Survival after spinal cord injury: a systematic review

Value of the Brain and Spinal Injury Center Score in Assessment and Prognosis of Acute Traumatic Spinal Cord Injury

The objective was to assess the severity of neurological injury in acute traumatic spinal cord injury (ATSCI) using the BASIC (Brain and Spinal Injury Center) score, to correlate with the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at admission and at 3 months postinjury in patients managed for ATSCI at National Hospital, Abuja, and thereby validate the novel BASIC score. This was a prospective longitudinal hospital-based study involving consecutive patients diagnosed with ATSCI and managed at the National Hospital, Abuja. Sixty-five participants met the inclusion criteria. Each patient was resuscitated along the Advanced Trauma Life Support protocol, followed by history, neurological examination according to the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI), and AIS grades that were recorded. Magnetic resonance imaging scan of the injured spinal cord was done, and BASIC scores were assigned. Further management was as per the standard. Three months after injury, neurological examination was again carried out based on ISNCSCI and AIS grades assigned. Data were collected, analyzed, and correlated using Excel and SPSS version 23. Means, medians, correlation coefficients, and Fisher's exact t-tests were determined. p-Value <0.05 was considered statistically significant. Results show mean age was 39.1 ± 12.3 years. The majority (81.5%) were males, whereas 18.5% were females. The majority (67.7%) were skilled professionals, 13.8% were unskilled, and 18.5% were students. Most injuries (90.8%) were due to road traffic accidents, whereas 9.2% were due to falls. Majority (72.3%) of the patients had complete SCI (AIS grade A), whereas AIS grade E accounted for the least number (3.1%). Cervical spine injury affected 92.3% of patients, whereas 7.7% had thoracic spine injury. Most patients had BASIC 4 pattern on MRI (44.6%), whereas BASIC 1 pattern was the fewest (3.1%). Surgery was not done for 58.5% of patients, whereas 41.5% had surgical decompression and spine fusion. At 3 months postinjury, 15.4% of patients had AIS grade improvement, whereas 84.6% maintained their AIS grade. The largest AIS grade improvement was from grade B to C (6.2%), which was statistically significant (p = 0.04). BASIC score correlated moderately with admission AIS grade (p = 0.532). BASIC score also correlated moderately with AIS grade at 3 months postinjury (p = 0.546). BASIC score 4 was best at predicting poor outcome in ATSCI. In conclusion, BASIC score has a moderate correlation with AIS grade in ATSCI and can predict poor outcomes in ATSCI. BASIC score of 4 has the best discriminant value in prognosticating and represents severe SCI.

AMPA receptors play an important role in the biological consequences of spinal cord injury: Implications for AMPA receptor modulators for therapeutic benefit

Spinal cord injury (SCI) afflicts millions of individuals globally. There are few therapies available to patients. Ascending and descending excitatory glutamatergic neural circuits in the central nervous system are disrupted by SCI, making α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (AMPARs) a potential therapeutic drug target. Emerging research in preclinical models highlights the involvement of AMPARs in vital processes following SCI including breathing, pain, inflammation, bladder control, and motor function. However, there are no clinical trial data reported in this patient population to date. No work on the role of AMPA receptors in sexual dysfunction after SCI has been disclosed. Compounds with selective antagonist and potentiating effects on AMPA receptors have benefit in animal models of SCI, with antagonists generally showing protective effects early after injury and potentiators (ampakines) producing improved breathing and bladder function. The role of AMPARs in pathophysiology and recovery after SCI depends upon the time post injury, and the timing of AMPAR augmentation or antagonism. The roles of inflammation, synaptic plasticity, sensitization, neurotrophic factors, and neuroprotection are considered in this context. The data summarized and discussed in this paper document proof of principle and strongly encourage additional studies on AMPARs as novel gateways to therapeutic benefit for patients suffering from SCI. The availability of both AMPAR antagonists such as perampanel and AMPAR allosteric modulators (i.e., ampakines) such as CX1739, that have been safely administered to humans, provides an expedited means of clinical inquiry for possible therapeutic advances.

Integrating Patient Preferences with Guideline-Based Care in Neurogenic Lower Urinary Tract Dysfunction After Spinal Cord Injury

Individual and social factors are important for clinical decision-making in patients with neurogenic bladder secondary to spinal cord injury (SCI). These factors include the availability of caregivers, social infrastructure, and personal preferences, which all can drive bladder management decisions. These elements can be overlooked in clinical decision-making; therefore, there is a need to elicit and prioritize patient preferences and values into neurogenic bladder care to facilitate personalized bladder management choices. For the purposes of this article, we review the role of guideline-based care and shared decision-making in the SCI population with neurogenic lower urinary tract dysfunction.

The effect of craniocervical flexion and neck endurance exercises plus pulmonary rehabilitation on pulmonary function in spinal cord injury: a pilot single-blinded randomised controlled trial

STUDY DESIGN

Randomised controlled trial with computerised allocation, assessor blinding and intention-to-treat analysis.

OBJECTIVE

This study wanted to prove that cervicocranial flexion exercise (CCFE) and superficial neck flexor endurance training combined with common pulmonary rehabilitation is feasible for improving spinal cord injury people's pulmonary function.

SETTING

Taoyuan General Hospital, Ministry of Health and Welfare: Department of Physiotherapy, Taiwan.

METHOD

Thirteen individuals who had sustained spinal cord injury for less than a year were recruited and randomised assigned into two groups. The experimental group was assigned CCFEs and neck flexor endurance training plus normal cardiopulmonary rehabilitation. The control group was assigned general neck stretching exercises plus cardiopulmonary rehabilitation. Lung function parameters such as forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, peak expiratory flow rate (PEFR), inspiratory capacity (IC), dyspnoea, pain, and neck stiffness were recorded once a week as short-term outcome measure.

RESULT

The experimental group showed significant time effects for FVC (pre-therapy: 80.4 ± 21.4, post-therapy: 86.9 ± 16.9, p = 0.021, 95% CI: 0.00-0.26) and PEFR (pre-therapy: 67.0 ± 33.4; post-therapy: 78.4 ± 26.9, p = 0.042, 95% CI: 0.00-0.22) after the therapy course. Furthermore, the experimental group showed significant time effects for BDI (experimental group: 6.3 ± 3.0; control group: 10.8 ± 1.6, p = 0.012, 95% CI: 0.00-0.21).

CONCLUSION

The exercise regime for the experimental group could efficiently increase lung function due to the following three reasons: first, respiratory accessory muscle endurance increases through training. Second, posture becomes less kyphosis resulting increasing lung volume. Third, the ratio between superficial and deep neck flexor is more synchronised.

IRB TRIAL REGISTRATION

TYGH108045.

CLINICAL TRIAL REGISTRATION

NCT04500223.

Ultra-early (≤8 hours) surgery for thoracolumbar spinal cord injuries: A systematic review and meta-analysis

Background

The impact of the timing of surgery on neurological recovery in thoracolumbar spinal cord injuries (tSCI) is still a subject of discussion. Accumulating evidence is supporting early decompression (<24 hours) following tSCI. However, the potential advantages of earlier decompression remain uncertain. This systematic review and meta-analysis summarize and analyze the current evidence on the effectiveness of ultra-early decompression surgery on clinical outcomes following tSCI.

Methods

A search was conducted in the electronic databases Medline, Embase, Scopus, and Web of Science from their inception until May 2022 for human studies. Groups were stratified into ultra-early (surgery within 8 hours of injury) vs control group operated >8 hours of injury. The authors included the study data from their institutional case series of thoracolumbar spinal cord injury from 2015 to 2018. An arm-based meta-analysis was performed on all studies using the R Studio. For studies that qualified, a contrast-based meta-analysis was also performed with a standardized mean difference (SMD). Outcomes were reported as effect size, treatment effect, and effect difference, all with 95% confidence intervals (CI).

Results

Of the 133 patients, 74.4% patients were male. 76 (57.1%) underwent decompression ≤8 hours, while 57 (42.9%) underwent decompression >8 hours from injury. Quantitative analysis using the SMD model showed a significant difference in mean AIS improvement in the ultra-early group (Effect size 1.15 [0.62-1.67], p<.0001). On arm-based meta-analysis, a statistically significant treatment effect was found for the ultra-early arm (1.25 [0.91-1.67]), while > 8-hour arm did not show significance (0.30 [-0.08-0.71]). There was a statistically significant effect difference between the two arms (0.96 [0.49-1.48]).

Conclusions

This study observed a significant improvement in the mean AIS score in patients undergoing decompression within 8 hours of tSCI. Given the scant literature regarding ultra-early decompression of tSCI, this study solidifies the need to further explore the role of early interventions for tSCIs to improve patient outcomes.

Global, regional, and national burden of spinal cord injury, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Spinal cord injury (SCI) is a major cause of health loss due to premature mortality and long-term disability. We aimed to report on the global, regional, and national incidence, prevalence, and years of life lived with disability (YLDs) for SCI from 1990 to 2019, using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

Using GBD 2019 data pooled in DisMod-MR 2.1, a Bayesian meta-regression tool, we systematically derived numbers and age-standardised rate changes with 95% uncertainty intervals (95% UIs) for the incidence, prevalence, and YLDs for SCI from 1990 to 2019 for the whole world, 21 GBD regions, and 204 countries and territories. We report trends based on age, sex, year, cause of injury, and level of injury.

