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Garside T, Stanford R, Flower O, Li T, Dababneh E, Hammond N, Bass F, Middleton J, Tang J, Ball J, Delaney A. Acute assessment of spinal cord injury in New South Wales: A retrospective study of current practice in two spinal cord injury referral centers. J Spinal Cord Med 2023:1-8. [PMID: 37707355 DOI: 10.1080/10790268.2023.2247625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Interventions provided in the early phases after spinal cord injury (SCI) may improve neurological recovery and provide for best possible functional outcomes. Knowing this relies on early and clear documentation of the level and grade of the spinal cord injury. Guidelines advocate for early documentation of neurological status within 72 h of injury to allow early prognostication and to help guide initial management. It is unclear whether this is current practice in New South Wales (NSW). METHODS Patients with acute SCI who were admitted to two SCI referral centers during 2018-2019 in NSW were included. Data relating to documentation of neurological status, timing of imaging, surgery and transfer to spinal cord injury center were collected and summarized using descriptive statistics. RESULTS Only 18 percent of patients had an acceptable neurological examination according to the International Standards for Classification of Spinal Cord Injury (ISNCSCI) within 72 h of injury (either not done, or unable to determine the neurological level of injury). At the first neurological examination, the neurological level of injury and grade was unable to be determined in 26.8% of patients and 29.9% of patients respectively. At discharge from acute care and transfer to rehabilitation, the neurological level was undetermined in 28.9% of patients and grade undetermined in 26.8%. ISNCSCI examination was most commonly performed by spinal rehabilitation doctors after patients were discharged from the intensive care unit (ICU). CONCLUSIONS Documentation of neurological level and grade of SCI within 72 h of injury is not being performed in the large majority of this cohort, which may impede evaluation of neurological improvement in response to acute treatment, and hinder prognostication.
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Affiliation(s)
- Tessa Garside
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - Ralph Stanford
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Oliver Flower
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Trent Li
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Edward Dababneh
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - Frances Bass
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - James Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and The University of Sydney, Sydney, Australia
| | - Jonathan Tang
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Jonathan Ball
- Department of Neurosurgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
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2
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Graham ZA, Siedlik JA, Toro CA, Harlow L, Cardozo CP. Boldine Alters Serum Lipidomic Signatures after Acute Spinal Cord Transection in Male Mice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6591. [PMID: 37623175 PMCID: PMC10454893 DOI: 10.3390/ijerph20166591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
Traumatic spinal cord injury (SCI) results in wide-ranging cellular and systemic dysfunction in the acute and chronic time frames after the injury. Chronic SCI has well-described secondary medical consequences while acute SCI has unique metabolic challenges as a result of physical trauma, in-patient recovery and other post-operative outcomes. Here, we used high resolution mass spectrometry approaches to describe the circulating lipidomic and metabolomic signatures using blood serum from mice 7 d after a complete SCI. Additionally, we probed whether the aporphine alkaloid, boldine, was able to prevent SCI-induced changes observed using these 'omics platforms'. We found that SCI resulted in large-scale changes to the circulating lipidome but minimal changes in the metabolome, with boldine able to reverse or attenuate SCI-induced changes in the abundance of 50 lipids. Multiomic integration using xMWAS demonstrated unique network structures and community memberships across the groups.
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Affiliation(s)
- Zachary A. Graham
- Research Service, Birmingham VA Health Care System, Birmingham, AL 35233, USA
- Healthspan, Resilience & Performance, Florida Institute for Human and Machine Cognition, Pensacola, FL 32502, USA
- Department of Cell, Developmental, and Integrative Biology, University of Alabama-Birmingham, Birmingham, AL 35294, USA
| | - Jacob A. Siedlik
- Department of Exercise Science and Pre-Health Professions, Creighton University, Omaha, NE 68178, USA;
- School of Medicine, Creighton University, Omaha, NE 68178, USA
| | - Carlos A. Toro
- Spinal Cord Damage Research Center, Bronx, NY 10468, USA; (C.A.T.); (L.H.); (C.P.C.)
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Lauren Harlow
- Spinal Cord Damage Research Center, Bronx, NY 10468, USA; (C.A.T.); (L.H.); (C.P.C.)
| | - Christopher P. Cardozo
- Spinal Cord Damage Research Center, Bronx, NY 10468, USA; (C.A.T.); (L.H.); (C.P.C.)
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Medical Service, James J. Peters VA Medical Center, Bronx, NY 10468, USA
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North N, Adams A. Neurogenic Shock: A Case Report. J Emerg Nurs 2023; 49:495-498. [PMID: 37393074 DOI: 10.1016/j.jen.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/07/2023] [Accepted: 04/01/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Neurogenic shock is a life-threatening emergency associated with spinal cord injuries. Early cervical spine immobilization to reduce the risk of neurogenic shock is imperative. In addition, early recognition and treatment of neurogenic shock are essential to prevent hypoperfusion-related injuries and death. CASE PRESENTATION This case outlines a 65-year-old male who experienced a cervical spine fracture after a motorcycle crash. The patient received stabilizing treatment by a flight crew consisting of both a registered nurse and paramedic. After assessment and stabilization, he was diagnosed as having neurogenic shock. Despite invasive treatment and resuscitation efforts, the patient succumbed to his injuries. CONCLUSION It is important for emergency nurses to quickly identify the risk factors for cervical spine injuries and maintain cervical spine immobilization to minimize the risk of neurogenic shock.
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Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock. Anesthesiol Clin 2023; 41:1-25. [PMID: 36871993 DOI: 10.1016/j.anclin.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.
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Sneij A, Farkas GJ, Carino Mason MR, Gater DR. Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers. J Pers Med 2022; 12:2029. [PMID: 36556250 PMCID: PMC9786330 DOI: 10.3390/jpm12122029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/31/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.
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Affiliation(s)
- Alicia Sneij
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, P.O. Box 016960 (C-206), Miami, FL 33101, USA
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33101, USA
| | - Gary J. Farkas
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, P.O. Box 016960 (C-206), Miami, FL 33101, USA
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33101, USA
| | - Marisa Renee Carino Mason
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, P.O. Box 016960 (C-206), Miami, FL 33101, USA
| | - David R. Gater
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, P.O. Box 016960 (C-206), Miami, FL 33101, USA
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33101, USA
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- South Florida Spinal Cord Injury Model System, University of Miami Miller School of Medicine, Miami, FL 33101, USA
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Liu G, Tan JH, Kong JC, Tan YHJ, Kumar N, Liang S, Shawn SJS, Ting CS, Lim LL, Dennis HHW, Kumar N, Thambiah J, Wong HK. Thoracolumbar Injury Classification and Severity Score Is Predictive of Perioperative Adverse Events in Operatively Treated Thoracic and Lumbar Fractures. Asian Spine J 2022; 16:848-856. [PMID: 36599371 PMCID: PMC9827217 DOI: 10.31616/asj.2021.0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 01/03/2022] [Indexed: 12/31/2022] Open
Abstract
STUDY DESIGN A retrospective cohort study of patients with surgically treated thoracolumbar fractures. PURPOSE This study aimed to describe the incidence of adverse events (AEs) after surgical stabilization of thoracolumbar spine injuries and to identify predictive factors for the occurrence of AEs. OVERVIEW OF LITERATURE Thoracolumbar spine fractures are frequently present in patients with blunt trauma and are associated with significant morbidity. AEs can occur due to the initial spinal injury or secondary to surgical treatment. There is a lack of emphasis in the literature on the AEs that can occur after operative management of thoracolumbar fractures. METHODS We performed a retrospective review of 199 patients with surgically treated thoracolumbar fractures operated between January 2007 and January 2018. The potential risk factors for the development of AEs as well as the development of common complications were evaluated by univariate analysis, and a multivariate logistic regression analysis was performed to identify independent risk factors predictive of the above. RESULTS The overall rate of AEs was 46.7%; 83 patients (41.7%) had nonsurgical AEs, whereas 24 (12.1%) had surgical adverse events. The most common AEs were urinary tract infections in 43 patients (21.6%), and hospital-acquired pneumonia in 21 patients (10.6%). On multivariate logistic regression, a Thoracolumbar Injury Classification and Severity (TLICS) score of 8-10 (odds ratio [OR], 6.39; 95% confidence interval [CI], 2.33-17.51), the presence of polytrauma (OR, 2.64; 95% CI, 1.17-5.99), and undergoing open surgery (OR, 2.31; 95% CI, 1.09-4.88) were significant risk factors for AEs. The absence of neurological deficit was associated with a lower rate of AEs (OR, 0.47; 95% CI, 0.31-0.70). CONCLUSIONS This study suggests the presence of polytrauma, preoperative American Spinal Injury Association score, and TLICS score are predictive of AEs in patients with surgically treated thoracolumbar fractures. The results might also suggest a role for minimally invasive surgical methods in reducing AEs in these patients.
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Affiliation(s)
- Gabriel Liu
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore,Corresponding author: Gabriel Liu University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore Tel: +65-677224330, Fax: +65-67780720, E-mail:
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Jun Cheong Kong
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Yong Hao Joel Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Nishant Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Shen Liang
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Chiu Shi Ting
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lau Leok Lim
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Hey Hwee Weng Dennis
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Joseph Thambiah
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Hee-Kit Wong
- University Spine Centre, Department of Orthopaedic Surgery, National University Hospital, Singapore
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7
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Wilton A. Risk Factors for Postoperative Complications and In-Hospital Mortality Following Surgery for Cervical Spinal Cord Injury. Cureus 2022; 14:e31960. [DOI: 10.7759/cureus.31960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 11/29/2022] Open
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8
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Pascoal A, Lourenço C, Pires C, Paiva A, Vaz IM. Good Bronchial Hygiene Reaches the Left Lung: Successful Extubation in a Tetraplegic Patient With Spinal Cord Injury. Cureus 2022; 14:e28732. [PMID: 36211093 PMCID: PMC9531700 DOI: 10.7759/cureus.28732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 11/05/2022] Open
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9
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Costa F, Sharif S, Bajamal AH, Shaikh Y, Anania CD, Zileli M. Clinical and Radiological Factors Affecting Thoracolumbar Fractures Outcome: WFNS Spine Committee Recommendations. Neurospine 2022; 18:693-703. [PMID: 35000322 PMCID: PMC8752690 DOI: 10.14245/ns.2142518.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/16/2021] [Indexed: 11/19/2022] Open
Abstract
To obtain a list of recommendations about clinical and radiological factors affecting outcome in thoraco-lumbar fractures with the aim of helping spine surgeons in daily practice. A systematic literature search in PubMed and Google Scholar database was done from 2010 to 2020 on the topic "thoracolumbar fracture AND radiology AND surgical outcomes" and "thoracolumbar fracture AND radiology AND surgical outcomes." A total of 58 papers were analyzed and WFNS (World Federation of Neurosurgical Societies) Spine Committee organized 2 consensus meetings to formulate the specific recommendations the first in Peshawar in December 2019 and in a subsequent virtual meeting in June 2020 to reach an agreement. Both meetings utilized the Delphi method to analyze preliminary literature review statements based on the current evidence levels to generate recommendations through a comprehensive voting session. Eight statements were presented and reached the consensus about this topic. A variety of clinical factors is known to influence outcome of patients with thoracolumbar fractures. Some of these are well-known established factors such as blood pressure augmentation and patient age, while some are not well studied. Overall, the quality of evidence is low and we need more randomized controlled studies to validate our results. Similarly, radiological factors that can predict outcome are well stated and there is a high accordance worldwide. In reverse, still under debate is the application to choose which surgical treatment is advisable based on them.
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Affiliation(s)
- Francesco Costa
- IRCCS Humanitas Research Hospital, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Abdul Hafid Bajamal
- Division of Neuro-Spine, Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Airlangga, Indonesia.,Airlangga University Hospital, Surabaya, Indonesia
| | - Yousuf Shaikh
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | | | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Izmir, Turkey
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10
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In-hospital mortality in people with complete acute traumatic spinal cord injury at a tertiary care center in India-a retrospective analysis. Spinal Cord 2022; 60:210-215. [PMID: 34172928 PMCID: PMC8231086 DOI: 10.1038/s41393-021-00657-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
STUDY DESIGN This is a retrospective study. OBJECTIVES To analyze the causes and risk factors of mortality in people admitted with complete acute traumatic spinal cord injury (ATSCI). SETTING The study was performed at the Indian Spinal Injuries Centre, New Delhi. METHODS Data between 2000 and 2016 were retrospectively collected from case records of people with ATSCI. Risk factors for mortality were examined using multivariable logistic regression. RESULTS Mortality rate in ATSCI admissions (n = 758) during the study period was 10%. Median (IQR) age of study participants was 34 (21) years with a range of 14-85 years. Respiratory complications, septicemia, and cardiovascular causes were responsible for 42%, 28, and 18% of deaths. Mortality rate in people with paraplegia and tetraplegia was 3% and 22%, respectively. The proportion surviving at 6 weeks was significantly different across people with paraplegia and people with high and low tetraplegia (p < 0.001). Greater age (OR (multivariable models) = 1.03, 95% CI = 1.01-1.06), associated injuries (OR = 2.42, 95% CI = 1.11-5.27), high tetraplegia (OR = 5.09, 95% CI = 2.21-11.72), low tetraplegia (OR = 4.84, 95% CI = 1.29-18.09), need for ventilator support (OR = 31.32, 95% CI = 14.92-65.35), septicemia (OR = 4.60, 95% CI = 1.05-20.07), respiratory complications (OR = 3.46, 95% CI = 1.63-7.33), and cardiovascular causes (OR = 39.03, 95% CI = 8.29-183.89) were significant risk factors associated with mortality. CONCLUSION Respiratory complications, septicemia, and cardiovascular causes were the commonest causes of in-hospital mortality in people with complete ATSCI. Greater age, presence of associated injuries, tetraplegia, and ventilator support were risk factors significantly associated with mortality. To reduce morbidity and mortality in the acute phase, there is a need to focus on respiratory management and prevention of infections, especially in tetraplegics.
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11
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Almeida CA, Torres-Espin A, Huie JR, Sun D, Noble-Haeusslein LJ, Young W, Beattie MS, Bresnahan JC, Nielson JL, Ferguson AR. Excavating FAIR Data: the Case of the Multicenter Animal Spinal Cord Injury Study (MASCIS), Blood Pressure, and Neuro-Recovery. Neuroinformatics 2022; 20:39-52. [PMID: 33651310 PMCID: PMC9015816 DOI: 10.1007/s12021-021-09512-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 01/07/2023]
Abstract
Meta-analyses suggest that the published literature represents only a small minority of the total data collected in biomedical research, with most becoming 'dark data' unreported in the literature. Dark data is due to publication bias toward novel results that confirm investigator hypotheses and omission of data that do not. Publication bias contributes to scientific irreproducibility and failures in bench-to-bedside translation. Sharing dark data by making it Findable, Accessible, Interoperable, and Reusable (FAIR) may reduce the burden of irreproducible science by increasing transparency and support data-driven discoveries beyond the lifecycle of the original study. We illustrate feasibility of dark data sharing by recovering original raw data from the Multicenter Animal Spinal Cord Injury Study (MASCIS), an NIH-funded multi-site preclinical drug trial conducted in the 1990s that tested efficacy of several therapies after a spinal cord injury (SCI). The original drug treatments did not produce clear positive results and MASCIS data were stored in boxes for more than two decades. The goal of the present study was to independently confirm published machine learning findings that perioperative blood pressure is a major predictor of SCI neuromotor outcome (Nielson et al., 2015). We recovered, digitized, and curated the data from 1125 rats from MASCIS. Analyses indicated that high perioperative blood pressure at the time of SCI is associated with poorer health and worse neuromotor outcomes in more severe SCI, whereas low perioperative blood pressure is associated with poorer health and worse neuromotor outcome in moderate SCI. These findings confirm and expand prior results that a narrow window of blood-pressure control optimizes outcome, and demonstrate the value of recovering dark data for assessing reproducibility of findings with implications for precision therapeutic approaches.
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Affiliation(s)
- Carlos A Almeida
- Department of Neurological Surgery, Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California San Francisco, San Francisco, CA, USA
| | - Abel Torres-Espin
- Department of Neurological Surgery, Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California San Francisco, San Francisco, CA, USA
| | - J Russell Huie
- Department of Neurological Surgery, Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California San Francisco, San Francisco, CA, USA
| | - Dongming Sun
- W.M. Keck Center for Collaborative Neuroscience, Rutgers University, New Brunswick, NJ, USA
| | - Linda J Noble-Haeusslein
- Department of Neurology, University of Texas, Austin, TX, USA
- Department of Psychology, University of Texas, Austin, TX, USA
| | - Wise Young
- W.M. Keck Center for Collaborative Neuroscience, Rutgers University, New Brunswick, NJ, USA
| | - Michael S Beattie
- Department of Neurological Surgery, Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California San Francisco, San Francisco, CA, USA
| | - Jacqueline C Bresnahan
- Department of Neurological Surgery, Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California San Francisco, San Francisco, CA, USA
| | - Jessica L Nielson
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA.
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA.
| | - Adam R Ferguson
- Department of Neurological Surgery, Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California San Francisco, San Francisco, CA, USA.
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
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12
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Kripa KC, Khanal S. Use of midodrine and fludrocortisone in neurogenic shock: A case report. Ann Med Surg (Lond) 2021; 70:102811. [PMID: 34603715 PMCID: PMC8463817 DOI: 10.1016/j.amsu.2021.102811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 10/27/2022] Open
Abstract
Our case report includes a 42 year old male who had C6-C7 fracture dislocation with complete spinal cord injury following a motor vehicle accident. The patient underwent combined anterior and posterior fixation of the cervical spine. However, the patient had hypotension as a part of neurogenic shock and required vasopressor to maintain mean arterial pressure. The patient was treated in Intensive Care Unit with noradrenaline infusion to maintain mean arterial pressure but it was really challenging to stop the vasopressor. The patient was started on oral Midodrine and Fludrocortisone; vasopressor dose was tapered and finally stopped.
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Affiliation(s)
- K C Kripa
- Department of Critical Care, Grande International Hospital, Kathmandu, Nepal
| | - Sushil Khanal
- Department of Critical Care, Grande International Hospital, Kathmandu, Nepal
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13
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Zhang XY, Yu WY, Teng WJ, Song YC, Yang DG, Liu HW, Liu SH, Li XB, Wang WZ, Li JJ. Effect of vocal respiratory training on respiratory function and respiratory neural plasticity in patients with cervical spinal cord injury: a randomized controlled trial. Neural Regen Res 2021; 17:1065-1071. [PMID: 34558534 PMCID: PMC8552850 DOI: 10.4103/1673-5374.324856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In previous studies, researchers have used singing to treat respiratory function in patients with spinal cord injury. However, few studies have examined the way in which vocal training affects respiratory neural plasticity in patients with spinal cord injury. Vocal respiratory training (VRT) is a type of vocal muscle-related treatment that is often a component of music therapy (MT) and focuses on strengthening respiratory muscles and improving lung function. In this randomized controlled study, we analyzed the therapeutic effects of VRT on respiratory dysfunction at 3 months after cervical spinal cord injury. Of an initial group of 37 patients, 26 completed the music therapy intervention, which comprised five 30-minute sessions per week for 12 weeks. The intervention group (n = 13) received VRT training delivered by professional certified music therapists. The control group (n = 13) received respiratory physical therapy delivered by professional physical therapists. Compared with the control group, we observed a substantial increase in respiratory function in the intervention group after the 12-week intervention. Further, the nerve fiber bundles in the respiratory center in the medulla exhibited a trend towards increased diversification, with an increased number, path length, thickness, and density of nerve fiber bundles. These findings provide strong evidence for the effect of music therapeutic VRT on neural plasticity. This study was approved by the Ethics Committee of China Rehabilitation Research Center (approval No. 2020-013-1) on April 1, 2020, and was registered with the Chinese Clinical Trial Registry (registration No. ChiCTR2000037871) on September 2, 2020.
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Affiliation(s)
- Xiao-Ying Zhang
- School of Rehabilitation Medicine, Capital Medical University; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; Music Therapy Center, Department of Psychology, China Rehabilitation Research Center, Beijing, China
| | - Wei-Yong Yu
- School of Rehabilitation Medicine, Capital Medical University; Department of Imaging, China Rehabilitation Research Center, Beijing, China
| | - Wen-Jia Teng
- School of Rehabilitation Medicine, Capital Medical University; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
| | - Yi-Chuan Song
- School of Rehabilitation Medicine, Capital Medical University; Music Therapy Center, Department of Psychology, China Rehabilitation Research Center, Beijing, China
| | - De-Gang Yang
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Functional Reconstruction, China Rehabilitation Research Center, Beijing, China
| | - Hong-Wei Liu
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Functional Reconstruction, China Rehabilitation Research Center, Beijing, China
| | - Song-Huai Liu
- School of Rehabilitation Medicine, Capital Medical University; Music Therapy Center, Department of Psychology, China Rehabilitation Research Center, Beijing, China
| | - Xiao-Bing Li
- Department of Music Artificial Intelligence and Music Scientific Technology, Central Conservatory of Music, Beijing, China
| | - Wen-Zhu Wang
- School of Rehabilitation Medicine, Capital Medical University; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
| | - Jian-Jun Li
- School of Rehabilitation Medicine, Capital Medical University; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
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14
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Seelig J, Heller RA, Haubruck P, Sun Q, Georg Klingenberg J, Hackler J, Crowell HL, Daniel V, Moghaddam A, Schomburg L, Biglari B. Selenium-Binding Protein 1 (SELENBP1) as Biomarker for Adverse Clinical Outcome After Traumatic Spinal Cord Injury. Front Neurosci 2021; 15:680240. [PMID: 34140879 PMCID: PMC8204909 DOI: 10.3389/fnins.2021.680240] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Traumatic spinal cord injury (TSCI) presents a diagnostic challenge as it may have dramatic consequences for the affected patient. Additional biomarkers are needed for improved care and personalized therapy. Objective: Serum selenium binding protein 1 (SELENBP1) has been detected in myocardial infarction, reflecting hypoxic tissue damage and recovery odds. As SELENBP1 is usually not detected in the serum of healthy subjects, we tested the hypothesis that it may become detectable in TSCI and indicate tissue damage and regeneration odds. Methods: In this prospective observational study, patients with comparable injuries were allocated to three groups; vertebral body fractures without neurological impairment (control “C”), TSCI without remission (“G0”), and TSCI with signs of remission (“G1”). Consecutive serum samples were available from different time points and analyzed for SELENBP1 by sandwich immunoassay, for trace elements by X-ray fluorescence and for cytokines by multiplex immunoassays. Results: Serum SELENBP1 was elevated at admission in relation to the degree of neurological impairment [graded as A, B, C, or D according to the American Spinal Injury Association (AISA) impairment scale (AIS)]. Patients with the most severe neurological impairment (classified as AIS A) exhibited the highest SELENBP1 concentrations (p = 0.011). During the first 3 days, SELENBP1 levels differed between G0 and G1 (p = 0.019), and dynamics of SELENBP1 correlated to monocyte chemoattractant protein 1, chemokine ligand 3 and zinc concentrations. Conclusion: Circulating SELENBP1 concentrations are related to the degree of neurological impairment in TSCI and provide remission odds information. The tight correlation of SELENBP1 with CCL2 levels provides a novel link between Se metabolism and immune cell activation, with potential relevance for neurological damage and regeneration processes, respectively.
