Management of acute spinal cord injuries in an intensive care unit or other monitored setting

Lumbar Spine Orientation Affects Compressive Fracture Outcome

PURPOSE

Understanding how spinal orientation affects injury outcome is essential to understand lumbar injury biomechanics associated with high-rate vertical loading.

METHODS

Whole-column human lumbar spines (T12-L5) were dynamically loaded using a drop tower to simulate peak axial forces associated with high-speed aircraft ejections and helicopter crashes. Spines were allowed to maintain natural lordotic curvature for loading, resulting in a range of orientations. Pre-test X-rays were used to quantify specimen orientation at the time of loading. Primary fracture types were identified (wedge, n = 6; burst, n = 4; hyperextension, n = 4) and compared for loading parameters and lumbar orientation.

RESULTS

Fracture type was dependent on peak acceleration, bending moment, Cobb angle, sagittal spinal tilt, and location of the applied load.

CONCLUSIONS

Lumbar spine orientation under high-rate axial acceleration affected the resulting fracture type. Analysis of pre-test X-rays revealed that spines that sustained wedge and burst fractures were oriented straighter at the time of loading. The load was applied centrally to T12 in spines with burst fractures, and anteriorly to T12 in spines with wedge fractures. Spines that sustained hyperextension fracture had lower peak accelerations, larger Cobb angles at the time of loading, and sustained larger extension moments. Fracture presentation is an important and understudied factor that influences biomechanical stability, clinical course, and long-term patient outcomes.

Sovateltide (ILR-1620) Improves Motor Function and Reduces Hyperalgesia in a Rat Model of Spinal Cord Injury

BACKGROUND

Spinal cord injury (SCI) presents a major global health challenge, with rising incidence rates and substantial disability. Although progress has been made in understanding SCI's pathophysiology and early management, there is still a lack of effective treatments to mitigate long-term consequences. This study investigates the potential of sovateltide, a selective endothelin B receptor agonist, in improving clinical outcomes in an acute SCI rat model.

METHODS

Thirty male Sprague-Dawley rats underwent sham surgery (group A) or SCI and treated with vehicle (group B) or sovateltide (group C). Clinical tests, including Basso, Beattie, and Bresnahan scoring, inclined plane, and allodynia testing with von Frey hair, were performed at various time points. Statistical analyses assessed treatment effects.

RESULTS

Sovateltide administration significantly improved motor function, reducing neurological deficits and enhancing locomotor recovery compared with vehicle-treated rats, starting from day 7 post injury. Additionally, the allodynic threshold improved, suggesting antinociceptive properties. Notably, the sovateltide group demonstrated sustained recovery, and even reached preinjury performance levels, whereas the vehicle group plateaued.

CONCLUSIONS

This study suggests that sovateltide may offer neuroprotective effects, enhancing neurogenesis and angiogenesis. Furthermore, it may possess anti-inflammatory and antinociceptive properties. Future clinical trials are needed to validate these findings, but sovateltide shows promise as a potential therapeutic strategy to improve functional outcomes in SCI. Sovateltide, an endothelin B receptor agonist, exhibits neuroprotective properties, enhancing motor recovery and ameliorating hyperalgesia in a rat SCI model. These findings could pave the way for innovative pharmacological interventions for SCI in clinical settings.

The role of neurosciences intensive care in trauma and neurosurgical conditions

The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.

Clinical prediction model for acute inpatient complications after traumatic cervical spinal cord injury: a subanalysis from the Surgical Timing in Acute Spinal Cord Injury Study

OBJECT

While the majority of existing reports focus on complications sustained during the chronic stages after traumatic spinal cord injury (SCI), the objective in the current study was to characterize and quantify acute inpatient complications. In addition, the authors sought to create a prediction model using clinical variables documented at hospital admission to predict acute complication development.

