Early complications of high-dose methylprednisolone sodium succinate treatment in the follow-up of acute cervical spinal cord injury

Salidroside promotes the repair of spinal cord injury by inhibiting astrocyte polarization, promoting neural stem cell proliferation and neuronal differentiation

Spinal cord injury (SCI) remains a formidable challenge, lacking effective treatments. Following SCI, neural stem cells (NSCs) migrate to SCI sites, offering a potential avenue for nerve regeneration, but the effectiveness of this intrinsic repair mechanism remains suboptimal. Salidroside has demonstrated pro-repair attributes in various pathological conditions, including arthritis and cerebral ischemia, and the ability to curtail early-stage inflammation following SCI. However, the specific role of salidroside in the late-stage repair processes of SCI remains less defined. In this investigation, we observed that continuous salidroside treatment in SCI mice improved motor function recovery. Immunofluorescence-staining corroborated salidroside's capacity to stimulate nerve regeneration and remyelination, suppress glial scar hyperplasia, reduce the activation of neurotoxic A1 astrocytes, and facilitate NSCs migration towards the injured region. Mechanistically, in vitro experiments elucidated salidroside's significant role in restraining astrocyte proliferation and A1 polarization. It was further established that A1 astrocytes hinder NSCs proliferation while inducing their differentiation into astrocytes. Salidroside effectively ameliorated this inhibition of NSCs proliferation through diminishing c-Jun N-terminal kinase (JNK) pathway phosphorylation and restored their differentiation into neurons by suppressing the signal transducer and activator of transcription 3 (STAT3) pathway. In summary, our findings suggest that salidroside holds promise as a therapeutic agent for traumatic SCI treatment.

Traumatic spinal cord and spinal column injuries: A bibliometric analysis of the 200 most cited articles

Study Design

Bibliometric analysis.

Objectives

This study aimed to highlight the 200 most influential articles related to traumatic spinal cord and spinal column injuries and provide an insight of past and current global trends in spinal trauma research.

Methods

The Web of Science database was used to identify the top 200 most cited articles on the topic of traumatic spinal cord injury (SCI) and spinal column injuries between using a prespecified algorithm. The articles were manually reviewed; bibliometrics were collected on title, first and corresponding authors' country, institution, journal, publication year, and citation data.

Results

The search string yielded 30,551 articles during 1977-2019. The average time from the publication was 19.5 years. A total of 1356 authors contributed to 67 different journals, the top 200 most cited articles amassing a total of 88,115 citations and an average 440.6 citations. The United States of America (USA) contributed the most with 110 articles; the top institution was the University of Toronto with 34 publications. Most studies focused on basic science research on SCI. Keyword analysis revealed the most commonly used keywords: SCI, inflammation, apoptosis, incidence/prevalence, and regeneration; four word-clusters were identified. Institutions from the USA and Canada collaborated the most and two major and two minor institutional collaboration subnetworks were identified. Co-citation analysis detected three main clusters of authors.

Conclusion

This overview of the most cited articles on traumatic spinal cord and spinal column injuries provides insight into the international spinal trauma community and the terrain in this field, potentially acting as a springboard for further collaboration development.

Models and approaches to comprehend and address glial inflammation following spinal cord injury

Spinal cord injury (SCI) culminates in chronic inflammation and glial scar formation driven by the activation of microglia and astrocytes. Current anti-inflammatory strategies to treat glial activation associated with SCI have several limitations. Existing in vitro and ex vivo models studying molecular mechanisms associated with inflammation focus only on the acute phase. However, the progression of glial cell-derived inflammation over the acute-to-chronic phases has not been assessed. Understanding this progression will help establish a framework for evaluating therapeutic strategies. Additionally, new models could be useful as high-throughput screening (HTS) platforms. This review aims to highlight currently available models and future methods that could facilitate screening of novel therapeutics for SCI.

Methylprednisolone in acute traumatic spinal cord injury: case-matched outcomes from the NASCIS2 and Sygen historical spinal cord injury studies with contemporary statistical analysis

OBJECTIVE

Methylprednisolone (MP) to treat acute traumatic spinal cord injury (ATSCI) remains controversial since the release of the second National Acute Spinal Cord Injury Study (NASCIS2) in 1990. As two historical studies, NASCIS2 and Sygen in ATSCI, used identical MP dosages, it was possible to construct a new case-level pooled ATSCI data set satisfying contemporary criteria and able to clarify the effect of MP.

METHODS

The new pooled data set was first modernized by excluding patients with injury levels caudal to T10, lower-extremity American Spinal Injury Association (ASIA) motor scores (LEMSs) ≥ 46, Glasgow Coma Scale scores ≤ 11, and age < 15 or > 75 years, and then standardized to the ASIA grading and scoring format. A new updated NASCIS2 data set from this pooled data set contained 31.6% fewer patients than the 1990 NASCIS2 data set.

RESULTS

In the new pooled data set, recovery of LEMSs from baseline to 26 weeks, the primary outcome variable, was separated statistically into five different injury severity cohorts (p < 0.0001). The severity cohorts contained groups with severe floor (62.9%) and ceiling (10.7%) effects, which do not contribute to drug effects. The new NASCIS2 data set duplicated the p value for MP versus placebo in the sub-subgroup analysis of MP initiated ≤ 8 hours (the subgroup) and recovery of motor function on only the right side of the body (a further subgroup within the ≤ 8-hour subgroup), presented as the positive MP effect in the original NASCIS2 reporting. However, current statistical interpretation considers results seen only in post hoc sub-subgroups, without multi-test corrections, to be random effects without clinical significance. The combined case-level pooled data set from the NASCIS2 and Sygen studies increased the MP group from 106 to 431 patients, creating a new MP combined group. This new data set served as a surrogate for a contemporary MP study and found that administration of MP did not enhance ASIA motor score improvement in the lower extremities at 26 weeks. Secondary analysis of descending ASIA motor and sensory cervical neurological levels in cervical ATSCI patients at 26 weeks also found no MP drug effect.

CONCLUSIONS

Analysis of both the new updated NASCIS2 data set and the new case-matched pooled data set from two historical ATSCI studies revealed that administration of MP after spinal cord injury did not demonstrate any enhancement in neurological recovery at 26 weeks. The results of this analysis warrant review by clinical guideline groups.

Immune response following traumatic spinal cord injury: Pathophysiology and therapies

Traumatic spinal cord injury (SCI) is a devastating condition that is often associated with significant loss of function and/or permanent disability. The pathophysiology of SCI is complex and occurs in two phases. First, the mechanical damage from the trauma causes immediate acute cell dysfunction and cell death. