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Levy HA, Pinter ZW, Kazarian ER, Sodha S, Rhee JM, Fehlings MG, Freedman BA, Nassr AN, Karamian BA, Sebastian AS, Currier B. Contemporary Practice Patterns in the Treatment of Cervical Stenosis and Central Cord Syndrome: A Survey of the Cervical Spine Research Society. Clin Spine Surg 2024:01933606-990000000-00346. [PMID: 39101583 DOI: 10.1097/bsd.0000000000001663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 06/28/2024] [Indexed: 08/06/2024]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVE To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia. SUMMARY OF BACKGROUND DATA There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia. METHODS A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants. RESULTS Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms. CONCLUSIONS Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | - Erick R Kazarian
- Department of Orthopedic Surgery, Rothman Institute, New York City, NY
| | | | - John M Rhee
- Department of Orthopedic Surgery, Emory University, Atlanta, GA
| | - Michael G Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | | | - Ahmad N Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Brian A Karamian
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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Wang S, Xu W, Wang J, Hu X, Wu Z, Li C, Xiao Z, Ma B, Cheng L. Tracing the evolving dynamics and research hotspots of spinal cord injury and surgical decompression from 1975 to 2024: a bibliometric analysis. Front Neurol 2024; 15:1442145. [PMID: 39161868 PMCID: PMC11330800 DOI: 10.3389/fneur.2024.1442145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 07/23/2024] [Indexed: 08/21/2024] Open
Abstract
Background Exploration of the benefits and timing of surgical decompression in spinal cord injury (SCI) has been a research hotspot. However, despite the higher volume and increasing emphasis on quality there remains no bibliometric view on SCI and surgical decompression. In this study, we aimed to perform bibliometric analysis to reveal the core countries, affiliations, journals, authors, and developmental trends in SCI and surgical decompression across the past 50 years. Methods Articles and reviews were retrieved from web of science core collection between 1975 and 2024. The bibliometrix package in R was used for data analysis and visualizing. Results A total of 8,688 documents were investigated, indicating an ascending trend in annual publications. The USA and China played as the leaders in scientific productivity. The University of Toronto led in institutional productions. Core authors, such as Michael G. Fehlings, showed high productivity, and occasional authors showed widespread interests. Core journals like Spine and Spinal Cord served as beacons in this field. The interaction of core authors and international collaboration accentuated the cross-disciplinary feature of the field. Prominent documents emphasized the clinical significance of early decompression in 24 h post SCI. Conclusion Based on comprehensive bibliometric analysis and literature review, we identified the hotspots and future directions of this field: (1) further investigation into the molecular and cellular mechanisms to provide pre-clinical evidence for biological effects of early surgical decompression in SCI animal models; (2) further evaluation and validation of the optimal time window of surgical decompression based on large cohort, considering the inherent heterogeneity of subpopulations in complicated immune responses post SCI; (3) further exploration on the benefits of early decompression on the neurological, functional, and clinical outcomes in acute SCI; (4) evaluation of the optimal surgical methods and related outcomes; (5) applications of artificial intelligence-based technologies in spinal surgical decompression.
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Affiliation(s)
- Siqiao Wang
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
| | - Wei Xu
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
- Institute of Spinal and Spinal Cord Injury, Tongji University School of Medicine, Shanghai, China
- Stem Cell Translational Research Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jianjie Wang
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
- Institute of Spinal and Spinal Cord Injury, Tongji University School of Medicine, Shanghai, China
- Stem Cell Translational Research Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiao Hu
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
- Institute of Spinal and Spinal Cord Injury, Tongji University School of Medicine, Shanghai, China
- Stem Cell Translational Research Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhourui Wu
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
- Institute of Spinal and Spinal Cord Injury, Tongji University School of Medicine, Shanghai, China
- Stem Cell Translational Research Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chen Li
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
- Institute of Spinal and Spinal Cord Injury, Tongji University School of Medicine, Shanghai, China
- Stem Cell Translational Research Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhihui Xiao
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
| | - Bei Ma
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
- Institute of Spinal and Spinal Cord Injury, Tongji University School of Medicine, Shanghai, China
- Stem Cell Translational Research Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Liming Cheng
- Division of Spine, Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration (Tongji University), Ministry of Education, Shanghai, China
- Institute of Spinal and Spinal Cord Injury, Tongji University School of Medicine, Shanghai, China
- Stem Cell Translational Research Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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Luo T, Zhong M, An Z. A commentary on 'Prognosis and conditional nomogram of cervical spine fracture in patients with severe spinal cord injury: a multicenter retrospective study'. Int J Surg 2024; 110:5264-5265. [PMID: 38729130 PMCID: PMC11325901 DOI: 10.1097/js9.0000000000001550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Tongfu Luo
- Tongxiang Second People's Hospital, Tongxiang
| | - Musen Zhong
- The Second Clinical Medical College of Zhejiang Chinese Medical University
| | - Zhongcheng An
- The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, People's Republic of China
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Wang Y, Zhang J, Yuan J, Li Q, Zhang S, Wang C, Wang H, Wang L, Zhang B, Wang C, Sun Y, Lu X. Application of a novel nested ensemble algorithm in predicting motor function recovery in patients with traumatic cervical spinal cord injury. Sci Rep 2024; 14:17403. [PMID: 39075134 PMCID: PMC11286788 DOI: 10.1038/s41598-024-65755-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/24/2024] [Indexed: 07/31/2024] Open
Abstract
Traumatic cervical spinal cord injury (TCSCI) often causes varying degrees of motor dysfunction, common assessed by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale. Accurate prediction of motor function recovery is extremely important for formulating effective diagnosis, therapeutic and rehabilitation programs. The aim of this study is to investigate the validity of a novel nested ensemble algorithm that uses the very early ASIA motor score (AMS) of ISNCSCI examination to predict motor function recovery 6 months after injury in TCSCI patients. This retrospective study included complete data of 315 TCSCI patients. The dataset consisting of the first AMS at ≤ 24 h post-injury and follow-up AMS at 6 months post-injury was divided into a training set (80%) and a test set (20%). The nested ensemble algorithm was established in a two-stage manner. Support Vector Classification (SVC), Adaboost, Weak-learner and Dummy were used in the first stage, and Adaboost was selected as second-stage model. The prediction results of the first stage models were uploaded into second-stage model to obtain the final prediction results. The model performance was evaluated using precision, recall, accuracy, F1 score, and confusion matrix. The nested ensemble algorithm was applied to predict motor function recovery of TCSCI, achieving an accuracy of 80.6%, a F1 score of 80.6%, and balancing sensitivity and specificity. The confusion matrix showed few false-negative rate, which has crucial practical implications for prognostic prediction of TCSCI. This novel nested ensemble algorithm, simply based on very early AMS, provides a useful tool for predicting motor function recovery 6 months after TCSCI, which is graded in gradients that progressively improve the accuracy and reliability of the prediction, demonstrating a strong potential of ensemble learning to personalize and optimize the rehabilitation and care of TCSCI patients.
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Affiliation(s)
- Yijin Wang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jianjun Zhang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jincan Yuan
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Qingyuan Li
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
| | - Shiyu Zhang
- UCSI University, No. 1, Jalan UCSI, UCSI Heights, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Chenfeng Wang
- Zhejiang University, No. 866 Yuhangtang Road, Xihu District, Hangzhou, 310058, Zhejiang, People's Republic of China
| | - Haibing Wang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Liang Wang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Bangke Zhang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Can Wang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Yuling Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
| | - Xuhua Lu
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
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Jug M, Komadina R, Wendt K, Pape HC, Bloemers F, Nau C. Thoracolumbar spinal cord injury: management, techniques, timing. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02595-8. [PMID: 39020127 DOI: 10.1007/s00068-024-02595-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 07/01/2024] [Indexed: 07/19/2024]
Abstract
Acute traumatic spinal cord injury (tSCI) is a complex and heterogeneous injury, where the level of injury, injury severity, duration and degree of spinal cord compression, and blood pressure management seem to influence neurologic outcome. Although data in the literature seem to be inconsistent regarding the effectiveness of surgical decompression and spinal fixation in patients with thoracic and thoracolumbar tSCI, some single-center studies suggest that early surgical decompression may lead to a superior neurologic outcome, especially in patients with incomplete tSCI, suggesting surgical decompression to be performed as soon as possible. However, high energy injuries, especially to the upper thoracic levels, may be too severe to be influenced by surgical decompression, which may represent a critical second hit for the polytraumatized patient. Therefore, the surgeon first needs to critically evaluate the potential for neurologic recovery in each patient before determining the ideal timing of surgery. Circulatory stabilization must be achieved before surgical intervention, and minimally invasive procedures should be preferred. Invasive blood pressure monitoring should be started on admission, and maintenance of a MAP between 85 and 90 mmHg is recommended for a duration of 5-7 days, with special attention to the prevention of hypoxia, fever, acidosis and deep venous thrombosis. The role of a 24-hour infusion of high-dose MPSS is still controversial, but it may be offered at the discretion of the treating surgeon to adult patients within 8 h of acute tSCI as a treatment option, especially in the case of very early decompression or incomplete tSCI.
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Affiliation(s)
- Marko Jug
- University Medical Centre Ljubljana, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
| | - Radko Komadina
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Klaus Wendt
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Frank Bloemers
- Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Christoph Nau
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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Alvi MA, Pedro KM, Quddusi AI, Fehlings MG. Advances and Challenges in Spinal Cord Injury Treatments. J Clin Med 2024; 13:4101. [PMID: 39064141 PMCID: PMC11278467 DOI: 10.3390/jcm13144101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Spinal cord injury (SCI) is a debilitating condition that is associated with long-term physical and functional disability. Our understanding of the pathogenesis of SCI has evolved significantly over the past three decades. In parallel, significant advances have been made in optimizing the management of patients with SCI. Early surgical decompression, adequate bony decompression and expansile duraplasty are surgical strategies that may improve neurological and functional outcomes in patients with SCI. Furthermore, advances in the non-surgical management of SCI have been made, including optimization of hemodynamic management in the critical care setting. Several promising therapies have also been investigated in pre-clinical studies, with some being translated into clinical trials. Given the recent interest in advancing precision medicine, several investigations have been performed to delineate the role of imaging, cerebral spinal fluid (CSF) and serum biomarkers in predicting outcomes and curating individualized treatment plans for SCI patients. Finally, technological advancements in biomechanics and bioengineering have also found a role in SCI management in the form of neuromodulation and brain-computer interfaces.
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Affiliation(s)
- Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada; (M.A.A.); (K.M.P.); (A.I.Q.)
| | - Karlo M. Pedro
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada; (M.A.A.); (K.M.P.); (A.I.Q.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Ayesha I. Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada; (M.A.A.); (K.M.P.); (A.I.Q.)
| | - Michael G. Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada; (M.A.A.); (K.M.P.); (A.I.Q.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
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Guimbard-Pérez JH, Camino-Willhuber G, Romero-Muñoz LM, Peral-Alarma M, Brocca ME, Barriga-Martín A. [Translated article] Efficacy of early versus delayed spinal cord decompression in neurological recovery after traumatic spinal cord injury: Systematic review and meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00116-4. [PMID: 38971564 DOI: 10.1016/j.recot.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 07/08/2024] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To compare early (<24h) versus late (>24h) spinal cord decompression on neurological recovery in patients with acute spinal cord injury. METHODS A systematic review was performed according to the PRISMA protocol to identify studies published up to December 2022. Prospective cohort studies and controlled trials comparing early versus delayed decompression on neurological recovery were included. Variables included number of patients, level of injury, treatment time, ASIA grade, neurological recovery, use of corticosteroids, and complications. For the meta-analysis, the "forest plot" graph was developed. The risk of bias of the included studies was assessed using the ROBINS-I22 and Rob223 tools. RESULTS Six of the seven studies selected for our review were included in the meta-analysis, with a total of 1188 patients (592 patients in the early decompression group and 596 in the delayed decompression group), the mean follow-up was 8 months, in 5 studies used methylprednisolone, the most reported complications were thromboembolic cardiopulmonary events. Five studies showed significant differences in favour of early decompression (risk difference 0.10, 95% confidence interval 0.07-0.14, heterogeneity 46%). The benefit was greatest in cervical and incomplete injuries. CONCLUSION There is scientific evidence to recommend early decompression in the first 24h after traumatic spinal cord injury, as it improves final neurological recovery, and it should be recommended whenever the patient and hospital conditions allow it to be safely done.