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Affiliation(s)
- Julian Seelig
- Institute for Experimental Endocrinology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Raban Arved Heller
- Institute for Experimental Endocrinology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Heidelberg Trauma Research Group, Department of Trauma and Reconstructive Surgery, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Patrick Haubruck
- Heidelberg Trauma Research Group, Department of Trauma and Reconstructive Surgery, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Raymond Purves Bone and Joint Research Laboratories, Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, St Leonards, NSW, Australia
| | - Qian Sun
- Institute for Experimental Endocrinology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Jochen Georg Klingenberg
- Institute for Experimental Endocrinology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Julian Hackler
- Institute for Experimental Endocrinology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Helena Lucia Crowell
- SIB Swiss Institute of Bioinformatics, University of Zurich, Zurich, Switzerland.,Systems Biology Ph.D. Program, Life Science Zurich Graduate School, ETH Zürich and University of Zurich, Zurich, Switzerland
| | - Volker Daniel
- Transplantation Immunology, Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arash Moghaddam
- Aschaffenburg Trauma and Orthopaedic Research Group, Centre for Orthopaedics, Trauma Surgery and Sports Medicine, Hospital Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Bahram Biglari
- Department of Paraplegiology, BG Trauma Centre Ludwigshafen, Ludwigshafen, Germany
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15
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Kish B, Herr S, Yang HCS, Sun S, Shi R, Tong Y. Whole body measurements using near-infrared spectroscopy in a rat spinal cord contusion injury model. J Spinal Cord Med 2021; 46:508-520. [PMID: 33890843 PMCID: PMC10116927 DOI: 10.1080/10790268.2021.1911504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Spinal cord injuries cause great damage to the central nervous system as well as the peripheral vasculature. While treatments for spinal cord injury typically focus on the spine itself, improvements in the function of the peripheral vasculature after spinal cord injury have shown to improve overall neurological recovery. OBJECTIVE This study focused on the use of near-infrared spectroscopy (NIRS) as a mode to monitor cerebral and peripheral vascular condition non-invasively during the recovery process. DESIGN Animal research study. METHODS Rats underwent spinal contusion or sham injury and relative concentrations of de-/oxyhemoglobin (Δ[HbO]/Δ[Hb]) over time were measured over the cerebral, spinal, and pedal regions via NIRS. Correlational relationships across the body were determined. Rats received 1 NIRS measurement before injury and 3 after injury: 4, 7, and 14 days post. RESULTS Correlational relationships between signals across the body, between animals with and without spinal cord injury, indicate that NIRS was able to detect patterns of vascular change in the spine and the periphery occurring secondary to spinal cord injury and evolving during subsequent recovery. Additionally, NIRS determined an overall correlational decrease within the central nervous system, between spinal and cerebral measurements. CONCLUSION NIRS was able to closely reflect physiologic changes in the rat during recovery, demonstrating a promising method to monitor whole body hemodynamics after spinal cord injury.
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Affiliation(s)
- Brianna Kish
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Seth Herr
- Center for Paralysis Research and Department of Basic Medical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| | - Ho-Ching Shawn Yang
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Siyuan Sun
- Center for Paralysis Research and Department of Basic Medical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| | - Riyi Shi
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA.,Center for Paralysis Research and Department of Basic Medical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| | - Yunjie Tong
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
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16
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Weinberg JA, Farber SH, Kalamchi LD, Brigeman ST, Bohl MA, Varda BM, Sioda NA, Radosevich JJ, Chapple KM, Snyder LA. Mean arterial pressure maintenance following spinal cord injury: Does meeting the target matter? J Trauma Acute Care Surg 2021; 90:97-106. [PMID: 33003016 DOI: 10.1097/ta.0000000000002953] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Neurosurgical guidelines recommend maintaining mean arterial pressure (MAP) between 85 and 90 mm Hg following acute spinal cord injury (SCI). In our hospital, SCI patients receive orders for MAP targeting for 72 hours following admission, but it is unclear how often the patient's MAP meets the target and whether or not this affects outcome. We hypothesized that the proportion of MAP measurements ≥85 mm Hg would be associated with neurologic recovery. METHODS Spinal cord injury patients with blunt mechanism of injury admitted between 2014 and 2019 were identified from the registry of a level 1 trauma center. Proportion of MAP values ≥85 mm Hg was calculated for each patient. Neurologic improvement, as measured by positive change in American Spinal Injury Association (ASIA) impairment scale by ≥1 level from admission to discharge was evaluated with respect to proportion of elevated MAP values. RESULTS A total of 136 SCI patients were evaluated. Average proportion of elevated MAP values was 75%. Admission ASIA grades were as follows: A, 30 (22.1%); B, 20 (14.7%); C, 28 (20.6%); and D, 58 (42.6%). One hundred six patients (77.9%) required vasopressors to elevate MAP (ASIA A, 86.7%; B, 95.0%; C, 92.9%; D, 60.3%). Forty patients (29.4%) were observed to have improvement in ASIA grade by discharge (admission ASIA A, 15%; B, 33%; C, 40%; D, 13%). The proportion of elevated MAP values was higher for patients with neurologic improvement (0.81 ± 0.15 vs. 0.72 ± 0.25, p = 0.014). Multivariate modeling demonstrated a significant association between proportion of elevated MAP values and neurologic improvement (p = 0.028). An interaction revealed this association to be moderated by vasopressor dose (p = 0.032). CONCLUSION The proportion of MAP measurements ≥85 mm Hg was determined to be an independent predictor of neurologic improvement. Increased vigilance regarding MAP maintenance above 85 mm Hg is warranted to optimize neurologic recovery following SCI. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Jordan A Weinberg
- From the Department of Surgery (J.A.W., L.D.K., B.M.V., N.A.S., K.M.C.), Creighton University School of Medicine, St. Joseph's Hospital and Medical Center; Department of Neurosurgery (S.H.F., S.T.B., M.A.B., L.A.S.), Barrow Neurological Institute; and St. Joseph's Hospital and Medical Center, Phoenix, Arizona (J.J.R.)
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17
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Abstract
Individuals with spinal cord injury (SCI) are at increased risk of respiratory complications during wake and sleep. Sleep-disordered breathing (SDB) is commonly associated with SCI and requires an individualized approach to its management. Respiratory control plays a key role in the pathogenesis of SDB in cervical SCI. Noninvasive ventilation plays an important role in the management of respiratory complications in individuals with SCI acutely and in chronic phases. Positive airway pressure treatment may be effective in eliminating SDB and improving sleepiness symptoms, but adherence to treatment is poor and effect on long-term outcomes is questionable.
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Affiliation(s)
- Asil Daoud
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Samran Haider
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Abdulghani Sankari
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University, 3990 John R, 3-Hudson, Detroit, MI 48201, USA; Ascension Providence Hospital, Southfield, MI, USA.
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18
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Haldrup M, Dyrskog S, Thygesen MM, Kirkegaard H, Kasch H, Rasmussen MM. Initial blood pressure is important for long-term outcome after traumatic spinal cord injury. J Neurosurg Spine 2020; 33:256-260. [PMID: 32197239 DOI: 10.3171/2020.1.spine191005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with traumatic spinal cord injury (TSCI) are at risk of developing neurogenic shock that causes hypotension and thereby secondary injury to the spinal cord due to ischemia. Hemodynamic treatment of patients with acute TSCI remains inadequately elucidated. Guidelines for management are divergent and based on limited evidence. To this end, the authors evaluated whether mean arterial blood pressure (MABP) during the prehospital and initial hospital phases of TSCI treatment is correlated with long-term neurological outcome. METHODS The authors performed a retrospective cohort study based on a chart review of MABP data collected during the prehospital transport, in the operating room (OR), and in the neurointensive care unit (NICU) during the first 7 days after trauma. Data from the NICU were divided into two periods: days 1-2 and days 3-7. Data were analyzed using Spearman's rank correlation to evaluate for any correlation between MABP and changes in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) score 1 year postinjury. In the analysis, the MABP target value was 80 mm Hg. Hypotension was treated with metaoxedrin or norepinephrine. Statistically significant differences were evaluated using Spearman's rank correlation coefficient. RESULTS The chart review yielded 129 patients treated for TSCI. The inclusion period was 2010-2017. For the prehospital transport measurements of MABP, the Spearman's rank correlation coefficient was a rho of 0.5662 (p < 0.001), for OR measurements it was a rho of 0.6818 (p < 0.001), and for the NICU measurements it was a rho of 0.4611 (p < 0.001); for NICU unit days 1-2 and days 3-7, the Spearman's rank correlation coefficient was a rho of 0.2209 (p = 0.0681). CONCLUSIONS Continuous MABP levels exceeding 80 mm Hg have a significant impact on neurological outcome-from earliest possible stabilization in the prehospital care, through hospital admission, the surgical phase, and into the first 2 days in the NICU.
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Affiliation(s)
- Mette Haldrup
- 1Department of Neurosurgery, CENSE-Spine, Aarhus University Hospital
| | - Stig Dyrskog
- 2Department of Neuro-Intensive Care, Aarhus University Hospital
| | | | | | - Helge Kasch
- 4Department of Clinical Medicine, Spinal Cord Injury Center of Western Denmark, Aarhus, Denmark
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19
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Jang WH, Lee SB, Kim DW, Lee YH, Uhm YJ, Yang SW, Kim JH, Kim JB. ICT-Based Health Care Services for Individuals with Spinal Cord Injuries: A Feasibility Study. SENSORS 2020; 20:s20092491. [PMID: 32354052 PMCID: PMC7249337 DOI: 10.3390/s20092491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/15/2020] [Accepted: 04/24/2020] [Indexed: 11/16/2022]
Abstract
In the Republic of Korea, 90.5% of those living with spinal cord injury (SCI) are faced with medical complications that require chronic care. Some of the more common ones include urinary tract infections, pressure sores, and pain symptomatology. These and other morbidities have been recognized to deteriorate the individual's health, eventually restricting their community participation. Telerehabilitation, using information and communication technology, has propelled a modern-day movement in providing comprehensive medical services to patients who have difficulty in mobilizing themselves to medical care facilities. This study aims to verify the effectiveness of health care and management in the SCI population by providing ICT-based health care services. We visited eight individuals living with chronic SCI in the community, and provided ICT-based health management services. After using respiratory and urinary care devices with the provision of home visit occupational therapy, data acquisition was achieved and subsequently entered into a smart device. The entered information was readily accessible to the necessary clinicians and researchers. The clients were notified if there were any concerning results from the acquired data. Subsequently, they were advised to follow up with their providers for any immediate medical care requirements. Digital hand-bike ergometers and specialized seating system cushions are currently in development. The ICT-based health care management service for individuals with SCI resulted in a favorable expected level of outcome. Based on the results of this study, we have proposed and are now in preparation for a randomized clinical trial.
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Affiliation(s)
- Wan-ho Jang
- Department of Occupational Therapy, The Graduate School, Yonsei University, Wonju 26493, Korea; (W.-h.J.); (D.-w.K.); (Y.-h.L.)
| | - Seung-bok Lee
- Clinical Team, Yonsei Enabling Science and Technology Research Center, Wonju 26493, Korea; (S.-b.L.); (S.-w.Y.)
| | - Dong-wan Kim
- Department of Occupational Therapy, The Graduate School, Yonsei University, Wonju 26493, Korea; (W.-h.J.); (D.-w.K.); (Y.-h.L.)
| | - Yun-hwan Lee
- Department of Occupational Therapy, The Graduate School, Yonsei University, Wonju 26493, Korea; (W.-h.J.); (D.-w.K.); (Y.-h.L.)
| | - Yun-jeong Uhm
- Department of Ergonomic Therapy, The Graduate School of Health and Environment, Yonsei University, Wonju 26493, Korea;
| | - Seung-wan Yang
- Clinical Team, Yonsei Enabling Science and Technology Research Center, Wonju 26493, Korea; (S.-b.L.); (S.-w.Y.)
| | - Jeong-hyun Kim
- Usability Center, Yonsei Enabling Science Technology Research Center, Wonju 26493, Korea;
| | - Jong-bae Kim
- Department of Occupational Therapy, College of Health Science, Yonsei University, Wonju 26493, Korea
- Correspondence:
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20
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Evaniew N, Mazlouman SJ, Belley-Côté EP, Jacobs WB, Kwon BK. Interventions to Optimize Spinal Cord Perfusion in Patients with Acute Traumatic Spinal Cord Injuries: A Systematic Review. J Neurotrauma 2020; 37:1127-1139. [PMID: 32024432 DOI: 10.1089/neu.2019.6844] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Interventions to optimize spinal cord perfusion via support of mean arterial pressure (MAP) or spinal cord perfusion pressure (SCPP) are thought to play a critical role in the management of patients with acute traumatic spinal cord injuries, but there is ongoing controversy about efficacy and safety. We aimed to determine the effects of optimizing spinal cord perfusion on neurological recovery and risks for adverse events. We searched multiple databases for published and unpublished reports. Two reviewers independently screened articles, extracted data, and evaluated risk of bias. We synthesized data and evaluated confidence in anticipated treatment effects according to the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. We identified 20 eligible observational studies and 1 eligible randomized controlled trial. According to low or very low quality evidence, the effect of MAP support on neurological recovery after acute traumatic spinal cord injury is uncertain, and the use of vasopressors to support MAP may be associated with increased rates of predominantly cardiac adverse events. Increased SCPP appears likely to be associated with improved neurological recovery, but SCPP monitoring via intradural catheters at the anatomical site of injury may involve increased risks of cerebrospinal fluid leakage requiring revision surgery or pseudomeningocele. No study directly compared the effects of specific MAP goal ranges, SCPP ranges, SCPP monitoring techniques, or durations of treatment. Very low quality evidence suggests that norepinephrine may have less risk of adverse events than dopamine. The current literature is insufficient to make strong recommendations about interventions to support spinal cord perfusion via MAP or SCPP goals in patients with acute traumatic spinal cord injuries. Data are compatible with a variety of treatment decisions, and individualized approaches may be optimal. Further investigation to clarify the risks, benefits, and alternatives to MAP or SCPP support in this population is warranted.
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Affiliation(s)
- Nathan Evaniew
- Vancouver Spine Surgery Institute (VSSI), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Shahriar J Mazlouman
- International Collaboration on Repair Discoveries (ICORD), Department of Orthopaedics, Vancouver, British Columbia, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - W Bradley Jacobs
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Brian K Kwon
- Vancouver Spine Surgery Institute (VSSI), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries (ICORD), Department of Orthopaedics, Vancouver, British Columbia, Canada
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21
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Jiang F, Jaja BNR, Kurpad SN, Badhiwala JH, Aarabi B, Grossman RG, Harrop JS, Guest JD, Schär RT, Shaffrey CI, Boakye M, Toups EG, Wilson JR, Fehlings MG. Acute Adverse Events After Spinal Cord Injury and Their Relationship to Long-term Neurologic and Functional Outcomes: Analysis From the North American Clinical Trials Network for Spinal Cord Injury. Crit Care Med 2019; 47:e854-e862. [PMID: 31389834 DOI: 10.1097/ccm.0000000000003937] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There are few contemporary, prospective multicenter series on the spectrum of acute adverse events and their relationship to long-term outcomes after traumatic spinal cord injury. The goal of this study is to assess the prevalence of adverse events after traumatic spinal cord injury and to evaluate the effects on long-term clinical outcome. DESIGN Multicenter prospective registry. SETTING Consortium of 11 university-affiliated medical centers in the North American Clinical Trials Network. PATIENTS Eight-hundred one spinal cord injury patients enrolled by participating centers. INTERVENTIONS Appropriate spinal cord injury treatment at individual centers. MEASUREMENTS AND MAIN RESULTS A total of 2,303 adverse events were recorded for 502 patients (63%). Penalized maximum logistic regression models were fitted to estimate the likelihood of neurologic recovery (ASIA Impairment Scale improvement ≥ 1 grade point) and functional outcomes in subjects who developed adverse events at 6 months postinjury. After accounting for potential confounders, the group that developed adverse events showed less neurologic recovery (odds ratio, 0.55; 95% CI, 0.32-0.96) and was more likely to require assisted breathing (odds ratio, 6.55; 95% CI, 1.17-36.67); dependent ambulation (odds ratio, 7.38; 95% CI, 4.35-13.06) and have impaired bladder (odds ratio, 9.63; 95% CI, 5.19-17.87) or bowel function (odds ratio, 7.86; 95% CI, 4.31-14.32) measured using the Spinal Cord Independence Measure subscores. CONCLUSIONS Results from this contemporary series demonstrate that acute adverse events are common and are associated with worsened long-term outcomes after traumatic spinal cord injury.
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Affiliation(s)
- Fan Jiang
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
- Division of Orthopaedic Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Blessing N R Jaja
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Shekar N Kurpad
- Division of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jetan H Badhiwala
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Bizhan Aarabi
- Division of Neurosurgery, Shock Trauma, University of Maryland, Baltimore, MD
| | | | - James S Harrop
- Division of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jim D Guest
- Division of Neurosurgery, University of Miami, Miami, FL
| | - Ralph T Schär
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Chris I Shaffrey
- Division of Neurosurgery, University of Virginia, Chalottesville, VA
| | - Max Boakye
- Division of Neurosurgery, University of Louisville, Louisville, KY
| | | | - Jefferson R Wilson
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
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22
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Sun H, Wilson J, Roach MJ, Hefzy MS, Nemunaitis G. Demonstration of pressure reduction in a new proof of concept spine board. Assist Technol 2019; 33:341-349. [PMID: 31437094 DOI: 10.1080/10400435.2019.1658658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Pressure injuries are a significant problem following spinal cord injury (SCI). High interface pressures while lying on a spine board during emergency transport appear to play a major role in their formation. The aim of the present study was to assess the interface pressures and sensing area between the body and the standard spine board (SSB) and a proof of concept spine board prototype (P-5). Twenty-one able-bodied subjects were assessed on each board. Interface pressures and sensing area were recorded every minute over 15 min. The mean peak pressure was higher on the SSB at the head, scapulothoracic (S-T), sacroiliac (S-I), and heels (227.6 mmHg, 148.9 mmHg, 360.3 mmHg, and 179.3 mmHg) compared to P-5 (51.9 mmHg, 60.1 mmHg, 66.8 mmHg, and 60.2 mmHg). The peak pressure index (PPI) at the head, S-T and S-I was higher on the SSB (100.2 mmHg, 101.6 mmHg, and 270.6 mmHg) compared to P-5 (41.6 mmHg, 51.9 mmHg and 58.7 mmHg). An analysis using pairwise comparisons for repeated measures showed that interface pressures (p < .05) and PPI (p < .001) were reduced at all locations. Modifications of a spine board incorporated in P-5 can dramatically reduce interface pressures and reduce pressure injury formation.
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Affiliation(s)
- Helen Sun
- Case Western Reserve University School of Medicine , Cleveland , Ohio , USA
| | - James Wilson
- Case Western Reserve University School of Medicine , Cleveland , Ohio , USA.,Department of Physical Medicine and Rehabilitation, Veterans Affairs Northeast Ohio Healthcare System , Cleveland , OH , USA
| | - Mary Joan Roach
- Case Western Reserve University School of Medicine , Cleveland , Ohio , USA.,MetroHealth Rehabilitation Institute, Cleveland , Ohio , USA.,Center for Health Research and Policy , Cleveland , Ohio , USA
| | - Mohamed Samir Hefzy
- Department of Mechanical, Industrial and Manufacturing Engineering, University of Toledo , Toledo , Ohio , USA
| | - Greg Nemunaitis
- Case Western Reserve University School of Medicine , Cleveland , Ohio , USA.,Center for Health Research and Policy , Cleveland , Ohio , USA
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23
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Abstract
OBJECTIVES To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU. DATA SOURCES AND STUDY SELECTION A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord. DATA EXTRACTION AND DATA SYNTHESIS The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries. CONCLUSIONS The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.