METHODS

Analyses were based on data from the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) data registry, which contains prospective information on adult patients with cervical SCIs who were enrolled at 6 North American centers over a 7-year period. All patients who underwent a standardized American Spinal Injury Association (ASIA) neurological examination within 24 hours of injury and whose follow-up information was available at the acute hospital discharge were included in the study. For purposes of classification, complications were divided into 5 major categories: 1) cardiopulmonary, 2) surgical, 3) thrombotic, 4) infectious, and 5) decubitus ulcer development. Univariate statistical analyses were performed to determine the relationship between complication occurrence and individual demographic, injury, and treatment variables. Multivariate logistic regression was subsequently performed to create a complication prediction model. Model discrimination was judged according to the area under the receiver operating characteristic curve.

RESULTS

Complete complication information was available for 411 patients at the acute care discharge. One hundred sixty patients (38.9%) experienced 240 complications. The mean age among those who experienced at least one complication was 45.9 years, as compared with 43.5 years among those who did not have a complication (p = 0.18). In the univariate analysis, patients with complications were less likely to receive steroids at admission (p = 0.01), had a greater severity of neurological injury as indicated by the ASIA Impairment Scale (AIS) grade at presentation (p < 0.01), and a higher frequency of significant comorbidity (p = 0.04). In a multivariate logistic regression model, a severe initial AIS grade (p < 0.01), a high-energy injury mechanism (p = 0.07), an older age (p = 0.05), the absence of steroid administration (p = 0.02), and the presence of comorbid illness (p = 0.02) were associated with a greater likelihood of complication development during the period of acute hospitalization. The area under the curve value for the full model was 0.75, indicating acceptable predictive discrimination.

CONCLUSIONS

These results will help clinicians to identify patients with cervical SCIs at greatest risk for complication development and thus allowing for the institution of aggressive complication prevention measures.

Methodology of systematic reviews and recommendations

Although research in the field of spinal cord injury (SCI) is a relatively new endeavor, a remarkable number of papers focused on this subspecialty have been published in a broad variety of journals over the last two decades. A multidisciplinary group of experts, including clinical epidemiologists, neurosurgical and orthopedic spine surgeons, basic scientists, rehabilitation specialists, intensivists, and allied health professionals (nursing and physical therapy) was assembled through the Spinal Cord Injury Solutions Network to summarize the existing literature focusing on 12 key topics related to acute traumatic SCI, which have not been recently reviewed. The objective was to develop evidence-based recommendations to help translate current science into clinical practice and to identify new directions for research. For each topic one to three specific questions were formulated by consensus through the expert panel. A systematic review of the literature was performed to determine the current evidence for the specific questions. A primary literature search was performed using MEDLINE, CINAHL, EMBASE, and Cochrane databases. A secondary search strategy incorporated additional articles referenced in significant publications (i.e., meta-analysis, systematic and nonsystematic review articles). Two reviewers independently reviewed the titles and abstracts yielded by this comprehensive search and subsequently selected articles based on the predetermined inclusion and inclusion criteria. Data were extracted for population into evidentiary tables. Selected articles were rated for level of evidence and methodological quality, information that was also included in evidentiary tables. Disagreements were resolved by a third reviewer or consensus-based discussion. Based on the evidence compiled, answers to the targeted questions were formulated and recommendations generated by consensus-based discussion and anonymized voting using Delphi methodology. A level of consensus of 80% or higher was considered to represent strong agreement.

Brown-Séquard-plus syndrome because of penetrating trauma in children

Brown-Séquard syndrome is an uncommon condition involving incomplete spinal cord injury, with ipsilateral motor and proprioception loss, contralateral pain, and decreased temperature. Brown-Séquard-plus syndrome is associated with additional neurologic findings involving the eyes, bowel, or bladder. We describe an adolescent with Brown-Séquard-plus syndrome attributable to a stab injury. Our patient's clinical features of spinal and neurogenic shock overlapped at presentation. He was managed with high-dose steroids, along with intense physiotherapy and rehabilitation, resulting in good neurologic recovery. Appropriate medical (and surgical, when indicated) management usually results in good to complete recovery of neurologic function, depending on the level and grade of injury. With the increasing incidence of gunshot wounds and stab injuries in children, pediatricians, including pediatric neurologists and emergency physicians, are more likely to encounter these types of spinal cord injuries in children.

