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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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Khadour FA, Khadour YA, Meng L, XinLi C, Xu T. Epidemiology features of traumatic and non-traumatic spinal cord injury in China, Wuhan. Sci Rep 2024; 14:1640. [PMID: 38238504 PMCID: PMC10796334 DOI: 10.1038/s41598-024-52210-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/16/2024] [Indexed: 01/22/2024] Open
Abstract
Spinal cord injuries are incredibly disabling and can have fatal consequences. At present, there is a lack of available information regarding the epidemiological characteristics of patients who have experienced spinal cord injury (SCI) in China. This retrospective hospital-based study was conducted in the Rehabilitation department of Wuhan's Tongji Hospital between 2016 and 2022. A total of 649 individuals diagnosed with SCI (both traumatic and non-traumatic) were admitted during this period. Data regarding various epidemiological features were gathered, including sex, age, etiology, occupation, neurological level of injury, the American Spinal Injury Association Impairment Scale at the time of admission, and information on any accompanying injuries. Out of the 649 cases of SCI, there were 539 cases of traumatic SCI and 110 cases of non-traumatic SCI. The mean age at the time of injury was 45.6 ± 14.8 years. The ratio of male to female patients was higher in traumatic SCI at 2.82:1compared to non-traumatic SCI at 1.68:1. Traffic accidents were the most common cause of TSCI, accounting for (n = 207/539; 38.40%) of cases. On the other hand, neoplasm was the most common cause of NTSCI, accounting for (n = 38/110; 34.54%) of cases. The findings indicated a higher proportion of males, with traffic accidents being the main cause of injury among TSCI patients. It is crucial to prioritize the risk of falling among older adults and allocate more attention to this issue. These results emphasize the need for tailored preventive strategies that consider the unique characteristics of different types of SCI patients.
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Affiliation(s)
- Fater A Khadour
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095#, Jie-Fang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
- Department of Rehabilitation, Faculty of Medicine, Al Baath University, Homs, Syria
- Department of Physical Therapy, Faculty of Health Science, Al-Baath University, Homs, Syria
| | - Younes A Khadour
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095#, Jie-Fang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
- Department of Rehabilitation, Faculty of Medicine, Al Baath University, Homs, Syria
- Department of Physical Therapy, Cairo University, Cairo, Egypt, 11835
| | - Ling Meng
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095#, Jie-Fang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
| | - Cui XinLi
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095#, Jie-Fang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China
| | - Tao Xu
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095#, Jie-Fang Avenue, Qiaokou District, Wuhan, 430030, Hubei, China.
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3
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Adegeest CY, Ter Wengel PV, Peul WC. Traumatic spinal cord injury: acute phase treatment in critical care. Curr Opin Crit Care 2023; 29:659-665. [PMID: 37909371 DOI: 10.1097/mcc.0000000000001110] [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: 11/03/2023]
Abstract
PURPOSE OF REVIEW Surgical timing in traumatic spinal cord injury (t-SCI) remains a point of debate. Current guidelines recommend surgery within 24 h after trauma; however, earlier timeframes are currently intensively being investigated. The aim of this review is to provide an insight on the acute care of patients with t-SCI. RECENT FINDINGS Multiple studies show that there appears to be a beneficial effect on neurological recovery of early surgical decompression within 24 h after trauma. Currently, the impact of ultra-early surgery is less clear as well as lacking evidence for the most optimal surgical technique. Nevertheless, early surgery to decompress the spinal cord by whatever method can impact the occurrence for perioperative complications and potentially expedite rehabilitation. There are clinical and socioeconomic barriers in achieving timely and adequate surgical interventions for t-SCI. SUMMARY In this review, we provide an overview of the recent insights of surgical timing in t-SCI and the current barriers in acute t-SCI treatment.