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Affiliation(s)
- J H Guimbard-Pérez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, Spain; Centro de Biotecnología e Innovación Científica (CEBIC), Toledo, Spain.
| | - G Camino-Willhuber
- Spine Care Institute, Hospital for Special Surgery, New York, United States
| | - L M Romero-Muñoz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, Spain
| | - M Peral-Alarma
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, Spain
| | - M E Brocca
- Laboratorio de Biología de Membranas y Reparación Axonal, Hospital Nacional de Parapléjicos, Toledo, Spain
| | - A Barriga-Martín
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, Spain
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Carr MT, Jagtiani P, Bhimani AD, Karabacak M, Kwon B, Margetis K. Optimal Timing in Cervical Spinal Cord Injury: A Comprehensive Meta-Analysis of Ultra-Early Surgical Intervention Within Five Hours. Cureus 2024; 16:e62015. [PMID: 38984005 PMCID: PMC11233154 DOI: 10.7759/cureus.62015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 07/11/2024] Open
Abstract
The optimal timing of surgery for cervical spinal cord injuries (SCI) and its impact on neurological recovery continue to be subjects of debate. This systematic review and meta-analysis aims to consolidate and assess the existing evidence regarding the efficacy of ultra-early decompression surgery in improving clinical outcomes after cervical SCI. A search was conducted in PubMed, Embase, Cochrane, and CINAHL databases from inception until September 18, 2023, focusing on human studies. The groups were categorized into ultra-early decompression (decompression surgery ≤ 5 hours post-injury) and a control group (decompression surgery between 5-24 hours post-injury). A random effects meta-analysis was performed on all studies using R Studio. Outcomes were reported as effect size (OR, treatment effect, and 95% CI. Of the 140 patients, 63 (45%) underwent decompression ≤ 5 hours, while 77 (55%) underwent decompression > 5 hours post-injury. Analysis using the OR model showed no statistically significant difference in the odds of neurological improvement between the ultra-early group and the early group (OR = 1.33, 95% CI: 0.22-8.18, p = 0.761). This study did not observe significant neurological improvement among cervical SCI patients who underwent decompression within five hours. Due to the scarcity of literature on the ultra-early decompression of cervical SCI, this study underscores the necessity for additional investigation into the potential benefits of earlier interventions for cervical SCI to enhance patient outcomes.
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Affiliation(s)
| | - Pemla Jagtiani
- School of Medicine, State University of New York (SUNY) Downstate Health Sciences University, Queens, USA
| | - Abhiraj D Bhimani
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Brian Kwon
- Neurosurgery, University of British Columbia, Vancouver, CAN
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Fischer G, Bättig L, Stienen MN, Curt A, Fehlings MG, Hejrati N. Advancements in neuroregenerative and neuroprotective therapies for traumatic spinal cord injury. Front Neurosci 2024; 18:1372920. [PMID: 38812974 PMCID: PMC11133582 DOI: 10.3389/fnins.2024.1372920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/10/2024] [Indexed: 05/31/2024] Open
Abstract
Traumatic spinal cord injuries (SCIs) continue to be a major healthcare concern, with a rising prevalence worldwide. In response to this growing medical challenge, considerable scientific attention has been devoted to developing neuroprotective and neuroregenerative strategies aimed at improving the prognosis and quality of life for individuals with SCIs. This comprehensive review aims to provide an up-to-date and thorough overview of the latest neuroregenerative and neuroprotective therapies currently under investigation. These strategies encompass a multifaceted approach that include neuropharmacological interventions, cell-based therapies, and other promising strategies such as biomaterial scaffolds and neuro-modulation therapies. In addition, the review discusses the importance of acute clinical management, including the role of hemodynamic management as well as timing and technical aspects of surgery as key factors mitigating the secondary injury following SCI. In conclusion, this review underscores the ongoing scientific efforts to enhance patient outcomes and quality of life, focusing on upcoming strategies for the management of traumatic SCI. Each section provides a working knowledge of the fundamental preclinical and patient trials relevant to clinicians while underscoring the pathophysiologic rationale for the therapies.
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Affiliation(s)
- Gregor Fischer
- Department of Neurosurgery, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
| | - Linda Bättig
- Department of Neurosurgery, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
| | - Martin N. Stienen
- Department of Neurosurgery, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Nader Hejrati
- Department of Neurosurgery, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
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10
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Fehlings MG, Tetreault LA, Hachem L, Evaniew N, Ganau M, McKenna SL, Neal CJ, Nagoshi N, Rahimi-Movaghar V, Aarabi B, Hofstetter CP, Wengel VT, Nakashima H, Martin AR, Kirshblum S, Rodrigues Pinto R, Marco RAW, Wilson JR, Kahn DE, Newcombe VFJ, Zipser CM, Douglas S, Kurpad SN, Lu Y, Saigal R, Samadani U, Arnold PM, Hawryluk GWJ, Skelly AC, Kwon BK. An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery. Global Spine J 2024; 14:174S-186S. [PMID: 38526922 DOI: 10.1177/21925682231181883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Clinical practice guideline development. OBJECTIVES Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). METHODS A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. CONCLUSIONS It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.
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Affiliation(s)
- Michael G Fehlings
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - Laureen Hachem
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Nathan Evaniew
- Department of Surgery, Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mario Ganau
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Chris J Neal
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Valerie Ter Wengel
- Department of Neurosurgery, Amsterdam UMC VUMC Site, Amsterdam, Netherlands
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Allan R Martin
- Department of Neurological Surgery, University of California-Davis, Sacramento, CA, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ricardo Rodrigues Pinto
- Spinal Unit (UVM), Centro Hospitalar Universitário de Santo António, Hospital CUF Trindade, Porto, Portugal
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Jefferson R Wilson
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
| | - David E Kahn
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Virginia F J Newcombe
- Department of Medicine, University Division of Anaesthesia and PACE, University of Cambridge, Cambridge, UK
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Sam Douglas
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yi Lu
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Rajiv Saigal
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Uzma Samadani
- Department of Surgery, Minneapolis Veterans Affairs, Minneapolis, MN, USA
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | | | | | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
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11
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Fehlings MG, Moghaddamjou A, Evaniew N, Tetreault LA, Alvi MA, Skelly AC, Kwon BK. The 2023 AO Spine-Praxis Guidelines in Acute Spinal Cord Injury: What Have We Learned? What Are the Critical Knowledge Gaps and Barriers to Implementation? Global Spine J 2024; 14:223S-230S. [PMID: 38526926 DOI: 10.1177/21925682231196825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Narrative summary of the 2023 AO Spine-Praxis clinical practice guidelines for management in acute spinal cord injury (SCI). OBJECTIVES The objective of this article is to summarize the key findings of the clinical practice guidelines for the optimal management of traumatic and intraoperative SCI (ISCI). This article will also highlight potential knowledge translation opportunities for each recommendation and discuss important knowledge gaps and areas of future research. METHODS Systematic reviews were conducted according to accepted methodological standards to evaluate the current body of evidence and inform the guideline development process. The summarized evidence was reviewed by a multidisciplinary guidelines development group that consisted of international multidisciplinary stakeholders. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to rate the certainty of the evidence for each critical outcome and the "evidence to recommendation" framework was used to formulate the final recommendations. RESULTS The key recommendations regarding the timing of surgical decompression, hemodynamic management, and the prevention, diagnosis, and management of ISCI are summarized. While a strong recommendation was made for early surgery, further prospective research is required to define what constitutes sufficient surgical decompression, examine the role of ultra-early surgery, and assess the impact of early surgery in different SCI phenotypes, including central cord syndrome. Furthermore, additional investigation is required to evaluate the impact of mean arterial blood pressure targets on neurological recovery and to determine the utility of spinal cord perfusion pressure measurements. Finally, there is a need to examine the role of neuroprotective agents for the treatment of ISCI and to prospectively validate the new AO Spine-Praxis care pathway for the prevention, diagnosis, and management of ISCI. To optimize the translation of these guidelines into practice, important barriers to their implementation, particularly in underserved areas, need to be explored. Ultimately, these recommendations will help to establish more personalized approaches to care for SCI patients. CONCLUSIONS The recommendations from the 2023 AO Spine-Praxis guidelines not only highlight the current best practice in the management of SCI, but reveal critical knowledge gaps and barriers to implementation that will help to guide further research efforts in SCI.
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Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ali Moghaddamjou
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | | | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
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12
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Fehlings MG, Hachem LD, Tetreault LA, Skelly AC, Dettori JR, Brodt ED, Stabler-Morris S, Redick BJ, Evaniew N, Martin AR, Davies B, Farahbakhsh F, Guest JD, Graves D, Korupolu R, McKenna SL, Kwon BK. Timing of Decompressive Surgery in Patients With Acute Spinal Cord Injury: Systematic Review Update. Global Spine J 2024; 14:38S-57S. [PMID: 38526929 DOI: 10.1177/21925682231197404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE Surgical decompression is a cornerstone in the management of patients with traumatic spinal cord injury (SCI); however, the influence of the timing of surgery on neurological recovery after acute SCI remains controversial. This systematic review aims to summarize current evidence on the effectiveness, safety, and cost-effectiveness of early (≤24 hours) or late (>24 hours) surgery in patients with acute traumatic SCI for all levels of the spine. Furthermore, this systematic review aims to evaluate the evidence with respect to the impact of ultra-early surgery (earlier than 24 hours from injury) on these outcomes. METHODS A systematic search of the literature was performed using the MEDLINE database (PubMed), Cochrane database, and EMBASE. Two reviewers independently screened the citations from the search to determine whether an article satisfied predefined inclusion and exclusion criteria. For all key questions, we focused on primary studies with the least potential for bias and those that controlled for baseline neurological status and specified time from injury to surgery. Risk of bias of each article was assessed using standardized tools based on study design. Finally, the overall strength of evidence for the primary outcomes was assessed using the GRADE approach. Data were synthesized both qualitatively and quantitively using meta-analyses. RESULTS Twenty-one studies met inclusion and exclusion criteria and formed the evidence base for this review update. Seventeen studies compared outcomes between patients treated with early (≤24 hours from injury) compared to late (>24 hours) surgical decompression. An additional 4 studies evaluated even earlier time frames: <4, <5, <8 or <12 hours. Based on moderate evidence, patients were 2 times more likely to recover by ≥ 2 grades on the ASIA Impairment Score (AIS) at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, moderate evidence suggested that patients receiving early decompression had an additional 4.50 (95% CI 1.70 to 7.29) point improvement on the ASIA motor score. With respect to administrative outcomes, there was low evidence that early decompression may decrease acute hospital length of stay. In terms of safety, there was moderate evidence that suggested the rate of major complications does not differ between patients undergoing early compared to late surgery. Furthermore, there was no difference in rates of mortality, surgical device-related complications, sepsis/systemic infection or neurological deterioration based on timing of surgery. Firm conclusions were not possible with respect to the impact of ultra-early surgery on neurological, functional or safety outcomes given the poor-quality studies, imprecision and the overlap in the time frames examined. CONCLUSIONS This review provides an evidence base to support the update on clinical practice guidelines related to the timing of surgical decompression in acute SCI. Overall, the strength of evidence was moderate that early surgery (≤24 hours from injury) compared to late (>24 hours) results in clinically meaningful improvements in neurological recovery. Further studies are required to delineate the role of ultra-early surgery in patients with acute SCI.