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24
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Bottasso E. Toward the Existence of a Sympathetic Neuroplasticity Adaptive Mechanism Influencing the Immune Response. A Hypothetical View-Part II. Front Endocrinol (Lausanne) 2019; 10:633. [PMID: 31620088 PMCID: PMC6760024 DOI: 10.3389/fendo.2019.00633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/30/2019] [Indexed: 01/16/2023] Open
Abstract
In the preceding work, a hypothesis on the existence of a specific neural plasticity program from sympathetic fibers innervating secondary lymphoid organs was introduced. This proposed adaptive mechanism would involve segmental retraction and degeneration of noradrenergic terminals during the immune system (IS) activation followed by regeneration once the IS returns to the steady-state. Starting from such view, this second part presents clinical and experimental evidence allowing to envision that this sympathetic neural plasticity mechanism is also operative on inflamed non-lymphoid peripheral tissues. Importantly, the sympathetic nervous system regulates most of the physiological bodily functions, ranging from cardiovascular, respiratory and gastro-intestinal functions to endocrine and metabolic ones, among others. Thus, it seems sensible to think that compensatory programs should be put into place during inflammation in non-lymphoid tissues as well, to avoid the possible detrimental consequences of a sympathetic blockade. Nevertheless, in many pathological scenarios like severe sepsis, chronic inflammatory diseases, or maladaptive immune responses, such compensatory programs against noradrenergic transmission impairment would fail to develop. This would lead to a manifest sympathetic dysfunction in the above-mentioned settings, partly accounting for their underlying pathophysiological basis; which is also discussed. The physiological/teleological significance for the whole neural plasticity process is postulated, as well.
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Affiliation(s)
- Emanuel Bottasso
- Departments of Pathology and Physiology, Faculty of Medicine, Centro de Altos Estudios en Ciencias Humanas y de la Salud, Universidad Abierta Interamericana, Rosario, Argentina
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Abstract
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.
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Shadgan B, Macnab A, Fong A, Manouchehri N, So K, Shortt K, Streijger F, Cripton PA, Sayre EC, Dumont GA, Pagano R, Kim KT, Kwon BK. Optical Assessment of Spinal Cord Tissue Oxygenation Using a Miniaturized Near Infrared Spectroscopy Sensor. J Neurotrauma 2019; 36:3034-3043. [PMID: 31044642 DOI: 10.1089/neu.2018.6208] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Despite advances in the treatment of acute spinal cord injury (SCI), measures to mitigate permanent neurological deficits in affected patients are limited. Immediate post-trauma hemodynamic management of patients, to maintain blood supply and improve oxygenation to the injured spinal cord, is currently one aspect of critical care which clinicians can utilize to improve neurological outcomes. However, without a way to monitor the response of spinal cord hemodynamics and oxygenation in real time, optimizing hemodynamic management is challenging and limited in scope. This study aims to investigate the feasibility and validity of using a miniaturized multi-wavelength near-infrared spectroscopy (NIRS) sensor for direct transdural monitoring of spinal cord oxygenation in an animal model of acute SCI. Nine Yorkshire pigs underwent a weight-drop T10 contusion-compression injury and received episodes of ventilatory hypoxia and alterations in mean arterial pressure (MAP). Spinal cord hemodynamics and oxygenation were monitored throughout by a non-invasive transdural NIRS sensor, as well as an invasive intraparenchymal sensor as a comparison. NIRS parameters of tissue oxygenation were highly correlated with intraparenchymal measures of tissue oxygenation. In particular, during periods of hypoxia and MAP alterations, changes of NIRS-derived spinal cord oxygenated hemoglobin and tissue oxygenation percentage corresponded well with the changes in spinal cord oxygen partial pressures measured by the intraparenchymal sensor. Our data confirm that during hypoxic episodes and as changes occur in the MAP, non-invasive NIRS can detect and measure real-time changes in spinal cord oxygenation with a high degree of sensitivity and specificity.
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Affiliation(s)
- Babak Shadgan
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
| | - Andrew Macnab
- Stellenbosch Institute for Advanced Study, Wallenberg Research Centre, Stellenbosch, South Africa
| | - Allan Fong
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
| | - Neda Manouchehri
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
| | - Kitty So
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
| | - Katelyn Shortt
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
| | - Femke Streijger
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
| | - Peter A Cripton
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Orthopaedic and Injury Biomechanics Group, Departments of Mechanical Engineering and Orthopaedics and School of Biomedical Engineering, UBC, Vancouver, British Columbia, Canada
| | - Eric C Sayre
- Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Guy A Dumont
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, British Columbia, Canada
| | - Roberto Pagano
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kyoung-Tae Kim
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Brian K Kwon
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
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Rashnavadi T, Macnab A, Cheung A, Shadgan A, Kwon BK, Shadgan B. Monitoring spinal cord hemodynamics and tissue oxygenation: a review of the literature with special focus on the near-infrared spectroscopy technique. Spinal Cord 2019; 57:617-625. [PMID: 31164734 DOI: 10.1038/s41393-019-0304-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 01/05/2023]
Abstract
STUDY DESIGN Review. OBJECTIVES Clinical studies have shown that the hemodynamic management of patients following acute spinal cord injury (SCI) is an important aspect of their treatment for maintaining spinal cord (SC) perfusion and minimizing ischemic secondary injury to the SC. While this highlights the importance of ensuring adequate perfusion and oxygenation to the injured cord, a method for the real-time monitoring of these hemodynamic measures within the SC is lacking. The purpose of this review is to discuss current and potential methods for SC hemodynamic monitoring with special focus on applications using near-infrared spectroscopy (NIRS). METHODS A literature search using the PubMed database. All peer-reviewed articles on NIRS monitoring of SC published from inception to May 2019 were reviewed. RESULTS Among 125 papers related to SC hemodynamics monitoring, 26 focused on direct/indirect NIRS monitoring of the SC. DISCUSSION Current options for continuous, non-invasive, and real-time monitoring of SC hemodynamics are challenging and limited in scope. As a relatively new technique, NIRS has been successfully used for monitoring human cerebral hemodynamics, and has shown promising results in intraoperative assessment of SC hemodynamics in both human and animal models. Although utilizing NIRS to monitor the SC has been validated, applying NIRS clinically following SCI requires further development and investigation. CONCLUSIONS NIRS is a promising non-invasive technique with the potential to provide real-time monitoring of relevant parameters in the SC. Currently, in its first developmental stages, further clinical and experimental studies are mandatory to ensure the validity and safety of NIRS techniques.
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Affiliation(s)
- Tahereh Rashnavadi
- The University of British Columbia, School of Biomedical Engineering, Vancouver, BC, V6T 1Z1, Canada
| | - Andrew Macnab
- International Collaborations on Repair Discoveries (ICORD), Blusson Spinal Cord Centre, Vancouver, Canada
| | - Amanda Cheung
- International Collaborations on Repair Discoveries (ICORD), Blusson Spinal Cord Centre, Vancouver, Canada
| | - Armita Shadgan
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
| | - Brian K Kwon
- International Collaborations on Repair Discoveries (ICORD), Blusson Spinal Cord Centre, Vancouver, Canada.,Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Babak Shadgan
- The University of British Columbia, School of Biomedical Engineering, Vancouver, BC, V6T 1Z1, Canada. .,International Collaborations on Repair Discoveries (ICORD), Blusson Spinal Cord Centre, Vancouver, Canada. .,Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada.
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Sewell MD, Vachhani K, Hockings J, Chan J, Alrawi A, Williams R. A Hemodynamic Safety Checklist Can Improve Blood Pressure Monitoring in Patients with Acute Spinal Cord Injury. World Neurosurg 2019; 128:e225-e230. [PMID: 31048060 DOI: 10.1016/j.wneu.2019.04.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The American Association and Congress of Neurological Surgeons recommended mean arterial blood pressure (MAP) in patients with acute spinal cord injury (SCI) should be 85-90 mm Hg for the first 7 days. We evaluated whether hemodynamic management differed between a primary-receiving and tertiary hospital in the first 24 hours for patients with acute SCI and assessed whether use of a checklist could improve hemodynamic management. METHODS Observational review was performed of 79 patients with acute SCI before and after introduction of a blood pressure monitoring checklist and staff educational program designed to improve tertiary center management. Hemodynamic management in the primary-receiving hospital was compared with the tertiary center before and after checklist introduction. RESULTS At the primary-receiving center, mean number of documented MAP readings/hour was 2.2 and 3 before and after checklist introduction. The proportion having >50% of MAP recordings <80 mm Hg was 26% and 22%. The proportion having >50% of MAP recordings <70 mm Hg was 8.5% and 7%. At the tertiary center, mean number of MAP readings/hour was 1.3 and 2.7 before and after checklist introduction (P = 0.02). The proportion having >50% of MAP recordings <80 mm Hg decreased from 36.5% to 16% after checklist introduction (P = 0.05). The proportion having >50% of MAP recordings <70 mm Hg decreased from 9% to 5.5% (P = 0.6). Polytrauma, inotrope use, and head injury significantly correlated with low MAP recordings (P < 0.05). Polytrauma was an independent risk predictor for low MAP recordings (P < 0.05). CONCLUSIONS Achieving MAP targets for patients with acute SCI is challenging. Checklist use and staff education were associated with improved hemodynamic management. Presence of polytrauma identified patients at particular risk.
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Affiliation(s)
- Mathew David Sewell
- Spinal Unit, The Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia.
| | - Kathak Vachhani
- Spinal Unit, The Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Jason Hockings
- Spinal Unit, The Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Jonathan Chan
- Spinal Unit, The Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia
| | - Asif Alrawi
- Spinal Unit, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Richard Williams
- Spinal Unit, The Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia
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Sharwood LN, Joseph A, Guo C, Flower O, Ball J, Middleton JW. Heterogeneous emergency department management of published recommendation defined hypotension in patients with acute traumatic spinal cord injury: A multi-centre overview. Emerg Med Australas 2019; 31:967-973. [PMID: 30968575 DOI: 10.1111/1742-6723.13290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 02/20/2019] [Accepted: 03/02/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Evidence-based management for patients with acute traumatic spinal cord injury (TSCI) in the ED has a critical impact on long-term outcomes. Acute hypotension post-injury may compromise spinal cord perfusion and extend neurological damage. Published guidelines recommend mean arterial blood pressure (BP) maintenance between 85 and 90 mmHg for 7 days post-injury; the extent to which this is followed in Australia is unknown. METHODS Prospective observational study of patients ≥16 years with TSCI, treated at 48 hospitals across two Australian states. Mean arterial BPs were recorded in the Ambulance, and ED arrival and discharge. Patients' medical records documented treatment provided (intravenous fluids, vasopressors or both) for BP augmentation. Hypotension was defined as mean arterial BP <85 mmHg, per the American Association of Neurological Surgeons guidelines. RESULTS The 208 patients with TSCI in the present study were more likely to receive BP augmentation if they experienced direct transport to a Spinal Cord Service hospital (OR 5.57, 95% CI 2.32-10.11), had a cervical level injury (OR 2.32, 95% CI 1.01-5.5) or were hypotensive on ED arrival (OR 2.42, 95% CI 1.34-4.39). Of the 112 patients who were hypotensive, 71 (63.4%) received treatment for this; however, the majority (76%) remained hypotensive on discharge. CONCLUSION Hypotensive patients' post-TSCI experienced heterogeneous ED care discordant with published guidelines; varying by hospital type. Specialist care and more severe injury increased likelihood of guideline adherence. Lack of adherence may influence patient outcomes. Level 1 evidence is needed along with consistent guideline implementation and clinician training to likely improve TSCI management and outcomes.