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Affiliation(s)
- Charlotte Y Adegeest
- University Neurosurgical Center Holland (UNCH), LUMC | HMC | HAGA, Leiden-The Hague, the Netherlands
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Lambrechts MJ, Issa TZ, Hilibrand AS. Updates in the Early Management of Acute Spinal Cord Injury. J Am Acad Orthop Surg 2023; 31:e619-e632. [PMID: 37432977 DOI: 10.5435/jaaos-d-23-00281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future.
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Affiliation(s)
- Mark J Lambrechts
- From the Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
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5
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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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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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7
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Chanbour H, Chen JW, Ehtesham SA, Ivey C, Pandey AK, Dewan MC, Zuckerman SL. Time to Surgery in Spinal Trauma: A Meta-Analysis of the World's Literature Comparing High-Income Countries to Low-Middle Income Countries. World Neurosurg 2022; 167:e268-e282. [PMID: 35948226 DOI: 10.1016/j.wneu.2022.07.140] [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: 07/25/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We conducted a systematic review and meta-analysis to: 1) compare time from traumatic spinal injury (TSI) to operating room (OR) in high-income countries (HICs) versus low-middle-income countries (LMICs), and 2) evaluate hospital length of stay (LOS) in HICs versus LMICs. METHODS A systematic literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving articles of all languages. INCLUSION CRITERIA published between 1991 and 2021, spine trauma population, single country/region, and recorded time from injury to OR. The primary outcome was time from injury to OR, and the secondary outcome was LOS. Means and standard deviations were estimated in a random effects model by DerSimonian and Laird methods. RESULTS Of 2367 articles, 163 met the inclusion criteria for systematic review. Regarding time from injury to OR, 23 articles were eligible for meta-analysis; 16 studies were conducted in HICs and 7 in LMICs, comprising 3819 patients with TSI. A significantly shorter mean time from injury to OR was found in HICs (1.92 days, 95% confidence interval 1.44-2.41) compared with LMICs (3.27 days, 95% confidence interval 2.27-4.27) (P = 0.020). Regarding length of stay, 14 articles were eligible for meta-analysis, 10 studies were conducted in HICs and 4 in LMICs, comprising 11,003 patients. There was no difference in LOS between HICs and LMICs (25.76 days vs. 20.48 days, P = 0.140). CONCLUSIONS Patients with traumatic spinal injuries in HICs were more likely to undergo earlier surgery compared to patients in LMICs. No difference was found in total LOS between HICs and LMICs. While multiple factors can influence time to surgery, these findings draw attention to the global disparity in spinal trauma care.
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Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey W Chen
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | | | - Camille Ivey
- Annette and Irwin Eskind Family Biomedical Library and Learning Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Awadhesh Kumar Pandey
- Department of Orthopedic Surgery, Welwistchia Medipark Hospital, Walvis Bay & Ongwediva Medipark Hospital, Namibia
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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8
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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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9
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Qiu Y, Chen Y, Xie Y, Xie H, Dong J. Comparative analysis of the efficacy of early and late surgical intervention for acute spinal cord injury: A systematic review and meta-analysis based on 16 studies. Int J Surg 2021; 94:106098. [PMID: 34509672 DOI: 10.1016/j.ijsu.2021.106098] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/05/2021] [Accepted: 09/08/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Spinal cord injuries (SCI) are a devastating condition and can lead to severe functional and psychosocial problems. However, the influence of the timing of the surgical intervention for acute SCI remains debated, with substantial variability in clinical practice. Thus, this study aims to compare the efficacy of early and late surgical