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Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Laureen D Hachem
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Allan R Martin
- Department of Neurological Surgery, University of California, Davis, CA, USA
| | - Benjamin Davies
- Department of Neurosurgery, Cambridge University, Cambridge, UK
| | - Farzin Farahbakhsh
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - James D Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Daniel Graves
- Department of Rehabilitation Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
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13
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Weisbrod LJ, Nilles-Melchert TT, Bergjord JR, Surdell DL. Safety and Efficacy of Riluzole in Traumatic Spinal Cord Injury: A Systematic Review With Meta-Analyses. Neurotrauma Rep 2024; 5:117-127. [PMID: 38414779 PMCID: PMC10898229 DOI: 10.1089/neur.2023.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
Traumatic spinal cord injury (SCI) is a cause of significant morbidity, often resulting in long-term disability. We aimed to compare outcomes after riluzole versus patients who received placebo or standard of care with no specific intervention. MEDLINE, Embase, Scopus, and Cochrane Library database searches yielded 92 records, and five met the study inclusion criteria. Fixed-effect and random-effects models were used to establish odds ratios (ORs) and mean difference (MD) with 95% confidence intervals (CIs) for each outcome. The results of the pooled analysis showed that in patients with acute traumatic SCI, riluzole resulted in increased American Spinal Injury Association (ASIA) motor scores at 3 months (MD 0.26, 95% CI [-0.10,0.61], I2 = 0%; p = 0.157) and 6 months (MD 0.21, 95% CI [-0.17,0.60], I2 = 0%; p = 0.280) and change in ASIA Impairment Scale (AIS) at 3 months (OR 0.59, 95% CI [-0.12,1.30], I2 = 0%, p = 0.101) and 6 months (OR 0.28, 95% CI [-0.50,1.06], I2 = 0%, p = 0.479) in comparison to the control groups, though not to a level of statistical significance. Riluzole resulted in fewer adverse events than the control groups (OR -0.12, 95% CI [-1.59,1.35], I2 = 0%, p = 0.874) and lower mortality (OR -0.20, 95% CI [-1.03,0.63], I2 = 0%, p = 0.640), though also not to a level of statistical significance. These meta-analyses suggest that riluzole for the treatment of traumatic SCI is safe and results in improved neurological outcomes when compared to controls, though not to a level of statistical significance. More robust prospective, randomized studies are necessary to help inform the safety and efficacy of riluzole for traumatic SCI.
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Affiliation(s)
- Luke J Weisbrod
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | | | - Daniel L Surdell
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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14
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Segi N, Nakashima H, Ito S, Yokogawa N, Sasagawa T, Watanabe K, Nori S, Funayama T, Eto F, Nakajima H, Terashima Y, Hirota R, Hashimoto K, Onoda Y, Furuya T, Yunde A, Ikegami S, Uehara M, Suzuki H, Imajo Y, Uei H, Sawada H, Kawaguchi K, Nakanishi K, Suzuki N, Oshima Y, Hasegawa T, Iizuka Y, Tonomura H, Terai H, Akeda K, Seki S, Ishihara M, Inoue G, Funao H, Yoshii T, Kaito T, Kiyasu K, Tominaga H, Kakutani K, Sakai D, Ohba T, Otsuki B, Miyazaki M, Murotani K, Okada S, Imagama S, Kato S. Early Versus Delayed Surgery for Elderly Traumatic Cervical Spinal Injury: A Nationwide Multicenter Study in Japan. Global Spine J 2024:21925682241227430. [PMID: 38229410 DOI: 10.1177/21925682241227430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES The effectiveness of early surgery for cervical spinal injury (CSI) has been demonstrated. However, whether early surgery improves outcomes in the elderly remains unclear. This study investigated whether early surgery for CSI in elderly affects complication rates and neurological outcomes. METHODS This retrospective multicenter study included 462 patients. We included patients with traumatic acute cervical spinal cord injury aged ≥65 years who were treated surgically, whereas patients with American Spinal Injury Association (ASIA) Impairment Scale E, those with unknown operative procedures, and those waiting for surgery for >1 month were excluded. The minimum follow-up period was 6 months. Sixty-five patients (early group, 14.1%) underwent surgical treatment within 24 hours, whereas the remaining 397 patients (85.9%) underwent surgery on a standby basis (delayed group). The propensity score-matched cohorts of 63 cases were compared. RESULTS Patients in the early group were significantly younger, had significantly more subaxial dislocations (and fractures), tetraplegia, significantly lower ASIA motor scores, and ambulatory abilities 6 months after injury. However, no significant differences in the rate of complications, ambulatory abilities, or ASIA Impairment Scale scores 6 months after injury were observed between the matched cohorts. At 6 months after injury, 61% of the patients in the early group (25% unsupported and 36% supported) and 53% of the patients in the delayed group (34% unsupported and 19% supported) were ambulatory. CONCLUSIONS Early surgery is possible for CSI in elderly patients as the matched cohort reveals no significant difference in complication rates and neurological or ambulatory recovery between the early and delayed surgery groups.
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Affiliation(s)
- Naoki Segi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Sadayuki Ito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Noriaki Yokogawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Takeshi Sasagawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
- Department of Orthopaedic Surgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Fumihiko Eto
- Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences University of Fukui, Fukui, Japan
| | - Yoshinori Terashima
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
- Department of Orthopaedic Surgery, Matsuda Orthopedic Memorial Hospital, Sapporo, Japan
| | - Ryosuke Hirota
- Department of Orthopaedic Surgery, Sapporo Medical University, Sapporo, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshito Onoda
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsushi Yunde
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hidenori Suzuki
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Hirokatsu Sawada
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuo Nakanishi
- Department of Orthopaedics, Traumatology and Spine Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Nobuyuki Suzuki
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, The University of TokyoHospital, Tokyo, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yoichi Iizuka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka Metropolitan UniversityGraduate School of Medicine, Osaka, Japan
| | - Koji Akeda
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, Chiba, Japan
- Department of Orthopaedic Surgery and Spine and Spinal Cord Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Hiroyuki Tominaga
- Department of Orthopaedic Surgery, Graduate School of medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Sakai
- Department of Orthopaedics Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Bungo Otsuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | | | - Seiji Okada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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15
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Jang K, Garraway SM. A review of dorsal root ganglia and primary sensory neuron plasticity mediating inflammatory and chronic neuropathic pain. NEUROBIOLOGY OF PAIN (CAMBRIDGE, MASS.) 2024; 15:100151. [PMID: 38314104 PMCID: PMC10837099 DOI: 10.1016/j.ynpai.2024.100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/04/2024] [Accepted: 01/19/2024] [Indexed: 02/06/2024]
Abstract
Pain is a sensory state resulting from complex integration of peripheral nociceptive inputs and central processing. Pain consists of adaptive pain that is acute and beneficial for healing and maladaptive pain that is often persistent and pathological. Pain is indeed heterogeneous, and can be expressed as nociceptive, inflammatory, or neuropathic in nature. Neuropathic pain is an example of maladaptive pain that occurs after spinal cord injury (SCI), which triggers a wide range of neural plasticity. The nociceptive processing that underlies pain hypersensitivity is well-studied in the spinal cord. However, recent investigations show maladaptive plasticity that leads to pain, including neuropathic pain after SCI, also exists at peripheral sites, such as the dorsal root ganglia (DRG), which contains the cell bodies of sensory neurons. This review discusses the important role DRGs play in nociceptive processing that underlies inflammatory and neuropathic pain. Specifically, it highlights nociceptor hyperexcitability as critical to increased pain states. Furthermore, it reviews prior literature on glutamate and glutamate receptors, voltage-gated sodium channels (VGSC), and brain-derived neurotrophic factor (BDNF) signaling in the DRG as important contributors to inflammatory and neuropathic pain. We previously reviewed BDNF's role as a bidirectional neuromodulator of spinal plasticity. Here, we shift focus to the periphery and discuss BDNF-TrkB expression on nociceptors, non-nociceptor sensory neurons, and non-neuronal cells in the periphery as a potential contributor to induction and persistence of pain after SCI. Overall, this review presents a comprehensive evaluation of large bodies of work that individually focus on pain, DRG, BDNF, and SCI, to understand their interaction in nociceptive processing.
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Affiliation(s)
- Kyeongran Jang
- Department of Cell Biology, Emory University, School of Medicine, Atlanta, GA, 30322, USA
| | - Sandra M. Garraway
- Department of Cell Biology, Emory University, School of Medicine, Atlanta, GA, 30322, USA
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16
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Zhu YK, Lu FT, Zhang GD, Liu ZP. A Review of Strategies Associated with Surgical Decompression in Traumatic Spinal Cord Injury. J Neurol Surg A Cent Eur Neurosurg 2023; 84:570-577. [PMID: 35354217 DOI: 10.1055/a-1811-8201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Traumatic spinal cord injury (TSCI) is frequent. Timely diagnosis and treatment have reduced the mortality, but the long-term recovery of neurologic functions remains ominous. After TSCI, tissue bleeding, edema, and adhesions lead to an increase in the intraspinal pressure, further causing the pathophysiologic processes of ischemia and hypoxia and eventually accelerating the cascade of secondary spinal cord injury. Timely surgery with appropriate decompression strategies can reduce that secondary injury. However, disagreement about the safety and effectiveness of decompression surgery and the timing of surgery still exists. The level and severity of spinal cord injury do have an impact on the timing of surgery; therefore, TSCI subpopulations may benefit from early surgery. Early surgery perhaps has little effect on recovery from complete TSCI but might be of benefit in patients with incomplete injury. Early decompression should be considered in patients with incomplete cervical TSCI. Patient age should not be used as an exclusion criterion for early surgery. The best time point for early surgery is although influenced by the shortest duration to thoroughly examine the patient's condition and stabilize the patient's state. After the patient's condition is fully evaluated, we can perform the surgical modality of emergency myelotomy and decompression. Therefore, a number of conditions should be considered, such as standardized decompression methods, indications and operation timing to ensure the effectiveness and safety of early surgical intervention, and promotion of the functional recovery of residual nerve tissue.
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Affiliation(s)
- Ying-Kang Zhu
- Department of Orthopedics, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
| | - Fa-Tai Lu
- Department of Orthopedics, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
| | - Guo-Dong Zhang
- Department of Orthopedics, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
| | - Zun-Peng Liu
- Department of Orthopedics, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
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17
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Guimbard-Pérez JH, Camino-Willhuber G, Romero-Muñoz LM, Peral-Alarma M, Brocca ME, Barriga-Martín A. Efficacy of early versus delayed spinal cord decompression in neurological recovery after traumatic spinal cord injury: Systematic review and meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023:S1888-4415(23)00200-X. [PMID: 37805026 DOI: 10.1016/j.recot.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/09/2023] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To compare early (<24h) versus late (>24h) spinal cord decompression on neurological recovery in patients with acute spinal cord injury. METHODS A systematic review was performed according to the PRISMA protocol to identify studies published up to December 2022. Prospective cohort studies and controlled trials comparing early versus delayed decompression on neurological recovery were included. Variables included number of patients, level of injury, treatment time, ASIA grade, neurological recovery, use of corticosteroids, and complications. For the meta-analysis, the «forest plot» graph was developed. The risk of bias of the included studies was assessed using the ROBINS-I22 and Rob223 tools. RESULTS Six of the seven studies selected for our review were included in the meta-analysis, with a total of 1188 patients (592 patients in the early decompression group and 596 in the delayed decompression group), the mean follow-up was 8 months, in 5 studies used methylprednisolone, the most reported complications were thromboembolic cardiopulmonary events. Five studies showed significant differences in favor of early decompression (risk difference 0.10, 95% confidence interval 0.07-0.14, heterogeneity 46%). The benefit was greatest in cervical and incomplete injuries. CONCLUSION There is scientific evidence to recommend early decompression in the first 24h after traumatic spinal cord injury, as it improves final neurological recovery, and it should be recommended whenever the patient and hospital conditions allow it to be safely done.
