Factors predictive of survival and estimated years of life lost in the decade following nontraumatic and traumatic spinal cord injury

Sex disparities in adverse outcomes after surgically managed isolated traumatic spinal injury

BACKGROUND

Traumatic spinal injury (TSI) encompasses a wide range of injuries affecting the spinal cord, nerve roots, bones, and soft tissues that result in pain, impaired mobility, paralysis, and death. There is some evidence suggesting that women may have different physiological responses to traumatic injury compared to men; therefore, this study aimed to investigate if there are any associations between sex and adverse outcomes following surgically managed isolated TSI.

METHODS

Using the 2013-2019 TQIP database, all adult patients with isolated TSI, defined as a spine AIS ≥ 2 with an AIS ≤ 1 in all other body regions, resulting from blunt force trauma requiring spinal surgery, were eligible for inclusion in the study. The association between the sex and in-hospital mortality as well as cardiopulmonary and venothromboembolic complications was determined by calculating the risk ratio (RR) after adjusting for potential confounding using inverse probability weighting.

RESULTS

A total of 43,756 patients were included. After adjusting for potential confounders, female sex was associated with a 37% lower risk of in-hospital mortality [adjusted RR (95% CI): 0.63 (0.57-0.69), p < 0.001], a 27% lower risk of myocardial infarction [adjusted RR (95% CI): 0.73 (0.56-0.95), p = 0.021], a 37% lower risk of cardiac arrest [adjusted RR (95% CI): 0.63 (0.55-0.72), p < 0.001], a 34% lower risk of deep vein thrombosis [adjusted RR (95% CI): 0.66 (0.59-0.74), p < 0.001], a 45% lower risk of pulmonary embolism [adjusted RR (95% CI): 0.55 (0.46-0.65), p < 0.001], a 36% lower risk of acute respiratory distress syndrome [adjusted RR (95% CI): 0.64 (0.54-0.76), p < 0.001], a 34% lower risk of pneumonia [adjusted RR (95% CI): 0.66 (0.60-0.72), p < 0.001], and a 22% lower risk of surgical site infection [adjusted RR (95% CI): 0.78 (0.62-0.98), p < 0.032], compared to male sex.

CONCLUSION

Female sex is associated with a significantly decreased risk of in-hospital mortality as well as cardiopulmonary and venothromboembolic complications following surgical management of traumatic spinal injuries. Further studies are needed to elucidate the cause of these differences.

LncRNA KCNQ1OT1 promotes the apoptosis and inflammatory response of microglia by regulating the miR-589-5p/NPTN axis after spinal cord injury

Spinal cord injury (SCI) is a devastating traumatic condition accompanied with excessive inflammatory response and apoptosis of microglia. Long noncoding RNAs (lncRNAs) have been confirmed to be key regulators of cell inflammatory response. Nevertheless, the role of lncRNA KCNQ1OT1 in microglia apoptosis or inflammatory response after SCI remains to be explored. Our study focused on exploring the role and mechanism of KCNQ1OT1 in microglia after SCI. RT-qPCR showed that SCI induced the increase of KCNQ1OT1 level in mice spinal cord. Inhibition of KCNQ1OT1 suppressed the inflammatory response and apoptosis of microglia. In addition, KCNQ1OT1 was proved to bind with miR-589-5p, and NPTN was directly targeted by miR-589-5p. Furthermore, KCNQ1OT1 was negatively correlated with miR-589-5p and positively associated with NPTN. Rescue assays indicated that NPTN overexpression reversed the anti-inflammatory and anti-apoptosis effects of KCNQ1OT1 silencing. In summary, these data revealed that KCNQ1OT1 promoted inflammatory response and apoptosis of microglia by regulating the miR-589-5p/NPTN axis after SCI, which may offer a novel promising therapeutic target for SCI.