intervention for acute SCI. METHODS A systematic search of PubMed, Embase, Cochrane Library and Web of Science up to January 10, 2021 was conducted for relevant studies that compared early and late acute SCI. Neurological outcomes were assessed by American Spinal Injury Association (ASIA). Early surgery was defined as the surgical intervention within 24 h after spinal injury. The primary outcome was the change of ASIA score from baseline to follow-up time after spinal injury. Second primary outcomes were clinical outcomes including neurological improvement rate, mortality, length of stay (LOS), charges ($), complications and ASIA Impairment Scale (AIS). All statistical analyses were performed using standard statistical procedures provided in Review Manager 5.2. RESULTS A total of 16 studies including 3977 SCI patients were identified finally. Our pooled results indicated that, compared with late surgery, patients who underwent early surgery experienced more ASIA score improvement, with pooled MDs of 2.32 points (95% CI 1.07-3.57; P = 0.0003) in total motor scores, 5.13 points (95% CI 3.94-6.32; P < 0.0001) in light touch scores, and 4.49 points (95% CI 2.22-6.76; P = 0.0001) in pin prick scores respectively. In addition, patients receiving early surgery experienced more total motor score after surgery (MD 3.30; 95% CI 0.82-5.79; P = 0.009). Patients who had early surgery also had higher neurological improvement rate (OR 1.66; 95% CI 1.19-2.31; P = 0.003), shorter LOS (MD -4.77; 95% CI -7.42 to -2.12), less charges ($) (MD -0.33; 95% CI -0.43 to -0.22), lower incidence of complications (OR 0.62; 95% CI 0.48-0.81), and higher AIS improvement rate (OR 1.71; 95% CI 1.20-2.44) respectively. CONCLUSIONS Compared with late surgery, acute SCI patients who underwent early surgery experienced greater recovery after spinal injury, with better neurological improvement, shorter LOS, less charges and lower incidence of complications.
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Affiliation(s)
- Yuanyuan Qiu
- Rehabilitation Center, Beijing Daxing District Hospital of Traditional Chinese and Western Medicine, Beijing, 100076, China Department of Rehabilitation Medicine, Beijing Tongren Hospital of Capital Medical University, Beijing, 100073, China Department of Rehabilitation Medicine, Beijing Friendship Hospital of Capital Medical University, Beijing, 100050, China Rehabilitation Department, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, 100020, China
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10
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Dial AG, Monaco CMF, Grafham GK, Patel TP, Tarnopolsky MA, Hawke TJ. Impaired Function and Altered Morphology in the Skeletal Muscles of Adult Men and Women With Type 1 Diabetes. J Clin Endocrinol Metab 2021; 106:2405-2422. [PMID: 33890059 DOI: 10.1210/clinem/dgab261] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Previous investigations on skeletal muscle health in type 1 diabetes (T1D) have generally focused on later stages of disease progression where comorbidities are present and are posited as a primary mechanism of muscle dysfunction. OBJECTIVE To investigate skeletal muscle function and morphology across the adult lifespan in those with and without T1D. DESIGN Participants underwent maximal contraction (MVC) testing, resting muscle biopsy, and venous blood sampling. SETTING Procedures in this study were undertaken at the McMaster University Medical Centre. PARTICIPANTS Sixty-five healthy adult (18-78 years old) men/males and women/females (T1D = 34; control = 31) matched for age/biological sex/body mass index; self-reported physical activity levels were included. MAIN OUTCOME MEASURES Our primary measure in this study was MVC, with supporting histological/immunofluorescent measures. RESULTS After 35 years of age ("older adults"), MVC declined quicker in T1D subjects compared to controls. Loss of strength in T1D was accompanied by morphological changes associated with accelerated aging. Type 1 myofiber grouping was higher in T1D, and the groups were larger and more numerous than in controls. Older T1D females exhibited more myofibers expressing multiple myosin heavy chain isoforms (hybrid fibers) than controls, another feature of accelerated aging. Conversely, T1D males exhibited a shift toward type 2 fibers, with less evidence of myofiber grouping or hybrid fibers. CONCLUSIONS These data suggest impairments to skeletal muscle function and morphology exist in T1D. The decline in strength with T1D is accelerated after 35 years of age and may be responsible for the earlier onset of frailty, which characterizes those with diabetes.