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Affiliation(s)
- J H Guimbard-Pérez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, España; Centro de Biotecnología e Innovación Científica (CEBIC), Toledo, España.
| | | | - L M Romero-Muñoz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, España
| | - M Peral-Alarma
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, España
| | - M E Brocca
- Laboratorio de Biología de Membranas y Reparación Axonal, Hospital Nacional de Parapléjicos, Toledo, España
| | - Andrés Barriga-Martín
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Nacional de Parapléjicos, Toledo, España
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18
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Klockner F, Roch J, Jäckle K, Driesen T, Meier MP, Reinhold M, Lehmann W, Weiser L. [Surgical management of acute traumatic spinal cord injury : Stability vs. functionality]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:756-763. [PMID: 37341733 DOI: 10.1007/s00113-023-01341-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Traumatic spinal cord injuries represent a devastating condition in the lives of those affected, with physical, emotional, and economic burdens for the patients themselves, their social environment, and society as a whole. OBJECTIVE Surgical approach and techniques in traumatic spinal cord injuries. RESULTS Traumatic spinal cord injuries should be surgically treated as soon as possible, but at least within 24 h of injury. If accompanying dural injuries occur, suturing or applying a patch is the primary method of choice. Early surgical decompression is essential, particularly in cervical spinal cord injuries. Stabilization in terms of instrumentation or fusion is inevitable and should be carried out over short segments to maintain the functionality of the cervical spine. Long-distance dorsal instrumentation with prior reduction in thoracolumbar spinal cord injuries provides high stability and preserved functionality in patients. Injuries to the thoracolumbar junction often require a two-stage anterior treatment. CONCLUSION Early surgical decompression, reduction, and stabilization of traumatic spinal cord injuries within 24 h are recommended. While short-segment stabilization is recommended in the cervical spine in addition to decompression, instrumentation should be over long segments in the thoracolumbar spine to provide the necessary stability while maintaining functionality.
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Affiliation(s)
- Friederike Klockner
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland.
| | - Jonathan Roch
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Katharina Jäckle
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Tobias Driesen
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Marc-Pascal Meier
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Maximilian Reinhold
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Wolfgang Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Lukas Weiser
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
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19
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Sehmisch S. [Spinal trauma]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:747-748. [PMID: 37747490 DOI: 10.1007/s00113-023-01362-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Stephan Sehmisch
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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20
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Zeinaddini-Meymand A, Baigi V, Mousavi-Nasab MM, Shool S, Sadeghi-Naini M, Azadmanjir Z, Jazayeri SB, Berchi Kankam S, Dashtkoohi M, Shakeri A, Fakharian E, Kouchakinejad-Eramsadati L, Pirnejad H, Sadeghi-Bazargani H, Bagheri L, Pourandish Y, Amiri M, Pour-Rashidi A, Harrop J, Rahimi-Movaghar V. Pre-Hospital and Post-Hospital Quality of Care in Traumatic Spinal Column and Cord Injuries in Iran. Global Spine J 2023:21925682231202425. [PMID: 37732722 DOI: 10.1177/21925682231202425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
STUDY DESIGN A retrospective study. OBJECTIVES The quality of care (QoC) for spinal column/cord injury patients is a major health care concern. This study aimed to implement the QoC assessment tool (QoCAT) in the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to define the current state of pre- and post-hospital QoC of individuals with Traumatic Spinal Column and Spinal Cord Injuries (TSC/SCIs). METHODS The QoCAT, previously developed by our team to measure the QoC in patients with TSC/SCIs, was implemented in the NSCIR-IR. The pre-hospital QoC was evaluated through a retrospective analysis of NSCIR-IR registry data. Telephone interviews and follow-ups of patients with SCI evaluated the QoC in the post-hospital phase. RESULTS In the pre-hospital phase, cervical collars and immobilization were implemented in 46.4% and 48.5% of the cases, respectively. Transport time from the scene to the hospital was documented as <1 hour and <8 hours in 33.4% and 93.9% of the patients, respectively. Post-hospital indicators in patients with SCI revealed a first-year mortality rate of 12.5% (20/160), a high incidence of secondary complications, reduced access to electrical wheelchairs (4.2%) and modified cars (7.7%), and low employment rate (21.4%). CONCLUSION These findings revealed a significant delay in transport time to the first care facilities, low use of immobilization equipment indicating low pre-hospital QoC. Further, the high incidence of secondary complications, low employment rate, and low access to electrical wheelchairs and modified cars indicate lower post-hospital QoC in patients with SCI. These findings imply the need for further planning to improve the QoC for patients with TSC/SCIs.
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Affiliation(s)
| | - Vali Baigi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Sina Shool
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Sadeghi-Naini
- Department of Neurosurgery, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Zahra Azadmanjir
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Behnam Jazayeri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Samuel Berchi Kankam
- International Neurosurgery Group (ING), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mohammad Dashtkoohi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Aidin Shakeri
- Department of Neurosurgery, Arak University of Medical Sciences, Arak, Iran
| | - Esmail Fakharian
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | | | - Habibollah Pirnejad
- Patient Safety Research Center, Clinical Research Institute, Urmia University of Medical Sciences, Urmia, Iran
| | - Homayoun Sadeghi-Bazargani
- Research Center for Evidence Based Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Laleh Bagheri
- Shahid Rahnemoun Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Yasaman Pourandish
- Department of Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran
| | - Malihe Amiri
- Department of Neurosurgery, Imam Hossein Hospital, Shahroud University of Medical Sciences, Shahroud, Iran
| | | | - James Harrop
- Department of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, 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
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21
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Mansoor Ali D, Sivaganesan A, Neal CJ, Thalheimer S, Ugiliweneza B, Toups EG, Abd-El-Barr M, Jimsheleishvili G, Kurpad SN, Aarabi B, Shaffrey CI, Fehlings MG, Tator CH, Grossman RG, Guest JD, Harrop JS. Bulbocavernosus Reflex Has No Prognostic Features During the Acute Evaluation of Spinal Cord Injuries. J Neurotrauma 2023; 40:1970-1975. [PMID: 36884291 DOI: 10.1089/neu.2022.0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
The bulbocavernosus reflex (BCR) has been used during the initial evaluation of a spinal cord injury patient as a metric to determine prognosis and whether the patient is in "spinal shock." This reflex has been less utilized over the last decade, and therefore a review was performed to assess the value of BCR in patient prognosis. The North American Clinical Trials Network (NACTN) for Spinal Cord Injury (SCI) is a consortium of tertiary medical centers that includes a prospective SCI registry. The NACTN registry data was analyzed to evaluate the prognostic implication of the BCR during the initial evaluation of a spinal cord injury patient. SCI patients were divided into those with an intact or absent BCR during their initial evaluation. Associations of participants' descriptors and neurological status on follow-up were performed, followed by associations with the presence of a BCR. A total of 769 registry patients with recorded BCRs were included in the study. The median age was 49 years (32-61 years), and the majority were male (n = 566, 77%) and white (n = 519, 73%). Among included patients, high blood pressure was the most common comorbidity (n = 230, 31%). Cervical spinal cord injury was the most common (n = 470, 76%) with fall (n = 320, 43%) being the most frequent mechanism of injury. BCR was present in 311 patients (40.4%), while 458 (59.6%) had a negative BCR within 7 days of injury or before surgery. At 6 months post-injury, 230 patients (29.9%) followed up, of which 145 had a positive BCR, while 85 had a negative BCR. The presence/absence of BCR was significantly different in patients with cervical (p = 0.0015) or thoracic SCI (p = 0.0089), or conus medullaris syndrome (p = 0.0035), and in those who were American Spinal Injury Association Impairment Scale grade A (p = 0.0313). No significant relationship was observed between BCR results and demographics, AIS grade conversion, motor score changes (p = 0.1669), and changes in pin prick (p = 0.3795) and light touch scores (p = 0.8178). In addition, cohorts were not different in surgery decision (p = 0.7762) and injury to surgery time (p = 0.0681). In our review of the NACTN spinal cord registry, the BCR did not provide prognostic utility in the acute evaluation of spinal cord injury patients. Therefore, it should not be used as a reliable marker for predicting neurological outcomes post-injury.
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Affiliation(s)
| | | | - Chris J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Sara Thalheimer
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, 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
| | | | - 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
| | - James S Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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22
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Futch BG, Kouam RW, Ugiliweneza B, Harrop J, Kurpad S, Foster N, Than K, Crutcher C, Goodwin CR, Tator C, Shaffrey CI, Aarabi B, Fehlings M, Neal CJ, Guest J, Abd-El-Barr MM. Demographics, Mechanism of Injury, and Outcomes for Acute Upper and Lower Cervical Spinal Cord Injuries: An Analysis of 470 Patients in the Prospective, Multi-Center, North American Clinical Trials Network Registry. J Neurotrauma 2023; 40:1918-1927. [PMID: 36852492 DOI: 10.1089/neu.2022.0407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
There is a paucity of data comparing the demographics, mechanism of injury, and outcomes of upper versus lower cervical spinal cord injuries (cSCI). The study objective was to define different clinical manifestations of cSCI. Data were collected prospectively through centers of the North American Clinical Trials Network (NACTN). Data was collected on 470 patients (21% women, mean age 50 years). Cervical vertebral level was analyzed as an ordinal variable to determine a natural demarcation to classify upper versus lower cSCI. For continuous variable analysis, falls were associated with C3 more than C4 vertebral level injuries (60% vs. 42%; p = 0.0126), while motor vehicle accidents were associated with C4 more than C3 (40% vs. 29%; p = 0.0962). Motor International Standards for Neurological Classification of Spinal Cord Injury scores also demonstrated a natural demarcation between C3 and C4, with C3 having higher median American Spinal Injury Association (ASIA) motor scores (40 [4-73] vs. 11 [3-59], p = 0.0227). There were no differences when comparing C2 to C3 nor C4 to C5. Given the significant differences seen between C3 and C4, but not C2 and C3 nor C4 and C5, upper cSCI was designated as C1-C3, and lower cSCI was designated as C4-C7. Compared with a lower cSCI, patients with an upper cSCI were more likely to have a fall as their mechanism of injury (54% vs. 36%; p = 0.0072). Patients with an ASIA C cSCI were likely to have an upper cervical injury: 23% vs. 11% (p = 0.0226). Additionally, patients with an upper cSCI were more likely to have diabetes prior to injury: 37% versus 22%, respectively (p = 0.0084). Lower cSCI were more likely injured through sports (19% vs. 8%, p = 0.0171) and present with ASIA A (42% vs. 25%, p = 0.0186) neurological grade. Patients with lower cSCI were also significantly more likely to have complications such as shock, pulmonary embolism, and pleural effusion. In conclusion, there appears to be a natural demarcation of injury type between C3 and C4. Upper cSCI (C1-C3) was more associated with falls and diabetes, whereas lower cSCI (C4-C7) was more associated with sports, worse ASIA scores, and more complications. Further research will be needed to understand the mechanistic and biological differences between these two groups and whether different treatments may be appropriate for each of these groups.
