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Neal CJ, Ugiliweneza B, Toups EG, Abd-El-Barr M, Jimsheleishvili G, Kurpad SN, Aarabi B, Harrop JS, Shaffrey CI, Fehlings MG, Tator CH, Grossman RG, Guest JD. Variability in Early Surgery for Acute Cervical Spinal Cord Injury Patients: An Opportunity for Enhanced Care Delivery. J Neurotrauma 2023; 40:1907-1917. [PMID: 37125447 DOI: 10.1089/neu.2022.0507] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Data supporting the benefits of early surgical intervention in acute spinal cord injury (SCI) is growing. For early surgery to be accomplished, understanding the causes of variabilities that effect the timing of surgery is needed to achieve this goal. The purpose of this analysis is to determine factors that affect the timing of surgery for acute cervical SCI within the North American Clinical Trials Network (NACTN) for SCI registry. Patients in the NACTN SCI registry from 2005 to 2019 with a cervical SCI, excluding acute traumatic central cord syndrome, were analyzed for time elapsed from injury to arrival to the hospital, and time to surgery. Two categories were defined: 1) Early Arrival with Early Surgery (EAES) commenced within 24 h of injury, and 2) Early Arrival but Delayed Surgery (EADS), with surgery occurring between 24 to 72 h post-injury. Patients' demographic features, initial clinical evaluation, medical comorbidities, neurological status, surgical intervention, complications, and outcome data were correlated with respect to the two arrival groups. Of the 222 acute cervical SCI patients undergoing surgery, 163 (73.4%) were EAES, and 59 (26.6%) were EADS. There was no statistical difference in arrival time between the EAES and EADS groups. There was a statistical difference in the median arrival time to surgery between the EAES group (9 h) compared with the EADS group (31 h; p < 0.05). There was no statistical difference in race, sex, age, mechanism of injury, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores, or medical comorbidities between the two groups, but the EAES group did present with a significantly lower systolic blood pressure (p < 0.05). EADS patients were more likely to present as an American Spinal Injury Association Impairment Scale (AIS) D than EAES (p < 0.05). Early surgery was statistically more likely to occur if the injury occurred over the weekend (p < 0.05). There were variations in the rates of early surgery between the eight NACTN sites within the study, ranging from 57 to 100%. Of the 114 patients with 6-month outcome data, there was no significant change between the two groups regarding AIS grade change and motor/pin prick/light touch score recovery. A trend towards improved motor scores with early surgery was not statistically significant (p = 0.21). Although there is data that surgery within 24 h of injury improves outcomes and can be performed safely, there remain variations in care outside of clinical trials. In the present study of cervical SCI, NACTN achieved its goal of early surgery in 73.4% of patients from 2005-2019 who arrived within 24 h of their injury. Variability in achieving this goal was related to severity of neurological injury, the day of the week, and the treating NACTN center. Evaluating variations within our network improves understanding of potential systemic limitations and our decision-making process to accomplish the goal of early surgery.
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Affiliation(s)
- Chris J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Elizabeth G Toups
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | | | | | - Shekar N Kurpad
- Neuroscience Institute. the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Bizhan Aarabi
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - James S Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Charles H Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Robert G Grossman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | - James D Guest
- The Miami Project to Cure Paralysis, University of Miami, Miami, Florida, USA
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2
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Azad TD, Nair SK, Kalluri AL, Materi J, Ahmed AK, Khalifeh J, Abu-Bonsrah N, Sharwood LN, Sterner RC, Brooks NP, Alomari S, Musharbash FN, Mo K, Lubelski D, Witham TF, Theodore N, Bydon A. Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review. World Neurosurg 2023; 169:e121-e130. [PMID: 36441093 DOI: 10.1016/j.wneu.2022.10.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI. OBJECTIVE To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis. RESULTS After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review. CONCLUSIONS Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anita L Kalluri
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jawad Khalifeh
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nancy Abu-Bonsrah
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA; Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Lisa N Sharwood
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School-Northern, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Robert C Sterner
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nathaniel P Brooks
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Farah N Musharbash
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kevin Mo
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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3
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Pedro KM, Fehlings MG. Time is spine: What's over the horizon. J Clin Orthop Trauma 2022; 35:102043. [PMID: 36340959 PMCID: PMC9634004 DOI: 10.1016/j.jcot.2022.102043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/13/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
The overarching theme in the early treatment of acute spinal cord injury (SCI) is to reduce the extent of secondary damage to facilitate early neurological and functional recovery. Although multiple studies have brought us innovative and potential new therapies to treat SCI, ameliorating neural damage remains a formidable challenge. Knowledge translation of clinical and basic research studies has shown that surgical intervention is a valuable treatment modality; however, the role, timing and optimal technique in surgery remains a topic of great controversy. While evidence to support the concept of ultra-early surgery for acute SCI continues to emerge, current protocols and international guidelines that encourage reducing time from trauma to surgery support the concept of "Time is Spine". The present article provides a critical narrative review of the current best practice, with a particular focus on the timing of surgical intervention, which shapes our understanding of how time is of the essence in the management of acute SCI.
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Affiliation(s)
- Karlo M. Pedro
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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4
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Surgical timing in traumatic spinal cord injury: current practice and obstacles to early surgery in Latin America. Spinal Cord 2022; 60:368-374. [DOI: 10.1038/s41393-022-00789-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/08/2022]
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5
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Khosravi S, Khayyamfar A, Shemshadi M, Koltapeh MP, Sadeghi-Naini M, Ghodsi Z, Shokraneh F, Bardsiri MS, Derakhshan P, Komlakh K, Vaccaro AR, Fehlings MG, Guest JD, Noonan V, Rahimi-Movaghar V. Indicators of Quality of Care in Individuals With Traumatic Spinal Cord Injury: A Scoping Review. Global Spine J 2022; 12:166-181. [PMID: 33487062 PMCID: PMC8965305 DOI: 10.1177/2192568220981988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
STUDY DESIGN Scoping review. OBJECTIVES To identify a practical and reproducible approach to organize Quality of Care Indicators (QoCI) in individuals with traumatic spinal cord injury (TSCI). METHODS A comprehensive literature review was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL) (Date: May 2018), MEDLINE (1946 to May 2018), and EMBASE (1974 to May 2018). Two independent reviewers screened 6092 records and included 262 full texts, among which 60 studies were included for qualitative analysis. We included studies, with no language restriction, containing at least 1 quality of care indicator for individuals with traumatic spinal cord injury. Each potential indicator was evaluated in an online, focused group discussion to define its categorization (healthcare system structure, medical process, and individuals with Traumatic Spinal Cord Injury related outcomes), definition, survey options, and scale. RESULTS A total of 87 indicators were identified from 60 studies screened using our eligibility criteria. We defined each indicator. Out of 87 indicators, 37 appraised the healthcare system structure, 30 evaluated medical processes, and 20 included individuals with TSCI related outcomes. The healthcare system structure included the impact of the cost of hospitalization and rehabilitation, as well as staff and patient perception of treatment. The medical processes included targeting physical activities for improvement of health-related outcomes and complications. Changes in motor score, functional independence, and readmission rates were reported as individuals with TSCI-related outcomes indicators. CONCLUSION Indicators of quality of care in the management of individuals with TSCI are important for health policy strategists to standardize healthcare assessment, for clinicians to improve care, and for data collection efforts including registries.
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Affiliation(s)
- Sepehr Khosravi
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran,Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmahdi Khayyamfar
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran,Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Milad Shemshadi
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran,Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Pourghahramani Koltapeh
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran,Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Sadeghi-Naini
- Neurosurgery Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Ghodsi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Shokraneh
- King’s Technology Evaluation Centre, London Institute of Healthcare Engineering, School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK,The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Pegah Derakhshan
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran,Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Khalil Komlakh
- Neurosurgery Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alex R. Vaccaro
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael G. Fehlings
- Department of Surgery, University of Toronto and Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada
| | - James D. Guest
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Vanessa Noonan
- Rick Hansen Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Universal Scientific Education and Research Network (USERN), Tehran, Iran,Vafa Rahimi-Movaghar, Sina Trauma and Surgery Research Center, Tehran University of Medical Science, Tehran, Iran.
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6
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SohrabiAsl M, Ghodsi Z, Arejan RH, Azadmanjir Z, Sharif-Alhoseini M, Khormali M, Shojaei M, Rahimiforoushani A, Khoshnevisan A, Vaccaro AR, Fehlings MG, Rahimi-Movaghar V. Reasons for delayed spinal cord decompression in individuals with traumatic spinal cord injuries in Iran: A qualitative study from the perspective of neurosurgeons. Chin J Traumatol 2021; 24:356-359. [PMID: 34281782 PMCID: PMC8606607 DOI: 10.1016/j.cjtee.2021.07.001] [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: 03/31/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The median time from the event leading to the spinal cord injury (SCI) to the time of decompressive surgery is estimated to be 6.9 days in Iran, which is much longer than the proposed ideal time (less than 24 h) in published guidelines. The current qualitative study aimed to determine the reasons for the observed decompression surgery delay in Iran from the perspective of neurosurgeons. METHODS This qualitative study is designed to perform content analysis on the gathered data from face-to-face semi-structured interviews with 12 Iranian neurosurgeons. RESULTS The findings of the current study suggest that patient-related factors constitute more than half of the codes extracted from the interviews. Overall, the type of injury, presence of polytrauma, and surgeons' wrong attitude are the main factors causing delayed spinal cord decompression in Iranian patients from the perspective of neurosurgeons. Other notable factors include delay in transferring patients to the trauma center, delay in availability of necessary equipment, and scarce medical personnel. CONCLUSION In the perspective of neurosurgeons, the type of injury, presence of polytrauma, and surgeons' wrong attitude are the leading reasons for delayed decompressive surgery of individuals with SCI in Iran.