FINDINGS

Globally, 20·6 million (95% UI 18·9 to 23·6) individuals were living with SCI in 2019. The incidence of SCI was 0·9 million (0·7 to 1·2) cases with an estimated 6·2 million (4·5 to 8·2) YLDs. SCI rates increased substantially from 1990 to 2019 for global prevalence (81·5%, 74·2 to 87·1), incidence (52·7%, 30·3 to 69·8), and YLDs (65·4%, 56·3 to 76·0). However, global age-standardised rates per 100 000 population showed small changes in prevalence (5·8%, 2·6 to 9·5), incidence (-6·1%, -17·2 to 1·5), and YLDs (-1·5%, -5·5 to 3·2). Data for 2019 shows that the incidence of SCI increases sharply until age 15-19 years, where it remains reasonably constant until 85 years of age and older. By contrast, prevalence and YLDs showed similar patterns to each other, with one peak at around age 45-54 years. The incidence, prevalence, and YLDs of SCI have consistently been higher in men than in women globally, with a slight and steady increase for both men and women from 1990 to 2019. Between 1990 and 2019, SCI at neck level was more common than SCI below neck level in terms of incidence (492 thousand [354 to 675] vs 417 thousand [290 to 585]), prevalence (10·8 million [9·5 to 13·9] vs 9·7 million [9·2 to 10·4]), and YLDs (4·2 million [3·0 to 5·8] vs 1·9 million [1·3 to 2·5]). Falls (477 thousand [327 to 683] cases) and road injuries (230 thousand [122 to 389] cases) were the two leading causes of SCI globally in 2019.

INTERPRETATION

Although age-standardised rates of incidence, prevalence, and YLDs for SCI changed only slightly, absolute counts increased substantially from 1990 to 2019. Geographical heterogeneity in demographic, spatial, and temporal patterns of SCI, at both the national and regional levels, should be considered by policy makers aiming to reduce the burden of SCI.

FUNDING

Bill & Melinda Gates Foundation.

Research priorities to enhance life for people with spinal cord injury: a Swedish priority setting partnership

STUDY DESIGN

Mixed-method consensus development project.

OBJECTIVE

To identify the top ten research priorities for spinal cord injury (SCI).

SETTING

Nationwide in Sweden in 2021-22.

METHODS

The PSP process proposed by the James Lind Alliance was used. It comprises two main phases: question identification and priority selection. People living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI were included.

RESULTS

In the first phase, 242 respondents provided 431 inputs addressing potentially unanswered questions. Of these, 128 were beyond the scope of this study. The remaining 303 were merged to formulate 57 questions. The literature review found one question answered, so 56 questions proceeded to the prioritisation. In the second phase, the interim prioritisation survey, 276 respondents ranked the 56 questions. The top 24 questions then proceeded to the final prioritisation workshop, at which 23 participants agreed on the top ten priorities.

CONCLUSIONS

This paper reveals issues that people living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI find difficult to get answered. The top-priority questions for people living with SCI in Sweden concern specialist SCI care and rehabilitation, followed by a number of questions addressing physical health. Other topics, from the 56 key questions include Mental health, Ageing with SCI, Community support and personal care assistance, and Body functions. This result can guide researchers to design appropriate studies relevant to people with SCI.

SPONSORSHIP

The project was funded by the Gothenburg Competence Centre for Spinal Cord Injury and the Swedish Association for Survivors of Accident and Injury (RTP).

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

Functional and structural impairments of the pulmonary system in middle-aged people with cervical and upper thoracic spinal cord injuries

OBJECTIVES

To describe functional and structural impairments of the pulmonary system in middle-aged people with cervical and upper thoracic spinal cord injuries (SCI), and compare findings to the general population. To determine if the neurological level of injury (NLI) is related to functional and structural impairments, and if age is related to structural impairments.

DESIGN

Cross-sectional study with matched controls. Data from the Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment (SPICA). Matched control data were obtained from the Swedish CArdioPulmonary bioImage Study (SCAPIS).

SETTING

Outpatient SCI unit in southern Sweden.

PARTICIPANTS

25 people (20% women, mean age 58 years, mean time since injury 28 years, NLIs C2-T6, American Spinal Injury Association Impairment Scale A-C).

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Lung function was assessed with spirometry, diffusing capacity and impulse oscillometry. Structural assessments were performed with computed tomography.

RESULTS

Pulmonary function was generally worse compared to the controls. Structural impairments were common (75% of the participants and 65% of the controls; P = 0.36, NS). NLI was significantly related to some of the functional and structural impairments.

CONCLUSIONS

Middle-aged people with long-term cervical and upper thoracic SCI can have substantial pulmonary functional impairments, whereas structural impairments do not differ considerably from the general population. Further larger and longitudinal studies should focus on the clinical impact of these impairments over time.

In-hospital mortality rate in subaxial cervical spinal cord injury patients: a systematic review and meta-analysis

PURPOSE

To determine existing trends concerning in-hospital mortality in patients with traumatic subaxial cervical spinal cord injury (SCI) over the last four decades.

METHODS

We searched MEDLINE and EMBASE to assess the role of the following factors on in-hospital mortality over the last four decades: neurological deficit, age, surgical decompression, use of computed tomography (CT) and magnetic resonance imaging (MRI), use of methylprednisolone in the acute post-injury period, and study location (developing versus developed countries).

RESULTS

Among 3333 papers after deduplication, 21 studies met the eligibility criteria. The mortality rate was 17.88% [95% confidence interval (CI): 12.9-22.87%]. No significant trend in mortality rate was observed over the 42-year period (meta-regression coefficient = 0.317; p = 0.372). Subgroup analysis revealed no significant association between acute subaxial cervical SCI-related mortality when stratified by use of surgery, administration of methylprednisolone, use of MRI and CT imaging, study design (prospective versus retrospective study), and study location. The mortality rate was significantly higher in complete SCI (20.66%, p = 0.002) and American Spinal Injury Association impairment scale (AIS) A (20.57%) and B (9.28%) (p = 0.028).

CONCLUSION

A very low level of evidence showed that in-hospital mortality in patients with traumatic subaxial cervical SCI did not decrease over the last four decades despite diagnostic and therapeutic advancements. The overall acute mortality rate following subaxial cervical SCI is 17.88%. We recommend reporting a stratified mortality rate according to key factors such as treatment paradigms, age, and severity of injury in future studies.

Inspiratory muscle training on quality of life in individuals with spinal cord injury: A systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

The objective was to summarize the effectiveness of Inspiratory Muscle Training (IMT) on the quality of life in individuals with Spinal Cord Injury (SCI).

METHODS

An online systematic literature search was conducted in the following databases: PubMed/MEDLINE, PubMed CENTRAL, EMBASE, ISI Web of Science, SciELO, CINAHL/SPORTDiscus, and PsycINFO. Randomized and non-randomized clinical studies investigating the effectiveness of IMT in quality of life were included in the present study. The results used the mean difference and 95% confidence interval for maximal inspiratory pressure (MIP), forced expiratory volume in 1 s (FEV1), maximal expiratory pressure (MEP), and the standardized mean differences for the quality of life and maximum ventilation volume.

RESULTS

The search found 232 papers, and after the screening, four studies met the inclusion criteria and were included in the meta-analytical procedures (n = 150 participants). No changes were demonstrated in the quality of life domains (general health, physical function, mental health, vitality, social function, emotional problem, and pain) after IMT. The IMT provided a considerable effect over the MIP but not on FEV1 and MEP. Conversely, it was not able to provide changes in any of the quality of life domains. None of the included studies evaluated the IMT effects on the expiratory muscle maximal expiratory pressure.

CONCLUSION

Evidence from studies shows that inspiratory muscle training improves the MIP; however, this effect does not seem to translate to any change in the quality of life or respiratory function outcomes in individuals with SCI.

A mechanistic overview of spinal cord injury, oxidative DNA damage repair and neuroprotective therapies

Despite substantial development in medical treatment strategies scientists are struggling to find a cure against spinal cord injury (SCI) which causes long term disability and paralysis. The prime rationale behind it is the enlargement of primary lesion due to an initial trauma to the spinal cord which spreads to the neighbouring spinal tissues It begins from the time of traumatic event happened and extends to hours and even days. It further causes series of biological and functional alterations such as inflammation, excitotoxicity and ischemia, and promotes secondary lesion to the cord which worsens the life of individuals affected by SCI. Oxidative DNA damage is a stern consequence of oxidative stress linked with secondary injury causes oxidative base alterations and strand breaks, which provokes cell death in neurons. It is implausible to stop primary damage however it is credible to halt the secondary lesion and improve the quality of the patient's life to some extent. Therefore it is crucial to understand the hidden perspectives of cell and molecular biology affecting the pathophysiology of SCI. Thus the focus of the review is to connect the missing links and shed light on the oxidative DNA damages and the functional repair mechanisms, as a consequence of the injury in neurons. The review will also probe the significance of neuroprotective strategies in the present scenario. HIGHLIGHTSSpinal cord injury, a pernicious condition, causes excitotoxicity and ischemia, ultimately leading to cell death.Oxidative DNA damage is a consequence of oxidative stress linked with secondary injury, provoking cell death in neurons.Base excision repair (BER) is one of the major repair pathways that plays a crucial role in repairing oxidative DNA damages.Neuroprotective therapies curbing SCI and boosting BER include the usage of pharmacological drugs and other approaches.

Feasibility study of high-intensity interval training to reduce cardiometabolic disease risks in individuals with acute spinal cord injury

INTRODUCTION

Individuals ageing with spinal cord injury (SCI) experience an accelerated trajectory of diseases and disorders, such as cardiovascular disease and diabetes, that resemble those experienced with ageing alone. Currently, an evidence-based approach toward managing this problem does not exist and therefore the purpose of this study is to determine the feasibility of conducting a high-intensity exercise intervention in individuals with acute (<6 months postinjury) SCI to improve cardiometabolic health.

