Influence of Previous Comorbidities and Common Complications on Motor Function after Early Surgical Treatment of Patients with Traumatic Spinal Cord Injury

Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors

PURPOSE

To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors.

METHODS

Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant.

RESULTS

Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions.

CONCLUSION

sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.

Impact of vitamin D on the prognosis after spinal cord injury: A systematic review

Vitamin D (VitD) insufficiency is a worldwide health problem and affects billions of people. Spinal cord injury (SCI) patients seem more susceptible to developing suboptimal levels of VitD. However, the literature regarding its impact on the prognosis of SCI is limited. Thus, in this review, we systematically investigated the published studies via a combination of keywords associated with SCI and VitD in four medical databases (Medline, Embase, Scopus, and Web of Science). All included studies were analyzed, and selected clinical data on the prevalence of VitD insufficiency (serum 25-hydroxyvitamin D < 30 ng/ml) and deficiency (serum 25-hydroxyvitamin D < 20 ng/ml) were collected for further meta-analysis via random effects. Through literature review, a total of 35 studies were eligible and included. The meta-analysis of VitD status (13 studies, 1,962 patients) indicated high prevalence of insufficiency (81.6% [75.7, 87.5]) and deficiency (52.5% [38.1, 66.9]) after SCI. Besides, low levels of VitD were reported to be associated with a higher risk of skeletal diseases, venous thromboembolism, psychoneurological syndromes, and chest illness after injury. Existing literature suggested that supplemental therapy might act as an adjuvant treatment to facilitate post-injury rehabilitation. Non-human experimental studies highlighted the neuroprotective effect of VitD, which was associated with enhancing axonal and neuronal survival, suppressing neuroinflammation, and modulating autophagy. Therefore, the current evidence suggests that the prevalence of VitD insufficiency is high in the SCI population, and low-level VitD may impair functional restoration after SCI. VitD supplemental treatment may have potential benefits to accelerate rehabilitation in mechanistically related processes after SCI. However, due to the limitation of the available evidence, more well-designed randomized controlled trials and mechanism experimental research are still needed to validate its therapeutic effect, elucidate its neuroprotective mechanism, and develop novel treatments.

Time to Surgery in Spinal Trauma: A Meta-Analysis of the World's Literature Comparing High-Income Countries to Low-Middle Income Countries

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.

Identification of novel multipotent stem cells in mouse spinal cord following traumatic injury

We showed that injury-induced multipotent stem cells (iSCs) emerge in the brain after stroke. These brain-derived iSCs (B-iSCs) can differentiate into various lineages, including neurons. This study aimed to determine whether similar stem cells can be induced even after non-ischemic injuries, such as trauma to the spinal cord. We characterized these cells, mainly focusing on their stemness, multipotency, and neuronal differentiation activities. Spinal cord injury was produced using forceps in adult mice. On day 3 after spinal cord injury, samples were obtained from the injured areas. Spinal cord sections were subjected to histological analyses. Cells were isolated and assessed for proliferative activities, immunohistochemistry, RT-PCR, FACS, and microarray analysis. Although nerve cell morphology was disrupted within the injured spinal cord, our histological observations revealed the presence of cells expressing stem cells, such as nestin and Sox2 in these areas. In addition, cells extracted from injured areas exhibited high proliferative abilities. These cells also expressed markers of both neural stem cells (e.g., nestin, Sox2) and multipotent stem cells (e.g., Sox2, c-myc, Klf4). They differentiated into adipocytes, osteocytes and chondrocytes, as well as neuronal cells. Microarray analysis further identified similar properties between spinal cord (SC)-derived iSCs and B-iSCs. However, SC-iSCs revealed specific genes related to the regulation of stemness and neurogenesis. We identified similar features related to multipotency in SC-iSCs compared to B-iSCs, including neuronal differentiation potential. Although the differences between SC-iSCs and B-iSCs remain largely undetermined, the present study shows that iSCs can develop even after non-ischemic injuries such as trauma. This phenomenon can occur outside the brain within the CNS.

Bioinformatic Analysis of the Proteome in Exosomes Derived From Plasma: Exosomes Involved in Cholesterol Metabolism Process of Patients With Spinal Cord Injury in the Acute Phase