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Affiliation(s)
- Masoud SohrabiAsl
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Ghodsi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Roya Habibi Arejan
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Rehabilitation Office, State Welfare Organization of Iran, Tehran, Iran
| | - Zahra Azadmanjir
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Health Information Management Department, Tehran University of Medical Sciences
| | - Mahdi Sharif-Alhoseini
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Moein Khormali
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Shojaei
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Rahimiforoushani
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Khoshnevisan
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran Iran
| | - Alexander R. Vaccaro
- Department of Orthopaedics and Neurosurgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, PA, USA
| | - Michael G. Fehlings
- Department of Surgery, University of Toronto, Senior Scientist Krembil Brain Institute and McEwen Centre for Regenerative Medicine, Toronto Western Hospital, University Health Network, Canada
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran Iran,Universal Scientific Education and Research Network (USERN), Tehran, Iran,Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran,Visiting Professor, Spine Program, University of Toronto, Toronto, Canada,Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran,Corresponding author. Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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7
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Chikuda H, Koyama Y, Matsubayashi Y, Ogata T, Ohtsu H, Sugita S, Sumitani M, Kadono Y, Miura T, Tanaka S, Akiyama T, Ando K, Anno M, Azuma S, Endo K, Endo T, Fujiyoshi T, Furuya T, Hayashi H, Higashikawa A, Hiyama A, Horii C, Iimoto S, Iizuka Y, Ikuma H, Imagama S, Inokuchi K, Inoue H, Inoue T, Ishii K, Ishii M, Ito T, Itoi A, Iwamoto K, Iwasaki M, Kaito T, Kato T, Katoh H, Kawaguchi Y, Kawano O, Kimura A, Kobayashi K, Koda M, Komatsu M, Kumagai G, Maeda T, Makino T, Mannoji C, Masuda K, Masuda K, Matsumoto K, Matsumoto M, Matsunaga S, Matsuyama Y, Mieda T, Miyoshi K, Mochida J, Moridaira H, Motegi H, Nakagawa Y, Nohara Y, Oae K, Ogawa S, Okazaki R, Okuda A, Onishi E, Ono A, Oshima M, Oshita Y, Saita K, Sasao Y, Sato K, Sawakami K, Seichi A, Seki S, Shigematsu H, Suda K, Takagi Y, Takahashi M, Takahashi R, Takasawa E, Takenaka S, Takeshita K, Takeshita Y, Tokioka T, Tokuhashi Y, Tonosu J, Uei H, Wada K, Watanabe M, Yahata T, Yamada K, Yasuda T, Yasui K, Yoshii T. Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2133604. [PMID: 34751757 PMCID: PMC8579238 DOI: 10.1001/jamanetworkopen.2021.33604] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. OBJECTIVE To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. INTERVENTIONS Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. MAIN OUTCOMES AND MEASURES The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. RESULTS Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, -4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients). CONCLUSIONS AND RELEVANCE These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780.
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Affiliation(s)
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University, Maebashi, Gunma, Japan
| | - Yurie Koyama
- Kitasato University School of Nursing, Sagamihara, Japan
| | | | - Toru Ogata
- Department of Rehabilitation Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Ohtsu
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Shurei Sugita
- Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | | | | | - Sakae Tanaka
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Toru Akiyama
- Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kei Ando
- Nagoya University Hospital, Nagoya, Japan
| | - Masato Anno
- Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | | | | | - Toru Endo
- Wakayama Medical University Hospital, Wakayama, Japan
| | | | | | | | | | | | - Chiaki Horii
- Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Seiji Iimoto
- Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Gunma University, Maebashi, Gunma, Japan
| | | | | | - Koichi Inokuchi
- Saitama Medical University Saitama Medical Center, Kawagoe, Japan
| | - Hirokazu Inoue
- Jichi Medical University Hospital, Shimotsuke, Tochigi, Japan
| | - Tomoo Inoue
- Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | | | | | - Takui Ito
- Niigata City General Hospital, Niigata, Japan
| | - Akira Itoi
- Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Kohei Iwamoto
- Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | | | | | - Tsuyoshi Kato
- Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | | | | | | | - Atsushi Kimura
- Jichi Medical University Hospital, Shimotsuke, Tochigi, Japan
| | | | | | - Miki Komatsu
- Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | | | | | | | | | | | | | | | | | | | | | - Tokue Mieda
- Department of Orthopaedic Surgery, Gunma University, Maebashi, Gunma, Japan
| | | | | | | | | | | | | | - Kazunori Oae
- Saitama Medical University Saitama Medical Center, Kawagoe, Japan
| | | | | | | | - Eijiro Onishi
- Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Atsushi Ono
- Hirosaki University Hospital, Hirosaki, Japan
| | | | - Yusuke Oshita
- Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Kazuo Saita
- Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yutaka Sasao
- St Marianna University Hospital, Kawasaki, Japan
| | | | | | - Atsushi Seichi
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Shoji Seki
- Toyama University Hospital, Toyama, Japan
| | | | - Kota Suda
- Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | | | | | | | - Eiji Takasawa
- Department of Orthopaedic Surgery, Gunma University, Maebashi, Gunma, Japan
| | | | | | | | | | | | | | - Hiroshi Uei
- Nihon University Itabashi Hospital, Tokyo, Japan
| | | | | | - Tadashi Yahata
- Saitama Medical University Saitama Medical Center, Kawagoe, Japan
| | - Kei Yamada
- Kurume University Hospital, Kurume, Japan
| | | | - Keigo Yasui
- Hokkaido Spinal Cord Injury Center, Bibai, Japan
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8
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Qiu Y, Chen Y, Xie Y, Xie H, Dong J. Comparative analysis of the efficacy of early and late surgical intervention for acute spinal cord injury: A systematic review and meta-analysis based on 16 studies. Int J Surg 2021; 94:106098. [PMID: 34509672 DOI: 10.1016/j.ijsu.2021.106098] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/05/2021] [Accepted: 09/08/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Spinal cord injuries (SCI) are a devastating condition and can lead to severe functional and psychosocial problems. However, the influence of the timing of the surgical intervention for acute SCI remains debated, with substantial variability in clinical practice. Thus, this study aims to compare the efficacy of early and late surgical intervention for acute SCI. METHODS A systematic search of PubMed, Embase, Cochrane Library and Web of Science up to January 10, 2021 was conducted for relevant studies that compared early and late acute SCI. Neurological outcomes were assessed by American Spinal Injury Association (ASIA). Early surgery was defined as the surgical intervention within 24 h after spinal injury. The primary outcome was the change of ASIA score from baseline to follow-up time after spinal injury. Second primary outcomes were clinical outcomes including neurological improvement rate, mortality, length of stay (LOS), charges ($), complications and ASIA Impairment Scale (AIS). All statistical analyses were performed using standard statistical procedures provided in Review Manager 5.2. RESULTS A total of 16 studies including 3977 SCI patients were identified finally. Our pooled results indicated that, compared with late surgery, patients who underwent early surgery experienced more ASIA score improvement, with pooled MDs of 2.32 points (95% CI 1.07-3.57; P = 0.0003) in total motor scores, 5.13 points (95% CI 3.94-6.32; P < 0.0001) in light touch scores, and 4.49 points (95% CI 2.22-6.76; P = 0.0001) in pin prick scores respectively. In addition, patients receiving early surgery experienced more total motor score after surgery (MD 3.30; 95% CI 0.82-5.79; P = 0.009). Patients who had early surgery also had higher neurological improvement rate (OR 1.66; 95% CI 1.19-2.31; P = 0.003), shorter LOS (MD -4.77; 95% CI -7.42 to -2.12), less charges ($) (MD -0.33; 95% CI -0.43 to -0.22), lower incidence of complications (OR 0.62; 95% CI 0.48-0.81), and higher AIS improvement rate (OR 1.71; 95% CI 1.20-2.44) respectively. CONCLUSIONS Compared with late surgery, acute SCI patients who underwent early surgery experienced greater recovery after spinal injury, with better neurological improvement, shorter LOS, less charges and lower incidence of complications.