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Affiliation(s)
- Lisa N Sharwood
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Joseph
- Trauma Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Cici Guo
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Oliver Flower
- Intensive Care Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jonathon Ball
- Department of Neurosurgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Sankari A, Vaughan S, Bascom A, Martin JL, Badr MS. Sleep-Disordered Breathing and Spinal Cord Injury: A State-of-the-Art Review. Chest 2018; 155:438-445. [PMID: 30321507 DOI: 10.1016/j.chest.2018.10.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 09/20/2018] [Accepted: 10/02/2018] [Indexed: 12/15/2022] Open
Abstract
Individuals living with spinal cord injury or disease (SCI/D) are at increased risk for sleep-disordered breathing (SDB), with a prevalence that is three- to fourfold higher than the general population. The main features of SDB, including intermittent hypoxemia and sleep fragmentation, have been linked to adverse cardiovascular outcomes including nocturnal hypertension in patients with SCI/D. The relationship between SDB and SCI/D may be multifactorial in nature given that level and completeness of injury can affect central control of respiration and upper airway collapsibility differently, promoting central and/or obstructive types of SDB. Despite the strong association between SDB and SCI/D, access to diagnosis and management remains limited. This review explores the role of SCI/D in the pathogenesis of SDB, poor sleep quality, the barriers in diagnosing and managing SDB in SCI/D, and the alternative approaches and future directions in the treatment of SDB, such as novel pharmacologic and nonpharmacologic treatments.
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Affiliation(s)
- Abdulghani Sankari
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI
| | - Sarah Vaughan
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI
| | - Amy Bascom
- John D. Dingell VA Medical Center, Detroit, MI
| | - Jennifer L Martin
- VA Greater Los Angeles Healthcare System, North Hills, CA; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI.
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Lax P, Dagal A. Recent Advances in the Use of Vasopressors and Inotropes in Neurotrauma. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0255-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zimering JH, Mesfin A. Posterior reversible encephalopathy syndrome following elevated mean arterial pressures for cervical spinal cord injury. J Spinal Cord Med 2018; 41:111-114. [PMID: 27917700 PMCID: PMC5810795 DOI: 10.1080/10790268.2016.1250030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Increasing the mean arterial pressure (MAP) is an accepted treatment modality to minimize the risk for irreversible neurologic damage secondary to spinal cord ischemia. Posterior reversible encephalopathy syndrome (PRES) is a rare complication occurring after transplantation surgery, in persons having an autoimmune disorder or after abrupt increases in blood pressure of various etiologies. STUDY DESIGN Case report. METHODS Retrospective evaluation of medical records. RESULTS A 68-year-old female with long-standing diabetes, and rheumatoid arthritis (treated with methotrexate) presented with bilateral upper extremity weakness and numbness developing several days after a motor vehicle accident. Physical examination confirmed decreased upper extremity motor strength and decreased sensation to light touch and pinprick in the C5-C6 dermatomal distribution. Magnetic resonance imaging (MRI) demonstrated C5-C6 subluxation with spinal cord compression. The patient had traction applied and mean arterial pressures were elevated greater than 85 mmg. The following day the patient underwent anterior and posterior cervical spine fusion and decompression. Immediately post-operatively, the patient developed status epilepticus. Head MRI revealed areas of high T2 signal intensity in the bilateral occipital lobes, consistent with a diagnosis of PRES. Two weeks later, the patient had resolution of her symptoms and resolution of PRES on imaging. CONCLUSION This is the first report of posterior reversible encephalopathy syndrome secondary to therapeutic blood pressure increase in the setting of cervical spine fracture with neurological deficits. The patients had resolution of symptoms following discontinuation of the MAP goals. Posterior reversible encephalopathy syndrome (PRES) is a life-threatening condition characterized by seizures, confusion, visual disturbance, and headaches alongside neuroradiological findings indicative of posterior cerebral hemispheric white matter edema.1,2 PRES has been described in association with abrupt blood pressure elevation, autoimmune disorders, or transplantation.1-4 In this case report PRES presented with typical status epilepticus5 but in an unexpected clinical setting, immediately after anterior cervical decompression and fusion (ACDF) and posterior cervical fusion (PCF) with laminectomy of C5-C6.
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Affiliation(s)
- Jeffrey H. Zimering
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, University of Rochester, Rochester, NY, USA,Correspondence to: Addisu Mesfin, Assistant Professor of Orthopaedic Surgery and Oncology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 665, Rochester, NY 14642 USA.
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Richard-Denis A, Feldman D, Thompson C, Albert M, Mac-Thiong JM. The impact of a specialized spinal cord injury center as compared with non-specialized centers on the acute respiratory management of patients with complete tetraplegia: an observational study. Spinal Cord 2017; 56:142-150. [PMID: 29138486 DOI: 10.1038/s41393-017-0003-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/12/2017] [Accepted: 08/14/2017] [Indexed: 12/31/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To compare the proportion of tracheostomy placement and duration of mechanical ventilation (MV) in patients with a complete cervical spinal cord injury (SCI) that were managed early or lately in a specialized acute SCI-center. The second objective was to determine the impact of the timing of admission to the SCI-center on the MV support duration. SETTING A single Level-1 trauma center specialized in SCI care in Quebec (Canada). METHODS A cohort of 81 individuals with complete tetraplegia over a 6-years period was included. Group 1 (N = 57- early group-) was admitted before surgical management in one specialized acute SCI-center, whereas Group 2 (N = 24 -late group-) was surgically managed in a non-specialized center and transferred to the SCI-center for post-operative management only. The proportion of tracheostomy placement and MV duration were compared. Multivariate regression analysis was used to assess the impact of the timing of admission to the SCI-center on the MV duration during the SCI-center stay. RESULTS Patients in Group 2 had a higher proportion of tracheostomy (70.8 vs. 35.1%, p = 0.004) and a higher mean duration of MV support (68.0 ± 64.2 days vs. 21.8 ± 29.7 days, p = 0.006) despite similar age, trauma severity (ISS), neurological level of injury and proportion of pneumonia. Later transfer to the specialized acute SCI-center was the main predictive factor of longer MV duration, with a strong impact factor (s = 946.7, p < 0.001). CONCLUSIONS Early admission to a specialized acute SCI-center for surgical and peri-operative management after a complete tetraplegia is associated with lower occurrence of tracheostomy and shorter mechanical ventilation duration support. SPONSORSHIP MENTOR Program of the Canadian Institute of Health Research and US Department of Defense Spinal Cord Injury Research Program.
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Affiliation(s)
- Andréane Richard-Denis
- Research Center, Hopital du Sacré-Cœur de Montréal, Montréal, QC, Canada. .,Faculty of Medicine, University of Montreal, CP 6128, Succ Centre-ville, Pavillon 7077 Avenue du Parc, Montréal, Québec, Canada.
| | - Debbie Feldman
- Faculty of Medicine, University of Montreal, CP 6128, Succ Centre-ville, Pavillon 7077 Avenue du Parc, Montréal, Québec, Canada
| | - Cynthia Thompson
- Research Center, Hopital du Sacré-Cœur de Montréal, Montréal, QC, Canada
| | - Martin Albert
- Research Center, Hopital du Sacré-Cœur de Montréal, Montréal, QC, Canada.,Faculty of Medicine, University of Montreal, CP 6128, Succ Centre-ville, Pavillon 7077 Avenue du Parc, Montréal, Québec, Canada
| | - Jean-Marc Mac-Thiong
- Research Center, Hopital du Sacré-Cœur de Montréal, Montréal, QC, Canada.,Faculty of Medicine, University of Montreal, CP 6128, Succ Centre-ville, Pavillon 7077 Avenue du Parc, Montréal, Québec, Canada.,CHU Ste-Justine, Montreal, Canada
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Streijger F, So K, Manouchehri N, Tigchelaar S, Lee JHT, Okon EB, Shortt K, Kim SE, McInnes K, Cripton P, Kwon BK. Changes in Pressure, Hemodynamics, and Metabolism within the Spinal Cord during the First 7 Days after Injury Using a Porcine Model. J Neurotrauma 2017; 34:3336-3350. [PMID: 28844181 DOI: 10.1089/neu.2017.5034] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Traumatic spinal cord injury (SCI) triggers many perturbations within the injured cord, such as decreased perfusion, reduced tissue oxygenation, increased hydrostatic pressure, and disrupted bioenergetics. While much attention is directed to neuroprotective interventions that might alleviate these early pathophysiologic responses to traumatic injury, the temporo-spatial characteristics of these responses within the injured cord are not well documented. In this study, we utilized our Yucatan mini-pig model of traumatic SCI to characterize intraparenchymal hemodynamic and metabolic changes within the spinal cord for 1 week post-injury. Animals were subjected to a contusion/compression SCI at T10. Prior to injury, probes for microdialysis and the measurement of spinal cord blood flow (SCBF), oxygenation (in partial pressure of oxygen; PaPO2), and hydrostatic pressure were inserted into the spinal cord 0.2 and 2.2 cm from the injury site. Measurements occurred under anesthesia for 4 h post-injury, after which the animals were recovered and measurements continued for 7 days. Close to the lesion (0.2 cm), SCBF levels decreased immediately after SCI, followed by an increase in the subsequent days. Similarly, PaPO2 plummeted, where levels remained diminished for up to 7 days post-injury. Lactate/pyruvate (L/P) ratio increased within minutes. Further away from the injury site (2.2 cm), L/P ratio also gradually increased. Hydrostatic pressure remained consistently elevated for days and negatively correlated with changes in SCBF. An imbalance between SCBF and tissue metabolism also was observed, resulting in metabolic stress and insufficient oxygen levels. Taken together, traumatic SCI resulted in an expanding area of ischemia/hypoxia, with ongoing physiological perturbations sustained out to 7 days post-injury. This suggests that our clinical practice of hemodynamically supporting patients out to 7 days post-injury may fail to address persistent ischemia within the injured cord. A detailed understanding of these pathophysiological mechanisms after SCI is essential to promote best practices for acute SCI patients.