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Affiliation(s)
- Athan G Dial
- Dept of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Cynthia M F Monaco
- Dept of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Grace K Grafham
- Dept of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Tirth P Patel
- Dept of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Thomas J Hawke
- Dept of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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11
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Li JJ, Liu H, Zhu Y, Yan L, Liu R, Wang G, Wang B, Zhao B. Animal Models for Treating Spinal Cord Injury Using Biomaterials-Based Tissue Engineering Strategies. TISSUE ENGINEERING PART B-REVIEWS 2021; 28:79-100. [PMID: 33267667 DOI: 10.1089/ten.teb.2020.0267] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jiao Jiao Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, Australia
| | - Haifeng Liu
- Department of Orthopedics and Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Yuanyuan Zhu
- Department of Pharmacy, Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Lei Yan
- Department of Orthopedics and Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Ruxing Liu
- Department of Orthopedics and Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Guishan Wang
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, China
| | - Bin Wang
- Department of Orthopedics and Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
- Department of Sports Medicine and Adult Reconstruction Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Bin Zhao
- Department of Orthopedics and Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
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12
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Badhiwala JH, Wilson JR, Witiw CD, Harrop JS, Vaccaro AR, Aarabi B, Grossman RG, Geisler FH, Fehlings MG. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol 2020; 20:117-126. [PMID: 33357514 DOI: 10.1016/s1474-4422(20)30406-3] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although there is a strong biological rationale for early decompression of the injured spinal cord, the influence of the timing of surgical decompression for acute spinal cord injury (SCI) remains debated, with substantial variability in clinical practice. We aimed to objectively evaluate the effect of timing of decompressive surgery for acute SCI on long-term neurological outcomes. METHODS We did a pooled analysis of individual patient data derived from four independent, prospective, multicentre data sources, including data from December, 1991, to March, 2017. Three of these studies had been published; of these, only one study previously specifically analysed the effect of the timing of surgical decompression. These four datasets were selected because they were among the highest quality acute SCI datasets available and contained highly granular data. Individual patient data were obtained by request from study authors. All patients who underwent decompressive surgery for acute SCI within these datasets were included. Patients were stratified into early (<24 h after spinal injury) and late (≥24 h after spinal injury) decompression groups. Neurological outcomes were assessed by American Spinal Injury Association (ASIA), or International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), examination. The primary endpoint was change in total motor score from baseline to 1 year after spinal injury. Secondary endpoints were ASIA Impairment Scale (AIS) grade and change in upper-extremity motor, lower-extremity motor, light touch, and pin prick scores after 1 year. One-stage meta-analyses were done by hierarchical mixed-effects regression adjusting for baseline score, age, mechanism of injury, AIS grade, level of injury, and administration of methylprednisolone. Effect sizes were summarised by mean difference (MD) for sensorimotor scores and common odds ratio (cOR) for AIS grade, with corresponding 95% CIs. As a secondary analysis, change in total motor score was regressed against time to surgical decompression (h) as a continuous variable, using a restricted cubic spline with adjustment for the same covariates as in the primary analysis. FINDINGS We identified 1548 eligible patients from the four datasets. Outcome data at 1 year after spinal injury were available for 1031 patients (66·6%). Patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at 1 year after spinal injury; total motor scores improved by 23·7 points (95% CI 19·2-28·2) in the early surgery group versus 19·7 points (15·3-24·0) in the late surgery group (MD 4·0 points [1·7-6·3]; p=0·0006), light touch scores improved by 19·0 points (15·1-23·0) vs 14·8 points (11·2-18·4; MD 4·3 [1·6-7·0]; p=0·0021), and pin prick scores improved by 18·3 points (13·7-22·9) versus 14·2 points (9·8-18·6; MD 4·0 [1·5-6·6]; p=0·0020). Patients who had early decompression also had better AIS grades at 1 year after surgery, indicating less severe impairment, compared with patients who had late surgery (cOR 1·48 [95% CI 1·16-1·89]; p=0·0019). When time to surgical decompression was modelled as a continuous variable, there was a steep decline in change in total motor score with increasing time during the first 24-36 h after injury (p<0·0001); and after 36 h, change in total motor score plateaued. INTERPRETATION Surgical decompression within 24 h of acute SCI is associated with improved sensorimotor recovery. The first 24-36 h after injury appears to represent a crucial time window to achieve optimal neurological recovery with decompressive surgery following acute SCI. FUNDING None.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert G Grossman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | | | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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13
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Wilson JR, Cronin S, Fehlings MG, Kwon BK, Badhiwala JH, Ginsberg HJ, Witiw C, Jaglal S. Epidemiology and Impact of Spinal Cord Injury in the Elderly: Results of a Fifteen-Year Population-Based Cohort Study. J Neurotrauma 2020; 37:1740-1751. [DOI: 10.1089/neu.2020.6985] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jefferson R. Wilson
- Division of Neurosurgery, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Shawna Cronin
- Institute of Clinical Evaluative Sciences, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Brian K. Kwon
- Spinal Program, Blusson Spinal Cord Center, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jetan H. Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Howard J. Ginsberg
- Division of Neurosurgery, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christopher Witiw
- Division of Neurosurgery, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Susan Jaglal
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
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14
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Speidel J, Mattucci S, Liu J, Kwon BK, Tetzlaff W, Oxland TR. Effect of Velocity and Duration of Residual Compression in a Rat Dislocation Spinal Cord Injury Model. J Neurotrauma 2020; 37:1140-1148. [PMID: 31950856 DOI: 10.1089/neu.2019.6747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Early decompression of the traumatically injured and persistently compressed spinal cord is intuitively beneficial for neurological outcome. Despite considerable pre-clinical evidence of a neurological benefit to early decompression, the effect of early surgical decompression in clinical spinal cord injury (SCI) remains less clear. The discrepancy between pre-clinical and clinical results may be due to differences between the biomechanical variables used in pre-clinical animal models and the biomechanical conditions occurring in clinical injuries. These pre-clinical variables include region of spinal cord, velocity of impact, and injury mechanism. In this study, the effect of velocity and duration of residual compression on injury severity were evaluated using a novel, rodent model of cervical dislocation SCI. Fifty-two male Sprague-Dawley rats were included in five groups: two timings of decompression (24 min, 240 min), two velocities (10 mm/sec, 500 mm/sec), and a sham group. All injuries involved a 1.45-mm dorsal dislocation of the C6 vertebra relative to C5 with subsequent residual compression of 0.8 mm. Animals were evaluated for motor function using the Martinez open field, grip strength, and grooming tests for 6 weeks post-injury. Immunohistochemistry and histology following sacrifice were conducted with counts for NeuN- and choline acetyltransferase (ChAT)-positive neurons, and length of cavitation. Behavioral testing and histological analysis revealed that injuries induced by the high velocity were consistently more severe than those induced by the low velocity, with behavioral correlations ranging between 0.46 and 0.58 (p < 0.05). Longer duration of residual compression did not produce significantly more severe injuries as measured by functional tests and histology. These findings demonstrate that the velocity of the initial traumatic impact may be a more important factor than duration of residual compression in determining SCI severity in a dislocation model of SCI.