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Affiliation(s)
- Yuanyuan Qiu
- Rehabilitation Center, Beijing Daxing District Hospital of Traditional Chinese and Western Medicine, Beijing, 100076, China Department of Rehabilitation Medicine, Beijing Tongren Hospital of Capital Medical University, Beijing, 100073, China Department of Rehabilitation Medicine, Beijing Friendship Hospital of Capital Medical University, Beijing, 100050, China Rehabilitation Department, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, 100020, China
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9
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Balas M, Prömmel P, Nguyen L, Jack A, Lebovic G, Badhiwala JH, Da Costa L, Nathens AB, Fehlings MG, Wilson JR, Witiw CD. The Reality of Accomplishing Surgery Within 24 hours for Complete Cervical Spinal Cord Injury: Clinical Practices and Safety. J Neurotrauma 2021; 38:3011-3019. [PMID: 34382411 DOI: 10.1089/neu.2021.0177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Substantial clinical data supports an association between superior neurological outcomes and early (within 24 hours) surgical decompression for those with traumatic cervical spinal cord injury (SCI). Despite this, much discussion persists around feasibility and safety of this time threshold, particularly for those with a complete cervical SCI. This study aims to assess clinical practices and the safety profile of early surgery across a large sample of North American trauma centers. Data was derived from the Trauma Quality Improvement Program database from 2010-2016. Adult patients with a complete cervical SCI (ASIA A) who underwent surgery were included. Patients were stratified into those receiving surgery at or before 24 hours and those receiving delayed intervention. Risk-adjusted variability in surgical timing across trauma centers was investigated using mixed-effects regression. In-hospital adverse events including mortality, major complications, and immobility-related complications were compared between groups after propensity score matching. 2,862 patients from 353 North American trauma centers were included. 1,760 (61.5%) underwent surgery within 24 hours. Case-mix and hospital-level characteristics explained only 6% of the variability in surgical timing both between-centers and within-centers. No significant differences in adverse events were identified between groups. These findings suggest a relatively large proportion of patients are not receiving surgery within the recommended timeframe, despite apparent safety. Moreover, patient and hospital-level characteristics explain little of the variability in time-to-surgery. Further knowledge translation is needed to increase the proportion of patients in whom surgery is performed before the 24-hour threshold so patients might reach their greatest potential for neurologic recovery.
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Affiliation(s)
- Michael Balas
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, 27 King's College Cirle, Toronto, Ontario, Canada, M5S;
| | - Peter Prömmel
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada.,Kantonsspital St Gallen, 30883, Department of Neurosurgery, Sankt Gallen, SG, Switzerland;
| | - Laura Nguyen
- University of Ottawa, 6363, School of Medicine, Ottawa, Ontario, Canada;
| | - Andrew Jack
- University of California San Francisco, 8785, Neurological Surgery, 400 Parnassus Ave, San Francisco, California, United States, 94143;
| | - Gerald Lebovic
- St Michael's Hospital Li Ka Shing Knowledge Institute, 518773, Toronto, Ontario, Canada.,University of Toronto Institute of Health Policy Management and Evaluation, 206712, Toronto, Ontario, Canada;
| | - Jetan H Badhiwala
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada;
| | - Leodante Da Costa
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, 71545, Sunnybrook Research Institute, Toronto, Ontario, Canada;
| | - Avery B Nathens
- Sunnybrook Health Sciences Centre, 71545, Sunnybrook Research Institute, Toronto, Ontario, Canada.,University of Toronto, 7938, Division of General Surgery, Department of Surgery, Toronto, Ontario, Canada.,American College of Surgeons, 2417, Medical Director, Trauma Quality Improvement Program, Chicago, Illinois, United States;
| | - Michael G Fehlings
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada.,Toronto Western Hospital, 26625, Spine Program, Krembil Brain Institute, Toronto, Ontario, Canada;
| | - Jefferson R Wilson
- St Michael's Hospital, 10071, Division of Neurosurgery, Toronto, Ontario, Canada.,St Michael's Hospital, 10071, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.,University of Toronto, 7938, Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada;
| | - Christopher D Witiw
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada.,St Michael's Hospital, 10071, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.,University of Toronto, 7938, Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada;
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10
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Badhiwala JH, Wilson JR, Witiw CD, Harrop JS, Vaccaro AR, Aarabi B, Grossman RG, Geisler FH, Fehlings MG. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol 2020; 20:117-126. [PMID: 33357514 DOI: 10.1016/s1474-4422(20)30406-3] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although there is a strong biological rationale for early decompression of the injured spinal cord, the influence of the timing of surgical decompression for acute spinal cord injury (SCI) remains debated, with substantial variability in clinical practice. We aimed to objectively evaluate the effect of timing of decompressive surgery for acute SCI on long-term neurological outcomes. METHODS We did a pooled analysis of individual patient data derived from four independent, prospective, multicentre data sources, including data from December, 1991, to March, 2017. Three of these studies had been published; of these, only one study previously specifically analysed the effect of the timing of surgical decompression. These four datasets were selected because they were among the highest quality acute SCI datasets available and contained highly granular data. Individual patient data were obtained by request from study authors. All patients who underwent decompressive surgery for acute SCI within these datasets were included. Patients were stratified into early (<24 h after spinal injury) and late (≥24 h after spinal injury) decompression groups. Neurological outcomes were assessed by American Spinal Injury Association (ASIA), or International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), examination. The primary endpoint was change in total motor score from baseline to 1 year after spinal injury. Secondary endpoints were ASIA Impairment Scale (AIS) grade and change in upper-extremity motor, lower-extremity motor, light touch, and pin prick scores after 1 year. One-stage meta-analyses were done by hierarchical mixed-effects regression adjusting for baseline score, age, mechanism of injury, AIS grade, level of injury, and administration of methylprednisolone. Effect sizes were summarised by mean difference (MD) for sensorimotor scores and common odds ratio (cOR) for AIS grade, with corresponding 95% CIs. As a secondary analysis, change in total motor score was regressed against time to surgical decompression (h) as a continuous variable, using a restricted cubic spline with adjustment for the same covariates as in the primary analysis. FINDINGS We identified 1548 eligible patients from the four datasets. Outcome data at 1 year after spinal injury were available for 1031 patients (66·6%). Patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at 1 year after spinal injury; total motor scores improved by 23·7 points (95% CI 19·2-28·2) in the early surgery group versus 19·7 points (15·3-24·0) in the late surgery group (MD 4·0 points [1·7-6·3]; p=0·0006), light touch scores improved by 19·0 points (15·1-23·0) vs 14·8 points (11·2-18·4; MD 4·3 [1·6-7·0]; p=0·0021), and pin prick scores improved by 18·3 points (13·7-22·9) versus 14·2 points (9·8-18·6; MD 4·0 [1·5-6·6]; p=0·0020). Patients who had early decompression also had better AIS grades at 1 year after surgery, indicating less severe impairment, compared with patients who had late surgery (cOR 1·48 [95% CI 1·16-1·89]; p=0·0019). When time to surgical decompression was modelled as a continuous variable, there was a steep decline in change in total motor score with increasing time during the first 24-36 h after injury (p<0·0001); and after 36 h, change in total motor score plateaued. INTERPRETATION Surgical decompression within 24 h of acute SCI is associated with improved sensorimotor recovery. The first 24-36 h after injury appears to represent a crucial time window to achieve optimal neurological recovery with decompressive surgery following acute SCI. FUNDING None.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert G Grossman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | | | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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11
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Zinc Concentration Dynamics Indicate Neurological Impairment Odds after Traumatic Spinal Cord Injury. Antioxidants (Basel) 2020; 9:antiox9050421. [PMID: 32414139 PMCID: PMC7278606 DOI: 10.3390/antiox9050421] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 12/24/2022] Open
Abstract
Traumatic Spinal Cord Injury (TSCI) is debilitating and often results in a loss of motor and sensory function caused by an interwoven set of pathological processes. Oxidative stress and inflammatory processes are amongst the critical factors in the secondary injury phase after TSCI. The essential trace element Zinc (Zn) plays a crucial role during this phase as part of the antioxidant defense system. The study aims to determine dynamic patterns in serum Zn concentration in patients with TSCI and test for a correlation with neurological impairment. A total of 42 patients with TSCI were enrolled in this clinical observational study. Serum samples were collected at five different points in time after injury (at admission, and after 4 h, 9 h, 12 h, 24 h, and 3 days). The analysis of the serum Zn concentrations was conducted by total reflection X-ray fluorescence (TXRF). The patients were divided into two groups—a study group S (n = 33) with neurological impairment, including patients with remission (G1, n = 18) and no remission (G0, n = 15) according to a positive AIS (American Spinal Injury Association (ASIA) Impairment Scale) conversion within 3 months after the trauma; and a control group C (n = 9), consisting of subjects with vertebral fractures without neurological impairment. The patient data and serum concentrations were examined and compared by non-parametric test methods to the neurological outcome. The median Zn concentrations in group S dropped within the first 9 h after injury (964 µg/L at admission versus 570 µg/L at 9 h, p < 0.001). This decline was stronger than in control subjects (median of 751 µg/L versus 729 µg/L, p = 0.023). A binary logistic regression analysis including the difference in serum Zn concentration from admission to 9 h after injury yielded an area under the curve (AUC) of 82.2% (CI: 64.0–100.0%) with respect to persistent neurological impairment. Early Zn concentration dynamics differed in relation to the outcome and may constitute a helpful diagnostic indicator for patients with spinal cord trauma. The fast changes in serum Zn concentrations allow an assessment of neurological impairment risk on the first day after trauma. This finding supports strategies for improving patient care by avoiding strong deficits via adjuvant nutritive measures, e.g., in unresponsive patients after trauma.