Exosome-shuttled miR-672-5p from anti-inflammatory microglia repair traumatic spinal cord injury by inhibiting AIM2/ASC/Caspase-1 signaling pathway mediated neuronal pyroptosis

Traumatic spinal cord injury (TSCI) is a devastating traumatic disease of the central nervous system, which leads to refractory loss of motor and sensory function. So far, there is no effective treatment for TSCI. Recently, however, nano-sized exosomes from various spinal cord cells have shown great prospects in the treatment of various diseases, including TSCI. Microglia are one of the components of the spinal cord microenvironment. Anti-inflammatory microglia (M2) have been shown to inhibit inflammation and promote the functional recovery of spinal cord after TSCI. However, the role micro RNAs (miRNAs) in exosomes derived from M2 microglia in the treatment of TSCI is unclear. In this study, we investigated whether M2 microglial exosomes (M2-Exos) could better promote the functional behavior recovery of mice with TSCI than M0 microglial exosomes (Exos). Compared with Exos, M2-Exos were found to have a better effect in promoting the recovery of functional behavior, promoting axon regeneration and reducing the level of pyroptosis of spinal cord neurons after TSCI. Through a series of experiments, we also confirmed that miR-672-5p is the most critical miRNA associated with M2-Exos, and that its targeting gene is AIM2. M2-Exos rich in miR-672-5p could inhibit the AIM2/ASC/Caspase-1 signaling pathway by inhibiting AIM2 activity, so as to inhibit neuronal pyroptosis and finally promote the recovery of functional behavior in mice with TSCI. In conclusion, our study suggests that the application of M2-Exos may be a promising treatment strategy for TSCI.

Conceptual changes needed to improve outcomes in rehabilitation medicine: A clinical commentary

Rehabilitation medicine has expanded the horizon of all medicine and brought about new human achievements. To facilitate continued advances in achievement, several changes are suggested in customary rehabilitation strategic goals, concepts, and practices. The main rehabilitation goals should focus on prolonged survival, contrary to the opinions of most authors on rehabilitation, and on achievement of maximum ability realization, rather than of independence or any given (including previous) level of functioning. Setting rehabilitation goals should benefit the patient, rather than the caregiver or the insurer. Training should focus on tasks that contribute to the patients' interests and desires, rather than on any task that reduces the burden of care. The main criterion for admission to a rehabilitation ward should be based on expected advantage in prolonging patient survival and maximizing ability realization.

Survival, discharge destination, and referral for rehabilitation after metastatic spinal cord compression surgery

STUDY DESIGN

A retrospective review of medical records.

OBJECTIVE

The objective of this study was to examine probability of survival after 90- and 180-days after surgery, to document the rehabilitation needs, patients discharge destination, and whether discharge destination, re-admission, and probability of survival among patients with metastatic spinal cord compression (MSCC) were associated with potential risk factors.

SETTING

Copenhagen University Hospital, Rigshospitalet that serves a population of 2.8 million people from the Eastern part of Denmark, Faroe Islands, and Greenland.

METHODS

Adult (≥18 years) patients with MSCC undergoing surgery in 2017-2018 were included. Descriptive statistics were used to investigate the probability of survival after 90- and 180-days, rehabilitation needs documented in the patient's medical record, and discharge destination. Univariate logistic regression analyses were used to examine the associations between a priory defined potential risk factors for mortality and readmission.

RESULTS

Seventy-four medical records were included in final analysis. The probability of survival after 90- and 180-days post-surgery were 78% and 57%, respectively. Higher age was the only defined variable that was significantly associated with higher mortality. Ninety-three percent of the patient's medical records described rehabilitation potential, but only 44.6% of the patients were discharged with a rehabilitation plan. Seventy-three percent of the patients were discharged to their home. None had a specialized rehabilitation plan.

CONCLUSION

Almost all patients diagnosed with MSCC have a rehabilitation potential described in their medical records. However, only half of these patients are discharged with a rehabilitation plan indicating an unmet potential for rehabilitation.

Effect of cerebrospinal fluid pressure elevation on spinal cord perfusion during aortic cross-clamping with distal aortic perfusion

 

OBJECTIVES

Distal aortic perfusion (DaP) is a widely accepted protective adjunct facilitating early reinstitution of visceral perfusion during extended thoracic and thoraco-abdominal aortic repair. DaP has also been suggested to secure distal inflow to the paraspinal collateral network via the hypogastric arteries and thereby reduce the risk of spinal cord ischaemia. However, an increase in cerebrospinal fluid (CSF) pressure is frequently observed during thoracoabdominal aortic aneurysm repair. The aim of this study was to evaluate the effects of DaP on regional spinal cord blood flow (SCBF) during descending aortic cross-clamping and iatrogenic elevation of cerebrospinal fluid pressure.

METHODS

Eight juvenile pigs underwent central cannulation for cardiopulmonary bypass according to our established experimental protocol followed by aortic cross-clamping of the descending thoracic and abdominal aorta-mimicking sequential aortic clamping-with the initiation of DaP. Thereafter, CSF pressure elevation was induced by the infusion of blood plasma until baseline CSF pressure was tripled. At each time-point, microspheres of different colours were injected allowing for regional SCBF analysis.

RESULTS

DaP led to a pronounced hyperperfusion of the distal spinal cord [SCBF up to 480%, standard deviation (SD): 313%, compared to baseline]. However, DaP provided no or only limited additional flow to the upper and middle segments of the spinal cord (C1-Th7: 5% of baseline, SD: 5%; Th8-L2: 24%, SD: 39%), which was compensated by proximal flow only at C1-Th7 level. Furthermore, DaP could not counteract an experimental CSF pressure elevation, which led to a further decrease in regional SCBF most pronounced in the mid-thoracic spinal cord segment.

CONCLUSIONS

Protective DaP during thoraco-abdominal aortic repair may be associated with inadequate spinal protection particularly at the mid-thoracic spinal cord level ('watershed area') and result in the adverse effect of a potentially dangerous hyperperfusion of the distal spinal cord segments.

Microfluidic and Microscale Assays to Examine Regenerative Strategies in the Neuro Retina

Bioengineering systems have transformed scientific knowledge of cellular behaviors in the nervous system (NS) and pioneered innovative, regenerative therapies to treat adult neural disorders. Microscale systems with characteristic lengths of single to hundreds of microns have examined the development and specialized behaviors of numerous neuromuscular and neurosensory components of the NS. The visual system is comprised of the eye sensory organ and its connecting pathways to the visual cortex. Significant vision loss arises from dysfunction in the retina, the photosensitive tissue at the eye posterior that achieves phototransduction of light to form images in the brain. Retinal regenerative medicine has embraced microfluidic technologies to manipulate stem-like cells for transplantation therapies, where de/differentiated cells are introduced within adult tissue to replace dysfunctional or damaged neurons. Microfluidic systems coupled with stem cell biology and biomaterials have produced exciting advances to restore vision. The current article reviews contemporary microfluidic technologies and microfluidics-enhanced bioassays, developed to interrogate cellular responses to adult retinal cues. The focus is on applications of microfluidics and microscale assays within mammalian sensory retina, or neuro retina, comprised of five types of retinal neurons (photoreceptors, horizontal, bipolar, amacrine, retinal ganglion) and one neuroglia (Müller), but excludes the non-sensory, retinal pigmented epithelium.

Patterns of spinal cord injury in automobiles versus motorcycles and bicycles

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To examine the patterns and relative rates of occurrence of spinal cord injury (SCI) in automobiles compared to motorcycles and bicycles.

SETTING

Los Angeles County, California.

METHODS

A retrospective chart review of SCI consults at Rancho Los Amigos National Rehabilitation Center in Los Angeles County, California between 2003 and 2013 were selected and screened for a mechanism of injury involving a vehicular accident. Chart review was performed to determine neurological levels and extent of impairment, which were graded according to the International Standards for Neurological Classification of Spinal Cord Injury.

RESULTS

We identified 398 cases of SCI from 2003 to 2013 that fit the inclusion criteria. Overall, the relative percentages of ASIA impairment scale (AIS) A/B/C/D did not differ statistically across automobiles, motorcycles, or bicycles. When stratified by spinal region, motorcycles had a higher percentage of thoracic SCIs compared to automobiles. Automobiles resulted in more cervical SCIs with few injuries in the lumbar region. Bicycle patterns followed automobiles, not motorcycles. Thoracic SCIs were more likely graded motor complete than cervical or lumbar injuries, regardless of the mechanism.