Management of the unstable cervical spine: elective versus emergent cases

PURPOSE OF REVIEW

The present review focuses on similarities and discrepancies in the management of emergent and elective unstable cervical spine (C-spine) patients.

RECENT FINDINGS

During mobilization, lifting is superior to rolling in limiting spine movements. Before prone position surgery, the transfer of the patient on a rotating table is preferable to rolling. In trauma patients, helical computed tomography (CT) with sagittal reconstruction is the first choice for clearing the C-spine. In those patients, airway compromise may be related to hidden cervical edema or hematoma. Several devices can be of help in performing safe tracheal intubation in patients with limited neck movements, but awake fiberoptic intubation remains the safest procedure. The muscle relaxant antagonist sugammadex can improve safety for rapid sequence induction. It can rapidly reverse profound steroid-based neuromuscular blockade and allows avoidance of succinylcholine in this indication. Propofol anesthesia better prevents coughing upon emergence than inhaled anesthesia. Neuroprotection in cord-damaged patients is disappointing, and the controversy on the efficacy of high-dose methylprednisolone is not closed. Nevertheless, maintenance of homeostasis remains the cornerstone of neuroprotection.

SUMMARY

Subtle details differentiate the management of emergent and elective unstable C-spine patients. In both situations, the presence or the absence of a neurological insult governs the therapeutic strategy.

Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and management

Cardiovascular complications in the acute stage following traumatic spinal cord injury (SCI) require prompt medical attention to avoid neurological compromise, morbidity, and death. In this review, the authors summarize the neural regulation of the cardiovascular system as well as the pathophysiology, diagnosis, and management of major cardiovascular complications that can occur following acute (up to 30 days) traumatic SCI. Hypotension (both supine and orthostatic), autonomic dysreflexia, and cardiac arrhythmias (including persistent bradycardia) are attributed to the loss of supraspinal control of the sympathetic nervous system that commonly occurs in patients with severe spinal cord lesions at T-6 or higher. Current evidence-based guidelines recommend: 1) monitoring of cardiac and hemodynamic parameters in the acute phase of SCI; 2) maintenance of a minimum mean arterial blood pressure of 85 mm Hg during the hyperacute phase (1 week after SCI); 3) timely detection and appropriate treatment of neurogenic shock and cardiac arrhythmias; and 4) immediate and adequate treatment of episodes of acute autonomic dysreflexia. In addition to these forms of cardiovascular dysfunction, individuals with acute SCIs are at high risk for deep venous thrombosis (DVT) and pulmonary embolism due to loss of mobility and, potentially, altered fibrinolytic activity, abnormal platelet function, and impaired circadian variations of hemostatic and fibrinolytic parameters. Current evidence supports a recommendation for thromboprophylaxis using mechanical methods and anticoagulants during the acute stage up to 3 months following SCI, depending on the severity and level of injury. Low-molecular-weight heparin is the first choice for anticoagulant prophylaxis in patients with acute SCI. Although there is insufficient evidence to recommend (or refute) the use of screening tests for DVT in asymptomatic adults with acute SCI, this strategy may detect asymptomatic DVT in at least 9.4% of individuals who undergo thromboprophylaxis using lowmolecular- weight heparin. Indications and treatment of DVT and acute pulmonary embolism are well established and are summarized in this review. Recognition of cardiovascular complications after acute SCI is essential to minimize adverse outcomes and to optimize recovery.