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12
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Kelly ML, He J, Roach MJ, Moore TA, Steinmetz MP, Claridge JA. Regionalization of Spine Trauma Care in an Urban Trauma System in the United States: Decreased Time to Surgery and Hospital Length of Stay. Neurosurgery 2020; 85:773-778. [PMID: 30329091 DOI: 10.1093/neuros/nyy452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/13/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The effect of regionalized trauma care (RT) on hospital-based outcomes for traumatic spine injury (TSI) in the United States is unknown. OBJECTIVE To test the hypothesis that RT would be associated with earlier time to surgery and decreased length of stay (LOS). METHODS TSI patients >14 yr were identified using International Classification of Diseases Ninth Revision Clinical Modification diagnostic codes. Data from 2008 through 2012 were analyzed before and after RT in 2010. RESULTS A total of 4072 patients were identified; 1904 (47%) pre-RT and 2168 (53%) post-RT. Injury severity scores, Spine Abbreviated Injury Scale scores, and the percentage of TSIs with spinal cord injury (tSCI) were similar between time periods. Post-RT TSIs demonstrated a lower median intensive care unit (ICU) LOS (0 vs 1 d; P < 0.0001), underwent spine surgery more frequently (13% vs 11%; P = 0.01), and had a higher rate of spine surgery performed within 24 h of admission (65% vs 55%; P = 0.02). In patients with tSCI post-RT, ICU LOS was decreased (1 vs 2 d; P < 0.0001) and ventilator days were reduced (average days: 2 vs 3; P = 0.006). The post-RT time period was an independent predictor for spine surgery performed in less than 24 h for all TSIs (odds ratio [OR] 1.52, 95% confidence interval [CI]: 1.04-2.22, C-stat = 0.65). Multivariate linear regression analysis demonstrated an independent effect on reduced ICU LOS post-RT for TSIs (OR -1.68; 95% CI: -2.98 to 0.39; R2 = 0.74) and tSCIs (OR -2.42, 95% CI: -3.99-0.85; R2 = 0.72). CONCLUSION RT is associated with increased surgical rates, earlier time to surgery, and decreased ICU LOS for patients with TSI.
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Affiliation(s)
- Michael L Kelly
- Department of Neurosurgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Jack He
- Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Mary Jo Roach
- Center for Healthcare Research and Policy, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Timothy A Moore
- Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | | | - Jeffrey A Claridge
- Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio.,Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio.,Northern Ohio Trauma System, Case Western Reserve University School of Medicine, Cleveland, Ohio
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13
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Early Decompression (<8 Hours) Improves Functional Bladder Outcome and Mobility After Traumatic Thoracic Spinal Cord Injury. World Neurosurg 2020; 134:e847-e854. [DOI: 10.1016/j.wneu.2019.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/02/2019] [Accepted: 11/04/2019] [Indexed: 12/15/2022]
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14
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Wilson JR, Witiw CD, Badhiwala J, Kwon BK, Fehlings MG, Harrop JS. Early Surgery for Traumatic Spinal Cord Injury: Where Are We Now? Global Spine J 2020; 10:84S-91S. [PMID: 31934526 PMCID: PMC6947677 DOI: 10.1177/2192568219877860] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE There is a strong biological rationale to perform early decompression after traumatic spinal cord injury (SCI). With an enlarging clinical evidence base, most spine surgeons internationally now favor early decompression for the majority of SCI patients; however, a number of pertinent questions remain surrounding this therapy. METHODS A narrative review evaluating the status of early surgery for SCI. In particular, we addressed the following questions: (1) Which patients stand to benefit most from early surgery? 2) What is the most appropriate time threshold defining early surgery? RESULTS Although heterogeneity exists, the evidence generally seems to support early surgery. While the best evidence exists for cervical SCI, there is insufficient data to support a differential effect for early surgery depending on neurological level or injury severity. When comparing thresholds to define early versus late surgery-including a later threshold (48-72 hours), an earlier threshold (24 hours), and an ultra-early threshold (8-12 hours)-the 2 earlier time points seem to be associated with the greatest potential for improved outcomes. However, existing prehospital and hospital logistics pose barriers to early surgery in a significant proportion of patients. An overview of recommendations from the recent AOSpine guidelines is provided. CONCLUSION In spite of increasing acceptance of early surgery post SCI, further research is needed to (1) identify subgroups of patients who stand to derive particular benefit-in particular to develop more evidence-based approaches for central cord syndrome and (2) investigate the efficacy and feasibility of ultra-early surgery targeting more aggressive timelines.
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Affiliation(s)
- Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,Jefferson R. Wilson, Division of Neurosurgery, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
| | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
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15
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Furlan JC, Craven BC, Fehlings MG. Is there any gender or age-related discrepancy in the waiting time for each step in the surgical management of acute traumatic cervical spinal cord injury? J Spinal Cord Med 2019; 42:233-241. [PMID: 31573451 PMCID: PMC6781466 DOI: 10.1080/10790268.2019.1614291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Context/Objective: Prior studies indicate that patient's gender and age can influence treatment choices during spine disease management. This study examines whether individual's gender and age at injury onset influence the waiting time for each step in the surgical management of patients with acute traumatic cervical spinal cord injury (atcSCI). Design: Retrospective cohort study. Setting: Quaternary spine trauma center. Participants: This study included consecutive individuals with atcSCI admitted from August/2002 to October/2008 who were enrolled in the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS). Interventions: Spinal cord decompression. Outcome Measures: Data on the periods of time for each step in the surgical management were analyzed to explore the potential effects of gender and age at injury onset. Results: There were 64 individuals with atcSCI (17 women, 47 men; age range: 18-78 years; mean age: 50.5 ± 2.1 years). Older age was associated with longer stay in the acute spine center, but this association was cofounded by major pre-existing medical co-morbidities. Age did not significantly affect the waiting time for each step in the surgical management of these individuals with atcSCI. Women underwent surgical assessment earlier than men. Gender did not influence other key steps in the surgical management. Conclusion: The study results suggest that older age at injury onset was associated with longer stay in the acute spine care center, and women had a shorter waiting time for surgical assessment than men. Nevertheless, no other age or gender bias was identified in the waiting times for the steps in the management of atcSCI.
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Affiliation(s)
- Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada,Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada,Correspondence to: Julio C. Furlan, 520 Sutherland Drive, Room 206-J, Toronto, Ontario, Canada, M4G 3V9; Ph:416-597-4322 (Ext. 6129); 416-425-9923. E-mail:
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada,Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Michael G. Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada,Spinal Program, Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Canada
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Grassner L, Wutte C, Zimmermann G, Grillhösl A, Schmid K, Weiβ T, Maier W, Hauck S, Hollerith T, Vogel M, Bierschneider M, Vastmans J, Thomé C, Gonschorek O, Strowitzki M. Influence of Preoperative Magnetic Resonance Imaging on Surgical Decision Making for Patients with Acute Traumatic Cervical Spinal Cord Injury: A Survey Among Experienced Spine Surgeons. World Neurosurg 2019; 131:e586-e592. [PMID: 31404692 DOI: 10.1016/j.wneu.2019.08.009] [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: 07/14/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Early decompression after acute spinal cord injury (SCI) is recommended. Acute care is crucial, but optimal management is unclear. The aim of this study was to investigate the role of preoperative magnetic resonance imaging (MRI) in addition to computed tomography (CT) in surgical decision making for acute cervical SCI. METHODS All patients with cervical SCI between 2008 and 2016 who had preoperative CT and MRI (n = 63) at the Trauma Center Murnau, Germany, were included. We administered a survey to 10 experienced spine surgeons (5 neurosurgeons, 5 trauma surgeons) regarding the surgical management. First, the surgeons were shown clinical information and CT scans. Two months later, the survey was repeated with additional MRI. Corresponding percentages of change and agreement were obtained for each rater and survey item. Finally, results from both parts of the survey were compared with the definitive treatment option (i.e., real-world decision). RESULTS MRI modified surgical timing in a median of 41% of patients (interquartile range 38%-56%). In almost every fifth patient (17%), no surgery would have been indicated with CT alone. The advocated surgical approach was changed in almost half of patients (median 48%, interquartile range 33%-49%). Surgically addressed levels were changed in a median of 57% of patients (interquartile range 56%-60%). MRI led to higher agreement with the real-world decision concerning addressed levels (median 35% vs. 73%), timing (median 51% vs. 57%), and approach (median 44% vs. 65%). CONCLUSIONS Preoperative MRI influenced surgical decision making substantially in our cohort and has become a new standard for patients with cervical SCI in our institution if medically possible.