Spinal cord injury (SCI) is a common but severe disease caused by traffic accidents. Coronary atherosclerotic heart disease (CHD) caused by dyslipidemia is known as the leading cause of death in patients with SCI. However, the quantitative analysis showed that the cholesterol and lipoprotein concentrations in peripheral blood (PB) did not change significantly within 48 h after SCI. Due to the presence of the Blood spinal cord barrier (BSCB), there are only few studies concerning the plasma cholesterol metabolism in the acute phase of SCI. Exosomes have a smaller particle size, which enables them relatively less limitation of BSCB. This study uses exosomes derived from the plasma of 43 patients in the acute phase of SCI and 71 patients in the control group as samples. MS proteomics and bioinformatics analysis found 590 quantifiable proteins, in which 75 proteins were upregulated and 153 proteins were downregulated, and the top 10 differentially expressed proteins are those including downregulating proteins: HIST1H4A, HIST2H3A, HIST2H2BE, HCLS1, S100A9, HIST1H2BM, S100A8, CALM3, YWHAH, and SFN, and upregulating proteins: SERPIND1, C1QB, SPTLC3, IGHV4-28, C4A, IGHV4-38-2, IGHV4-30-2, SLC15A1, C4B, and ACTG2. Enrichment analysis showed that the largest part of proteins was related to cholesterol metabolism among the downregulated proteins. The main components of cholesterol [ApoB-48 and ApoB-100 increased, ApoA-I, ApoA-II, ApoA-IV, ApoC, ApoE, and Apo(a) decreased] were changed in exosomes derived from plasma of patients. ELISA analysis showed that some components were disordered in the acute phase of SCI. These results suggested that the exosomes might be involved in cholesterol metabolism regulation in the acute phase of SCI.

Influence of early extensive posterior decompression on hyponatremia and cardiopulmonary dysfunction after severe traumatic cervical spinal cord injury: A clinical observational study

Retrospective single institution observational study.The aim of the present study was to analyze the influence of early extensive posterior decompression on complications in patients with severe traumatic cervical spinal cord injury (tcSCI).Cervical SCI is associated with a high prevalence of hyponatremia and cardiopulmonary dysfunction. However, very few studies have focused on this exploration to reduce the incidence of SCI early complications.We reviewed the medical records of consecutive patients undergoing extensive posterior decompression within 24 h for severe tcSCI (American Spinal Injury Association Impairment Scale [AIS] A to C) admitted between January 2009 and January 2018. The data collected retrospectively included age, gender, mechanism, and level of SCI, AIS grade, fracture or dislocation, electrolyte, and cardiopulmonary complications.Of the 97 enrolled patients, the baseline AIS grade was AIS A in 14, AIS B in 31, and AIS C in 52. Improvement of at least two AIS grades was found in 26 (26.8%), and improvement of at least one grade was found in 80.4% of patients at discharge. Twenty-nine (29.9%) patients had mild hyponatremia, 8 (8.2%) had moderate hyponatremia, and 3 (3.1%) had severe hyponatremia during hospitalization. The incidences of hyponatremia, hypotension, and tracheotomy were 41.2%, 13.4%, and 6.2%, respectively. The mean forced vital capacity (FVC) on admission and at discharge was 1.34 ± 0.46 L and 2.21 ± 0.41 L (P < .0001), respectively. Five patients developed pneumonia.Our results suggest that early expansive posterior decompression significantly reduces the incidence of hyponatremia, hypotension, and tracheotomy by promoting recovery of spinal cord function after severe tcSCI.

Impact of complications at admission to rehabilitation on the functional status of patients with spinal cord lesion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Aim of the study is to evaluate the impact of complications at admission on the functional status of spinal cord lesions patients.

SETTING

Rehabilitation hospital in Italy.

METHODS

Two hundred and seven patients with complications (mostly pressure ulcers) at admission to rehabilitation were matched for neurological level of injury and AIS grade with 207 patients without complications.

MEASURES

International Standards for Neurological Classification of Spinal Cord Injury, Spinal Cord Independence Measure, Rivermead Mobility Index, and Walking Index for Spinal Cord Injury. These measures were recorded at admission to rehabilitation and at discharge. We also recorded length of acute and rehabilitation stay and discharge destination.

STATISTICS

Student's T test for paired samples, McNemar's chi-square test.

RESULTS

Patients with complications at admission suffered more often from a traumatic lesions. The functional status at admission and discharge of the patients without complications was significantly better than the functional status of patients with complications (Spinal Cord Independence Measure mean difference between the two groups 5.7 (CI 2.8-8.5) at admission, and 10 (CI 5.3-14.7) at discharge). Length of stay was significantly higher in patients with complications. Patients with complications were more often institutionalized than their counterparts (46/161 vs. 20/187, odds ratio 0.4 (CI 0.2-0.7)).

CONCLUSIONS

Complications seem to be more frequent in patients with traumatic lesions. The presence of complications has a negative effect on patients' functional status at discharge and length of stay, and it determines a higher risk of being institutionalized.

Association of Pneumonia, Wound Infection, and Sepsis with Clinical Outcomes after Acute Traumatic Spinal Cord Injury

 < 0.001). There were no statistical differences between participants with or without PWS with respect to time from injury to surgery, and administration of steroids. Dominance analysis showed injury level, baseline AIS grade, and subject pre-morbid medical status collectively accounted for 77.7% of the predicted variance of PWS. Regression analysis indicated subjects with PWS demonstrated higher odds for respiratory (odds ratio [OR] 3.91, 95% confidence interval [CI]: 1.42-10.79) and ambulatory (OR 3.94, 95% CI: 1.50-10.38) support at 6 month follow-up in adjusted analysis. This study has shown an association between PWS occurring during acute admission and poorer functional outcomes following SCI.

Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis

OBJECTIVE

Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance.

METHODS

A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis.

RESULTS

A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups.