CONCLUSIONS

Automobile, motorcycle, and bicycle related SCIs occur primarily in the cervicothoracic region. SCIs due to motorcycle accidents have a higher predilection for the thoracic region, and there is a statistically higher percentage of motor complete injuries. A higher percentage of cervical SCIs occur as a result of automobile and bicycle accidents. Extrapolations from motor vehicle usage data suggest that the relative rate of occurrence of SCI for motorcycles is higher than for automobiles.

A Narrative Review of Pediatric Nontraumatic Spinal Cord Dysfunction

This article provides a narrative review of seven key issues relevant to pediatric onset of spinal cord damage not due to trauma, or spinal cord dysfunction (SCDys). The first topic discussed is terminology issues. There is no internationally accepted term for spinal cord damage not due to trauma. The implications of this terminology issue and an approach to addressing this are discussed. Second, a brief history of SCDys is presented, focusing on conditions relevant to pediatrics. Third, the classification of SCDys is outlined, based on the International Spinal Cord Injury Data Sets for Non-Traumatic Spinal Cord Injury. Following this, a summary is given of the epidemiology of pediatric SCDys, primarily focused on the incidence, prevalence, and etiology, with a comparison to traumatic spinal cord injury. Next, important clinical rehabilitation principles unique to children with SCDys are highlighted. Then important prevention opportunities for SCDys in children are discussed. Finally, trends, challenges, and opportunities regarding research in SCDys are mentioned.

The Emerging Role of lncRNAs in Spinal Cord Injury

Spinal cord injury (SCI) is a highly debilitating disease and is increasingly being recognized as an important global health priority. However, the mechanisms underlying SCI have not yet been fully elucidated, and effective therapies for SCI are lacking. Long noncoding RNAs (lncRNAs), which form a major class of noncoding RNAs, have emerged as novel targets for regulating several physiological functions and mediating numerous neurological diseases. Notably, gene expression profile analyses have demonstrated aberrant changes in lncRNA expression in rats or mice after traumatic or nontraumatic SCI. LncRNAs have been shown to be associated with multiple pathophysiological processes following SCI including inflammation, neural apoptosis, and oxidative stress. They also play a crucial role in the complications associated with SCI, such as neuropathic pain. At the same time, some lncRNAs have been found to be therapeutic targets for neural stem cell transplantation and hydrogen sulfide treatment aimed at alleviating SCI. Therefore, lncRNAs could be promising biomarkers for the diagnosis, treatment, and prognosis of SCI. However, further researches are required to clarify the therapeutic effects of lncRNAs on SCI and the mechanisms underlying these effects. In this study, we reviewed the current progress of the studies on the involvement of lncRNAs in SCI, with the aim of drawing attention towards their roles in this debilitating condition.

Factors affecting long-term mortality rate after diagnosis of syringomyelia in disabled spinal cord injury patients: a population-based study

STUDY DESIGN

A retrospective, population-based study.

OBJECTIVES

To identify factors affecting long-term mortality and medical resources use in disabled spinal cord injury (SCI) patients after syringomyelia diagnosis.

SETTING

A National Health Insurance Research Database containing 10,374 patients with SCI.

METHODS

Data recorded between 1997 and 2012 for 376 disabled SCI patients with syringomyelia and 376 characteristics-matched disabled SCI patients without syringomyelia were collected. The index date was the date of syringomyelia diagnosis. Cox proportional hazards regression model was used to investigate the factors affecting 10-year mortality in these patients. Medical resources use was compared for 1 year before and after index date.