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Affiliation(s)
- Lukas Grassner
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany; Center for Spinal Cord Injuries, BG Trauma Center Murnau, Murnau, Germany; Institute for Molecular Regenerative Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria; Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria.
| | - Christof Wutte
- Center for Spinal Cord Injuries, BG Trauma Center Murnau, Murnau, Germany
| | - Georg Zimmermann
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler Medical Center and Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Grillhösl
- Department of Neuroradiology, BG Trauma Center Murnau, Murnau, Germany
| | - Katharina Schmid
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany
| | - Thomas Weiβ
- Department of Spine Surgery, BG Trauma Center Murnau, Murnau, Germany
| | - Walter Maier
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany
| | - Stefan Hauck
- Department of Spine Surgery, BG Trauma Center Murnau, Murnau, Germany
| | - Tobias Hollerith
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany
| | - Matthias Vogel
- Center for Spinal Cord Injuries, BG Trauma Center Murnau, Murnau, Germany
| | | | - Jan Vastmans
- Center for Spinal Cord Injuries, BG Trauma Center Murnau, Murnau, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Oliver Gonschorek
- Department of Spine Surgery, BG Trauma Center Murnau, Murnau, Germany
| | - Martin Strowitzki
- Department of Neurosurgery, BG Trauma Center Murnau, Murnau, Germany
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Wutte C, Klein B, Becker J, Mach O, Panzer S, Strowitzki M, Maier D, Grassner L. Earlier Decompression (< 8 Hours) Results in Better Neurological and Functional Outcome after Traumatic Thoracolumbar Spinal Cord Injury. J Neurotrauma 2019; 36:2020-2027. [DOI: 10.1089/neu.2018.6146] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Christof Wutte
- Center for Spinal Cord Injuries, Trauma Center Murnau, Murnau, Germany
| | - Barbara Klein
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Salzburg, Austria
| | - Johannes Becker
- Center for Spinal Cord Injuries, Trauma Center Murnau, Murnau, Germany
- Institute of Biomechanics, BG Trauma Center Murnau, Germany, and Paracelsus Medical University, Salzburg, Austria
| | - Orpheus Mach
- Center for Spinal Cord Injuries, Trauma Center Murnau, Murnau, Germany
| | - Stephanie Panzer
- Department of Radiology, Trauma Center Murnau, Murnau, Germany
- Institute of Biomechanics, BG Trauma Center Murnau, Germany, and Paracelsus Medical University, Salzburg, Austria
| | | | - Doris Maier
- Center for Spinal Cord Injuries, Trauma Center Murnau, Murnau, Germany
| | - Lukas Grassner
- Center for Spinal Cord Injuries, Trauma Center Murnau, Murnau, Germany
- Department of Neurosurgery, Trauma Center Murnau, Murnau, Germany
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Salzburg, Austria
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18
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Mapping the continuum of care to surgery following traumatic spinal cord injury. Injury 2018; 49:1552-1557. [PMID: 29934095 DOI: 10.1016/j.injury.2018.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is a devastating injury, frequently resulting in paralysis and a lifetime of medical and social problems. Reducing time to surgery may improve patient outcomes. A vital first step to reduce times is to map current pathways of care from injury to surgery, identify rapid care pathways and factors associated with rapid care pathway times. METHODS A retrospective review of the Alfred Trauma Service records was undertaken for all cases of spinal injury recorded in the Alfred Trauma Registry over a three year period. Patients with an Abbreviated Injury Scale (AIS) code matching 148 codes for spinal injury were included in the study. Information extracted from the Alfred Trauma Registry included demographic, clinical and key care timelines. RESULTS Of the 342 cases identified, 119 had SCI. The average age of SCI patients was 52 years, with 84% male. The vast majority of SCI patients experienced multiple concurrent injuries (87%). Median time from injury to surgery was 17 h r 28 min for SCI patients in comparison to 28 h r 23 min for non-SCI patients. Three pathways to surgery were identified following Trauma Centre presentation- transfer to surgery direct from trauma unit (median time to surgery was 4 h 17 min.), via Intensive Care (median time to surgery was 24 h 33 min) and via the ward (median time to surgery 28 h r 35 min.) SCI was independently associated with the fastest pathway - direct transfer from trauma unit to surgery - with 41% of SCI cases transferred directly to surgery from the trauma unit. CONCLUSION Notwithstanding that the vast majority of SCI patients presented with other traumatic injuries, half of all SCI cases reached surgery within 18 h of injury, with 25% within 9 h. SCI was independently associated with direct transfer to surgery from the trauma unit. SCI patients achieve rapid times to surgery within a complex trauma service. Furthermore, the trauma system is well positioned to implement further time reductions to surgery for SCI patients.
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Chan BCF, Craven BC, Furlan JC. A scoping review on health economics in neurosurgery for acute spine trauma. Neurosurg Focus 2018; 44:E15. [DOI: 10.3171/2018.2.focus17778] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVEAcute spine trauma (AST) has a relatively low incidence, but it often results in substantial individual impairments and societal economic burden resulting from the associated disability. Given the key role of neurosurgeons in the decision-making regarding operative management of individuals with AST, the authors performed a systematic search with scoping synthesis of relevant literature to review current knowledge regarding the economic burden of AST.METHODSThis systematic review with scoping synthesis included original articles reporting cost-effectiveness, cost-utility, cost-benefit, cost-minimization, cost-comparison, and economic analyses related to surgical management of AST, whereby AST is defined as trauma to the spine that may result in spinal cord injury with motor, sensory, and/or autonomic impairment. The initial literature search was carried out using MEDLINE, EMBASE, CINAHL, CCTR, and PubMed. All original articles captured in the literature search and published from 1946 to September 27, 2017, were included. Search terms used were the following: (cost analysis, cost effectiveness, cost benefit, economic evaluation or economic impact) AND (spine or spinal cord) AND (surgery or surgical).RESULTSThe literature search captured 5770 titles, of which 11 original studies met the inclusion/exclusion criteria. These 11 studies included 4 cost-utility analyses, 5 cost analyses that compared the cost of intervention with a comparator, and 2 studies examining direct costs without a comparator. There are a few potentially cost-saving strategies in the neurosurgical management of individuals with AST, including 1) early surgical spinal cord decompression for acute traumatic cervical spinal cord injury (or traumatic thoracolumbar fractures, traumatic cervical fractures); 2) surgical treatment of the elderly with type-II odontoid fractures, which is more costly but more effective than the nonoperative approach among individuals with age at AST between 65 and 84 years; 3) surgical treatment of traumatic thoracolumbar spine fractures, which is implicated in greater direct costs but lower general-practitioner visit costs, private expenditures, and absenteeism costs than nonsurgical management; and 4) removal of pedicle screws 1–2 years after posterior instrumented fusion for individuals with thoracolumbar burst fractures, which is more cost-effective than retaining the pedicle screws.CONCLUSIONSThis scoping synthesis underscores a number of potentially cost-saving opportunities for neurosurgeons when managing patients with AST. There are significant knowledge gaps regarding the potential economic impact of therapeutic choices for AST that are commonly used by neurosurgeons.
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Affiliation(s)
- Brian C. F. Chan
- 1Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network; and
| | - B. Catharine Craven
- 1Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network; and
- 2Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Julio C. Furlan
- 1Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network; and
- 2Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
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Thompson C, Feldman DE, Mac-Thiong JM. Surgical management of patients following traumatic spinal cord injury: Identifying barriers to early surgery in a specialized spinal cord injury center. J Spinal Cord Med 2018; 41:142-148. [PMID: 27077578 PMCID: PMC5901449 DOI: 10.1080/10790268.2016.1165448] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
CONTEXT/OBJECTIVE Early surgery in individuals with traumatic spinal cord injury (T-SCI) can improve neurological recovery and reduce complications, costs and hospitalization. Patient-related and healthcare-related factors could influence surgical delay. This study aimed at determining factors contributing to surgical delay in individuals with T-SCI. DESIGN Prospective cohort study. SETTING Single Level I trauma center in Québec, Canada. PARTICIPANTS One hundred and forty-four patients who sustained a T-SCI. INTERVENTIONS None. OUTCOME MEASURES Socio-demographic and clinical administrative data were collected during the pre-operative period. The cohort was stratified in early surgery, or ES (<24 hours post-trauma) and late surgery, or LS (≥ 24 hours post-trauma) groups. A multivariate logistic regression analysis using patient- and healthcare-related factors was carried out to identify the main predictors of LS. RESULTS 93 patients had ES (15.6 ± 4.7 hours post-trauma), which is 31 hours earlier than the 51 patients in the LS group (46.9 ± 30.9 hours; P < 10-3). The transfer delay from trauma site to the SCI center was 8 hours shorter (5.0 ± 3.0 hours vs 13.6 ± 17.0; P < 10-3) for the ES group, and the surgical plan was completed 17 hours faster (6.0 ± 4.0 hours vs 23.3 ± 23.6 hours; P < 10-3) than for the LS group. The occurrence of LS was predicted by modifiable factors, such as the transfer delay to the SCI center, the delay before surgical plan completion, and the waiting time for the operating room. CONCLUSIONS A dedicated team for surgical treatment of individuals with T-SCI, involving direct transfer to the SCI center, faster surgery planning and access to the operating room in hospitals dealing with emergencies from all subspecialties could improve surgical delay and increase the rate of patients undergoing ES.
