2.86 [2.18, 3.75]), pressure ulcers (2.45 [1.89, 3.18]), UTI (3.84 [2.63, 5.62]) and spasticity (2.12 [1.67, 2.68]) had significantly higher odds of developing HO after spinal cord injury. In contrast, location of injury (Cervical vs. thoracic injury; (1.03 [0.72, 1.49]) and DVT (1.37 [0.91, 2.07]) were not associated with development of HO. Pooled results from existing literature on HO development show that several factors are significantly associated with development of HO. Given the complexity of SCI management, the results might have a positive impact on the clinical practice by leading to an effective screening aproach.
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Affiliation(s)
- Yagiz Ugur Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waseem Wahood
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anshit Goyal
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ronald K Reeves
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Wenchun Qu
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | | | - Sandy Goncalves
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
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Muscle localization of heterotopic ossification following spinal cord injury. Spine J 2017; 17:1519-1522. [PMID: 28456672 DOI: 10.1016/j.spinee.2017.04.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 03/29/2017] [Accepted: 04/21/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Heterotopic ossification (HO) is a known complication especially in people with traumatic spinal cord injury (SCI). Although some risk factors have already been described, the pathophysiology of HO is still unknown. The pelvis is the most common region for HO occurrence. However, the prevalence of HO by muscle groups about the hip is not well described. PURPOSE To analyze the prevalence of early HO in muscle groups about the hip in 267 patients with SCI. PATIENT SAMPLE 267 patients with traumatic SCI and pelvic HO. METHODS Between January 2001 and December 2014, 267 patients with SCI were treated in our university hospital and were included in the study. Patients were routinely screened for HO using ultrasound. The diagnosis of HO was validated using magnetic resonance imaging (MRI) or computed tomography (CT). The primary outcome measure was the prevalence of HO by muscle groups around the hip. The following muscle groups around the hip were defined: (1) gluteal group, (2) adductor group, (3) iliopsoas group, and (4) deep muscle group. Additionally, the prevalence of concomitant trochanteric bursitis was recorded in all cases. RESULTS The gluteal group showed the highest HO prevalence with 55.8%, followed by the deep muscle group with 31.1%. Concomitant trochanteric bursitis was found in 62 patients (23.2%). No association between pelvic trauma and HO development was observed (n=16, 11%). CONCLUSIONS The most common muscular location for the occurrence of HO about the hip was the gluteal muscle group. Considering that no laboratory parameters are currently available for screening for HO, highly sensitive ultrasound screening examinations should be routinely performed, with particular attention paid to the gluteal muscles. Additionally, routine range of motion examination for extension and external rotation of the hip joint is warranted.
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Kopp MA, Liebscher T, Watzlawick R, Martus P, Laufer S, Blex C, Schindler R, Jungehulsing GJ, Knüppel S, Kreutzträger M, Ekkernkamp A, Dirnagl U, Strittmatter SM, Niedeggen A, Schwab JM. SCISSOR-Spinal Cord Injury Study on Small molecule-derived Rho inhibition: a clinical study protocol. BMJ Open 2016; 6:e010651. [PMID: 27466236 PMCID: PMC4964175 DOI: 10.1136/bmjopen-2015-010651] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/25/2016] [Accepted: 05/19/2016] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The approved analgesic and anti-inflammatory drugs ibuprofen and indometacin block the small GTPase RhoA, a key enzyme that impedes axonal sprouting after axonal damage. Inhibition of the Rho pathway in a central nervous system-effective manner requires higher dosages compared with orthodox cyclooxygenase-blocking effects. Preclinical studies on spinal cord injury (SCI) imply improved motor recovery after ibuprofen/indometacin-mediated Rho inhibition. This has been reassessed by a meta-analysis of the underlying experimental evidence, which indicates an overall effect size of 20.2% regarding motor outcome achieved after ibuprofen/indometacin treatment compared with vehicle controls. In addition, ibuprofen/indometacin may also limit sickness behaviour, non-neurogenic systemic inflammatory response syndrome (SIRS), neuropathic pain and heterotopic ossifications after SCI. Consequently, 'small molecule'-mediated Rho inhibition after acute SCI warrants clinical investigation. METHODS AND ANALYSIS Protocol of an investigator-initiated clinical open-label pilot trial on high-dose ibuprofen treatment after acute traumatic, motor-complete SCI. A sample of n=12 patients will be enrolled in two cohorts treated with 2400 mg/day ibuprofen for 4 or 12 weeks, respectively. The primary safety end point is an occurrence of serious adverse events, primarily gastroduodenal bleedings. Secondary end points are pharmacokinetics, feasibility and preliminary effects on neurological recovery, neuropathic pain and heterotopic ossifications. The primary safety analysis is based on the incidence of severe gastrointestinal bleedings. Additional analyses will be mainly descriptive and casuistic. ETHICS AND DISSEMINATION The clinical trial protocol was approved by the responsible German state Ethics Board, and the Federal Institute for Drugs and Medical Devices. The study complies with the Declaration of Helsinki, the principles of Good Clinical Practice and all further applicable regulations. This safety and pharmacokinetics trial informs the planning of a subsequent randomised controlled trial. Regardless of the result of the primary and secondary outcome assessments, the clinical trial will be reported as a publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02096913; Pre-results.
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Affiliation(s)
- Marcel A Kopp
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Liebscher
- Treatment Centre for Spinal Cord Injury, Trauma Hospital Berlin, Berlin, Germany
| | - Ralf Watzlawick
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Martus
- Department of Clinical Epidemiology and Applied Biostatistics, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Stefan Laufer
- Department of Pharmaceutical and Medicinal Chemistry, Institute of Pharmacy, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Christian Blex
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ralf Schindler
- Division of Nephrology and Intensive Care, Department of Internal Medicine, Campus Virchow-Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Gerhard J Jungehulsing
- Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany Department of Neurology and Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sven Knüppel
- Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Germany
| | - Martin Kreutzträger
- Treatment Centre for Spinal Cord Injury, Trauma Hospital Berlin, Berlin, Germany
| | - Axel Ekkernkamp
- Trauma Surgery and Orthopedics Clinic, Trauma Hospital Berlin, Berlin, Germany
| | - Ulrich Dirnagl
- Department of Neurology and Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephen M Strittmatter
- Department of Neurology, Program in Cellular Neuroscience, Neurodegeneration and Repair, Yale University School of Medicine, New Haven, USA
| | - Andreas Niedeggen
- Treatment Centre for Spinal Cord Injury, Trauma Hospital Berlin, Berlin, Germany
| | - Jan M Schwab
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité-Universitätsmedizin Berlin, Berlin, Germany Treatment Centre for Spinal Cord Injury, Trauma Hospital Berlin, Berlin, Germany Department of Neurology, Spinal Cord Injury Division, The Ohio State University, Wexner Medical Center, Columbus, USA Department of Neuroscience and Center for Brain and Spinal Cord Repair, Department of Physical Medicine and Rehabilitation, The Neurological Institute, The Ohio State University, Wexner Medical Center, Columbus, USA
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