RESULTS

The survival rate at 10-year follow-up after syringomyelia diagnosis was estimated at 68.6%. The 10-year survival rate was comparable between the two groups. Age ≥ 60 (adjusted hazard ratios (aHR) 4.21, 95% confidence interval (CI) 2.97 to 5.96) and < 30 years (aHR 0.25, 95% CI 0.10 to 0.62), spinal cord or spinal canal operations within 1 year after the index date (aHR 1.84, 95% CI 1.19 to 2.84), history of pneumonia (aHR 1.55, 95% CI 1.07 to 2.26), and history of coronary heart disease (CHD) (aHR 1.85, 95% CI 1.18 to 2.89) were significantly associated with long-term mortality. Outpatient prescription costs were higher during 1 year after the diagnosis than those of 1 year before the diagnosis.

CONCLUSION

Age, spinal operations, history of pneumonia, and history of CHD are associated with 10-year mortality in disabled SCI patients with syringomyelia.

Psychological morbidity and chronic disease among adults with nontraumatic spinal cord injuries: a cohort study of privately insured beneficiaries

BACKGROUND

Individuals living with a spinal cord injury (SCI) are at heightened risk for a number of chronic health conditions such as secondary comorbidities that may develop or be influenced by the injury, the presence of impairment, and/or the process of aging. However, very little is known about the development of secondary comorbidities among individuals living with nontraumatic SCIs (NTSCIs).

PURPOSE

The objective of this study was to compare the prevalence of psychological morbidities and chronic diseases among adults with and without NTSCIs.

DESIGN

Cross-sectional cohort from a nationwide insurance claims database.

METHODS

Privately insured beneficiaries were included if they had an ICD-9-CM diagnostic code for a NTSCI and accompanying diagnosis of paraplegia, tetraplegia, quadriplegia, or unspecified paralysis (n=10,006). Adults without SCIs were also included (n=779,545). Prevalence estimates of common psychological morbidities, chronic diseases, and multimorbidity (≥2 conditions) were compared.

RESULTS

Adults with NTSCIs had a higher prevalence of adjustment reaction (11.4% vs 5.1%), anxiety disorders (23.7% vs 14.5%), depressive disorders (31.6% vs 9.6%), drug dependence (3.4% vs 0.8%), episodic mood disorders (15.9% vs 5.4%), central pain syndrome (1% vs 0%), psychogenic pain (1.9% vs 0.2%), dementia (5.2% vs 1.5%), and psychological multimorbidity (29.3% vs 11.6%), as compared to adults without SCIs. The adjusted odds of psychological multimorbidity were 1.86 (95% confidence interval: 1.76-2.00). Adults with NTSCIs also had a significantly higher prevalence of all chronic diseases and chronic disease multimorbidity (73.5% vs 18%), except HIV/AIDS. After propensity matching for age, education, race, sex, and the chronic diseases (n=7,419 matched pairs), there was still a higher prevalence of adjustment reaction (9.2% vs 5.4%), depressive symptoms (23.5% vs 16.0%), central pain syndrome (1% vs 0%), psychogenic pain (1.5% vs 0.3%), and psychological multimorbidity (20.2% vs 17.4%) among adults with NTSCIs.

CONCLUSIONS

Adults with NTSCIs have a significantly increased prevalence of psychological morbidities, chronic disease, and multimorbidity, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of disease onset/progression in this higher risk population.

Sex-related discrepancies in the epidemiology, injury characteristics and outcomes after acute spine trauma: A retrospective cohort study

Context/Objective: The potential effects of sex on injury severity and outcomes after acute spine trauma (AST) have been reported in pre-clinical and clinical studies, even though the data are conflicting. This study compared females and males regarding the epidemiology, injury characteristics, and clinical outcomes of AST. Design: Retrospective cohort study. Setting: Acute spine care quaternary center. Participants: All consecutive cases of AST admitted from January/1996 to December/2007 were included. Interventions: None. Outcome Measures: The potential effects of sex on the epidemiology, injury characteristics, and clinical outcomes of AST were studied. Results: There were 504 individuals with AST (161 females, 343 males; mean age of 49.44 ± 0.92 years). Sex was not associated with age or pre-existing co-morbidities as assessed using the Charlson Co-morbidity Index, however, females had a greater number of International Classifications of Diseases (ICD) codes at admission and higher Cumulative Illness Rating Scale (CIRS) than males. Over the 12-year period, the male-to-female ratio has not significantly changed. Although there were significant sex-related discrepancies regarding injury etiology, level and severity of AST, males and females had similar lengths of stay in the acute spine center, in-hospital survival post-AST, and need for mechanical ventilation and tracheostomy. Conclusion: This study suggests that females with AST present with a greater number of pre-existing co-morbidities, a higher frequency of thoraco-lumbar trauma, less severe neurological impairment and a greater proportion of MVA-related injuries. However, females and males have a similar length of stay in the acute spine center, and comparable in-hospital survival, need for mechanical ventilation, and tracheostomy after AST.