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Affiliation(s)
- Cynthia Thompson
- Research Center, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada,Correspondence to: Cynthia Thompson, Research Center, Hôpital Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, Québec, Canada, H4J 1C5. E-mail:
| | - Debbie E. Feldman
- School of Rehabilitation, University of Montréal, Montréal, Québec, Canada
| | - Jean-Marc Mac-Thiong
- Research Center, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada,Department of Surgery, Université de Montréal, Montréal, Québec, Canada,Department of Surgery, Hôpital Ste-Justine, Montréal, Québec, Canada
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Trends in Patient Care for Traumatic Spinal Injuries in the United States: A National Inpatient Sample Study of the Correlations With Patient Outcomes From 2001 to 2012. Spine (Phila Pa 1976) 2017; 42:1923-1929. [PMID: 28538594 DOI: 10.1097/brs.0000000000002246] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective database review. OBJECTIVE The aim of this study was to examine whether patient characteristics, distribution of care, and patient outcomes for spinal cord injury (SCI) in the United States have changed between 2001 and 2012. SUMMARY OF BACKGROUND DATA Although patient outcomes after cranial injury are better at high-volume centers with specialized, multidisciplinary teams, similar assessments have not been done for spinal injuries. METHODS We retrospectively reviewed the National and Nationwide Inpatient Samples for the years 2001, 2002, 2011, and 2012 to identify patients with spinal fracture with or without SCI. The demographic characteristics of the patient cohort, clinical course, hospital characteristics, interhospital transfer, and disposition were statistically analyzed relative to patient mortality, total hospital costs, and length of stay. How these data changed over this 11-year period was also evaluated. RESULTS A total of 159,875 cases were identified, with 141,737 fractures without SCI and 18,138 SCIs with or without fracture. There was a statistically significant decrease in the percentage of patients transferred with spine injury from 4.2% to 3.4% (P < 0.001) from the early years to the later years and in patient transfers for SCIs (8.1% vs. 6.5%, P < 0.001). Interestingly, the overall mortality rate (3.5% vs. 3.6%) remained unchanged (P = 0.679), but mortality from SCI increased (6.6-7.4%, P = 0.021). CONCLUSION From 2002 to 2012, the rate of interhospital transfer of spinal injury patients declined, while the mortality rate for patients with SCI increased. Interestingly, there was an increase in transfers after spinal surgery at the index hospital. The decentralization of spine care may be responsible for the increase in mortality. LEVEL OF EVIDENCE 4.
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Aarabi B, Sansur CA, Ibrahimi DM, Simard JM, Hersh DS, Le E, Diaz C, Massetti J, Akhtar-Danesh N. Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury. Neurosurgery 2017; 80:610-620. [PMID: 28362913 DOI: 10.1093/neuros/nyw053] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/14/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Evidence indicates that, over time, patients with spinal cord injury (SCI) improve neurologically in various degrees. We sought to further investigate indicators of grade conversion in cervical SCI. OBJECTIVE To detect predictors of ASIA impairment scale (AIS) grade conversion in SCI following surgical decompression. METHODS In a retrospective study, demographics, clinical, imaging, and surgical data from 100 consecutive patients were assessed for predictors of AIS grade conversion. RESULTS American Spinal Injury Association motor score was 17.1. AIS grade was A in 52%, B in 29%, and C in 19% of patients. Surgical decompression took place on an average of 17.6 h following trauma (≤12 h in 51 and >12 h in 49). Complete decompression was verified by magnetic resonance imaging (MRI) in 73 patients. Intramedullary lesion length (IMLL) on postoperative MRI measured 72.8 mm, and hemorrhage at the injury epicenter was noted in 71 patients. Grade conversion took place in 26.9% of AIS grade A patients, 65.5% of AIS grade B, and 78.9% of AIS grade C. AIS grade conversion had statistical relationship with injury severity score, admission AIS grade, extent of decompression, presence of intramedullary hemorrhage, American Spinal Injury Association motor score, and IMLL. A stepwise multiple logistic regression analysis indicated IMLL was the sole and strongest indicator of AIS grade conversion (odds ratio 0.950, 95% CI 0.931-0.969). For 1- and 10-mm increases in IMLL, the model indicates 4% and 40% decreases, respectively, in the odds of AIS grade conversion. CONCLUSION Compared with other surrogates, IMLL remained as the only predictor of AIS grade conversion.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.,R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles A Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David M Ibrahimi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David S Hersh
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth Le
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cara Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Massetti
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Noori Akhtar-Danesh
- School of Nursing and Depart-ment of Clinical Epidemiology and Bio-statistics, McMaster University, Hamilton, Ontario, Canada
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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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Early Spinal Surgery Following Thoracolumbar Spinal Cord Injury: Process of Care From Trauma to Theater. Spine (Phila Pa 1976) 2017; 42:E617-E623. [PMID: 27669041 DOI: 10.1097/brs.0000000000001903] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aims of this study were to (1) determine the timing of surgery for traumatic thoracolumbar spinal cord injury (TLSCI) between 2010 and 2014 and (2) identify major delays in the process of care from accident scene to surgery. SUMMARY OF BACKGROUND DATA Early spinal surgery may promote neurological recovery and reduce acute complications after TLSCI; however, it is difficult to achieve due to logistical issues and the frequent presence of other nonlife-threatening injuries. METHODS Data were extracted from the medical records of 46 cases of acute traumatic TLSCI (AIS level T1-L1) aged between 15 and 70 years. Patients with life-threatening injuries, not requiring spinal surgery or with poor general health, were excluded. RESULTS The median time to surgery was 27 hours [interquartile range (IQR): 20-43 hours] and improved from 27 hours in 2010 to 22 hours in 2014. Cases admitted via a pre-surgical hospital had a longer median time to surgery than direct surgical hospital admissions (28 vs. 24 hours, respectively). The median time from completion of radiological investigations to surgery was 18 hours, suggesting that theater access and organization of a surgical team were the major factors contributing to surgical delay. Number of vertebral levels fractured (≥5) and upper thoracic level of injury (T1-8) were also found to be associated with surgical delay. CONCLUSION Earlier spinal surgery in TLSCI would be facilitated by direct surgical hospital admission and improved access to the operating theater and surgical teams. LEVEL OF EVIDENCE 3.
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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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26
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An analysis of ideal and actual time to surgery after traumatic spinal cord injury in Canada. Spinal Cord 2017; 55:618-623. [DOI: 10.1038/sc.2016.177] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 09/19/2016] [Accepted: 10/21/2016] [Indexed: 11/08/2022]
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Grassner L, Wutte C, Klein B, Mach O, Riesner S, Panzer S, Vogel M, Bühren V, Strowitzki M, Vastmans J, Maier D. Early Decompression (< 8 h) after Traumatic Cervical Spinal Cord Injury Improves Functional Outcome as Assessed by Spinal Cord Independence Measure after One Year. J Neurotrauma 2016; 33:1658-66. [DOI: 10.1089/neu.2015.4325] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lukas Grassner
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
- Department of Neurosurgery, Trauma Center Murnau, Germany
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Austria
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Austria
| | - Christof Wutte
- Department of Neurosurgery, Trauma Center Murnau, Germany
| | - Barbara Klein
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Austria
- Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Austria
| | - Orpheus Mach
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | - Silvie Riesner
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | - Stephanie Panzer
- Department of Radiology, Trauma Center Murnau, Germany
- Institute of Biomechanics, Trauma Center Murnau and Paracelsus Medical University Salzburg, Murnau, Germany
| | - Matthias Vogel
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | - Volker Bühren
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | | | - Jan Vastmans
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
| | - Doris Maier
- Center for Spinal Cord Injuries, Trauma Center Murnau, Germany
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Wang K, Wang WT, Wang J, Chen Z, Song QX, Chen SY, Hao Q, He DW, Shen HX. Compared study of routine magnetic resonance imaging and diffusion tensor tractography on the predictive value of diagnosis and prognosis in acute cervical spinal cord injury. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Battistuzzo CR, Armstrong A, Clark J, Worley L, Sharwood L, Lin P, Rooke G, Skeers P, Nolan S, Geraghty T, Nunn A, Brown DJ, Hill S, Alexander J, Millard M, Cox SF, Rao S, Watts A, Goods L, Allison GT, Agostinello J, Cameron PA, Mosley I, Liew SM, Geddes T, Middleton J, Buchanan J, Rosenfeld JV, Bernard S, Atresh S, Patel A, Schouten R, Freeman BJ, Dunlop SA, Batchelor PE. Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery. J Neurotrauma 2016; 33:1161-9. [DOI: 10.1089/neu.2015.4207] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Camila R. Battistuzzo
- Department of Medicine (Royal Melbourne Hospital), the University of Melbourne, Melbourne, Australia
| | - Alex Armstrong
- School of Animal Biology, the University of Western Australia, Perth Australia
| | - Jillian Clark
- Center for Orthopedic and Trauma Research, the University of Adelaide, Adelaide, Australia
| | - Laura Worley
- Queensland Spinal Injuries Service, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Lisa Sharwood
- John Walsh Center for Rehabilitation Research, the University of Sydney, Sydney, Australia
| | - Peny Lin
- Orthopedic Department, Middlemore Hospital, Auckland, New Zealand
| | - Gareth Rooke
- Orthopedic Department, Christchurch Hospital, Christchurch, New Zealand
| | - Peta Skeers
- Department of Medicine (Royal Melbourne Hospital), the University of Melbourne, Melbourne, Australia
| | - Sherilyn Nolan
- School of Animal Biology, the University of Western Australia, Perth Australia