METHODS AND ANALYSIS

We will conduct a single-centre, two parallel-arm, randomised feasibility study of a high-intensity interval training (HIIT) intervention in individuals with acute SCI. We will enrol 40 individuals (20 intervention, 20 control) with acute SCI attending inpatient rehabilitation at Salisbury District Hospital. Participants will be randomly allocated to the intervention group (HIIT) or control group for 18 weeks. Both groups will participate in standard care throughout the duration of the study. The HIIT group only will also perform supervised HIIT exercise on an arm cycle ergometer three times per week. Over the course of the intervention, most participants will be discharged from the hospital, and at this time, an arm cycle ergometer will be installed in their home and the intervention will transition into outpatient care. We will assess cardiorespiratory fitness, glycaemic control, lipid profile and body habitus as well as qualitative assessments of acceptability at weeks 0, 9 and 18 with the primary outcome being the feasibility of a full Randomised Controlled Trial (RCT).

ETHICS AND DISSEMINATION

This study will inform a longer-term, definitive, multicentre RCT to establish the impact of this exercise intervention in maintaining the cardiometabolic health of patients during the acute phase following SCI. Results will be disseminated in different formats including peer-reviewed journal articles, conference presentations and internet media, to a wide audience including clinicians, researchers and individuals with SCI.

TRIAL REGISTRATION NUMBER

ISRCTN57514022.

Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: an international multi-professional Delphi consensus

PURPOSE

International multi-professional expert consensus was sought to develop best practice recommendations for clinical management of patients following cervical spinal cord injury with oropharyngeal dysphagia and associated complications. Additionally, risk factors for dysphagia were identified to support the development of a screening tool.

MATERIALS AND METHODS

A two-round Delphi study was undertaken with a 27-member panel of expert professionals in cervical spinal cord injury and complex dysphagia. They rated 85 statements across seven topic areas in round one, using a five-point Likert scale with a consensus set at 70%. Statements not achieving consensus were revised for the second round. Comparative group and individual feedback were provided at the end of each round.

RESULTS

Consensus was achieved for 50 (59%) statements in round one and a further 12 (48%) statements in round two. Recommendations for best practice were agreed for management of swallowing, respiratory function, communication, nutrition and oral care. Twelve risk factors for dysphagia were identified for components of a screening tool.

CONCLUSIONS

Best practice recommendations support wider clinical management to prevent complications and direct specialist care. Screening for risk factors allows early dysphagia identification with the potential to improve clinical outcomes. Further evaluation of the impact of these recommendations is needed.Implications for RehabilitationDysphagia is an added complication following cervical spinal cord injury (cSCI) affecting morbidity, mortality and quality of life.Early identification of dysphagia risk allows focused interventions that reduce associated nutritional and respiratory impairments.Best practice recommendations based on expert consensus provide a baseline of appropriate interventions, in the absence of empirical evidence.A multi-professional approach to rehabilitation encourages a consistent and coordinated approach to care across acute and rehabilitation settings.

Intermittent Hypoxia Differentially Regulates Adenosine Receptors in Phrenic Motor Neurons with Spinal Cord Injury

Cervical spinal cord injury (cSCI) impairs neural drive to the respiratory muscles, causing life- threatening complications such as respiratory insufficiency and diminished airway protection. Repetitive "low dose" acute intermittent hypoxia (AIH) is a promising strategy to restore motor function in people with chronic SCI. Conversely, "high dose" chronic intermittent hypoxia (CIH; ∼8 h/night), such as experienced during sleep apnea, causes pathology. Sleep apnea, spinal ischemia, hypoxia and neuroinflammation associated with cSCI increase extracellular adenosine concentrations and activate spinal adenosine receptors which in turn constrains the functional benefits of therapeutic AIH. Adenosine 1 and 2A receptors (A₁, A_2A) compete to determine net cAMP signaling and likely the tAIH efficacy with chronic cSCI. Since cSCI and intermittent hypoxia may regulate adenosine receptor expression in phrenic motor neurons, we tested the hypotheses that: 1) daily AIH (28 days) downregulates A_2A and upregulates A₁ receptor expression; 2) CIH (28 days) upregulates A_2A and downregulates A₁ receptor expression; and 3) cSCI alters the impact of CIH on adenosine receptor expression. Daily AIH had no effect on either adenosine receptor in intact or injured rats. However, CIH exerted complex effects depending on injury status. Whereas CIH increased A₁ receptor expression in intact (not injured) rats, it increased A_2A receptor expression in spinally injured (not intact) rats. The differential impact of CIH reinforces the concept that the injured spinal cord behaves in distinct ways from intact spinal cords, and that these differences should be considered in the design of experiments and/or new treatments for chronic cSCI.

A functional outcome prediction model of acute traumatic spinal cord injury based on extreme gradient boost

OBJECTIVE

We aimed to construct a nonlinear regression model through Extreme Gradient Boost (XGBoost) to predict functional outcome 1 year after surgical decompression for patients with acute spinal cord injury (SCI) and explored the importance of predictors in predicting the functional outcome.

METHODS

We prospectively enrolled 249 patients with acute SCI from 5 primary orthopedic centers from June 1, 2016, to June 1, 2020. We identified a total of 6 predictors with three aspects: (1) clinical characteristics, including age, American Spinal Injury Association (ASIA) Impairment Scale (AIS) at admission, level of injury and baseline ASIA motor score (AMS); (2) MR imaging, mainly including Brain and Spinal Injury Center (BASIC) score; (3) surgical timing, specifically comparing whether surgical decompression was received within 24 h or not. We assessed the SCIM score at 1 year after the operation as the functional outcome index. XGBoost was used to build a nonlinear regression prediction model through the method of boosting integrated learning.

RESULTS

We successfully constructed a nonlinear regression prediction model through XGBoost and verified the credibility. There is no significant difference between actual SCIM and nonlinear prediction model (t = 0.86, P = 0.394; Mean ± SD: 3.31 ± 2.8). The nonlinear model is superior to the traditional linear model (t = 6.57, P < 0.001). AMS and age played the most important roles in constructing predictive models. There is an obvious correlation between AIS, AMS and BASIC score.

CONCLUSION

We verified the feasibility of using XGBoost to construct a nonlinear regression prediction model for the functional outcome of patients with acute SCI, and proved that the predictive performance of the nonlinear model is better than the traditional linear regression prediction model. Age and baseline AMS play the most important role in predicting the functional outcome. We also found a significant correlation between AIS at admission, baseline AMS and BASIC score.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03103516.

Temporal changes in demographic and injury characteristics of traumatic spinal cord injuries in Nordic countries - a systematic review with meta-analysis

STUDY DESIGN

Systematic review with meta-analysis.

OBJECTIVES

To explore temporal changes in incidence rates, demographic and injury characteristics of incident traumatic spinal cord injury (TSCI) in Nordic countries.

METHODS

Peer-reviewed publications and periodic reports about epidemiology of TSCI in the Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) are identified, reviewed and included in the meta-analysis. Data are stratified into 20-year intervals to allow for chronological comparisons. Pooled estimates are derived using random effects meta-analysis.

RESULTS

Twenty-three data sources are included presenting a total of 5416 cases. The pooled incidence rate for 2001-2020 is 15.4 cases/million/year compared to 17.6 and 18.3 cases/million/year during the two previous 20-year intervals. The proportion of cases with TSCI in the 15-29 age-group decreases from 50% (1961-1980) to 20% (2001-2020), while it increases from 9% to 35% in 60+ age-group. Transportation-related injuries decrease from 44% (1961-1980) to 27% (2001-2020). Conversely, fall-related injuries increase from 32% (1961-1980) to 46% (2001-2020). The proportion of individuals with incomplete tetraplegia increases from 31% (1961-1980) to 43% (2001-2020), while complete paraplegia decreases from 25% to 16%.

CONCLUSION

The characteristics of TSCI in the Nordic countries have changed drastically over the last six decades, in line with clinical experiences, and limited research evidence from other countries. These changes indicate the need for adapting research focus, prevention strategies, design and provision of care, rehabilitation and community services towards older individuals, fall-related injuries, and incomplete injuries in Nordic countries and other settings internationally where such changes occur.

Isolated and anxious: A qualitative exploration of the impact of the COVID-19 pandemic on individuals living with spinal cord injury in the UK

OBJECTIVE

People living with spinal cord injury (SCI) are often immunocompromised, and at increased risk of respiratory infection. Given the restrictions in response to the COVID-19 pandemic, those with SCI may be at increased risk of health deterioration, though how this is experienced is poorly understood. This study explored the experiences of people living with SCI during the COVID-19 pandemic.

DESIGN

Participants completed an online survey consisting of demographic questions, and open-ended qualitative questions pertaining to their experiences during the pandemic. Thematic analysis was utilized for the analytical approach.

SETTING

Community-based sample in the UK.

PARTICIPANTS

Participants were recruited via social media outlets of UK-based SCI-specific support charities, and snowball sampling (N = 42, F = 34, M = 8).

RESULTS

Key themes included: (1) lost access to health services and support, capturing concerns surrounding barriers to healthcare and rehabilitation, which intensified secondary consequences of SCI such as spasm and pain; (2) health anxiety, which was perpetuated by perceived heightened vulnerabilities to respiratory complications; (3) social isolation, with significantly reduced social contact, even with care providers, compounding health experiences.