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Affiliation(s)
| | - Romaric Waguia Kouam
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina, USA
| | - Beatrice Ugiliweneza
- Kentucky Spinal Cord Injury Research Center, Louisville, Kentucky, USA
- Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - James Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Shekar Kurpad
- Neuroscience Institute. The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Norah Foster
- Department of Orthopedic Surgery, Premier Health, Centerville Ohio, USA
| | - Khoi Than
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Clifford Crutcher
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Charles Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Maryland, USA
| | - Michael Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Chris J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - James Guest
- Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami, Miami, Florida, USA
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23
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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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24
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Khanna A, Menon H, Chaudhary V, Sidhdhapuria P, Patel K, Narang C. Timing of Surgery and Pre-operative Physiological Parameters as Clinical Predictors of Surgical Outcomes in Traumatic Subaxial Cervical Spine Fractures and Dislocations. Rev Bras Ortop 2023; 58:e586-e591. [PMID: 37663183 PMCID: PMC10468239 DOI: 10.1055/s-0043-1772240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/05/2023] [Indexed: 09/05/2023] Open
Abstract
Objective To evaluate the risk factors and outcomes in patients surgically treated for subaxial cervical spine injuries with respect of the timing of surgery and preoperative physiological parameters of the patient. Methods 26 patients with sub-axial cervical spine fractures and dislocations were enrolled. Demographic data of patients, appropriate radiological investigation, and physiological parameters like respiratory rate, blood pressure, heart rate, PaO2 and ASIA impairment scale were documented. They were divided pre-operatively into 2 groups. Group U with patients having abnormal physiological parameters and Group S including patients having physiological parameters within normal range. They were further subdivided into early and late groups according to the timing of surgery as U early , U late, S early and S late . All the patients were called for follow-up at 1, 6 and 12 months. Results 56 percent of patients in Group S had neurological improvement by one ASIA grade and a good outcome irrespective of the timing of surgery. Patients in Group U having unstable physiological parameters and undergoing early surgical intervention had poor outcomes. Conclusion This study concludes that early surgical intervention in physiologically unstable patients had a strong association as a risk factor in the final outcome of the patients in terms of mortality and morbidity. Also, no positive association of improvement in physiologically stable patients with respect to the timing of surgery could be established.
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Affiliation(s)
- Aman Khanna
- Ortopedista e Traumatologista, Departamento de Ortopedia, New Civil Hospital Surat, Gujarat, Índia
| | - Hari Menon
- Ortopedista e Traumatologista, Departamento de Ortopedia, New Civil Hospital Surat, Gujarat, Índia
| | - Vijay Chaudhary
- Ortopedista e Traumatologista, Departamento de Ortopedia, New Civil Hospital Surat, Gujarat, Índia
| | - Pratik Sidhdhapuria
- Ortopedista e Traumatologista, Departamento de Ortopedia, New Civil Hospital Surat, Gujarat, Índia
| | - Kandarp Patel
- Ortopedista e Traumatologista, Departamento de Ortopedia, New Civil Hospital Surat, Gujarat, Índia
| | - Chandan Narang
- Ortopedista e Traumatologista, Departamento de Ortopedia, New Civil Hospital Surat, Gujarat, Índia
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25
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Kalyani P, Manasa Y, Ahammad SH, Suman M, Anwer TMK, Hossain MA, Rashed ANZ. Prediction of patient's neurological recovery from cervical spinal cord injury through XGBoost learning approach. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2140-2148. [PMID: 37060466 DOI: 10.1007/s00586-023-07712-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/07/2023] [Accepted: 04/06/2023] [Indexed: 04/16/2023]
Abstract
Due to the diversity of patient characteristics, therapeutic approaches, and radiological findings, it can be challenging to predict outcomes based on neurological consequences accurately within cervical spinal cord injury (SCI) entities and based on machine learning (ML) technique. Accurate neurological outcomes prediction in the patients suffering with cervical spinal cord injury is challenging due to heterogeneity existing in patient characteristics and treatment strategies. Machine learning algorithms are proven technology for achieving greater prediction outcomes. Thus, the research employed machine learning model through extreme gradient boosting (XGBoost) for attaining superior accuracy and reliability followed with other MI algorithms for predicting the neurological outcomes. Besides, it generated a model of a data-driven approach with extreme gradient boosting to enhance fault detection techniques (XGBoost) efficiency rate. To forecast improvements within functionalities of neurological systems, the status has been monitored through motor position (ASIA [American Spinal Injury Association] Impairment Scale [AIS] D and E) followed by the method of prediction employing XGBoost, combined with decision tree for regression logistics. Thus, with the proposed XGBoost approach, the enhanced accuracy in reaching the outcome is 81.1%, and from other models such as decision tree (80%) and logistic regression (82%), in predicting outcomes of neurological improvements within cervical SCI patients. Considering the AUC, the XGBoost and decision tree valued with 0.867 and 0.787, whereas logistic regression showed 0.877. Therefore, the application of XGBoost for accurate prediction and decision-making in the categorization of pre-treatment in patients with cervical SCI has reached better development with this study.
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Affiliation(s)
- P Kalyani
- Department of ECE, Vardhaman College of Engineering, Hyderabad, India
| | - Y Manasa
- Department of CSE, Prasad V Potluri Siddhartha Institute of Technology, Vijayawada, India
| | - Sk Hasane Ahammad
- Department of ECE, Koneru Lakshmaiah Education Foundation, Vaddeswaram, 522302, India
| | - M Suman
- Department of ECE, Koneru Lakshmaiah Education Foundation, Vaddeswaram, 522302, India
| | - Twana Mohammed Kak Anwer
- Department of Physics, College of Education, Salahaddin University-Erbil, Erbil, Kurdistan Region, 44002, Iraq
| | - Md Amzad Hossain
- Institute of Theoretical Electrical Engineering, Faculty of Electrical Engineering and Information Technology, Ruhr University Bochum, 44801, Bochum, Germany.
- Department of Electrical and Electronic Engineering, Jashore University of Science and Technology, Jashore, 7408, Bangladesh.
| | - Ahmed Nabih Zaki Rashed
- Electronics and Electrical Communications Engineering Department, Faculty of Electronic Engineering, Menoufia University, Menouf, 32951, Egypt.
- Department of VLSI Microelectronics, Institute of Electronics and Communication Engineering, Saveetha School of Engineering, SIMATS, Chennai, Tamilnadu, 602105, India.
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Ushirozako H, Suda K, Harmon SM, Komatsu M, Ota M, Shimizu T, Minami A, Takahata M, Iwasaki N, Matsuyama Y. Complications Associated with Preventive Management to Reduce the Risk of COVID-19 Spread After Surgery for Spinal Cord Injury. J Bone Joint Surg Am 2023; Publish Ahead of Print:00004623-990000000-00811. [PMID: 37216434 DOI: 10.2106/jbjs.22.00785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND Preventive management to reduce the risk of coronavirus disease-2019 (COVID-19) spread led to delays in active rehabilitation, which may have negatively impacted the outcomes of patients with traumatic spinal cord injury (SCI). Therefore, the aim of this study was to clarify the influence of preventive management on the rate of perioperative complications after surgical treatment for SCI. METHODS This single-center retrospective study examined the cases of 175 patients who had SCI surgery between 2017 and 2021. We could not continue early rehabilitation interventions starting on April 30, 2020, because of our preventive management to reduce the risk of COVID-19 spread. Using a propensity score-matched model, we adjusted for age, sex, American Spinal Injury Association impairment scale score at admission, and risk factors for perioperative complications described in previous studies. Perioperative complication rates were compared between the COVID-19 pandemic and prepandemic groups. RESULTS Of the 175 patients, 48 (the pandemic group) received preventive management. The preliminary analysis revealed significant differences between the unmatched pandemic and prepandemic groups with respect to age (75.0 versus 71.2 years, respectively; p = 0.024) and intraoperative estimated blood loss (152 versus 227 mL; p = 0.013). The pandemic group showed significant delays in visiting the rehabilitation room compared with the prepandemic group (10 versus 4 days from hospital admission; p < 0.001). There were significant differences between the pandemic and prepandemic groups with respect to the rates of pneumonia (31% versus 16%; p = 0.022), cardiopulmonary dysfunction (38% versus 18%; p = 0.007), and delirium (33% versus 13%; p = 0.003). With a propensity score-matched analysis (C-statistic = 0.90), 30 patients in the pandemic group and 60 patients in the prepandemic group were automatically selected. There were significant differences between the matched pandemic and prepandemic groups with respect to the rates of cardiopulmonary dysfunction (47% versus 23%; p = 0.024) and deep venous thrombosis (60% versus 35%; p = 0.028). CONCLUSIONS Even with early surgical intervention, late mobilization and delays in active rehabilitation during the COVID-19 pandemic increased perioperative complications after SCI surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hiroki Ushirozako
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Hokkaido, Japan
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kota Suda
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Hokkaido, Japan
| | - Satoko Matsumoto Harmon
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Hokkaido, Japan
| | - Miki Komatsu
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Hokkaido, Japan
| | - Masahiro Ota
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Hokkaido, Japan
| | - Tomoaki Shimizu
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Hokkaido, Japan
| | - Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Hokkaido, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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27
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Maroufi SF, Azadnajafabad S, Pour-Rashidi A, Jazayeri SB, Ghodsi Z, Ghawami H, Kheyri M, Farahbakhsh F, Azarhomayoun A, Bahreini M, Arab Kheradmand J, Faghih Jouibari M, Zareh M, Fehlings MG, Rahimi-Movaghar V. Adopting and adapting clinical practice guidelines for timing of decompressive surgery in acute spinal cord injury from a developed world context to a developing region. Acta Neurochir (Wien) 2023; 165:1401-1406. [PMID: 37074391 DOI: 10.1007/s00701-023-05591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/09/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE The proper application of high-quality clinical practice guidelines improves trauma patients' care and outcomes. This study aimed to adopt and adapt guidelines on the timing of decompressive surgery in acute spinal cord injury (SCI) in Iranian clinical settings. METHODS This study followed a systematic search and review of the literature to enter them into the selection process. The source guidelines' clinical suggestions were converted into clinical scenarios for clinical questions on the timing of decompressive surgery. After summarizing the scenarios, we prepared an initial list of recommendations based on the status of the Iranian patients and the health system. The ultimate conclusion was reached with the help of a national interdisciplinary expert panel comprising 20 experts throughout the country. RESULTS A total of 408 records were identified. After title and abstract screening, 401 records were excluded, and the full texts of the remaining seven records were reviewed. Based on our screening process, only one guideline included recommendations on the topic of interest. All of the recommendations were accepted by the expert panel with slight changes due to resource availability in Iran. The final two recommendations were the consideration of early surgery (≤24 h) as a treatment option in adult patients with traumatic central cord syndrome and in adult patients with acute SCI regardless of the level of injury. CONCLUSION Considering early surgery for adult patients with acute traumatic SCI regardless of the level of injury was the final recommendation for Iran. Although most of the recommendations are adoptable in developing countries, issues with infrastructure and availability of resources are the limitations.
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Affiliation(s)
- Seyed Farzad Maroufi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Azadnajafabad
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Pour-Rashidi
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Behnam Jazayeri
- 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
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Heshmatollah Ghawami
- Neuropsychology Division, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Kheyri
- National Board in Community and Preventive Medicine, Treatment Department, Ministry of Health and Medical Education, Tehran, Iran
| | - Farzin Farahbakhsh
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Azarhomayoun
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | | | - Mohammad Zareh
- Department of Orthopedic Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, Toronto, ON, Canada
- Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
- 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.
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Wendt K, Nau C, Jug M, Pape HC, Kdolsky R, Thomas S, Bloemers F, Komadina R. ESTES recommendation on thoracolumbar spine fractures : January 2023. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02247-3. [PMID: 37052627 DOI: 10.1007/s00068-023-02247-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/08/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Klaus Wendt
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Christoph Nau
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Marko Jug
- University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | | | - Richard Kdolsky
- University Clinic for Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Frank Bloemers
- Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Radko Komadina
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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29
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Birch NC, Cheung JPY, Takenaka S, El Masri WS. Which treatment provides the best neurological outcomes in acute spinal cord injury? Bone Joint J 2023; 105-B:347-355. [PMID: 36924170 DOI: 10.1302/0301-620x.105b4.bjj-2023-0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.