Autonomic dysfunction in spinal cord injury: clinical presentation of symptoms and signs

Spinal cord injury and especially cervical spinal cord injury implies serious disturbances in autonomic nervous system function. The clinical effects of these disturbances are striking. In the acute phase, the autonomic imbalance and its effect on cardiovascular, respiratory system and temperature regulation may be life threatening. Serious complications such as over-hydration with the risk of pulmonary edema or hyponatremia are seen. The cord-injured person suffers from autonomic nervous system dysfunction also affecting bladder and bowel control, renal and sexual function. Paralytic ileus may cause vomiting and aspiration, which in turn interferes with respiratory function in those with cervical spinal cord injury. The cord-injured person is at risk to develop pressure sores from the moment of the accident. Two to three months post-injury the cord-injured person with a lesion level above the fifth thoracic segment may develop autonomic dysreflexia, characterised by sympathetically mediated vasoconstriction in muscular, skin, renal and presumably gastrointestinal vascular beds induced by an afferent peripheral stimulation below lesion level. The reaction might cause cerebrovascular complications and has effects on metabolism. Some of the autonomic disturbances are transient and a new balance is reached months post-injury, while others persist for life.

Spontaneous acute thoracic epidural hematoma causing paraplegia in a patient with severe preeclampsia in early labor

This is a case of acute spontaneous thoracic epidural hematoma in a laboring patient at term who presented with severe preeclampsia and acute spinal cord compression, paraplegia, and sensory loss below T8. In early labor, at home, the patient experienced sudden lumbar back pain that progressed to mid-scapular pain leading to paraplegia and T8 sensory loss within one hour of onset of pain. Her symptoms were caused by a spontaneous thoracic epidural hematoma. Upon arrival at the first hospital, the correct presumptive diagnosis was made in the emergency room, magnesium sulfate was administered, and the patient was transferred to our medical center. Her hypertension was not treated despite severe preeclampsia in order to maintain spinal cord perfusion pressure. Following cesarean section under general anesthesia, thoracic laminectomy was performed and an epidural hematoma compressing the spinal cord to 2-3 mm was evacuated 13 h after the onset of symptoms. After approximately three months of paraplegia, five months with quad-walker and cane use, the patient can now walk with a cane or other minimal support but has remaining bowel and bladder problems. The conflicting anesthetic management objectives of severe preeclampsia and acute paraplegia secondary to spinal epidural hematoma required compromise in the management of her preeclampsia in order to preserve spinal cord perfusion.

Tracheostomy after anterior cervical spine fixation

BACKGROUND

Patients with cervical spine injury may require both anterior cervical spine fusion and tracheostomy, particularly in the setting of associated cervical spinal cord injury (SCI). Despite the close proximity of the two surgical incisions, we postulated that tracheostomy could be safely performed after anterior spine fixation. In addition, we postulated that the severity of motor deficits in patients with cervical spine injury would correlate with the need for tracheostomy.

METHODS

A retrospective review was undertaken of all adult trauma patients diagnosed with cervical spine fractures or cervical SCI admitted between June 1996 and June 2001 at our university Level I trauma center. Demographic data, severity of neurologic injury based on the classification of the American Spinal Injury Association (ASIA), complications, and use and type of tracheostomy were collected. In the subgroup of patients with unstable cervical spine injury that underwent anterior stabilization and tracheostomy, data regarding timing and technique of these procedures and wound outcomes were also collected. Categorical data were analyzed using chi analysis using Yates correction when appropriate, with p <0.05 considered significant.

RESULTS

During this time period, 275 adult survivors were diagnosed with cervical spinal cord or bony injury. Forty-five percent of patients with SCI (27 of 60) and 14% of patients without SCI (30 of 215) underwent tracheostomy (p <0.001). Moreover, on the basis of the ASIA classification system, 76% of ASIA A and B patients, 38% of ASIA C patients, 23% of ASIA D patients, and 14% of ASIA E patients were treated with tracheostomy (p <0.001). In the subgroup that underwent both anterior spine fixation and tracheostomy (n=17), the median time interval from spine fixation to airway placement was 7 days (interquartile range, 6-10 days), with 71% of these tracheostomies performed percutaneously. No patient developed a wound infection or nonunion as a consequence of tracheostomy placement, and there were no deaths because of complications of either procedure.