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Affiliation(s)
- Jason Speidel
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Department of Mechanical Engineering, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephen Mattucci
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Department of Mechanical Engineering, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jie Liu
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wolfram Tetzlaff
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Departments of Zoology and Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas R Oxland
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Department of Mechanical Engineering, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Wilson JR, Witiw CD, Badhiwala J, Kwon BK, Fehlings MG, Harrop JS. Early Surgery for Traumatic Spinal Cord Injury: Where Are We Now? Global Spine J 2020; 10:84S-91S. [PMID: 31934526 PMCID: PMC6947677 DOI: 10.1177/2192568219877860] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE There is a strong biological rationale to perform early decompression after traumatic spinal cord injury (SCI). With an enlarging clinical evidence base, most spine surgeons internationally now favor early decompression for the majority of SCI patients; however, a number of pertinent questions remain surrounding this therapy. METHODS A narrative review evaluating the status of early surgery for SCI. In particular, we addressed the following questions: (1) Which patients stand to benefit most from early surgery? 2) What is the most appropriate time threshold defining early surgery? RESULTS Although heterogeneity exists, the evidence generally seems to support early surgery. While the best evidence exists for cervical SCI, there is insufficient data to support a differential effect for early surgery depending on neurological level or injury severity. When comparing thresholds to define early versus late surgery-including a later threshold (48-72 hours), an earlier threshold (24 hours), and an ultra-early threshold (8-12 hours)-the 2 earlier time points seem to be associated with the greatest potential for improved outcomes. However, existing prehospital and hospital logistics pose barriers to early surgery in a significant proportion of patients. An overview of recommendations from the recent AOSpine guidelines is provided. CONCLUSION In spite of increasing acceptance of early surgery post SCI, further research is needed to (1) identify subgroups of patients who stand to derive particular benefit-in particular to develop more evidence-based approaches for central cord syndrome and (2) investigate the efficacy and feasibility of ultra-early surgery targeting more aggressive timelines.
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Affiliation(s)
- Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,Jefferson R. Wilson, Division of Neurosurgery, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
| | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
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16
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Yusuf AS, Mahmud MR, Alfin DJ, Gana SI, Timothy S, Nwaribe EE, Dalhat NK, Aruna AA, Idris MM. Clinical Characteristics and Challenges of Management of Traumatic Spinal Cord Injury in a Trauma Center of a Developing Country. J Neurosci Rural Pract 2019; 10:393-399. [PMID: 31595109 PMCID: PMC6779583 DOI: 10.1055/s-0039-1695696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Traumatic spinal cord injury (TSCI) is a major burden in trauma care worldwide. Most victims are young, and the injury results in economic loss and psychological and social burden on the individual and the society. The outcome depends on the severity of primary spinal cord injury, interventions to prevent secondary insults to the damaged cord, and access to a specialized care. The lack of standard prehospital care and dedicated facilities for spine care coupled with challenges of inadequate health insurance coverage impact negatively on the outcome of care in patients with spinal cord injury in our practice. Objectives This study was performed to determine the clinical profile of patients with TSCI and to highlight the factors that determine the early outcome in a resource-constrained trauma center. Materials and Methods This study was a retrospective review of trauma registry and medical records of all the patients with acute TSCI at the National Trauma Center Abuja from September 2014 to December 2016. Results A total of 133 patients with TSCI were studied. Most of these patients were young men with a mean age of 36 years. Most injury (72.2%) occurred following motor vehicular crash affecting mainly the cervical spinal cord (62.0%). None of the patients received standard prehospital care. Only 41.4% of the patients were transported to the hospital in an ambulance. About half (52.6%) of the patients suffered complete spinal cord injury (the American Spinal Injury Association [ASIA] A), and pressure ulcer was the most common complication (23.3%). Only 42% of the patients that needed surgical intervention were operated, mainly due to the inability to pay for the service. The ASIA grade on admission was the most significant determinant factor of morbidity and mortality. Conclusion Optimal care of patients with TSCI was hindered by inadequate facilities and economic constraints.