CONCLUSION

People living with SCI during the COVID-19 pandemic experienced a variety of personal physical, psychological, and social challenges, each of which could disrupt daily functioning and quality of life. Increased utilization of telehealth is recommended to support continued engagement in rehabilitation, and foster connection and community amongst others with SCI and health professionals.

Applicability of the AO Spine Patient Reported Outcome Spine Trauma (PROST) in people with motor-complete spinal cord injury: a cognitive interview study

STUDY DESIGN

This is a cognitive interview study.

OBJECTIVES

To examine the applicability of the Patient Reported Outcome Spine Trauma (AO Spine PROST) in people with motor-complete traumatic or non-traumatic spinal cord injury (SCI).

SETTING

Two rehabilitation centers in The Netherlands.

METHOD

Semi-structured cognitive interviews were conducted with 29 adults with a motor-complete SCI (AISA Impairment Scale A or B). Participants were asked to complete the AO Spine PROST and four additional evaluation questions rated on a 1-5-point Likert scale (5 most positive), while verbalizing their thoughts about their answers. Interviews were audio-recorded and transcribed. Codes were identified and linked to a coding scheme. Qualitative data were used to interpret the quantitative results.

RESULTS

Almost three-quarters of the participants (71.4%) had a traumatic SCI. Positive ratings of the measure were obtained regards comprehensibility (mean 4.0), non-offensiveness (4.6), relevance (4.2), and completeness (3.6). A question about the emotional impact of SCI was indicated to be missing. How using an assistive device should weigh in the score was a recurring topic. The use of multiple examples per item raised uncertainty, mostly solved by averaging their score. Some individuals indicated that the possibility to express even better function compared to before the onset of injury would be valuable.

CONCLUSIONS

Overall, the AO Spine PROST appears applicable in adults with a motor-complete traumatic or non-traumatic SCI. Recommendations are made for improvement in instructions, terminology, and examples used in the tool. This study contributes to the further development of the AO Spine PROST in spine trauma care and research.

Prospective analysis of a surgical algorithm to achieve ventilator weaning in cervical tetraplegia

Objectives: Chronic ventilator dependency in cervical tetraplegia is associated with substantial morbidity. When non-invasive weaning methods have failed the primary surgical treatment is diaphragm pacing. Phrenic nerve integrity and diaphragm motor units are requirements for effective pacing but may need to be restored for successful weaning. A surgical algorithm that includes: 1. Diaphragm pacing, 2. Phrenic nerve reconstruction, and 3. Diaphragm muscle replacement, may provide the capability of reducing or reversing ventilator dependency in virtually all cervical tetraplegics.Design: Prospective case series.Setting: A university-based hospital from 2015 to 2019.Participants: Ten patients with ventilator-dependent cervical tetraplegia.Interventions: I. Pacemaker alone, II. Pacemaker + phrenic nerve reconstruction, or III. Pacemaker + diaphragm muscle replacement.Outcome measures: Time from surgery to observed reduction in ventilator requirements (↓VR), ventilatory needs as of most recent follow-up [no change (NC), partial weaning (PW, 1-12 h/day), or complete weaning (CW, >12 h/day)], and complications.Results: Both patients in Group I achieved CW at 6-month follow-up. Two patients in Group II achieved CW, and in another two patients PW was achieved, at 1.5-2-year follow-up. The remaining two patients are NC at 6 and 8-month follow-up, respectively. In group III, both patients achieved PW at 2-year follow-up. Complications included mucous plugging (n = 1) and pacemaker malfunction requiring revision (n = 3).Conclusion: Although more investigation is necessary, phrenic nerve reconstruction or diaphragm muscle replacement performed (when indicated) with pacemaker implantation may allow virtually all ventilator-dependent cervical tetraplegics to partially or completely wean.

A New Scale for Predicting the Risk of In-hospital Mortality in Patients With Traumatic Spinal Cord Injury

Purpose

To analyze the relative factors influencing in-hospital mortality in patients with traumatic spinal cord injury (TSCI), and develop a score scale for predicting the risk of in-hospital mortality.

Method

We reviewed the medical records from 59 spine centers in mainland China from 1 January 2018 to 31 December 2018. The inclusion criteria were (1) confirmed diagnosis of TSCI, (2) hospitalization within 7 days of injury, and (3) affecting neurological level from C1 to L1. The exclusion criteria were (1) readmission, and (2) incomplete data. Included patients were classified into the survival and non-survival groups according to their status at discharge. Univariate and multivariate logistic regressions were performed to identify the factors related to in-hospital mortality in patients with TSCI. A new scale was developed, and the mortality rate in each risk group was calculated.

Results

Of the 3,176 participants, 23 (0.7%) died in the hospital, and most of them died from respiratory diseases (17/23, 73.9%). After univariate and multivariate logistic regression analysis, cervical spinal cord injury [odds ratio (OR) = 0.264, 95% confidence interval (CI): 0.076–0.917, P = 0.036], abdominal visceral injury (OR = 3.778, 95% CI: 1.038–13.755, P = 0.044), the American Spinal Injury Association (ASIA) score on admission (A: reference; B:OR = 0.326, 95% CI: 0.093–1.146, P = 0.081; C:OR = 0.070, 95% CI: 0.016–0.308, P < 0.001; D:OR = 0.069, 95% CI: 0.019–0.246, P < 0.001), and surgery (OR = 0.341, 95% CI: 0.146–0.796, P = 0.013) were significantly associated with in-hospital mortality. Scores for each of the four factors were derived according to mortality rates. The sum of the scores from all four factors was included in the scoring system and represented the risk of in-hospital mortality. The in-hospital mortality risk of the low-risk (0–3 points), moderate-risk (4–5 points), and high-risk groups (6–8 points) was 0.3, 2.7, and 9.7%, respectively (P < 0.001).

Conclusions

Cervical spinal cord injury, abdominal visceral injury, ASIA score on admission, and surgery were significantly associated with in-hospital mortality in patients with TSCI and stable condition. The scale system may be beneficial for clinical decision-making and for communicating relevant information to patients and their families.

Ac-SDKP peptide improves functional recovery following spinal cord injury in a preclinical model

Damage to the spinal cord triggers a local complex inflammatory reaction that results in irreversible impairments or complete loss of motor function. The evidence suggested that inhibiting the pro-inflammatory macrophage/microglia (M1 subsets) and stimulating the anti-inflammatory macrophage/microglia (M2 subsets) are potential strategies for the treatment of neuroinflammation-related diseases. We evaluated the potentially protective effect of Ac-SDKP as an endogenous tetrapeptide on rat spinal cord injury (SCI). Wistar rats were subjected to a weight-drop contusion model and were treated with Ac-SDKP (0.8 mg/kg) given subcutaneously once a day for 7 days starting at two clinically relevant times, at 2 h or 6 h post-injury. The effect of Ac-SDKP was assessed by motor functional analysis, real-time PCR (CD86 and CD206 mRNA), western blot (caspase-3), ELISA (TNF-a, IL-10), and histological analysis (toluidine blue staining). Ac-SDKP improved locomotor recovery and rescue motor neuron loss after SCI. Moreover, a decreased in TNF-a level as well as caspase 3 protein levels occurred in the lesion epicenter of the spinal cord following treatment. In addition, CD206 mRNA expression level increased significantly in Ac-SDKP treated rats compared with SCI. Together these data suggest that Ac-SDKP might be a novel immunomodulatory drug. It may be beneficial for the treatment of SCI with regards to increasing CD206 gene expression and suppress inflammatory cytokine to improve motor function and reducing histopathological lesion.

Neuromuscular rehabilitation interventions and COVID-19 management in a case of incomplete paraplegia with neurogenic bladder, post T3-T5 ependymoma

Spinal ependymomas are a group of mostly slow-growing tumors that can cause non-traumatic spinal cord injury with insidious clinical symptomatology ranging from neck or back pain to as-sociated sensory-motor impairment. Due to their neurological and systemic frailty, patients with spinal cord injury might be especially vulnerable to the effects of SARS-CoV-2 infection and the resulting respiratory impairment. CASE PRESENTATION: We present the case of a 66 year old women admitted in our Neuromuscular Rehabilitation Clinic Division for severe in-complete paraplegia and neurogenic bladder. She was previously diagnosed in the Neurosurgi-cal Ward with a thoracic grade II (classic) ependymoma and underwent a gross tumor resection. During the neurorehabilitation program the patient was diagnosed with COVID-19. The multi-drug related treatments were associated with supportive oxygen therapy and neuromuscular and respiratory rehabilitation techniques. RESULTS: Despite of the patient’s favorable rehabili-tation, consisting of walking abilities with support in a walking frame on short distances, her prognosis may be worsened by resting neurogenic bladder symptoms. COVID-19 has led to im-portant acute respiratory morbidity in our patient, regardless of the mild course of the disease, and might further cause a post-infectious respiratory impairment. ONCLUSION: Spinal cord in-jury remains a life-long condition and emphasizes the necessity of supporting the affected pati-ents on the long run. Keywords: students, balance, postural stability, physical exercise, progress, motor skills

Trans-Spinal Electrical Stimulation Therapy for Functional Rehabilitation after Spinal Cord Injury: Review

Spinal cord injury (SCI) is one of the most debilitating injuries in the world. Complications after SCI, such as respiratory issues, bowel/bladder incontinency, pressure ulcers, autonomic dysreflexia, spasticity, pain, etc., lead to immense suffering, a remarkable reduction in life expectancy, and even premature death. Traditional rehabilitations for people with SCI are often insignificant or ineffective due to the severity and complexity of the injury. However, the recent development of noninvasive electrical neuromodulation treatments to the spinal cord have shed a ray of hope for these individuals to regain some of their lost functions, a reduction in secondary complications, and an improvement in their life quality. For this review, 250 articles were screened and about 150 were included to summarize the two most promising noninvasive spinal cord electrical stimulation methods of SCI rehabilitation treatment, namely, trans-spinal direct current stimulation (tsDCS) and trans-spinal pulsed current stimulation (tsPCS). Both treatments have demonstrated good success in not only improving the sensorimotor function, but also autonomic functions. Due to the noninvasive nature and lower costs of these treatments, in the coming years, we expect these treatments to be integrated into regular rehabilitation therapies worldwide.