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Affiliation(s)
- Nick C Birch
- Spine and Bone Heath Department, Bragborough Hall Health Centre, Daventry, UK
| | - Jason P Y Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China
| | - Shota Takenaka
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Wagih S El Masri
- Keele University, Keele, UK.,Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, UK
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30
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Wang Z, Zhou W, Li M. Epidemiological characteristics of 1,806 patients with traumatic spinal cord injury: A retrospective study. Front Surg 2023; 9:988853. [PMID: 36684310 PMCID: PMC9852498 DOI: 10.3389/fsurg.2022.988853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/26/2022] [Indexed: 01/09/2023] Open
Abstract
Background Traumatic spinal cord injury (TSCI) is a type of highly disabling central nervous system trauma. In this study, we investigated the epidemiological characteristics of 1,806 TSCI patients and compared the characteristics of patients with traumatic cervical spinal cord injury (TCSCI) caused by cervical fracture/dislocation and disc herniation/bulging. Methods We retrospectively reviewed the hospital records of 1,806 TSCI patients. The detailed information included gender, marital status, occupation, age, neurological level of injury, etiology, American Spinal Injury Association (ASIA) grade, combined injuries, complications, treatment, the interval between admission and surgery, intubation/tracheostomy requirement, and the length of hospital stay. Results Cervical spinal cord injury (CSCI) was the most common injury. Compared to non-CSCI cases, patients with TCSCI were older, and more likely to suffer from tetraplegia and require intubation/tracheostomy, but had fewer other injuries or complications and a shorter length of hospital stay. Compared to patients with cervical fracture/dislocation, those with TCSCI caused by disc herniation/bulging were older and more likely to suffer from paraplegia, but required intubation/tracheostomy less frequently, exhibited fewer other injuries and complications, and required shorter hospitalization. Conclusions Men, married individuals, manual laborers, and individuals aged 31-75 years had the highest risk of TSCI. Patients with TCSCI tended to have a shorter length of hospital stay than patients with non-CSCI. More attention should be paid to the other injuries and complications of non-CSCI patients, which may increase the length of hospital stay and delay rehabilitation. Compared to patients with cervical disc herniation, the patients with fracture/dislocation tended to be younger, but prognosis was severely compromised by tetraplegia, a greater need for intubation/tracheostomy, additional injuries, and complications.
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31
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Yu Z, Xie H, Ouyang Z, Zhang H. Cervical single open-door laminoplasty with or without local lateral mass screw fixation and fusion to treat cervical spinal cord injuries accompanied by segmental spinal canal stenosis. Front Surg 2023; 9:1050308. [PMID: 36684349 PMCID: PMC9845616 DOI: 10.3389/fsurg.2022.1050308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023] Open
Abstract
Study Design Retrospective. Objectives To investigate the efficacy of cervical single open-door laminoplasty with and without local lateral mass screw fixation and fusion as treatments for cervical spinal cord injuries accompanied by multisegmental spinal canal stenosis. Setting The Second Affiliated Hospital, School of Medicine, Zhejiang University. Methods Of all enrolled patients, 42 formed a stable group who underwent cervical single open-door laminoplasty alone and 14 formed an unstable group who underwent the procedure combined with lateral mass screw fixation and fusion. Neurological function was evaluated before surgery, at discharge, and at final follow-up using the American Spinal Cord Injury Association (ASIA) impairment scale and the Japanese Orthopedic Association (JOA) score. Results ASIA scores reflected improved neurological function in 52.5% of the stable group (15 with grade-D and 4 with grade-A injuries did not improve) and 45.5% of the unstable group (3 with grade-D and 3 with grade-A injuries did not improve). Postoperative JOA scores reflected 19.1% ± 21.6% improvement in the stable group and 18.6% ± 18.4% improvement in the unstable group (P > 0.05). Final follow-up JOA scores reflected 49.2% ± 31.7% improvement in the stable group and 47.1% ± 39.2% improvement in the unstable group (P > 0.05). Conclusions Laminoplasty combined with local fusion aided the treatment of unstable cervical spinal cord injuries and spinal stenosis. Such stenosis is the main pathological factor causing multiple spinal cord compressions in patients with cervical spinal cord injuries.
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Affiliation(s)
- Zihao Yu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Orthopedics Research Institute, Zhejiang University, Hangzhou, China,Key Laboratoryof Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, China
| | - Hongwei Xie
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Orthopedics Research Institute, Zhejiang University, Hangzhou, China,Key Laboratoryof Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, China
| | - Ziyu Ouyang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Orthopedics Research Institute, Zhejiang University, Hangzhou, China,Key Laboratoryof Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, China
| | - Hua Zhang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China,Orthopedics Research Institute, Zhejiang University, Hangzhou, China,Key Laboratoryof Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, China,Correspondence: Hua Zhang
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32
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Lee BJ, Jeong JH. Early Decompression in Acute Spinal Cord Injury : Review and Update. J Korean Neurosurg Soc 2023; 66:6-11. [PMID: 36274255 PMCID: PMC9837486 DOI: 10.3340/jkns.2022.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/25/2022] [Accepted: 07/01/2022] [Indexed: 01/25/2023] Open
Abstract
Spinal cord injury (SCI) has a significant negative effect on the quality of life due to permanent neurologic damage and economic burden by continuous treatment and rehabilitation. However, determining the correct approach to ensure optimal clinical outcomes can be challenging and remains highly controversial. In particular, with the introduction of the concept of early decompression in brain pathology, the discussion of the timing of decompression in SCI has emerged. In addition to that, the concept of "time is spine" has been added recently, and the mortality and complications caused by SCI have been reduced by providing timely and professional treatment to patients. However, there are many difficulties in establishing international clinical guidelines for the timing of early decompression in SCI because policies for each country and medical institution differ according to the circumstances of medical infrastructure and economic conditions in the surgical treatment of SCI. Therefore, we aim to provide a current review of timing of early decompression in patient with SCI.
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Affiliation(s)
- Byung-Jou Lee
- Department of Neurosurgery and Neuroscience & Radiosurgery Hybrid Research Center, Inje University Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Korea
| | - Je Hoon Jeong
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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33
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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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34
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Marchesini N, Rubiano AM, Sala F, Demetriades AK, Alves OL. Secondary damage management of acute traumatic spinal cord injury in low and middle-income countries: A survey on a global scale (Part III). BRAIN & SPINE 2022; 2:101694. [PMID: 36605387 PMCID: PMC9808472 DOI: 10.1016/j.bas.2022.101694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/16/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
•In LMICs, several factor may affect the applicability of guidelines for secondary damage control of spinal cord injury.•In LMICs, the use of steroids for spinal cord injury is heterogeneous and admissions to an intensive care units are limited.•The delays for surgical decompression of spinal cord injury can be significan and vary across income and geographic region.•Transfer times seem to be the most common reason for surgical delay in all income and geographic regions.•Costs for surgery for spinal trauma may be a significant barrier to guideline adherence, especially in low-resource settings.
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Affiliation(s)
- Nicolò Marchesini
- Department of Neurosurgery, University Hospital Borgo Trento, Verona, Italy,Corresponding author. Department of Neurosurgery, University Hospital Borgo Trento, Piazzale Stefani 1, 37126, Verona, Italy.
| | - Andrés M. Rubiano
- Neuroscience Institute, Universidad El Bosque, Bogotá, Colombia,Meditech Foundation, Cali, Colombia
| | - Francesco Sala
- Department of Neurosurgery, University Hospital Borgo Trento, Verona, Italy
| | - Andreas K. Demetriades
- Department of Neurosurgery, Royal Infirmary, Edinburgh, UK,Department of Neurosurgery, Leiden University, the Netherlands
| | - Oscar L. Alves
- Department of Neurosurgery, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal,Department of Neurosurgery, Hospital Lusiadas Porto, Porto, Portugal
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35
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Kumarasamy D, Viswanathan VK, Shetty AP, Pratheep GK, Kanna RM, Rajasekaran S. The Role of Riluzole in Acute Traumatic Cervical Spinal Cord Injury with Incomplete Neurological Deficit: A Prospective, Randomised Controlled Study. Indian J Orthop 2022; 56:2160-2168. [PMID: 36507215 PMCID: PMC9705651 DOI: 10.1007/s43465-022-00758-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/22/2022] [Indexed: 02/04/2023]
Abstract
Introduction Riluzole, a benzothiazole sodium channel blocker is acknowledged as a neuroprotective agent in spinal cord injury (SCI). Most of this evidence is based on pre-clinical studies and its effectiveness in clinical setting is undetermined, heretofore. Methods A prospective, randomised-controlled study was conducted between April 2019 and March 2020 at a tertiary-level centre. Patients aged 18-65 years with sub-axial cervical spine injury, who presented within 72 h of injury with incomplete neuro-deficit, were included. They were randomised into groups A (riluzole was administered) and B (no adjuvants). All patients were followed up at 6 weeks/3/6/12 months, and clinical [ASIA motor/sensory scores/grade, SCIM3, and NRS (neuropathic pain)] and radiological evaluation was performed. Results Twenty-three and 20 patients were included in groups A and B. Two in group A were females, while others were males (p = 0.49). Mean age in groups A and B was 47.7 ± 14.8 and 51.2 ± 14.1 years (p = 0.44). Five patients died prior to 6th-week follow-up. Among the others, there was significant improvement in all neurological parameters in both groups (post-injury vs 1-year; motor score: p < 0.001, sensory score: p < 0.001, SCIM3: p < 0.001, NRS: p < 0.001). In both groups, initial significant improvement was noticed even at the 6th-week follow-up, which further continued until the end of 1 year. There was no statistically significant difference between groups A and B with respect to these neurological parameters (motor: p = 0.15, sensory: p = 0.39, SCIM3: p = 0.68, NRS: p = 0.06). Conclusion Administration of riluzole did not significantly improve neurological outcome/neuropathic pain in our cohort. Nevertheless, both our groups demonstrated an overall improvement in neurological outcome at 1 year, as compared with immediate post-injury status.
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Affiliation(s)
- Dinesh Kumarasamy
- Department of Spine Surgery, Ganga Medical Centre and Hospital, 313, Mettupalayam Road, Sai Baba Colony, Coimbatore, Tamil Nadu 641001 India
| | - Vibhu Krishnan Viswanathan
- Department of Spine Surgery, Ganga Medical Centre and Hospital, 313, Mettupalayam Road, Sai Baba Colony, Coimbatore, Tamil Nadu 641001 India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Centre and Hospital, 313, Mettupalayam Road, Sai Baba Colony, Coimbatore, Tamil Nadu 641001 India
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospital, 313, Mettupalayam Road, Sai Baba Colony, Coimbatore, Tamil Nadu 641001 India
| | - Guna K. Pratheep
- Department of Spine Surgery, Ganga Medical Centre and Hospital, 313, Mettupalayam Road, Sai Baba Colony, Coimbatore, Tamil Nadu 641001 India
| | - Rishi Mukesh Kanna
- Department of Spine Surgery, Ganga Medical Centre and Hospital, 313, Mettupalayam Road, Sai Baba Colony, Coimbatore, Tamil Nadu 641001 India
| | - S. Rajasekaran
- Department of Spine Surgery, Ganga Medical Centre and Hospital, 313, Mettupalayam Road, Sai Baba Colony, Coimbatore, Tamil Nadu 641001 India
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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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Lambrechts MJ, D’Antonio ND, Karamian BA, Kanhere AP, Dees A, Wiafe BM, Canseco JA, Woods BI, Kaye ID, Rihn J, Kurd M, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Does displacement of cervical and thoracolumbar dislocation-translation injuries predict spinal cord injury or recovery? J Neurosurg Spine 2022; 37:821-827. [PMID: 35962960 DOI: 10.3171/2022.6.spine22435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE For patients with cervical and thoracolumbar AO Spine type C injuries, the authors sought to 1) identify whether preoperative vertebral column translation is predictive of a complete spinal cord injury (SCI) and 2) identify whether preoperative or postoperative vertebral column translation is predictive of neurological improvement after surgical decompression. METHODS All patients who underwent operative treatment for cervical and thoracolumbar AO Spine type C injuries at the authors' institution between 2006 and 2021 were identified. CT and MRI were utilized to measure vertebral column translation in millimeters prior to and after surgery. A receiver operating characteristic (ROC) curve was generated to predict the probability of sustaining a complete SCI on the basis of the amount of preoperative vertebral column translation. ROC curves were then used to predict the probability of neurological recovery on the basis of preoperative and postoperative vertebral column translation. RESULTS ROC analysis of 67 patients identified 6.10 mm (area under the curve [AUC] 0.77, 95% CI 0.650-0.892) of preoperative vertebral column translation as predictive of complete SCI. Additionally, ROC curve analysis found that 10.4 mm (AUC 0.654, 95% CI 0.421-0.887) of preoperative vertebral column translation was strongly predictive of no postoperative neurological improvement. Residual postoperative vertebral column translation after fracture reduction and instrumentation had no predictive value on neurological recovery (AUC 0.408, 95% CI 0.195-0.622). CONCLUSIONS For patients with cervical and thoracolumbar AO Spine type C injuries, the amount of preoperative vertebral column translation is highly predictive of complete SCI and the likelihood of postoperative neurological recovery.