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Affiliation(s)
- Ayodeji Salman Yusuf
- Department of Surgery, Neurosurgery Unit, National Hospital Abuja, Abuja, Nigeria
| | - Muhammad Raji Mahmud
- Department of Surgery, Neurosurgery Unit, National Hospital Abuja, Abuja, Nigeria
| | - Dumura Jeneral Alfin
- Department of Surgery, Neurosurgery Unit, National Hospital Abuja, Abuja, Nigeria
| | - Samue Isa Gana
- Department of Surgery, Neurosurgery Unit, National Hospital Abuja, Abuja, Nigeria
| | - Samaila Timothy
- Department of Surgery, Neurosurgery Unit, National Hospital Abuja, Abuja, Nigeria
| | | | - Nasir Kurfi Dalhat
- Department of Surgery, Neurosurgery Unit, National Hospital Abuja, Abuja, Nigeria
| | - Ajibade Afeez Aruna
- Department of Surgery, Neurosurgery Unit, National Hospital Abuja, Abuja, Nigeria
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17
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Hachem LD, Ahuja CS, Fehlings MG. Assessment and management of acute spinal cord injury: From point of injury to rehabilitation. J Spinal Cord Med 2017; 40:665-675. [PMID: 28571527 PMCID: PMC5778930 DOI: 10.1080/10790268.2017.1329076] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
CONTEXT Spinal cord injury (SCI) is a devastating condition that can lead to significant neurological impairment and reduced quality of life. Despite advancements in our understanding of the pathophysiology and secondary injury mechanisms involved in SCI, there are currently very few effective treatments for this condition. The field, however, is rapidly changing as new treatments are developed and key discoveries are made. METHODS In this review, we outline the pathophysiology, management, and long-term rehabilitation of individuals with traumatic SCI. We also provide an in-depth overview of emerging therapies along the spectrum of the translational pipeline. EVIDENCE SYNTHESIS The concept of "time is spine" refers to the concept which emphasizes the importance of early transfer to specialized centers, early decompressive surgery, and early delivery of other treatments (e.g. blood pressure augmentation, methylprednisolone) to affect long-term outcomes. Another important evolution in management has been the recognition and prevention of the chronic complications of SCI including respiratory compromise, bladder dysfunction, Charcot joints, and pressure sores through directed interventions along with early integration of physical rehabilitation and mobilization. There have also been significant advances in neuroprotective and neuroregenerative strategies for SCI, many of which are actively in clinical trial including riluzole, Cethrin, stem cell transplantation, and the use of functional electrical stimulation. CONCLUSION Pharmacologic treatments, cell-based therapies, and other technology-driven interventions will likely play a combinatorial role in the evolving management of SCI as the field continues to evolve.
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Affiliation(s)
- Laureen D. Hachem
- Institute of Medical Science, University of Toronto, Toronto, ONT, Canada
| | - Christopher S. Ahuja
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ONT, Canada
- Institute of Medical Science, University of Toronto, Toronto, ONT, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ONT, Canada
- Institute of Medical Science, University of Toronto, Toronto, ONT, Canada
- McEwen Centre for Regenerative Medicine, UHN, University of Toronto, Toronto, ONT, Canada
- Department of Surgery, University of Toronto, Toronto, ONT, Canada
- Spine Program, University of Toronto, Toronto, ONT, Canada
- McLaughlin Center in Molecular Medicine, University of Toronto, Toronto, ONT, Canada
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18
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Cheng CL, Noonan VK, Shurgold J, Chen J, Rivers CS, Khaleghi Hamedani H, Humphreys S, Bailey CS, Attabib N, Mac Thiong JM, Goytan M, Paquet J, Fox R, Ahn H, Kwon BK, Fourney DR. Geomapping of Traumatic Spinal Cord Injury in Canada and Factors Related to Triage Pattern. J Neurotrauma 2017; 34:2856-2866. [PMID: 28325105 PMCID: PMC5652977 DOI: 10.1089/neu.2016.4929] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Current research indicates that more than half of patients with traumatic spinal cord injury (tSCI) experience delays in transfer and receive surgery >24 h post-injury. The objectives of this study were to determine the geographic distribution of tSCI in Canada relative to specialized treatment facilities, to assess clinical and logistical factors at play for indirect admissions to those facilities, and to explore differences in current time to admission and simulated scenarios in an attempt to assess the potential impact of changes to triage protocols. This study included data from 876 patients with tSCI enrolled in the prospectively collected acute Rick Hansen Spinal Cord Injury Registry (RHSCIR) between January 1, 2010 and December 31, 2013 for whom there were data on the location of their injury. Patients transported directly to a RHSCIR acute facility were more likely to reach the facility within 1 h of injury, whereas those transported indirectly were more likely to arrive 7 h later. Considering the injuries occurring within 40 km of a RHSCIR acute facility (n = 323), 249 patients (77%) were directly and 74 (23%) were indirectly admitted. In the multivariate regression analysis, only older age and longer road distance remained significantly associated with being indirectly admitted to a RHSCIR facility. Compared with the current status, the median time to admission decreased by 20% (3.5 h) in the 100% direct admission scenario, and increased by 102% (8.9 h) in the 100% indirect admission scenario.