| | - Timothy Geraghty
- Queensland Spinal Injuries Service, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Andrew Nunn
- Victorian Spinal Cord Service, Austin Hospital, Melbourne, Australia
| | | | - Steven Hill
- Victorian Spinal Cord Service, Austin Hospital, Melbourne, Australia
| | - Janette Alexander
- Victorian Spinal Cord Service, Austin Hospital, Melbourne, Australia
| | - Melinda Millard
- Victorian Spinal Cord Service, Austin Hospital, Melbourne, Australia
| | - Susan F. Cox
- Neuroscience Trials Australia, the Florey Institute of Neuroscience, Melbourne, Australia
| | - Sudhakar Rao
- Trauma Service, Royal Perth Hospital, Perth, Australia
| | - Ann Watts
- Spinal Unit, Royal Perth Hospital, Perth, Australia
| | - Louise Goods
- School of Animal Biology, the University of Western Australia, Perth Australia
| | - Garry T. Allison
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia
| | - Jacqui Agostinello
- Department of Medicine (Royal Melbourne Hospital), the University of Melbourne, Melbourne, Australia
| | - Peter A. Cameron
- Emergency and Trauma Center, the Alfred Hospital, Melbourne, Australia
| | - Ian Mosley
- College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
| | - Susan M. Liew
- Department of Orthopedic Surgery, the Alfred Hospital, Melbourne, Australia
| | - Tom Geddes
- Orthopedic Department, Middlemore Hospital, Auckland, New Zealand
| | - James Middleton
- John Walsh Center for Rehabilitation Research, the University of Sydney, Sydney, Australia
| | - John Buchanan
- Department of Physiotherapy, Royal Perth Hospital, Perth, Australia
| | | | - Stephen Bernard
- Intensive Care Unit, the Alfred Hospital, Melbourne, Australia
| | - Sridhar Atresh
- Queensland Spinal Injuries Service, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Alpesh Patel
- Orthopedic Department, Middlemore Hospital, Auckland, New Zealand
| | - Rowan Schouten
- Orthopedic Department, Christchurch Hospital, Christchurch, New Zealand
| | - Brian J.C. Freeman
- Department of Orthopedics and Trauma, the University of Adelaide, Adelaide, Australia
| | - Sarah A. Dunlop
- School of Animal Biology, the University of Western Australia, Perth Australia
| | - Peter E. Batchelor
- Department of Medicine (Royal Melbourne Hospital), the University of Melbourne, Melbourne, Australia
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Zhang J, Wang H, Zhang C, Li W. Intrathecal decompression versus epidural decompression in the treatment of severe spinal cord injury in rat model: a randomized, controlled preclinical research. J Orthop Surg Res 2016; 11:34. [PMID: 27006005 PMCID: PMC4802628 DOI: 10.1186/s13018-016-0369-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/15/2016] [Indexed: 11/30/2022] Open
Abstract
Background In the setting of severe spinal cord injury (SCI), there is no markedly efficacious clinical therapeutic regimen to improve neurological function. After epidural decompression, as is shown in animal models, the swollen cord against non-elastic dura and elevation of intrathecal pressure may be the main causes of aggravated neurologic function. We performed an intrathecal decompression by longitudinal durotomy to evaluate the neuroprotective effect after severe SCI by comparing with epidural decompression. Methods Eighty-four adult male Sprague-Dawley rats were assigned to three groups: sham group (group S), epidural decompression (group C), and intrathecal decompression group (group D). A weight-drop model was performed at T9. The Basso-Beattie-Bresnahan (BBB) score was used to evaluate neurological function. Animals were sacrificed at corresponding time points, and we performed pathohistological examinations including HE staining and immunohistochemical staining (IHC) of glial fibrillary acidic protein (GFAP), neurocan, and ED1 at the epicenter of injured cords. Finally, the lesions were quantitatively analyzed by SPSS 22.0. Results The mortality rates were, respectively, 5.55 % (2/36) and 13.9 % (5/36) in groups C and D, and there was no significant difference between groups C and D (P = 0.214). Compared with epidural decompression, intrathecal decompression could obviously improve BBB scores after SCI. HE staining indicated that more white matter was spared, and fewer vacuoles and less axon degradation were observed. The expression peak of GFAP, neurocan, and ED1 occurred at an earlier time and was down-regulated in group D compared to group C. Conclusions Our findings based on rat SCI model suggest that intrathecal decompression by longitudinal durotomy can prompt recovery of neurological function, and this neuroprotective mechanism may be related to the down-regulation of GFAP, neurocan, and ED1.
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Affiliation(s)
- Jian Zhang
- No.1 Department of Orthopedic Surgery, Tianjin Baodi Hospital, No.8, Guangchuan Road, Baodi District, Tianjin, 301800, China.
| | - Huili Wang
- No.1 Department of Orthopedic Surgery, Tianjin Baodi Hospital, No.8, Guangchuan Road, Baodi District, Tianjin, 301800, China
| | - Chenggang Zhang
- Institute of Radiation and Radiation Medicine, Academy of Military Medical Sciences, No.27, Taiping Road, Haidian District, Beijing, 100850, China
| | - Weiguang Li
- Institute of Radiation and Radiation Medicine, Academy of Military Medical Sciences, No.27, Taiping Road, Haidian District, Beijing, 100850, China
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Wilson JR, Voth J, Singh A, Middleton J, Jaglal SB, Singh JM, Mainprize TG, Yee A, Fehlings MG. Defining the Pathway to Definitive Care and Surgical Decompression after Traumatic Spinal Cord Injury: Results of a Canadian Population-Based Cohort Study. J Neurotrauma 2016; 33:963-71. [PMID: 26652196 DOI: 10.1089/neu.2015.4258] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Early access to specialized care after acute traumatic spinal cord injury (SCI) is associated with improved outcomes. However, many SCI patients do not receive timely access to such care. To characterize and quantify patients' pathway to definitive care and surgery post SCI, and to identify factors that may delay expeditious care, a population based cohort study was performed in Ontario. Using provincial administrative health data, adult patients with acute traumatic SCI who underwent surgery between 2002 and 2011 were identified using SCI specific ICD-10 codes. The relationship between predictor variables and a) time to arrival at the site of definitive care and b) time to surgery was statistically evaluated. Of 1,111 patients meeting eligibility criteria, mean times to arrival at the site of definitive care and to surgery were 8.1 ± 25.5 and 49.4 ± 65.0 hours respectively, with 53.3% of patients having surgery prior to 24 hours. While most patients (88.4%) reached the site of definitive care within 6 hours, only 34.2% reached surgery within 12 hours of arrival. Older age (IRR = 1.01; 95% CI: 1.01, 1.02), increased number of stops at intermediate health care centers (IRR = 7.70; 95% CI: 7.54, 7.86), higher comorbidity index (IRR = 1.43; 95% CI: 1.14, 1.72) and fall related SCI etiology (IRR = 1.16; 95% CI: 1.02, 1.29) were associated with increased time to arrival at definitive care. For surgery, increased age (OR = 1.02; 95% CI: 1.01, 1.03) and stops at intermediate health centers (OR = 2.48; 95% CI: 1.35, 4.56) were associated with a greater odds of undergoing late surgery (>24hrs). These results can inform policy decisions and facilitate creation of a streamlined path to specialized care for patients with acute SCI.
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Affiliation(s)
- Jefferson R Wilson
- 1 Division of Neurosurgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada
| | - Jennifer Voth
- 2 Institute of Clinical Evaluative Sciences, University of Toronto , Toronto, Ontario, Canada
| | - Anoushka Singh
- 1 Division of Neurosurgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada
| | - James Middleton
- 3 Rehabilitation Studies Unit, University of Sydney , Sydney, Australia
| | - Susan B Jaglal
- 2 Institute of Clinical Evaluative Sciences, University of Toronto , Toronto, Ontario, Canada .,4 Department of Physical Therapy, University of Toronto , Toronto, Ontario, Canada
| | - Jeffrey M Singh
- 4 Department of Physical Therapy, University of Toronto , Toronto, Ontario, Canada
| | - Todd G Mainprize
- 1 Division of Neurosurgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada
| | - Albert Yee
- 5 Division of Orthopedic Surgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada
| | - Michael G Fehlings
- 1 Division of Neurosurgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada
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Missios S, Bekelis K. Nonmedical factors and the transfer of spine trauma patients initially evaluated at Level III and IV trauma centers. Spine J 2015; 15:2028-35. [PMID: 25998327 DOI: 10.1016/j.spinee.2015.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/08/2015] [Accepted: 05/13/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The influence of nonmedical factors on the disposition of spine trauma patients, initially seen in less specialized institutions, remains an issue of debate. PURPOSE To investigate the association of lack of insurance and African-American race with the probability of being transferred to a Level I or II trauma center, after being evaluated in the emergency department (ED) of Level III or IV trauma centers for spine trauma. STUDY DESIGN/SETTING This was a retrospective cohort study. PATIENT SAMPLE A total of 14,133 patients who were registered in National Trauma Data Bank (NTDB) from 2009 to 2011 and initially evaluated in the ED of Level III or IV trauma centers for spine trauma were included. OUTCOME MEASURES The outcome measures were rates of transfer to a higher level of care trauma center. METHODS We performed a retrospective cohort study involving spine trauma patients, who were registered in the NTDB between 2009 and 2011. Regression techniques, controlling for clustering at the hospital level, were used to investigate the association of insurance status and race with the possibility of transfer. RESULTS Overall, 4,142 patients (29.31%) were transferred to a higher level of care institution, and 9,738 (70.69%) were admitted to a Level III or IV trauma center. Multivariable logistic regression analysis demonstrated an association of uninsured patients with increased possibility of transfer (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.22-1.61). This persisted after using a mixed effects model to control for clustering at the hospital level (OR, 1.65; 95% CI, 1.37-1.96). African-American race was not associated with the decision to transfer, when using a mixed effects model (OR, 1.15; 95% CI, 0.89-1.48). However, African-Americans with Glasgow Coma Scale greater than 8 (OR, 1.40; 95% CI, 1.13-1.74) or Injury Severity Score less than 15 (OR, 1.54; 95% CI, 1.21-1.96) were associated with a higher likelihood of transfer. CONCLUSIONS In summary, lack of insurance was associated with increased possibility of transfer to higher level of care institutions, after evaluation in a Level III or IV trauma center ED for spine trauma. The same was true for African-Americans with milder injuries.