The COVID-19 pandemic impacts all domains of quality of life in Egyptians with spinal cord injury: a retrospective longitudinal study

Background and objective

During the COVID-19 pandemic, several aspects of life have been affected. These aspects have been impacted especially in persons with spinal cord injury (SCI). The current study explored the overall effect of the COVID-19 pandemic on quality of life (QOL) domains in persons with SCI as well as evaluated their adherence to WHO-COVID 19-preventive measures.

Design

A retrospective longitudinal study was conducted after asking participants to complete an online validated Arabic version of the WHOQOL-BREF questionnaires including their demographics. The WHOQOL-BREF questionnaires were completed targeting two separate occasions to represent their scores prior to and during the pandemic. Participants were asked to rate their adherence to WHO-COVID-19 preventive measures on a 10-point scale.

Setting and participants

115 participants with complete/ incomplete SCI were recruited via social media and contacted by phone to complete the questionnaires.

Results

Persons with SCI had lower QOL scores during the COVID-19 period compared to their QOL during the pre-COVID-19 period; all QOL domains (Physical Health, Psychological, Social Relationships, and Environment) showed a significant decrease (P < 0.001). Regarding COVID-19 preventative measures, participants were most likely to endorse self-isolation as well as staying home measures and least likely to adhere to hand washing and social distancing measures.

Conclusion

The robustly reduced QOL reported by individuals with SCI during the COVID-19 pandemic highlights the need for rehabilitation and mental health services, particularly administered via telehealth, to buffer the effects of the pandemic. Additionally, psychoeducation and support regarding COVID-19 preventative behaviors in this region would be critical.

Utilising International Statistical Classification of Diseases and Related Health Conditions (ICD)-10 Australian Modification Classifications of "Health Conditions" to Achieve Population Health Surveillance in an Australian Spinal Cord Injury Cohort

Study design

Retrospective, non-randomised, registry controlled.

Objective

To develop a conceptual ICD-10 taxonomic framework for population health surveillance across all-phases of spinal cord injury and disorders (SCI/D).

Setting

Public Hospital Admitted Patient Care (APC) collection, South Australian Dept. Health, South Australia, Australia.

Methods

A core ICD-10-Australian Modification (AM) coded dataset was retrieved from the APC hospital patient admission collection (2012–2017). Search filters and key words referenced to the National Library of Medicine thesaurus identified and quantified incident SCI/D cases. Incident SCI/D case data held in the Australian Spinal Cord Injury Registry (ASCIR) of South Australia (2012–2017) tested fidelity. Data linkage to the South Australian Death Registry controlled for cohort attrition. Both unadjusted and case-mix adjusted core data set yields were evaluated. Outcomes were assessed in terms of APC frequency difference (Δ%) versus ASCIR.

Results

3,504 APC cases were extracted, of which 504 (mean, SD age 55 ± 20 yrs; 348 [69%] male, 202 [39%] traumatic; 135 [32%]) cervical; 51 [10.1%] thoracic and (16 [3.2%]) lumbar met criteria. Comparator data were 385 ASCIR new index cases mean, SD age 56 ± 19 yrs, 229 [75%] male, 162 [42%] traumatic. Case-mix adjusted analysis yielded 336 (APC Δ33%) all-cause incident cases (vs. ASCIR −13 Δ%) and 131 incident cases of traumatic aetiologies (vs. ASCIR −19 Δ%).

Conclusions

The ICD-10 core “Health Condition” data-set assembled extends our understanding of SCI/D epidemiology and with further development may create a cost-efficient and sustainable framework that will improve health system performance and equity within and between countries.

Sponsorship

The Lifetime Support Authority of South Australia sponsored the study.

Factors Associated With Ventilator Weaning Success and Failure in People With Spinal Cord Injury in an Acute Inpatient Rehabilitation Setting: A Retrospective Study

Objectives

To evaluate baseline characteristics, describe pulmonary outcomes, and identify weaning predictors for people with acute traumatic spinal cord injury (SCI) who are dependent on mechanical ventilation at admission to acute inpatient rehabilitation (AIR).

Methods

The retrospective study was conducted at an AIR facility in the United States. It included 91 adults with acute traumatic SCI from 2015 to 2019 who were dependent on mechanical ventilation.

Results

People who successfully weaned (85%) had fewer days from time of SCI to AIR admission (22 vs. 30, p = .04), higher vital capacity at admission to AIR (12 vs. 3 mL/kg predicted body weight [PBW]; p < .001), and lower (caudal) neurological injury level (p < .001) compared to those who failed weaning. The risk of pneumonia was higher in people who failed weaning compared to those who were weaned successfully (risk ratio, 5.5; 95% confidence interval [95% CI], 2.3-13). Receiver operating characteristics (ROC) curves suggest a vital capacity cutoff of 5.8 mL/kg PBW could predict weaning. The vital capacity of ≥ 5.8 mL/kg PBW is associated with 109 times higher odds (95% CI, 11-1041; p < .001) of weaning than vital capacity below that threshold.

Conclusion

In this retrospective study, there was an increased risk of pneumonia in people with SCI who failed weaning at discharge from AIR. Vital capacity was a better predictor of weaning from mechanical ventilation compared to the neurological level of injury, with a cutoff of 5.8 mL/kg PBW predictive of weaning success. Further research is needed on this critical topic.

Long-Term Survival and Causes of Death in Patients below the Age of 60 with Traumatic Spinal Cord Injury in Germany

To study the mortality, cause and risk indicators of death in German patients with traumatic spinal cord injury, patients with traumatic spinal cord injury admitted to Berufsgenossenschaftliches Trauma Hospital Hamburg between 1 January 1997 and 31 December 2018, aged between 16 and 60 with a minimal survival of one year after injury, were included. Further criteria were the absence of life-limiting comorbidities at the time of injury. 223 deceased patients with traumatic spinal cord injury were identified, investigated on and partly compared to the surviving subjects. We aimed to discover specific complications that were related to Spinal Cord Injury and responsible for a possibly limited life expectancy. Data collection was performed during in- and outpatient treatment. A statistical analysis was performed to compare groups. The post-injury life expectancy was 25.0 years with a significant correlation regarding the level of lesion and severity of injury. The leading causes of death were cardiovascular diseases and pneumonia. Bladder cancer was the most common fatal malignant tumor. The life expectancy of patients suffering from traumatic spinal cord injury is limited. The longer a patient survives after injury and the lower the level of lesion, the more likely an age-related cause of death becomes. Bladder cancer is significantly more frequent when compared to the overall distribution of tumor diseases in Germany.

Rebuilding Body-Brain Interaction from the Vagal Network in Spinal Cord Injuries

Spinal cord injuries (SCIs) exert devastating effects on body awareness, leading to the disruption of the transmission of sensory and motor inputs. Researchers have attempted to improve perceived body awareness post-SCI by intervening at the multisensory level, with the integration of somatic sensory and motor signals. However, the contributions of interoceptive-visceral inputs, particularly the potential interaction of motor and interoceptive signals, remain largely unaddressed. The present perspective aims to shed light on the use of interoceptive signals as a significant resource for patients with SCI to experience a complete sense of body awareness. First, we describe interoceptive signals as a significant obstacle preventing such patients from experiencing body awareness. Second, we discuss the multi-level mechanisms associated with the homeostatic stability of the body, which creates a unified, coherent experience of one's self and one's body, including real-time updates. Body awareness can be enhanced by targeting the vagus nerve function by, for example, applying transcutaneous vagus nerve stimulation. This perspective offers a potentially useful insight for researchers and healthcare professionals, allowing them to be better equipped in SCI therapy. This will lead to improved sensory motor and interoceptive signals, a decreased likelihood of developing deafferentation pain, and the successful implementation of modern robotic technologies.

A Nomogram for Predicting Acute Respiratory Failure After Cervical Traumatic Spinal Cord Injury Based on Admission Clinical Findings

OBJECTIVES

Acute respiratory failure (ARF) is a common medical complication in patients with cervical traumatic spinal cord injury (TSCI). To identify independent predictors for ARF onset in patients who underwent cervical TSCI without premorbid respiratory diseases and to apply appropriate medical supports based on accurate prediction, a nomogram relating admission clinical information was developed for predicting ARF during acute care period.

METHODS

We retrospectively reviewed clinical profiles of patients who suffered cervical TSCI and were emergently admitted to Qingdao Municipal Hospital from 2014 to 2020 as the training cohort. Univariate analysis was performed using admission clinical variables to estimate associated factors and a nomogram for predicting ARF occurrence was generated based on the independent predictors from multivariate logistic regression analysis. This nomogram was assessed by concordance index for discrimination and calibration curve with internal-validated bootstrap strategy. Receiver operating characteristic curve was conducted to compare the predictive accuracy between the nomogram and the traditional gold standard, which combines neuroimaging and neurological measurements by using area under the receiver operating characteristic curve (AUC). An additional 56-patient cohort from another medical center was retrospectively reviewed as the test cohort for external validation of the nomogram.