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Affiliation(s)
| | | | | | - Jason Chen
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Carly S Rivers
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | | | | | - Christopher S Bailey
- Division of Orthopaedics, Department of Surgery, Western University, London, Ontario, Canada
| | - Najmedden Attabib
- Horizon Health Network, Dalhousie University, Saint John, New Brunswick, Canada
| | - Jean-Marc Mac Thiong
- Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Michael Goytan
- Sections of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerome Paquet
- Sciences Neurologiques, Université Laval, Québec, Quebec, Canada
| | - Richard Fox
- Faculty of Medicine and Dentistry, Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Henry Ahn
- University of Toronto Spine Program, Toronto, Ontario, Canada
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daryl R Fourney
- Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada
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19
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Sharwood LN, Stanford R, Middleton JW, Burns B, Joseph A, Flower O, Rigby O, Ball J, Dhaliwal S. Improving care standards for patients with spinal trauma combining a modified e-Delphi process and stakeholder interviews: a study protocol. BMJ Open 2017; 7:e012377. [PMID: 28104707 PMCID: PMC5253580 DOI: 10.1136/bmjopen-2016-012377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Around 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year; a relatively low incidence injury with extremely high long-term associated costs. Care standards are inconsistent nationally, lacking in consensus across important components of care such as prehospital spinal immobilisation, timing of surgery and timeliness of transfer to specialist services. This study aims to develop 'expertly defined' and agreed standards of care across the majority of disciplines involved for these patients. METHODS AND ANALYSIS A modified e-Delphi process will be used to gain consensus for best practice across specific clinical early care areas for the patient with TSCI; invited participants will include clinicians across Australia with relevant and significant expertise. A rapid literature review will identify available evidence, including any current guidelines from 2005 to 2015. Level and strength of evidence identified, including areas of contention, will be used to formulate the first round survey questions and statements. Participants will undertake 2-3 online survey rounds, responding anonymously to questionnaires regarding care practices and indicating their agreement or otherwise with practice standard statements. Relevant key stakeholders, including patients, will also be interviewed face to face. ETHICS AND DISSEMINATION Ethics approval for this study was obtained by the NSW Population & Health Services Research Ethics Committee on 14 January 2016 (HREC/12/CIPHS/74). Seeking comprehensive understanding of how the variation in early care pathways and treatment can be addressed to achieve optimal patient outcomes and economic costs; the overall aim is the agreement to a consistent approach to the triage, treatment, transport and definitive care of acute TSCI victims. The agreed practice standards of care will inform the development of a Clinical Pathway with practice change strategies for implementation. These standards will offer a benchmark for state-wide and potentially national policy.
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Affiliation(s)
- Lisa N Sharwood
- Sydney Medical School Northern, The University of Sydney, Sydney, New South Wales, Australia
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ralph Stanford
- Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - James W Middleton
- Sydney Medical School Northern, The University of Sydney, Sydney, New South Wales, Australia
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
- State Spinal Cord Injury Service, NSW Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Brian Burns
- Sydney Medical School Northern, The University of Sydney, Sydney, New South Wales, Australia
- Greater Sydney Area Helicopter Emergency Medical Service, Sydney, New South Wales, Australia
| | - Anthony Joseph
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Oliver Flower
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Oran Rigby
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Greater Sydney Area Helicopter Emergency Medical Service, Sydney, New South Wales, Australia
- Institute for Trauma and Injury Management, NSW Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Jonathon Ball
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Shelly Dhaliwal
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, Sydney, New South Wales, Australia
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