CONCLUSION

These data support the safety of tracheostomy insertion 6 to 10 days after anterior cervical spine fixation, particularly in the presence of cervical SCI. The presence of severe motor neurologic deficits was strongly associated with the use of tracheostomy in patients with cervical spine injury. Percutaneous tracheostomy, which is our technique of choice, may be advantageous in this setting by virtue of creating only a small wound. The optimal timing and use of tracheostomy in patients with cervical spine injury requires further study.

Autonomic dysreflexia in acute spinal cord injury: an under-recognized clinical entity

While autonomic dysreflexia (AD) is well recognized in the chronic stage of spinal cord injury (SCI) this potentially life-threatening complication has been only rarely documented in the acute phase (1 month) after SCI. Based on our clinical experience we hypothesized that AD is under-recognized in the acute phase of SCI. This study was undertaken to determine the incidence and clinical associations of early AD in our center. We reviewed the charts of patients with acute traumatic SCI admitted to the Toronto Western Hospital Spinal Program between 1998 and 2000. Among 58 patients with acute traumatic SCI (15F, 43M; ages 17-89 years, mean of 55.4), all three individuals who developed evidence of early AD had complete cervical tetraplegia (1F, 2M; ages 31-42 years, mean of 38.3). The incidence of early AD was 5.2% (3 of 58), whereas the adjusted incidence for the population at risk (SCI at T6 or above) was 5.7% (3 of 53). A significant number of patients in this series (87.9%, or 51 of 58) had a cervical SCI. While the mean resting systolic arterial blood pressure among these three individuals was 105.7+/-3 mm Hg, the mean systolic blood pressure at the time of early AD was 173.3+/-14.8 mm Hg (increase in systolic blood pressure over baseline ranged from 35.5% to 95%). The earliest episode of AD occurred on the 4(th) post-injury day. The trigger mechanisms for AD were somatic pain, fecal impaction, and abdominal distention. Although numerous reports emphasize AD as a potential complication of chronic SCI, our study demonstrates that AD occurs in 5.7% of patients with acute SCI above T6. Patients with severe cervical SCI are particularly susceptible to the early onset of AD. Clinicians need to be aware and highly vigilant of the potential development of AD in the acute phase of SCI.

Administration of corticosteroids for acute spinal cord injury: the current practice of trauma medical directors and emergency medical system physician advisors

OBJECTIVE

In 1997, the results from the Third National Acute Spinal Cord Injury Study (NASCIS 3) were published. We undertook the present study to determine the treatment protocols for patients with spinal cord injuries in Colorado and assess whether there were any barriers to the administration of corticosteroids.

STUDY DESIGN

Cross-sectional.

METHODS

In May 1999, surveys were mailed to every trauma facility medical director and emergency medical system physician advisor in the state. Physicians were asked to provide information about their facilities' or agencies' current practice(s) for administering steroids to patients with spinal cord injuries. They were also asked about their opinion on whether the data on corticosteroid treatment for spinal cord injury support its use.

RESULTS

Ninety-eight percent (39 out of 41) of the medical directors who responded and treat patients with spinal cord injuries said that their facilities do administer steroids to those patients. Fourteen percent reported following the NASCIS 3 protocol; 75%, the NASCIS 2 protocol. About half of the medical directors were either uncertain or did not believe that the data regarding the corticosteroid treatment for spinal cord injury supported its use. The majority of physician advisors responded that they do not authorize the administration of corticosteroids to patients with spinal cord injuries in the field, primarily because of short transport times.

CONCLUSIONS

Our study demonstrated relatively poor compliance with the NASCIS 3 protocol, but good compliance with the NASCIS 2 protocol. There was skepticism about the efficacy of corticosteroid treatment among some Colorado physicians that treat patients with spinal cord injuries acutely; however, this does not completely explain the findings.