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Affiliation(s)
- Femke Streijger
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Kitty So
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Neda Manouchehri
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Seth Tigchelaar
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Jae H T Lee
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Elena B Okon
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Katelyn Shortt
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - So-Eun Kim
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Kurt McInnes
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada .,2 Departments of Mechanical Engineering and Orthopedics, University of British Columbia , Vancouver, British Columbia, Canada
| | - Peter Cripton
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada .,2 Departments of Mechanical Engineering and Orthopedics, University of British Columbia , Vancouver, British Columbia, Canada
| | - Brian K Kwon
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada .,3 Vancouver Spine Surgery Institute, Department of Orthopedics, University of British Columbia , Vancouver, British Columbia, Canada
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Legg Ditterline BE, Aslan SC, Randall DC, Harkema SJ, Castillo C, Ovechkin AV. Effects of Respiratory Training on Heart Rate Variability and Baroreflex Sensitivity in Individuals With Chronic Spinal Cord Injury. Arch Phys Med Rehabil 2017; 99:423-432. [PMID: 28802811 DOI: 10.1016/j.apmr.2017.06.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/13/2017] [Accepted: 06/27/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the effects of pressure threshold respiratory training (RT) on heart rate variability and baroreflex sensitivity in persons with chronic spinal cord injury (SCI). DESIGN Before-after intervention case-controlled clinical study. SETTING SCI research center and outpatient rehabilitation unit. PARTICIPANTS Participants (N=44) consisted of persons with chronic SCI ranging from C2 to T11 who participated in RT (n=24), and untrained control subjects with chronic SCI ranging from C2 to T9 (n=20). INTERVENTIONS A total of 21±2 RT sessions performed 5 days a week during a 4-week period using a combination of pressure threshold inspiratory and expiratory devices. MAIN OUTCOME MEASURES Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and beat-to-beat arterial blood pressure and heart rate changes during the 5-second-long maximum expiratory pressure maneuver (5s MEP) and the sit-up orthostatic stress test, acquired before and after the RT program. RESULTS In contrast to the untrained controls, individuals in the RT group experienced significantly increased FVC and FEV1 (both P<.01) in association with improved quality of sleep, cough, and speech. Sympathetically (phase II) and parasympathetically (phase IV) mediated baroreflex sensitivity both significantly (P<.05) increased during the 5s MEP. During the orthostatic stress test, improved autonomic control over heart rate was associated with significantly increased sympathetic and parasympathetic modulation (low- and high-frequency change: P<.01 and P<.05, respectively). CONCLUSIONS Inspiratory-expiratory pressure threshold RT is a promising technique to positively affect both respiratory and cardiovascular dysregulation observed in persons with chronic SCI.
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Affiliation(s)
- Bonnie E Legg Ditterline
- Department of Physiology, University of Louisville, Louisville, KY; Department of Neurological Surgery, University of Louisville, Louisville, KY
| | - Sevda C Aslan
- Department of Neurological Surgery, University of Louisville, Louisville, KY
| | - David C Randall
- Department of Physiology, University of Kentucky, Lexington, KY
| | - Susan J Harkema
- Department of Physiology, University of Louisville, Louisville, KY; Department of Neurological Surgery, University of Louisville, Louisville, KY
| | - Camilo Castillo
- Department of Neurological Surgery, University of Louisville, Louisville, KY
| | - Alexander V Ovechkin
- Department of Physiology, University of Louisville, Louisville, KY; Department of Neurological Surgery, University of Louisville, Louisville, KY.
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Optimization of the mean arterial pressure and timing of surgical decompression in traumatic spinal cord injury: a retrospective study. Spinal Cord 2017. [DOI: 10.1038/sc.2017.52] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rouanet C, Reges D, Rocha E, Gagliardi V, Silva GS. Traumatic spinal cord injury: current concepts and treatment update. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:387-393. [DOI: 10.1590/0004-282x20170048] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/14/2017] [Indexed: 01/03/2023]
Abstract
ABSTRACT Spinal cord injury (SCI) affects 1.3 million North Americans, with more than half occurring after trauma. In Brazil, few studies have evaluated the epidemiology of SCI with an estimated incidence of 16 to 26 per million per year. The final extent of the spinal cord damage results from primary and secondary mechanisms that start at the moment of the injury and go on for days, and even weeks, after the event. There is convincing evidence that hypotension contributes to secondary injury after acute SCI. Surgical decompression aims at relieving mechanical pressure on the microvascular circulation, therefore reducing hypoxia and ischemia. The role of methylprednisolone as a therapeutic option is still a matter of debate, however most guidelines do not recommend its regular use. Neuroprotective therapies aiming to reduce further injury have been studied and many others are underway. Neuroregenerative therapies are being extensively investigated, with cell based therapy being very promising.
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Affiliation(s)
| | | | - Eva Rocha
- Universidade Federal de São Paulo, Brasil
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Satyarthee GD. Ways to Improve Outcomes of Traumatic Acute Spinal Cord Injury: Integrated Approaches of Improved Prehospital Care, the Adoption of Synergistic Medical and Surgical Intervention, Along with Care for Associated Systemic Injury and Rehabilitation and Social Inclusion. World Neurosurg 2017; 101:786-787. [DOI: 10.1016/j.wneu.2017.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 11/27/2022]
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Cheng CL, Noonan VK, Shurgold J, Chen J, Rivers CS, Khaleghi Hamedani H, Humphreys S, Bailey CS, Attabib N, Mac Thiong JM, Goytan M, Paquet J, Fox R, Ahn H, Kwon BK, Fourney DR. Geomapping of Traumatic Spinal Cord Injury in Canada and Factors Related to Triage Pattern. J Neurotrauma 2017; 34:2856-2866. [PMID: 28325105 PMCID: PMC5652977 DOI: 10.1089/neu.2016.4929] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Current research indicates that more than half of patients with traumatic spinal cord injury (tSCI) experience delays in transfer and receive surgery >24 h post-injury. The objectives of this study were to determine the geographic distribution of tSCI in Canada relative to specialized treatment facilities, to assess clinical and logistical factors at play for indirect admissions to those facilities, and to explore differences in current time to admission and simulated scenarios in an attempt to assess the potential impact of changes to triage protocols. This study included data from 876 patients with tSCI enrolled in the prospectively collected acute Rick Hansen Spinal Cord Injury Registry (RHSCIR) between January 1, 2010 and December 31, 2013 for whom there were data on the location of their injury. Patients transported directly to a RHSCIR acute facility were more likely to reach the facility within 1 h of injury, whereas those transported indirectly were more likely to arrive 7 h later. Considering the injuries occurring within 40 km of a RHSCIR acute facility (n = 323), 249 patients (77%) were directly and 74 (23%) were indirectly admitted. In the multivariate regression analysis, only older age and longer road distance remained significantly associated with being indirectly admitted to a RHSCIR facility. Compared with the current status, the median time to admission decreased by 20% (3.5 h) in the 100% direct admission scenario, and increased by 102% (8.9 h) in the 100% indirect admission scenario.
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Affiliation(s)
| | | | | | - Jason Chen
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Carly S Rivers
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | | | | | - Christopher S Bailey
- Division of Orthopaedics, Department of Surgery, Western University, London, Ontario, Canada
| | - Najmedden Attabib
- Horizon Health Network, Dalhousie University, Saint John, New Brunswick, Canada
| | - Jean-Marc Mac Thiong
- Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Michael Goytan
- Sections of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerome Paquet
- Sciences Neurologiques, Université Laval, Québec, Quebec, Canada
| | - Richard Fox
- Faculty of Medicine and Dentistry, Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Henry Ahn
- University of Toronto Spine Program, Toronto, Ontario, Canada
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daryl R Fourney
- Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada
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Bao FP, Zhang HG, Zhu SM. Anesthetic considerations for patients with acute cervical spinal cord injury. Neural Regen Res 2017; 12:499-504. [PMID: 28469668 PMCID: PMC5399731 DOI: 10.4103/1673-5374.202916] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Anesthesiologists work to prevent or minimize secondary injury of the nervous system and improve the outcome of medical procedures. To this end, anesthesiologists must have a thorough understanding of pathophysiology and optimize their skills and equipment to make an anesthesia plan. Anesthesiologists should conduct careful physical examinations of patients and consider neuroprotection at preoperative interviews, consider cervical spinal cord movement and compression during airway management, and suggest awake fiberoptic bronchoscope intubation for stable patients and direct laryngoscopy with manual in-line immobilization in emergency situations. During induction, anesthesiologists should avoid hypotension and depolarizing muscle relaxants. Mean artery pressure should be maintained within 85-90 mmHg (1 mmHg = 0.133 kPa; vasoactive drug selection and fluid management). Normal arterial carbon dioxide pressure and normal blood glucose levels should be maintained. Intraoperative neurophysiological monitoring is a useful option. Anesthesiologists should be attentive to postoperative respiratory insufficiency (carefully considering postoperative extubation), thrombus, and infection. In conclusion, anesthesiologists should carefully plan the treatment of patients with acute cervical spinal cord injuries to protect the nervous system and improve patient outcome.
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Affiliation(s)
- Fang-Ping Bao
- Department of Anesthesiology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Hong-Gang Zhang
- Department of Anesthesiology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Sheng-Mei Zhu
- Department of Anesthesiology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Shank CD, Walters BC, Hadley MN. Management of acute traumatic spinal cord injuries. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:275-298. [PMID: 28187803 DOI: 10.1016/b978-0-444-63600-3.00015-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute traumatic spinal cord injury (SCI) is a devastating disease process affecting tens of thousands of people across the USA each year. Despite the increase in primary prevention measures, such as educational programs, motor vehicle speed limits, automobile running lights, and safety technology that includes automobile passive restraint systems and airbags, SCIs continue to carry substantial permanent morbidity and mortality. Medical measures implemented following the initial injury are designed to limit secondary insult to the spinal cord and to stabilize the spinal column in an attempt to decrease devastating sequelae. This chapter is an overview of the contemporary management of an acute traumatic SCI patient from the time of injury through the stay in the intensive care unit. We discuss initial triage, immobilization, and transportation of the patient by emergency medical services personnel to a definitive treatment facility. Upon arrival at the emergency department, we review initial trauma protocols and the evidence-based recommendations for radiographic evaluation of the patient's vertebral column. Finally, we outline closed cervical spine reduction and various aggressive medical therapies aimed at improving neurologic outcome.
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Affiliation(s)
- C D Shank
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - B C Walters
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - M N Hadley
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA.
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Hua A, Shah KH, Garg M, Legome E, Ufberg J. A Hanging and Its Complications. J Emerg Med 2016; 51:691-696. [DOI: 10.1016/j.jemermed.2016.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 07/01/2016] [Accepted: 07/19/2016] [Indexed: 12/27/2022]
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Catapano JS, John Hawryluk GW, Whetstone W, Saigal R, Ferguson A, Talbott J, Bresnahan J, Dhall S, Pan J, Beattie M, Manley G. Higher Mean Arterial Pressure Values Correlate with Neurologic Improvement in Patients with Initially Complete Spinal Cord Injuries. World Neurosurg 2016; 96:72-79. [PMID: 27565460 DOI: 10.1016/j.wneu.2016.08.053] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) guidelines recommend to maintain mean arterial pressures (MAPs) above 85 mm Hg for 7 days following SCI to minimize spinal cord ischemia. Some physicians doubt that patients with initially complete injuries benefit. OBJECTIVE To assess the relationship between MAP augmentation and neurologic improvement in SCI patients stratified by initial American Spinal Injury Association Impairment Scale (AIS) score. METHODS High-frequency MAP values of acute SCI patients admitted over a 6-year period were recorded, and values were correlated with degree of neurologic recovery in an analysis stratified by postresuscitation AIS score. RESULTS Sixty-two patients with SCI were analyzed. Thirty-three patients were determined to have complete injuries, and of those 11 improved at least 1 AIS grade by discharge. The average MAP of initially AIS A patients who improved versus those who did not was significantly higher (96.6 ± 0.07 mm Hg vs. 94.4 ± 0.06 mm Hg, respectively; P < 0.001), and the proportion of MAP values <85 mm Hg was significantly lower (13.5% vs. 25.6%, respectively; P < 0.001). A positive correlation between MAP values and outcome was also observed in AIS B and C patients but was not observed in patients who were initially AIS D. CONCLUSION A positive correlation was observed between MAP values and neurologic recovery in AIS A, B, and C patients but not AIS D patients. These data raise the possibility that patients with an initially complete SCI may derive greater benefit from MAP augmentation than patients with initial AIS D injuries.