Heterogeneity and Its Impact on Rehabilitation Outcomes and Interventions for Community Reintegration in People With Spinal Cord Injuries: An Integrative Review

Background: Various injury characteristics such as cause, level, severity, and time since injury divide individuals with spinal cord injury (SCI) into many subgroups. The heterogeneity among individuals' injuries and personal characteristics has significant implications for SCI rehabilitation practice, specifically directed toward community reintegration, which is a key goal of rehabilitation interventions for people with disabilities. Purpose: This study aims to summarize the evidence on attributes that make the SCI population heterogeneous, the impact of these attributes on community reintegration, and the implications of heterogeneity for rehabilitation interventions directed toward optimizing community reintegration. Methods: We used an integrative review approach to conduct this study. MEDLINE, PubMed, CINAHL, EMBASE, Google Scholar, and PsycINFO were searched from inception until May 2017. Out of 670 articles retrieved, 49 provided evidence on the impact of various attributes that make SCI heterogeneous on rehabilitation outcomes related to community reintegration. Results: An array of injury-related, personal, social, and environmental factors are associated with various rehabilitation outcomes that affect community reintegration of people with SCI. There is level 1 evidence that social support, self-efficacy, and self-esteem facilitate community reintegration among people with SCI while there is level 5 evidence that presence of psychological or medical complications decreases it. There is lack of clarity on the impact of injury-related factors on community reintegration. Conclusion: This integrative review found that social support and individuals' self-efficacy can improve community reintegration of people with SCI. However, evidence regarding the impact of injury characteristics on community reintegration is still underdeveloped. Approaches directed at community reintegration should involve components of psychosocial, physical, and vocational rehabilitation while considering personal and societal aspects of an individual's life.

Important Clinical Rehabilitation Principles Unique to People with Non-traumatic Spinal Cord Dysfunction

Background: Non-traumatic spinal cord dysfunction (SCDys) is caused by a large range of heterogeneous etiologies. Although most aspects of rehabilitation for traumatic spinal cord injury and SCDys are the same, people with SCDys have some unique rehabilitation issues. Purpose: This article presents an overview of important clinical rehabilitation principles unique to SCDys. Methods: Electronic literature search conducted (January 2017) using MEDLINE and Embase (1990-2016) databases for publications regarding SCDys. The focus of the literature search was on identifying publications that present suggestions regarding the clinical rehabilitation of SCDys. Results: The electronic search of MEDLINE and Embase identified no relevant publications, and the publications included were from the authors' libraries. A number of important clinical rehabilitation principles unique to people with SCDys were identified, including classification issues, general rehabilitation issues, etiology-specific issues, and a role for the rehabilitation physician as a diagnostic clinician. The classification issues were regarding the etiology of SCDys and the International Standards for Neurological Classification of Spinal Cord Injury. The general rehabilitation issues were predicting survival, improvement, and rehabilitation outcomes; admission to spinal rehabilitation units, including selection decision issues; participation in rehabilitation; and secondary health conditions. The etiology-specific issues were for SCDys due to spinal cord degeneration, tumors, and infections. Conclusions: Although there are special considerations regarding the rehabilitation of people with SCDys, such as the potential for progression of the underlying condition, functional improvement is typically significant with adequate planning of rehabilitation programs and special attention regarding the clinical condition of patients with SCDys.