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Affiliation(s)
- Symeon Missios
- Department of Surgery, Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756, USA
| | - Kimon Bekelis
- Department of Neurosurgery, Louisiana State University Health Sciences Center, 1541 Kings Hwy, Shreveport, LA 71103, USA.
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The volatile anesthetic methoxyflurane protects motoneurons against excitotoxicity in an in vitro model of rat spinal cord injury. Neuroscience 2014; 285:269-80. [PMID: 25446348 DOI: 10.1016/j.neuroscience.2014.11.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/21/2014] [Accepted: 11/13/2014] [Indexed: 11/23/2022]
Abstract
Neuroprotection of the spinal cord during the early phase of injury is an important goal to determine a favorable outcome by prevention of delayed pathological events, including excitotoxicity, which otherwise extend the primary damage and amplify the often irreversible loss of motor function. While intensive care and neurosurgical intervention are important treatments, effective neuroprotection requires further experimental studies focused to target vulnerable neurons, particularly motoneurons. The present investigation examined whether the volatile general anesthetic methoxyflurane might protect spinal locomotor networks from kainate-evoked excitotoxicity using an in vitro rat spinal cord preparation as a model. The protocols involved 1h excitotoxic stimulation on day 1 followed by electrophysiological and immunohistochemical testing on day 2. A single administration of methoxyflurane applied together with kainate (1h), or 30 or even 60 min later prevented any depression of spinal reflexes, loss of motoneuron excitability, and histological damage. Methoxyflurane per se temporarily decreased synaptic transmission and motoneuron excitability, effects readily reversible on washout. Spinal locomotor activity recorded as alternating electrical discharges from lumbar motor pools was fully preserved on the second day after application of methoxyflurane together with (or after) kainate. These data suggest that a volatile general anesthetic could provide strong electrophysiological and histological neuroprotection that enabled expression of locomotor network activity 1 day after the excitotoxic challenge. It is hypothesized that the benefits of early neurosurgery for acute spinal cord injury (SCI) might be enhanced if, in addition to injury decompression and stabilization, the protective role of general anesthesia is exploited.
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Harrop JS, Ghobrial GM, Chitale R, Krespan K, Odorizzi L, Fried T, Maltenfort M, Cohen M, Vaccaro A. Evaluating initial spine trauma response: injury time to trauma center in PA, USA. J Clin Neurosci 2014; 21:1725-9. [PMID: 24932590 DOI: 10.1016/j.jocn.2014.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 03/28/2014] [Indexed: 11/24/2022]
Abstract
Historical perceptions regarding the severity of traumatic spinal cord injury has led to considerable disparity in triage to tertiary care centers. This article retrospectively reviews a large regional trauma database to analyze whether the diagnosis of spinal trauma affected patient transfer timing and patterns. The Pennsylvania Trauma database was retrospectively reviewed. All acute trauma patient entries for level I and II centers were categorized for diagnosis, mechanism, and location of injury, analyzing transportation modality and its influence on time of arrival. A total of 1162 trauma patients were identified (1014 blunt injuries, 135 penetrating injuries and 12 other) with a mean transport time of 3.9 hours and a majority of patients arriving within 7 hours (>75%). Spine trauma patients had the longest mean arrival time (5.2 hours) compared to blunt trauma (4.2 hours), cranial neurologic injuries (4.35 hours), and penetrating injuries (2.13 hours, p<0.0001). There was a statistically significant correlation between earlier arrivals and both cranial trauma (p=0.0085) and penetrating trauma (p<0.0001). The fastest modality was a fire rescue (0.93 hours) or police (0.63 hours) vehicle with Philadelphia County (1.1 hour) having the quickest arrival times. Most trauma patients arrived to a specialty center within 7 hours of injury. However subsets analysis revealed that spine trauma patients had the greatest transit times. Present research trials for spinal cord injuries suggest earlier intervention may lead to improved recovery. Therefore, it is important to focus on improvement of the transportation triage system for traumatic spinal patients.
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Affiliation(s)
- James S Harrop
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA.
| | - George M Ghobrial
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Rohan Chitale
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Kelly Krespan
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Laura Odorizzi
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Tristan Fried
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Mitchell Maltenfort
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Murray Cohen
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
| | - Alexander Vaccaro
- Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University Hospital, 909 Walnut Street, Philadelphia, PA 19107, USA
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Levine JM, Cohen ND, Heller M, Fajt VR, Levine GJ, Kerwin SC, Trivedi AA, Fandel TM, Werb Z, Modestino A, Noble-Haeusslein LJ. Efficacy of a metalloproteinase inhibitor in spinal cord injured dogs. PLoS One 2014; 9:e96408. [PMID: 24788791 PMCID: PMC4006832 DOI: 10.1371/journal.pone.0096408] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/07/2014] [Indexed: 01/10/2023] Open
Abstract
Matrix metalloproteinase-9 is elevated within the acutely injured murine spinal cord and blockade of this early proteolytic activity with GM6001, a broad-spectrum matrix metalloproteinase inhibitor, results in improved recovery after spinal cord injury. As matrix metalloproteinase-9 is likewise acutely elevated in dogs with naturally occurring spinal cord injuries, we evaluated efficacy of GM6001 solubilized in dimethyl sulfoxide in this second species. Safety and pharmacokinetic studies were conducted in naïve dogs. After confirming safety, subsequent pharmacokinetic analyses demonstrated that a 100 mg/kg subcutaneous dose of GM6001 resulted in plasma concentrations that peaked shortly after administration and were sustained for at least 4 days at levels that produced robust in vitro inhibition of matrix metalloproteinase-9. A randomized, blinded, placebo-controlled study was then conducted to assess efficacy of GM6001 given within 48 hours of spinal cord injury. Dogs were enrolled in 3 groups: GM6001 dissolved in dimethyl sulfoxide (n = 35), dimethyl sulfoxide (n = 37), or saline (n = 41). Matrix metalloproteinase activity was increased in the serum of injured dogs and GM6001 reduced this serum protease activity compared to the other two groups. To assess recovery, dogs were a priori stratified into a severely injured group and a mild-to-moderate injured group, using a Modified Frankel Scale. The Texas Spinal Cord Injury Score was then used to assess long-term motor/sensory function. In dogs with severe spinal cord injuries, those treated with saline had a mean motor score of 2 (95% CI 0–4.0) that was significantly (P<0.05; generalized linear model) less than the estimated mean motor score for dogs receiving dimethyl sulfoxide (mean, 5; 95% CI 2.0–8.0) or GM6001 (mean, 5; 95% CI 2.0–8.0). As there was no independent effect of GM6001, we attribute improved neurological outcomes to dimethyl sulfoxide, a pleotropic agent that may target diverse secondary pathogenic events that emerge in the acutely injured cord.
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Affiliation(s)
- Jonathan M. Levine
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, United States of America
- * E-mail:
| | - Noah D. Cohen
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, United States of America
| | - Michael Heller
- Department of Bioengineering, University of California San Diego, San Diego, California, United States of America
| | - Virginia R. Fajt
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, United States of America
| | - Gwendolyn J. Levine
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, United States of America
| | - Sharon C. Kerwin
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, United States of America
| | - Alpa A. Trivedi
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Thomas M. Fandel
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Zena Werb
- Department of Anatomy, University of California San Francisco, San Francisco, California, United States of America
| | - Augusta Modestino
- Department of Bioengineering, University of California San Diego, San Diego, California, United States of America
| | - Linda J. Noble-Haeusslein
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
- Department of Physical Therapy and Rehabilitation, University of California San Francisco, San Francisco, California, United States of America
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