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Affiliation(s)
| | - Gregory William John Hawryluk
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA; Brain and Spinal Cord Injury Center, University of California, San Francisco, California, USA; Department of Neurosurgery, University of California, San Francisco, California, USA.
| | - William Whetstone
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Rajiv Saigal
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Adam Ferguson
- Brain and Spinal Cord Injury Center, University of California, San Francisco, California, USA; Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Jason Talbott
- Department of Radiology, University of California, San Francisco, California, USA
| | - Jacqueline Bresnahan
- Brain and Spinal Cord Injury Center, University of California, San Francisco, California, USA; Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Sanjay Dhall
- Brain and Spinal Cord Injury Center, University of California, San Francisco, California, USA; Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Jonathan Pan
- Department of Anaesthesia, University of California, San Francisco, California, USA
| | - Michael Beattie
- Brain and Spinal Cord Injury Center, University of California, San Francisco, California, USA; Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Geoffrey Manley
- Brain and Spinal Cord Injury Center, University of California, San Francisco, California, USA; Department of Neurosurgery, University of California, San Francisco, California, USA
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The differential effects of norepinephrine and dopamine on cerebrospinal fluid pressure and spinal cord perfusion pressure after acute human spinal cord injury. Spinal Cord 2016; 55:33-38. [PMID: 27271117 DOI: 10.1038/sc.2016.79] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/15/2016] [Accepted: 04/06/2016] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective vasopressor cross-over interventional studyObjectives:To examine how two vasopressors used in acute traumatic spinal cord injury (SCI) affect intrathecal cerebrospinal fluid pressure and the corresponding spinal cord perfusion pressure (SCPP). SETTING Vancouver, British Columbia, Canada. METHODS Acute SCI patients over the age of 17 with cervical or thoracic ASIA Impairment Scale (AIS). A, B or C injuries were enrolled in this study. Two vasopressors, norepinephrine and dopamine, were evaluated in a 'crossover procedure' to directly compare their effect on the intrathecal pressure (ITP). The vasopressor cross-over procedures were performed in the intensive care unit where ITP, mean arterial pressure (MAP) and heart rate were being continuously measured. The SCPP was calculated as the difference between MAP and ITP. RESULTS A total of 11 patients were enrolled and included in our analysis. There were 6 patients with AIS A, 3 with AIS B and 2 with AIS C injuries at baseline. We performed 24 cross-over interventions in these 11 patients. There was no difference in MAP with the use of norepinephrine versus dopamine (84±1 mm Hg for both; P=0.33). Conversely, ITP was significantly lower with the use of norepinephrine than with dopamine (17±1 mm Hg vs 20±1 mm Hg, respectively, P<0.001). This decrease in ITP with norepinephrine resulted in an increased SCPP during the norepinephrine infusion when compared with dopamine (67±1 mm Hg vs 65±1 mm Hg respectively, P=0.0049). CONCLUSION Norepinephrine was able to maintain MAP with a lower ITP and a correspondingly higher SCPP as compared with dopamine in this study. These results suggest that norepinephrine may be preferable to dopamine if vasopressor support is required post SCI to maintain elevated MAPs in accordance with published guidelines.
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Osterthun R, van Asbeck FWA, Nijendijk JHB, Post MWM. In-hospital end-of-life decisions after new traumatic spinal cord injury in the Netherlands. Spinal Cord 2016; 54:1025-1030. [DOI: 10.1038/sc.2016.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 11/09/2022]
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Teles AR, Cabrera J, Riew KD, Falavigna A. Steroid Use for Acute Spinal Cord Injury in Latin America: A Potentially Dangerous Practice Guided by Fear of Lawsuit. World Neurosurg 2016; 88:342-349. [DOI: 10.1016/j.wneu.2015.12.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022]
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Grassner L, Marschallinger J, Dünser MW, Novak HF, Zerbs A, Aigner L, Trinka E, Sellner J. Nontraumatic spinal cord injury at the neurological intensive care unit: spectrum, causes of admission and predictors of mortality. Ther Adv Neurol Disord 2015; 9:85-94. [PMID: 27006696 DOI: 10.1177/1756285615621687] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Nontraumatic spinal cord injuries (NTSCIs) form a heterogeneous group of diseases, which may evolve into a life-threatening condition. We sought to characterize spectrum, causes of admission and predictors of death in patients with NTSCI treated at the neurological intensive care unit (NICU). METHODS We performed a retrospective observational analysis of NTSCI cases treated at a tertiary care center between 2001 and 2013. Among the 3937 NICU admissions were 93 patients with NTSCI (2.4%). Using multivariate logistic regression analysis, we examined predictors of mortality including demographics, etiology, reasons for admission and GCS/SAPS (Glasgow Coma Scale/Simplified Acute Physiology Score) scores. RESULTS Infectious and inflammatory/autoimmune causes made up 50% of the NTSCI cases. The most common reasons for NICU admission were rapidly progressing paresis (49.5%) and abundance of respiratory insufficiency (26.9%). The mortality rate was 22.6% and 2.5-fold higher than in the cohort of all other patients treated at the NICU. Respiratory insufficiency as the reason for NICU admission [odds ratio (OR) 4.97, 95% confidence interval (CI) 1.38-17.9; p < 0.01], high initial SAPS scores (OR 1.04; 95% CI 1.003-1.08; p = 0.04), and the development of acute kidney injury throughout the stay (OR 7.25, 1.9-27.5; p = 0.004) were independent risk factors for NICU death. CONCLUSIONS Patients with NTSCI account for a subset of patients admitted to the NICU and are at risk for adverse outcome. A better understanding of predisposing conditions and further knowledge of management of critically ill patients with NTSCI is mandatory.
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Affiliation(s)
- Lukas Grassner
- Center for Spinal Cord Injuries, BG Trauma Center Murnau, Germany Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Julia Marschallinger
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Martin W Dünser
- Department of Anesthesiology, Perioperative Medicine and General Intensive Care Medicine, Salzburg University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Helmut F Novak
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Alexander Zerbs
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Ludwig Aigner
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Ignaz-Harrer-Str. 79, A-5020 Salzburg, Austria
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Bérubé M, Albert M, Chauny JM, Contandriopoulos D, DuSablon A, Lacroix S, Gagné A, Laflamme É, Boutin N, Delisle S, Pauzé AM, MacThiong JM. Development of theory-based knowledge translation interventions to facilitate the implementation of evidence-based guidelines on the early management of adults with traumatic spinal cord injury. J Eval Clin Pract 2015; 21:1157-68. [PMID: 25832735 DOI: 10.1111/jep.12342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2015] [Indexed: 12/12/2022]
Abstract
RATIONALE Optimal, early management following a spinal cord injury (SCI) can limit individuals' disabilities and costs related to their care. Several knowledge syntheses were recently published to guide health care professionals with regard to early interventions in SCI patients. However, no knowledge translation (KT) intervention, selected according to a behaviour change theory, has been proposed to facilitate the use of SCI guidelines in an acute care setting. OBJECTIVES To develop theory-informed KT interventions to promote the application of evidence-based recommendations on the acute care management of SCI patients. METHODS The first four phases of the knowledge-to-action model were used to establish the study design. Knowledge selection was based on the Grading of Recommendations Assessment, Development and Evaluation system. Knowledge adaptation to the local context was sourced from the ADAPTE process. The theoretical domains framework oriented the selection and development of the interventions based on an assessment of barriers and enablers to knowledge application. RESULTS Twenty-nine recommendations were chosen and operationalized in measurable clinical indicators. Barriers related to knowledge, skills, perceived capacities, beliefs about consequences, social influences, and the environmental context and resources theoretical domains were identified. The mapping of behaviour change techniques associated with those barriers led to the development of an online educational curriculum, interdisciplinary clinical pathways as well as policies and procedures. CONCLUSIONS This research project allowed us developing KT interventions according to a thorough behavioural change methodology. Exposure to the generated interventions will support health care professionals in providing the best care to SCI patients.
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Affiliation(s)
- Mélanie Bérubé
- Orthopaedics and Trauma, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,McGill University, Montreal, Quebec, Canada
| | - Martin Albert
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Marc Chauny
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université de Montréal, Montreal, Quebec, Canada
| | | | - Anne DuSablon
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Sébastien Lacroix
- Université de Montréal, Montreal, Quebec, Canada.,Hôtel Dieu de St-Jérôme, Montreal, Quebec, Canada
| | - Annick Gagné
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Élise Laflamme
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Nathalie Boutin
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | | | | | - Jean-Marc MacThiong
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université de Montréal, Montreal, Quebec, Canada
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Kim T, Jwa CS. Effect of Alpha-1-Adrenergic Agonist, Midodrine for the Management of Long-Standing Neurogenic Shock in Patient with Cervical Spinal Cord Injury: A Case Report. Korean J Neurotrauma 2015; 11:147-50. [PMID: 27169082 PMCID: PMC4847524 DOI: 10.13004/kjnt.2015.11.2.147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 07/07/2015] [Accepted: 07/27/2015] [Indexed: 11/15/2022] Open
Abstract
We report a rare case of a 71-year-old male patient who had suffered from long-lasting neurogenic shock for 13 weeks after cervical spinal cord injury (SCI) caused by a bicycle accident. The neurogenic shock was resolved dramatically 2 weeks after the administration of alpha-1-adrenergic agonist, midodrine hydrochloride. In usual cases, neurogenic shock tends to improve between 2 and 6 weeks after SCI; however, in a few cases, the shock lasts for several months. In our case, spinal shock lasted for 13 weeks and exhibited very sensitive decline of blood pressure for even a slight decrease of dopamine despite recovered bulbospongiosus reflex. Three days after midodrine hydrochloride was added, hypotension improved dramatically. We discuss our rare case with pertinent literatures.
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Affiliation(s)
- Taikwan Kim
- Department of Neurosurgery, National Medical Center, Seoul, Korea
| | - Cheol Su Jwa
- Department of Neurosurgery, National Medical Center, Seoul, Korea
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