CONCLUSIONS

The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.

Dynamic changes in intramedullary pressure 72 hours after spinal cord injury

Intramedullary pressure increases after spinal cord injury, and this can be an important factor for secondary spinal cord injury. Until now there have been no studies of the dynamic changes of intramedullary pressure after spinal cord injury. In this study, telemetry systems were used to observe changes in intramedullary pressure in the 72 hours following spinal cord injury to explore its pathological mechanisms. Spinal cord injury was induced using an aneurysm clip at T10 of the spinal cord of 30 Japanese white rabbits, while another 32 animals were only subjected to laminectomy. The feasibility of this measurement was assessed. Intramedullary pressure was monitored in anesthetized and conscious animals. The dynamic changes of intramedullary pressure after spinal cord injury were divided into three stages: stage I (steep rise) 1–7 hours, stage II (steady rise) 8–38 hours, and stage III (descending) 39–72 hours. Blood-spinal barrier permeability, edema, hemorrhage, and histological results in the 72 hours following spinal cord injury were evaluated according to intramedullary pressure changes. We found that spinal cord hemorrhage was most severe at 1 hour post-spinal cord injury and then gradually decreased; albumin and aquaporin 4 immunoreactivities first increased and then decreased, peaking at 38 hours. These results confirm that severe bleeding in spinal cord tissue is the main cause of the sharp increase in intramedullary pressure in early spinal cord injury. Spinal cord edema and blood-spinal barrier destruction are important factors influencing intramedullary pressure in stages II and III of spinal cord injury.

Early Predictors of Global Functional Outcome after Traumatic Spinal Cord Injury: A Systematic Review

Accurately predicting functional recovery is an asset for all clinicians and decision makers involved in the care of patients with acute traumatic spinal cord injury (TSCI). Unfortunately, there is a lack of information on the relative importance of significant predictors of global functional outcome. There is also a need for identifying functional predictors that can be timely optimized by the medical and rehabilitation teams throughout the hospitalizations phases. The main objective of this work was to systematically review and rate early factors that are consistently and independently associated with global functional outcome in individuals with TSCI. A literature search using MEDLINE, EMBASE, and Cochrane databases from January 1, 1970 to April 1, 2017 was performed. Two authors independently reviewed the titles and abstracts yielded by this literature search and subsequently selected studies to be included based on predetermined eligibility criteria. Disagreements were resolved by a consensus-based discussion, and if not, by an external reviewer. Data were extracted by three independent reviewers using a standardized table. The quality of evidence of the individual studies was assessed based on the Oxford Center for Evidence-Based Medicine modified by Wright and colleagues (2000) as well as the National Institutes of Health (2014). Fifteen articles identifying early clinical predictors of functional outcome using multiple regression analyses were included in this systematic review. Based on the compiled data, this review proposes a rating of early factors associated to global functional outcome according to their importance and their potential to be modified by the medical/rehabilitation team throughout the early phases of hospitalization. It also proposes a new conceptual framework that illustrates the impact of specific categories of factors and their interaction with each other. Ultimately, this review aims to guide clinicians and researchers in improving the continuum of care throughout early phases post-SCI.

The treatment of spinal cord injury in rats using bone marrow-derived neural-like cells induced by cerebrospinal fluid

This study aimed to evaluate the effect of bone mesenchymal stem cells (BMSCs) and BMSC neural-like cells (BMSC-Ns) on the spinal cord injury (SCI) in the rat model of SCI. BMSC-Ns were prepared from the third passage of BMSCs by induction of healthy cerebrospinal fluid (CSF) of an adult human. The SCI rat model was established through a surgical procedure, and after 7 days the rats were randomly divided into 3 (A, B and C) groups. Groups A (BMSC-Ns) and B (BMSCs) were treated with 1 × 10⁶/20 μl cells, while group C (saline) was treated with saline, all via intracerebroventricular injection. After transplantation, the BBB score of group A was significantly higher than that of group B, which in turn was significantly higher than that of group C (P < .05). The levels of Bdnf, Ngf, Ntf3 were statistically significantly higher in group A than those in groups B and C (P < .05). The levels of 5-HT, NA, Ach, DA, GABA in group A were significantly higher than those in groups B and C, whereas the level of Glu was significantly lower in group A than that in groups B and C (P < .05). The histopathological data showed remarkably less necrosis of the spinal cord in group A, compared to that in groups B and C. Transplanting BMSC-Ns or BMSCs into the lateral ventricles improved the neurological function of rats with SCI. Moreover, BMSC-Ns were significantly more effective than BMSCs, which provides a possible approach for the treatment of SCI.

Complications in the Management of Patients with Spine Trauma

More than 50% of patients diagnosed with acute, traumatic spinal cord injury will experience at least 1 complication during their hospitalization. Age, severity of neurological injury, concurrent traumatic brain injury, comorbid illness, and mechanism of injury are all associated with increasing risk of complication. More than 75% of complications will occur within 2 weeks of injury. The complications associated with SCI carry a significant risk of morbidity and mortality; their early identification and management is critical in the care of the SCI patient.