RESULTS

162 patients were eligible for this study and were included in the training cohort, among which 25 individuals developed ARF and were recorded to endure more complications. Despite the aggressive treatments and prolonged intensive care unit cares, 14 patients insulted with ARF died. Injury level, American Spinal Injury Association Impairment Scale (AIS) grade, admission hemoglobin (Hb), platelet to lymphocyte ratio, and neutrophil percentage to albumin ratio (NPAR) were independently associated with ARF onset. The concordance index of the nomogram incorporating these predictors was 0.933 in the training cohort and 0.955 in the test cohort, although both calibrations were good. The AUC of the nomogram was equal to concordance index, which presented better predictive accuracy compared with previous measurements using neuroimaging and AIS grade (AUC 0.933 versus 0.821, Delong's test p < 0.001). Similar significant results were also found in the test cohort (AUC 0.955 versus 0.765, Delong's test p = 0.034). In addition, this nomogram was translated to a Web-based calculator that could generate individual probability for ARF in a visualized form.

CONCLUSIONS

The nomogram incorporating the injury level, AIS grade, admission Hb, platelet to lymphocyte ratio, and NPAR is a promising model to predict ARF in patients with cervical TSCI who are absent from previous respiratory dysfunction. This nomogram can be offered to clinicians to stratify patients, strengthen evidence-based decision-making, and apply appropriate individualized treatment in the field of acute clinical care.

Exoskeleton-assisted walking improves pulmonary function and walking parameters among individuals with spinal cord injury: a randomized controlled pilot study

BACKGROUND

Exoskeleton-assisted walking (EAW) is expected to improve the gait of spinal cord injury (SCI) individuals. However, few studies reported the changes of pulmonary function (PF) parameters after EAW trainings. Hence, we aimed to explore the effect of EAW on PF parameters, 6-min walk test (6MWT) and lower extremity motor score (LEMS) in individuals with SCI and to compare those with conventional trainings.

METHODS

In this prospective, single-center, single-blinded randomized controlled pilot study, 18 SCI participants were randomized into the EAW group (n = 9) and conventional group (n = 9) and received 16 sessions of 50-60 min training (4 days/week, 4 weeks). Pulmonary function parameters consisting of the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), forced expiratory flow (FEF), peak expiratory flow, and maximal voluntary ventilation, 6MWT with assisted devices and LEMS were reported pre- and post-training.

RESULTS

Values of FVC (p = 0.041), predicted FVC% (p = 0.012) and FEV₁ (p = 0.013) were significantly greater in EAW group (FVC: 3.8 ± 1.1 L; FVC% _pred = 94.1 ± 24.5%; FEV₁: 3.5 ± 1.0 L) compared with conventional group (FVC: 2.8 ± 0.8 L; FVC% _pred = 65.4 ± 17.6%; FEV₁: 2.4 ± 0.6 L) after training. Participants in EAW group completed 6MWT with median 17.3 m while wearing the exoskeleton. There was no difference in LEMS and no adverse event.

CONCLUSIONS

The current results suggest that EAW has potential benefits to facilitate PF parameters among individuals with lower thoracic neurological level of SCI compared with conventional trainings. Additionally, robotic exoskeleton helped walking.

TRIAL REGISTRATION

Registered on 22 May 2020 at Chinese Clinical Trial Registry (ChiCTR2000033166). http://www.chictr.org.cn/edit.aspx?pid=53920&htm=4 .

Protocol-Specific Effects of Intermittent Hypoxia Pre-Conditioning on Phrenic Motor Plasticity in Rats with Chronic Cervical Spinal Cord Injury

"Low-dose" acute intermittent hypoxia (AIH; 3-15 episodes/day) is emerging as a promising therapeutic strategy to improve motor function after incomplete cervical spinal cord injury (cSCI). Conversely, chronic "high-dose" intermittent hypoxia (CIH; > 80-100 episodes/day) elicits multi-system pathology and is a hallmark of sleep apnea, a condition highly prevalent in individuals with cSCI. Whereas daily AIH (dAIH) enhances phrenic motor plasticity in intact rats, it is abolished by CIH. However, there have been no direct comparisons of prolonged dAIH versus CIH on phrenic motor outcomes after chronic cSCI. Thus, phrenic nerve activity and AIH-induced phrenic long-term facilitation (pLTF) were assessed in anesthetized rats. Experimental groups included: 1) intact rats exposed to 28 days of normoxia (Nx28; 21% O2; 8 h/day), and three groups with chronic C2 hemisection (C2Hx) exposed to either: 2) Nx28; 3) dAIH (dAIH28; 10, 5-min episodes of 10.5% O2/day; 5-min intervals); or 4) CIH (IH28-2/2; 2-min episodes; 2-min intervals; 8 h/day). Baseline ipsilateral phrenic nerve activity was reduced in injured versus intact rats but unaffected by dAIH28 or IH28-2/2. There were no group differences in contralateral phrenic activity. pLTF was enhanced bilaterally by dAIH28 versus Nx28 but unaffected by IH28-2/2. Whereas dAIH28 enhanced pLTF after cSCI, it did not improve baseline phrenic output. In contrast, unlike shorter protocols in intact rats, CIH28-2/2 did not abolish pLTF in chronic C2Hx. Mechanisms of differential responses to dAIH versus CIH are not yet known, particularly in the context of cSCI. Further, it remains unclear whether enhanced phrenic motor plasticity can improve breathing after cSCI.

Causes of death after spinal cord injury in the Czech Republic

STUDY DESIGN

A retrospective cohort study OBJECTIVES: To determine the causes of death in people with spinal cord injury (SCI) admitted to the Spinal Cord Unit (SCU) of the University Hospital Motol from 2004 to 2018.

SETTING

University Hospital Motol, Prague METHODS: From a cohort of people admitted to the SCU between 2004 and 2018, all deaths were identified based on the database of health insurance companies. The causes of death (ICD-10) were obtained from the Institute of Health Information and Statistics. The standardized mortality ratio (SMR) was calculated for most frequent causes of death.

RESULTS

During the study period, 990 patients with acute SCI were admitted to the SCU, out of which 183 (18.5%) died. Thirty-five people who had SCI due to cancer were excluded from the study. The leading cause of death in the remaining 148 people was pneumonia, followed by cardiac complications, pulmonary embolism, suicide, and urinary tract infection (UTI). In the group of the individuals who died within 1 year after SCI (N = 41), the main causes of death were pneumonia and pulmonary embolism (17.1% each). Among individuals who survived up to1 year after SCI (N = 107), the most common causes of death were pneumonia (14%) and pressure injuries (12.1%). The cause-specific SMRs were significantly increased for UTI, embolism, pneumonia, and suicide.

CONCLUSION

The frequent causes of death in our study group were pressure injuries and suicides. These findings are fundamental to the development and implementation of preventive programs to reduce mortality and increase life expectancy.

[Factors associated with functional improvement in patients with cervical spinal cord injuries]

OBJECTIVE

To determine the factors influencing functional improvement of cervical spinal cord injuries during hospital admission.

MATERIAL AND METHODS

We performed a retrospective study of patients with an acute cervical spinal cord injury who had completed a rehabilitation programme in the Spinal Cord Injuries Unit of the Canary Islands between 2001 and 2018. To measure functional improvement, we administered the Spinal Cord Independence Measure III (SCIM III) on admission and at discharge.

RESULTS

Of the 141 patients in our sample, 88% were men. Worse functional results were observed in older patients, those with a history of alcohol consumption, complete lesions and those with more severe lesions on the ASIA scale. Factors significantly associated with functional improvement were the interval between injury and admission to the unit, length of hospital stay, and the interval between injury and hospital discharge.

CONCLUSIONS

Older patients, as well as those with a history of alcohol intake, complete lesions and greater severity on the ASIA scale, had worse functional outcomes. In contrast, early admission was crucial to obtain better functional outcomes and was associated with shorter hospital stays.

Acute traumatic quadriplegia: Predictors of in-hospital and six-month mortality

Background

Traumatic spinal cord injury is one of the most disastrous and devastating health burdens all over the world with a high mortality rate. The present study aimed to evaluate the predictors of in-hospital and six-month mortality in these patients.

Methods

The electronic medical records of 87 consecutive patients with acute complete traumatic quadriplegia were reviewed to extract clinical, radiological, and laboratory data. Simple and multiple logistic regression models were used to estimate crude and adjusted odds with 95% confidence interval (CI) ratios for the predictors of in-hospital mortality and six-month mortality.

Results

There were 48 males and the mean age was 38.67 ± 12.81; in-hospital and six-month mortality were 21.84% and 11.76%, respectively. Traffic road accidents (67.8%) and falls (12.6%) were the most common causes of injury. The univariate analysis demonstrated advanced age, level of injury, late surgery or no surgical intervention, the lack of methylprednisolone therapy, a higher Charlson comorbidity index, the Injury Severity Score, and the presence of respiratory failure or bradycardia on admission were predictors of in-hospital mortality ( p < 0.05). In the final multiple logistic regression model, the level of injury (OR = 0.02 (0.001,0.35), p = 0.008) and the presence of respiratory failure (OR = 2.37 (0.03,13.88), p = 0.024) were the only predictors of in-hospital mortality. The univariate model showed that the level of injury, respiratory failure on admission, and the Injury Severity Score were the predictors of six-month mortality; however, the level of injury was the only predictor of the six-month mortality (OR = 1.12 (0.99, 1.27), p = 0.028) according to the multiple logistic regression model.