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Affiliation(s)
- Mark J. Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Nicholas D. D’Antonio
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Brian A. Karamian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Arun P. Kanhere
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Azra Dees
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Bright M. Wiafe
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jose A. Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Barrett I. Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - I. David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jeffrey Rihn
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mark Kurd
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alan S. Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Muacevic A, Adler JR, Cornwell B, Nagarajan M, Smith ZA. Robot-Assisted Thoracolumbar Fixation After Acute Spinal Trauma: A Case Series. Cureus 2022; 14:e31832. [PMID: 36579235 PMCID: PMC9788792 DOI: 10.7759/cureus.31832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pedicle screw fixation has become the workhorse for the stabilization of the thoracolumbar spine. Since accurate pedicle screw placement is necessary for a successful surgery, three-dimensional navigation has become a mainstay for placing pedicle screws. However, the published studies have an overrepresentation of lumbar screws despite the prevalence of thoracic fractures. Furthermore, no robotic-assisted pedicle screw study has focused solely on traumatic fractures. The goal of this study was to address whether (1) robot-assisted pedicle screw placement had comparable accuracy in the thoracic and thoracolumbar region and (2) robot-assisted spine surgery was feasible in an acute, traumatic setting. METHODS We performed 14 consecutive, thoracolumbar spinal stabilization procedures in which 126 pedicle screws were placed using the Globus ExcelsiusGPS® spine robot in an acute, traumatic setting. Operative times were measured, and the accuracy of pedicle screws was assessed with the Gertzbein and Robbins classification system by two board-certified neuroradiologists. RESULTS A total of 60-thoracic (T3-T11), the 24-thoracolumbar junction (T12-L1), 40-lumbar (L2-L5), and two-sacral pedicle screws were placed. Pedicle screw placement was accurate with a < 1% (1/126) pedicle breach rate. Thoracolumbar robotic spine surgery in an acute, traumatic setting was demonstrated to have a good safety profile with only one minor neurological deficit which was related to positioning. Furthermore, surgical times were inversely related to the case number. CONCLUSIONS These results together suggest that robot-assisted spine surgery is accurate in the thoracic spine. Furthermore, placement of thoracolumbar screws in an acute trauma is non-inferior to other methods when based on accuracy.
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Badhiwala JH, Wilson JR, Harrop JS, Vaccaro AR, Aarabi B, Geisler FH, Fehlings MG. Early vs Late Surgical Decompression for Central Cord Syndrome. JAMA Surg 2022; 157:1024-1032. [PMID: 36169962 PMCID: PMC9520438 DOI: 10.1001/jamasurg.2022.4454] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
Importance The optimal clinical management of central cord syndrome (CCS) remains unclear; yet this is becoming an increasingly relevant public health problem in the face of an aging population. Objective To provide a head-to-head comparison of the neurologic and functional outcomes of early (<24 hours) vs late (≥24 hours) surgical decompression for CCS. Design, Setting, and Participants Patients who underwent surgery for CCS (lower extremity motor score [LEMS] - upper extremity motor score [UEMS] ≥ 5) were included in this propensity score-matched cohort study. Data were collected from December 1991 to March 2017, and the analysis was performed from March 2020 to January 2021. This study identified patients with CCS from 3 international multicenter studies with data on the timing of surgical decompression in spinal cord injury. Participants were included if they had a documented baseline neurologic examination performed within 14 days of injury. Participants were eligible if they underwent surgical decompression for CCS. Exposures Early surgery was compared with late surgery. Main Outcomes and Measures Propensity scores were calculated as the probability of undergoing early compared with late surgery using the logit method and adjusting for relevant confounders. Propensity score matching was performed in a 1:1 ratio by an optimal-matching technique. The primary end point was motor recovery (UEMS, LEMS, American Spinal Injury Association [ASIA] motor score [AMS]) at 1 year. Secondary end points were Functional Independence Measure (FIM) motor score and complete independence in each FIM motor domain at 1 year. Results The final study cohort consisted of 186 patients with CCS. The early-surgery group included 93 patients (mean [SD] age, 47.8 [16.8] years; 66 male [71.0%]), and the late-surgery group included 93 patients (mean [SD] age, 48.0 [15.5] years; 75 male [80.6%]). Early surgical decompression resulted in significantly improved recovery in upper limb (mean difference [MD], 2.3; 95% CI, 0-4.5; P = .047), but not lower limb (MD, 1.1; 95% CI, -0.8 to 3.0; P = .30), motor function. In an a priori-planned subgroup analysis, outcomes were comparable with early or late decompressive surgery in patients with ASIA Impairment Scale (AIS) grade D injury. However, in patients with AIS grade C injury, early surgery resulted in significantly greater recovery in overall motor score (MD, 9.5; 95% CI, 0.5-18.4; P = .04), owing to gains in both upper and lower limb motor function. Conclusions and Relevance This cohort study found early surgical decompression to be associated with improved recovery in upper limb motor function at 1 year in patients with CCS. Treatment paradigms for CCS should be redefined to encompass early surgical decompression as a neuroprotective therapy.
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Affiliation(s)
- Jetan H. Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore
| | - Fred H. Geisler
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada
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Yang C, Wang Q, Xu S, Guan C, Li G, Wang G. Early expansive single sided laminoplasty decompression treatment severe traumatic cervical spinal cord injury. Front Surg 2022; 9:984899. [PMID: 36189395 PMCID: PMC9523128 DOI: 10.3389/fsurg.2022.984899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background Severe traumatic cervical spinal cord injury (tcSCI) is a disastrous event for patients and families. Maximizing spinal cord function recovery has become the primary therapeutic goal. This study investigated the effect of early extensive posterior decompression on spinal cord function improvement after severe tcSCI. Methods A retrospective review of 83 consecutive patients who underwent extensive open-door laminoplasty decompression within 24 h after severe tcSCI (American Spinal Injury Association (ASIA) impairment scale (AIS) grade A to C) between 2009 and 2017 at our institution was performed. The patient clinical and demographic data were collected. Neurological functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) score system, ASIA motor score (AMS) and AIS grade. Results Among the 83 patients initially included, the baseline AIS grade was A in 12, B in 28, and C in 43. Twenty-three patients (27.7%) had a high cervical injury. Cervical spinal stenosis (CSS) was identified in 37 patients (44.6%). The mean intramedullary lesion length was 59.6 ± 20.4 mm preoperatively and 34.2 ± 13.3 mm postoperatively (p < 0.0001). At the final follow-up visit, an improvement of at least one and two AIS grades was found in 75 (90.4%) and 41 (49.4%) patients, respectively. 24 (64.9%) patients with an improvement of least two AIS grades had CSS. The mean AMS and JOA score were significantly improved at discharge and the final follow-up visit compared with on admission (p < 0.0001). Conclusions Our results suggest that early expansive laminoplasty decompression may improve neurological outcomes after severe tcSCI, especially in patients with CSS. Larger and prospective controlled studies are needed to validate these findings.
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Affiliation(s)
- Chaohua Yang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Orthopedic surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Correspondence: Chaohua Yang Gaoju Wang
| | - Qing Wang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shuang Xu
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Can Guan
- Department of Orthopaedics, Xuanhan People's Hospital, DaZhou, China
| | - Guangzhou Li
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Gaoju Wang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Correspondence: Chaohua Yang Gaoju Wang
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Evidence-based Recommendations for Spine Surgery. Spine (Phila Pa 1976) 2022; 47:967-975. [PMID: 35238857 DOI: 10.1097/brs.0000000000004350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 02/01/2023]
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McDonald CL, Daniels AH, Anderson GA, Alsoof D, Kuris EO. Traumatic Cervical Facet Fractures and Dislocations. JBJS Rev 2022; 10:01874474-202205000-00005. [PMID: 35536995 DOI: 10.2106/jbjs.rvw.22.00023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Flexion-distraction, axial loading, and rotational forces can cause various degrees of osseoligamentous disruption of the cervical spine, leading to traumatic cervical facet fractures and dislocations. » Low-energy forces lead to minimally displaced facet fractures that often can be treated with immobilization only. High-energy forces are more likely to cause unstable injuries with or without neurologic compromise, which may require surgical intervention. » The initial treatment of cervical facet injuries requires patient evaluation and management through the Advanced Trauma Life Support (ATLS) protocols, while definitive management varies based on the biomechanical components of the injury, the neurologic status of the patient, and additional patient factors. » Cervical facet injuries often require a multidisciplinary approach to optimize long-term functional outcomes and minimize serious complications.
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Affiliation(s)
- Christopher L McDonald
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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A commentary on “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). Int J Surg 2022; 101:106606. [DOI: 10.1016/j.ijsu.2022.106606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/04/2022] [Indexed: 11/20/2022]
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Yang CH, Quan ZX, Wang GJ, He T, Chen ZY, Li QC, Yang J, Wang Q. Elevated intraspinal pressure in traumatic spinal cord injury is a promising therapeutic target. Neural Regen Res 2022; 17:1703-1710. [PMID: 35017417 PMCID: PMC8820714 DOI: 10.4103/1673-5374.332203] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The currently recommended management for acute traumatic spinal cord injury aims to reduce the incidence of secondary injury and promote functional recovery. Elevated intraspinal pressure (ISP) likely plays an important role in the processes involved in secondary spinal cord injury, and should not be overlooked. However, the factors and detailed time course contributing to elevated ISP and its impact on pathophysiology after traumatic spinal cord injury have not been reviewed in the literature. Here, we review the etiology and progression of elevated ISP, as well as potential therapeutic measures that target elevated ISP. Elevated ISP is a time-dependent process that is mainly caused by hemorrhage, edema, and blood-spinal cord barrier destruction and peaks at 3 days after traumatic spinal cord injury. Duraplasty and hypertonic saline may be promising treatments for reducing ISP within this time window. Other potential treatments such as decompression, spinal cord incision, hemostasis, and methylprednisolone treatment require further validation.