Conclusions

Several factors could affect in-hospital and six-month mortality in patients with traumatic spinal cord injury. Our findings demonstrated the level of injury and respiratory failure on admission as independent predictors of in-hospital mortality in these patients. Furthermore, the level of injury was the only independent predictor of six-month mortality in the present study.

Predictors of respiratory complications in patients with C5-T5 spinal cord injuries

Study design

Retrospective chart audit.

Objectives

Describing the respiratory complications and their predictive factors in patients with acute traumatic spinal cord injuries at C5–T5 level during the initial hospitalization.

Setting

Hospital Vall d’Hebron, Barcelona.

Methods

Data from patients admitted in a reference unit with acute traumatic injuries involving levels C5–T5. Respiratory complications were defined as: acute respiratory failure, respiratory infection, atelectasis, non-hemothorax pleural effusion, pulmonary embolism or haemoptysis. Candidate predictors of these complications were demographic data, comorbidity, smoking, history of respiratory disease, the spinal cord injury characteristics (level and ASIA Impairment Scale) and thoracic trauma. A logistic regression model was created to determine associations between potential predictors and respiratory complications.

Results

We studied 174 patients with an age of 47.9 (19.7) years, mostly men (87%), with low comorbidity. Coexistent thoracic trauma was found in 24 (19%) patients with cervical and 35 (75%) with thoracic injuries (p < 0.001). Respiratory complications were frequent (53%) and were associated to longer hospital stay: 83.1 (61.3) and 45.3 (28.1) days in patients with and without respiratory complications (p < 0.001). The strongest predictors of respiratory complications were: previous respiratory disease (OR 5.4, 95% CI: 1.5–19.2), complete motor function impairment (AIS A–B) (OR 4.7, 95% CI: 2.4–9.5) and concurrent chest trauma (OR 3.73, 95% CI: 1.8–7.9).

Conclusions

Respiratory complications are common in traumatic spinal cord injuries between C5–T5. We identified previous respiratory disease, complete motor function impairment and the coexistence of thoracic trauma as predictors of respiratory complications. Identification of patients at risk might help clinicians to implement preventive strategies.

Method and Apparatus for the Automated Delivery of Continuous Neural Stem Cell Trails Into the Spinal Cord of Small and Large Animals

BACKGROUND

Immature neurons can extend processes after transplantation in adult animals. Neuronal relays can form between injected neural stem cells (NSCs) and surviving neurons, possibly improving recovery after spinal cord injury (SCI). Cell delivery methods of single or multiple bolus injections of concentrated cell suspensions thus far tested in preclinical and clinical experiments are suboptimal for new tract formation. Nonuniform injectate dispersal is often seen due to gravitational cell settling and clumping. Multiple injections have additive risks of hemorrhage, parenchymal damage, and cellular reflux and require additional surgical exposure. The deposition of multiply delivered cells boluses may be uneven and discontinuous.

OBJECTIVE

To develop an injection apparatus and methodology to deliver continuous cellular trails bridging spinal cord lesions.

METHODS

We improved the uniformity of cellular trails by formulating NSCs in hyaluronic acid. The TrailmakerTM stereotaxic injection device was automatized to extend a shape memory needle from a single-entry point in the spinal cord longitudinal axis to "pioneer" a new trail space and then retract while depositing an hyaluronic acid-NSC suspension. We conducted testing in a collagen spinal models, and animal testing using human NSCs (hNSCs) in rats and minipigs.

RESULTS

Continuous surviving trails of hNSCs within rat and minipig naive spinal cords were 12 and 40 mm in length. hNSC trails were delivered across semi-acute contusion injuries in rats. Transplanted hNSCs survived and were able to differentiate into neural lineage cells and astrocytes.

CONCLUSION

The TrailmakerTM creates longitudinal cellular trails spanning multiple levels from a single-entry point. This may enhance the ability of therapeutics to promote functional relays after SCI.

Docosahexaenoic acid reduces microglia phagocytic activity via miR-124 and induces neuroprotection in rodent models of spinal cord contusion injury

Microglia are activated after spinal cord injury (SCI), but their phagocytic mechanisms and link to neuroprotection remain incompletely characterized. Docosahexaenoic acid (DHA) has been shown to have significant neuroprotective effects after hemisection and compression SCI and can directly affect microglia in these injury models. In rodent contusion SCI, we demonstrate that DHA (500 nmol/kg) administered acutely post-injury confers neuroprotection and enhances locomotor recovery, and also exerts a complex modulation of the microglial response to injury. In rodents, at 7 days after SCI, the level of phagocytosed myelin within Iba1-positive or P2Y12-positive cells was significantly lower after DHA treatment, and this occurred in parallel with an increase in intracellular miR-124 expression. Furthermore, intraspinal administration of a miR-124 inhibitor significantly reduced the DHA-induced decrease in myelin phagocytosis in mice at 7 days post-SCI. In rat spinal primary microglia cultures, DHA reduced the phagocytic response to myelin, which was associated with an increase in miR-124, but not miR-155. A similar response was observed in a microglia cell line (BV2) treated with DHA, and the effect was blocked by a miR-124 inhibitor. Furthermore, the phagocytic response of BV2 cells to stressed neurones was also reduced in the presence of DHA. In peripheral monocyte-derived macrophages, the expression of the M1, but not the M0 or M2 phenotype, was reduced by DHA, but the phagocytic activation was not altered. These findings show that DHA induces neuroprotection in contusion injury. Furthermore, the improved outcome is via a miR-124-dependent reduction in the phagocytic response of microglia.

Oleanolic acid inhibits mouse spinal cord injury through suppressing inflammation and apoptosis via the blockage of p38 and JNK MAPKs

Spinal cord injury (SCI) is reported as a devastating disease, leading to tissue loss and neurologic dysfunction. However, there is no effective therapeutic strategy for SCI treatment. Oleanolic acid (OA), as a triterpenoid, has anti-oxidant, anti-inflammatory, and anti-apoptotic activities. However, its regulatory effects on SCI have little to be elucidated, as well as the underlying molecular mechanisms. In this study, we attempted to explore the role of OA in SCI progression. Behavior tests suggested that OA treatments markedly alleviated motor function in SCI mice. Evans blue contents up-regulated in spinal cords of SCI mice were significantly reduced by OA in a dose-dependent manner, demonstrating the improved blood-spinal cord barrier. Moreover, we found that OA treatments significantly reduced the apoptotic cell death in spinal cord samples of SCI mice through decreasing the expression of cleaved Caspase-3. In addition, pro-inflammatory response in SCI mice was significantly attenuated by OA treatments. Furthermore, SCI mice exhibited higher activation of mitogen-activated protein kinases (MAPKs) and nuclear factor-κB (NF-κB) signaling pathways, but these effects were clearly blocked in SCI mice with OA treatments, as evidenced by the down-regulated phosphorylation of p38, c-Jun-NH 2 terminal kinase (JNK), IκB kinase α (IKKα), inhibitor of nuclear factor κB-α (IκBα) and NF-κB. The protective effects of OA against SCI were confirmed in lipopolysaccharide (LPS)-stimulated mouse neurons mainly through the suppression of apoptosis and inflammatory response, which were tightly associated with the blockage of p38 and JNK activation. Together, our data demonstrated that OA treatments could dose-dependently ameliorate spinal cord damage through impeding p38- and JNK-regulated apoptosis and inflammation, and therefore OA might be served as an effective therapeutic agent for SCI treatment.

Rib Hyperostosis as a Risk Factor for Poor Prognosis in Cervical Spine Injury Patients With Diffuse Idiopathic Skeletal Hyperostosis

STUDY DESIGN

Retrospective multi-center study.

OBJECTIVE

To identify the morphological features of costovertebral joints and ribs in surgically managed cervical injury patients with diffuse idiopathic skeletal hyperostosis (DISH) and to examine its impact on their vital prognosis.

SUMMARY OF BACKGROUND DATA

Several reports have indicated that DISH is an independent risk factor for mortality after spinal fracture. The reason for the high mortality in cervical injury patients with DISH is unclear, although some reports have suggested a possible association between pulmonary complications and mortality.

METHODS

From 1999 to 2017, a total of 50 DISH patients (44 males) with cervical spine injuries who underwent spinal surgery were enrolled (average age 74 yrs). Prognosis and clinical risk factor data were collected; the morphological features of the patients' costovertebral joints and ribs were evaluated with computed tomography. The influence of each proposed risk factor and thoracic morphological feature on mortality was tested with univariate and multivariate analyses.

RESULTS

The survival rate at 5 years after surgery was 52.3%. Nineteen (38%) patients died, and the most common cause of death was pneumonia (68%). Costovertebral bone excrescences and rib hyperostosis were found to be thoracic pathognomonic signs; their frequencies were 94% and 82%, respectively, and these conditions occurred in an average of 7.0 joints and 4.7 bones, respectively. The results of the log-rank test showed a significant difference in age, injury severity score (ISS), costovertebral bone excrescences, and rib hyperostosis. The results of age-adjusted multivariate analysis indicated that age (hazard ratio [HR] = 8.65, 95% confidence interval [CI] = 1.10-68.28, P = 0.041) and rib hyperostosis (HR = 3.82, 95% CI = 1.38-10.57, P = 0.010) were associated with mortality.

CONCLUSION

Reduced chest wall mobility associated with rib hyperostosis in cervical spine injury patients with DISH leads to a poor prognosis.

LEVEL OF EVIDENCE

3.

Advances in the Rehabilitation of the Spinal Cord-Injured Patient: The Orthopaedic Surgeons' Perspective

Acute traumatic spinal cord injury is a devastating condition affecting 17,700 new patients per year in the United States alone. Typically, orthopaedic surgeons focus on managing the acute surgical aspects of care (eg, surgical spinal decompression and stabilization). However, in the care of these patients, being familiar with how to prognosticate neurologic recovery and manage secondary complications is extremely important. In addition, as an integral part of the multidisciplinary care team, the surgeon should have an awareness of contemporary rehabilitation approaches to maximize function and facilitate reintegration into the community. The purpose of this review article is to provide a surgeon's perspective on these aspects of spinal cord injury care.

All-cause and cause-specific mortality following non-traumatic spinal cord injury: evidence from a population-based cohort study in Switzerland

Study design

Observational cohort study.

Objective

To benchmark all-cause and cause-specific mortality following NTSCI to the general population (GP).

Setting

Specialized rehabilitation centers in Switzerland.

Methods

Longitudinal data from the Swiss Spinal Cord Injury (SwiSCI) Medical Record study were probabilistically linked with cause of death (CoD) information from the Swiss National Cohort. Standardized mortality ratios (SMRs) were estimated for all-cause and cause-specific mortality. Competing risk frameworks were used to estimate the probability of death due to specific CoD.

Results

One thousand five hundred and one individuals were admitted for first rehabilitation with NTSCI between 1990–2011; CoD information was available for 454 individuals of the 525 individuals that died. Overall, the mortality rate for persons with NTSCI was 1.6 times greater than that of the GP. Deaths due to cardiovascular disease (39.8%), neoplasms (22%), and infection (9.9%) were most often reported. Individuals with an SCI due to a vascular etiology indicated the greatest burden of mortality from infection compared with the GP (SMR 5.4; 95% CI, 3.1 to 9.2).

Conclusions

Cause-specific SMRs varied according to etiology. This supports the need for targeted clinical care and follow-up. Cardiovascular disease, neoplasms, and infection, emerged as main causes of death following NTSCI and should thus be targets for future research and differential clinical management approaches.

Traumatic Spinal Cord Injury

PURPOSE OF REVIEW

This article provides an update on the acute and subacute management and prognostication of patients with traumatic spinal cord injury.

RECENT FINDINGS

Immobilization of the spine and spine clearance should be individualized depending on the ability to perform a reliable neurologic examination, the presence of neck pain, and the imaging findings. Early surgery (within 24 hours) to achieve definitive cord decompression and spine stabilization may be beneficial. Ensuring adequate oxygenation and perfusion and avoiding secondary systemic complications remain the goals of the critical care of these patients. No neuroprotective treatment has been shown to improve outcomes. In fact, the use of high-dose methylprednisolone is now generally discouraged because of its major systemic adverse effects. Survivors of severe cervical traumatic spinal cord injury typically sustain substantial long-term functional impairment. Advances in our understanding of neuroregenerative strategies, especially stem cell transplantation, can offer the future hope of functional improvement to the many patients currently living with the consequences of traumatic spinal cord injury. Yet, at present, these therapies remain strictly investigational.

SUMMARY

The treatment of traumatic spinal cord injury remains supportive, and prognosis is still poor for patients who are severely affected. While much remains to be learned about how to optimize the acute management of these patients, future efforts would be most useful if focused on injury prevention and the development of effective neuroregenerative therapies.

Possible Strategies to Optimize a Biomarker Discovery Approach to Correlate with Neurological Outcome in Patients with Spinal Cord Injury: A Pilot Study

The lack of reliable diagnostic and prognostic markers for spinal cord injured (SCI) patients is a severe obstacle in development and testing of new therapies, and it also impairs appropriate rehabilitation care. The sparse available data on the biochemical composition of cerebrospinal fluid (CSF) during the acute and/or chronic phase of the lesion provide, up until now, inconsistent results. In this pilot study, we then explored the possibility of combining a multi-parametric and bioinformatic analysis of CSF for its biological properties tested on different cells types, suitable for investigating inflammation and re-myelination. The patient enrollment was based on stringent inclusion criteria; that is, cervical and thoracic SCI trauma, CSF collection within 24 h of trauma, type of surgical approach for spine stabilization, and absence of steroid therapy before CSF collection. Eleven SCI patients and four healthy controls were included, and in three patients, CSF was also collected at 3 months after lesion. We identified 19 proteins among the 60 investigated cytokines, chemokines, growth factors, and structural biomarkers, which are transiently regulated 24 h after SCI. A bioinformatic analysis indicated that interleukin (IL)-6 and IL-10 are in the core of the interconnected net of activated proteins. Cell-based experiments indicate that CSF from SCI patients stimulates astroglia derivation from neural precursor cells, and an inverse correlation between IL-8 CSF level and oligodendrocyte precursor cells generated from neural stem cells was also observed. Results from this pilot study suggest that using a combined bioanalytic and biological approach to analyze SCI CSF at different times after injury could be a useful approach for identifying reliable diagnostic and prognostic markers in SCI.

Autonomic Dysreflexia in Patients With Spinal Cord Injury: What the Radiologist Needs to Know

OBJECTIVE. Autonomic dysreflexia (AD) is a potentially life-threatening condition that occurs in patients with cervical and high thoracic spinal cord injury (SCI). AD is not completely understood and has a high incidence that increases proportional to the level and severity of the SCI. The signs and symptoms can vary, but severe hypertension is a dominant feature and may be fatal. This condition can be precipitated by a wide range of triggers occurring below the level of the injury, several of which are common to both diagnostic and interventional radiology, such as manipulation or distention of the genitourinary or gastrointestinal tract, patient positioning, or the use of certain anesthetic techniques. There is little guidance in the radiology literature specific to risk stratification or the use of premedication in this population. The incidence and pathophysiology of AD are discussed, along with pragmatic tips to aid the radiologist in selecting patients who may require a higher level of care or anesthesiologist involvement, with instructions for the conservative and medical management of acute episodes of AD. CONCLUSION. Awareness of AD is essential for all health care practitioners involved in the care of patients with SCI. A variety of procedures in the radiology department, both diagnostic and interventional, may precipitate AD. Planning, monitoring procedures, knowledge of the relevant pathophysiology and pharmacology, and communication with clinical colleagues are essential to ensure safe practice. Clinicians ordering procedures and radiologists selecting protocols for those procedures should identify at-risk patients before booking a procedure to ensure appropriate supervision and anesthesiology support. Education of radiologists, interventional nursing staff, and technical staff can assist in prevention, early recognition, and successful management of AD.

Sleep Complaints and Sleep Quality in Spinal Cord Injury: A Web-Based Survey

STUDY OBJECTIVES

The purpose of this study was to determine sleep quality and presence of sleep disorders in participants with spinal cord injury (SCI).

METHODS

A web-based survey, available online from February 2011 to July 2013, using validated sleep questionnaires, advertised via the internet and locally through SCI consumer organizations in the United States, Australia, New Zealand, and Canada, was designed to evaluate sleep in adults with self-reported SCI. Demographic characteristics and medical history were obtained from participant self-report.

RESULTS

In our study population, 70% of the 304 participants were male with a mean age of 45 ± 13 years. The mean duration of injury was 16 ± 12 years. Cervical injuries were reported by 49% and thoracic injuries noted in 40% of participants. Increased sleep apnea risk was noted in 31% of participants, with 66% reporting snoring. Insomnia symptoms were reported by 54% of the respondents. Almost 40% of participants ranked their sleep quality as "fairly bad" to "very bad" in the previous month, 29% reported "often" or "almost always" waking up because of pain, and 22% had difficulty falling asleep because of leg cramps. In the past year, 27% of the respondents reported daily uncomfortable leg sensations and 28% found these leg symptoms to be "moderately to extremely distressing."

CONCLUSIONS

This study increases the awareness that insomnia, sleep apnea, and poor sleep quality are common in individuals with chronic SCI; often coexisting. There is a need for increased screening for sleep problems by healthcare providers taking care of individuals living with SCI.

CSF1R Inhibition Reduces Microglia Proliferation, Promotes Tissue Preservation and Improves Motor Recovery After Spinal Cord Injury

Spinal cord injury (SCI) induces a pronounced neuroinflammation driven by activation and proliferation of resident microglia as well as infiltrating peripheral monocyte-derived macrophages. Depending on the time post-lesion, positive and detrimental influences of microglia/macrophages on axonal regeneration had been reported after SCI, raising the issue whether their modulation may represent an attractive therapeutic strategy. Colony-stimulating factor 1 (CSF1) regulates microglia/macrophages proliferation, differentiation and survival thus, pharmacological treatments using CSF1 receptor (CSF1R) inhibitors had been used to ablate microglia. We analyzed the effect of chronic (10 weeks) food diet containing GW2580 (a CSF1R inhibitor) in mice that underwent lateral spinal cord hemisection (HS) at vertebral thoracic level 9. Treatment started 4 weeks prior to SCI and continued until 6 weeks post-lesion. We first demonstrate that GW2580 treatment did not modify microglial response in non-injured spinal cords. Conversely, a strong decrease in proliferating microglia was observed following SCI. Second, we showed that GW2580 treatment improved some parameters of motor recovery in injured animals through better paw placement. Using in and ex vivo magnetic resonance imaging (MRI), we then established that GW2580 treatment had no effect on lesion extension and volume. However, histological analyses revealed that GW2580-treated animals had reduced gliosis and microcavity formation following SCI. In conclusion, CSF1R blockade using GW2580 specifically inhibits SCI-induced microglia/macrophages proliferation, reduces gliosis and microcavity formations and improves fine motor recovery after incomplete SCI. Preventing microglial proliferation may offer therapeutic approach to limit neuroinflammation, promote tissue preservation and motor recovery following SCI.