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Affiliation(s)
- Chao-Hua Yang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province; Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng-Xue Quan
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gao-Ju Wang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Tao He
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhi-Yu Chen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiao-Chu Li
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jin Yang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Qing Wang
- Department of Orthopedics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
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Sterner RC, Brooks NP. Early Decompression and Short Transport Time After Traumatic Spinal Cord Injury are Associated with Higher American Spinal Injury Association Impairment Scale Conversion. Spine (Phila Pa 1976) 2022; 47:59-66. [PMID: 34882648 DOI: 10.1097/brs.0000000000004121] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DEIGN Retrospective cohort study. OBJECTIVES This retrospective cohort study aims to determine the association of early decompressive surgery and the impact of transport time on the neurological outcomes of traumatic spinal cord injury (tSCI) patients. SUMMARY OF BACKGROUND DATA tSCI is a catastrophic event that may result in permanent disability or loss of function. To date, there remains significant controversy over the optimal time for surgical decompression in tSCI patients. The aim of this study is to evaluate the neurological outcomes of tSCI patients undergoing early versus late surgical decompression and the impact of transport time on neurological outcomes. METHODS Data from 84 patients with tSCI requiring surgical decompression was collected. Regression analysis was used to establish time to decompression classification cutoffs. Patients were classified into the following subgroups: 0 to 12 or >12 hours as a factor of the total or admitting hospital time to decompression. The change in American Spinal Injury Association Impairment (AIS) Grade from admission to discharge was determined. Additionally, the effect of transport time on conversion of AIS grade was assessed as patients were grouped into transport times of <6 or >6 hours. RESULT Among the time to decompression subgroups there were no significant differences (P > 0.05) in confounding factors such as age, injury severity, and AIS grade. Patients who received decompression within 0 to 12 hours were associated with significantly (P < 0.0001) higher average improvements in ASIA grade (0.76). Patient transport times <6 hours were associated with significantly (P = 0.004) higher conversion of AIS grade to less impaired states. CONCLUSION The present study suggests an association of decompression within 12 hours and short transport times (<6 hours) with significant improvements in neurological outcomes.Level of Evidence: 4.
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Affiliation(s)
- Robert C Sterner
- Medical Scientist Training Program, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, WI
- Department of Cell Biology, Yale University School of Medicine, New Haven, CT
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI
| | - Nathaniel P Brooks
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI
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Iunes EA, Onishi FJ, Costa HRT, Azuaga TL. EFFECT OF TIME UNTIL DECOMPRESSION ON NEUROLOGIC RECOVERY AFTER SPINAL CORD INJURY. COLUNA/COLUMNA 2022. [DOI: 10.1590/s1808-185120222103265129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
ABSTRACT Spinal cord injuries can have serious consequences for the individual, such as loss of motor function, sensory impairment, and alteration of physiological systems functions. Treatments for spinal cord injuries involve the use of drugs and surgical approaches. In the surgical field, there is a question about the ideal time after the trauma to perform the surgical procedure. The studies divide the time until surgery after the injury into two categories: “early” and “late”. To review the scientific literature on this topic, and to assess the relative effectiveness of early versus late decompressive surgery, we considered early intervention up to 24 hours and late intervention from 24 hours after the injury. For this, we performed a literature review and selected retrospective, prospective observational studies, clinical studies, and reviews with meta-analysis that compared the recovery time of patients with spinal cord injury after surgeries performed within 24 hours (early) and after 24 hours (late). The results showed potential for neurological improvement with early or even ultra-early surgical decompression (up to 12 hours) in patients with traumatic cervical spinal cord injury. On the other hand, reports about the advantage of early decompression when there is a thoracic injury are scarce. In addition to the time to decompression, the concomitant use of some drugs seems to play an important role in patients’ recovery. Level of Evidence II; Literature review.
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Affiliation(s)
- Eduardo Augusto Iunes
- Universidade Federal de São Paulo, Brazil; Sociedade Brasileira de Coluna - São Paulo Regional, Brazil
| | - Franz Jooji Onishi
- Universidade Federal de São Paulo, Brazil; Sociedade Brasileira de Coluna - São Paulo Regional, Brazil
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Pursuing More Aggressive Timelines in the Surgical Treatment of Traumatic Spinal Cord Injury (TSCI): A Retrospective Cohort Study with Subgroup Analysis. J Clin Med 2021; 10:jcm10245977. [PMID: 34945273 PMCID: PMC8703655 DOI: 10.3390/jcm10245977] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/07/2021] [Accepted: 12/17/2021] [Indexed: 12/17/2022] Open
Abstract
Background: The optimal timing of surgical therapy for traumatic spinal cord injury (TSCI) remains unclear. The purpose of this study is to evaluate the impact of “ultra-early” (<4 h) versus “early” (4–24 h) time from injury to surgery in terms of the likelihood of neurologic recovery. Methods: The effect of surgery on neurological recovery was investigated by comparing the assessed initial and final values of the American Spinal Injury Association (ASIA) Impairment Scale (AIS). A post hoc analysis was performed to gain insight into different subgroup regeneration behaviors concerning neurological injury levels. Results: Datasets from 69 cases with traumatic spinal cord injury were analyzed. Overall, 19/46 (41.3%) patients of the “ultra-early” cohort saw neurological recovery compared to 5/23 (21.7%) patients from the “early” cohort (p = 0.112). The subgroup analysis revealed differences based on the neurological level of injury (NLI) of a patient. An optimal cutpoint for patients with a cervical lesion was estimated at 234 min. Regarding the prediction of neurological improvement, sensitivity was 90.9% with a specificity of 68.4%, resulting in an AUC (area under the curve) of 84.2%. In thoracically and lumbar injured cases, the estimate was lower, ranging from 284 (thoracic) to 245 min (lumbar) with an AUC of 51.6% and 54.3%. Conclusions: Treatment within 24 h after TSCI is associated with neurological recovery. Our hypothesis that intervention within 4 h is related to an improvement in the neurological outcome was not confirmed in our collective. In a clinical context, this suggests that after TSCI there is a time frame to get the right patient to the right hospital according to advanced trauma life support (ATLS) guidelines.
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Hildebrandt G, Joswig H, Stienen MN, Bratelj D. Pros and Cons of Early and Very Early Surgery for Traumatic Central Cord Syndrome with Spinal Stenosis: Literature Review and Case Report. J Neurol Surg A Cent Eur Neurosurg 2021; 83:57-65. [PMID: 34781407 DOI: 10.1055/s-0041-1735858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The case of a 69-year-old patient with an acute traumatic central cord syndrome (ATCCS) with preexisting spinal stenosis raised a discussion over the question of conservative versus surgical treatment in the acute setting. We provide a literature overview on the management (conservative vs. surgical treatment) of ATCCS with preexisting spinal stenosis. METHODS We reviewed the literature concerning essential concepts for the management of ATCCS with spinal stenosis and cervical spinal cord injury. The data retrieved from these studies were applied to the potential management of an illustrative case report. RESULTS Not rarely has ATCCS an unpredictable neurologic course because of its dynamic character with secondary injury mechanisms within the cervical spinal cord in the early phase, the possibility of functional deterioration, and the appearance of a neuropathic pain syndrome during late follow-up. The result of the literature review favors early surgical treatment in ATCCS patients with preexisting cervical stenosis. CONCLUSION Reluctance toward aggressive and timely surgical treatment of ATCCS should at least be questioned in patients with preexisting spinal stenosis.
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Affiliation(s)
- Gerhard Hildebrandt
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Holger Joswig
- Division of Neurosurgery, HMU Health and Medical University Potsdam, Ernst von Bergmann Hospital, Potsdam, Brandenburg, Germany
| | | | - Denis Bratelj
- Department of Spine Surgery, Swiss Paraplegic Centre, Nottwil, LU, Switzerland
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Hsieh YL, Tay J, Hsu SH, Chen WT, Fang YD, Liew CQ, Chou EH, Wolfshohl J, d'Etienne J, Wang CH, Tsuang FY. Early versus Late Surgical Decompression for Traumatic Spinal Cord Injury on Neurological Recovery: A Systematic Review and Meta-Analysis. J Neurotrauma 2021; 38:2927-2936. [PMID: 34314253 DOI: 10.1089/neu.2021.0102] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study aimed to investigate whether early surgical decompression was associated with favorable neurological recovery in patients with traumatic spinal cord injury (tSCI). We searched PubMed and Embase from the database inception through December 2020 and selected studies comparing the impact of early versus late surgical decompression on neurological recovery as assessed by American Spinal Injury Association Impairment Scale (AIS) for adult patients sustaining tSCI. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Subgroup analysis and meta-regression analysis was conducted to identify significant outcome moderator. We included 26 studies involving 3574 patients in the meta-analysis. The pooled results demonstrated significant association between early surgical decompression and an improvement of at least one AIS grade (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.41-2.41; I2, 48.06%). The benefits of early surgical decompression were consistently observed across different subgroups, including patients with cervical or thoracolumbar injury and patients with complete or incomplete injury. The meta-regression analysis indicated that cut-off timing defining early versus late decompression was a significant effect moderator, with early decompression performed before post-tSCI 8 or 12 h associated with greatest benefits (OR, 3.37; 95% CI, 1.74-6.50; I2, 53.52%). No obvious publication bias was detected by the funnel plot. In conclusion, early surgical decompression was associated with favorable neurological recovery for tSCI patients. However, there was a lack of high-quality evidence and the results need further examination.
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Affiliation(s)
- Yu-Lin Hsieh
- Department of Internal Medicine, Danbury Hospital, Danbury, Connecticut, USA
| | - Joyce Tay
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Hsien Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Ting Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-De Fang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiat-Qiao Liew
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Eric H Chou
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, Texas, USA
| | - Jon Wolfshohl
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, Texas, USA
| | - James d'Etienne
- Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University, Taipei, Taiwan
| | - Fon-Yih Tsuang
- Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
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Xue F, Zhan SZ, Zhang DY, Jiang BG. Early versus Delayed Surgery for Acute Traumatic Cervical/Thoracic Spinal Cord Injury in Beijing, China: The Results of a Prospective, Multicenter Nonrandomized Controlled Trial. Orthop Surg 2021; 13:2246-2254. [PMID: 34668332 PMCID: PMC8654671 DOI: 10.1111/os.13120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To compare the effects of early surgery (within 24 h) and delayed surgery on the outcomes of patients with acute cervical/thoracic spinal cord injury (SCI) in Beijing, China. METHODS We conducted a clinical trial involving patients who were aged 16-85 years, had acute SCI from 1 June 2016 to 1 June 2019 in Beijing. The enrolled patients were divided into two groups according to the timing of surgical decompression. The primary outcome was the ordinal change in the American Spinal Injury Association Impairment Scale (AIS) grade. The secondary outcomes included the surgical time, volume of surgical bleeding, rate of admission to the intensive care unit (ICU), length of stay in the ICU, duration of mechanical ventilation, length of hospital stay, and postoperative complications. And the time consumption of different phases before operation was recorded for the patients transported to hospital by ambulance. RESULTS A total of 148 patients were included in the study, including 55 in the early surgery group and 93 in the delayed surgery group. At 52 weeks post-surgery, 27.3% of the patients in the early surgery group showed AIS improvement by at least two grades, compared to 8.7% of the patients in the delayed surgery group (P = 0.102). According to the logistic regression analysis, the odds of at least a two-grade AIS improvement was six times higher among the patients who underwent early surgery than among those who underwent delayed surgery (OR = 6.66, 95%CI 1.14-38.84). The delay surgery group consumed significantly more time in the phases of transfer and inspection or examination than the early surgery group, and the Chinese regional trauma treatment system was widely used in the early surgery group. CONCLUSION Decompression within 24 h after SCI can improve patients' recovery of neurological function without increasing the incidence of postoperative complications and surgical risks. The Chinese regional trauma treatment system can improve the diagnosis and treatment efficiency of patients with acute SCI and speed up the operation timing.
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Affiliation(s)
- Feng Xue
- Department of Orthopaedics, Peking University People's Hospital, Beijing, China
| | - Si-Zheng Zhan
- Department of Orthopaedics, Peking University People's Hospital, Beijing, China
| | - Dian-Ying Zhang
- Department of Orthopaedics, Peking University People's Hospital, Beijing, China
| | - Bao-Guo Jiang
- Department of Orthopaedics, Peking University People's Hospital, Beijing, China.,Institute of Trauma and Nerve Regeneration, Peking University People's Hospital, Beijing, China
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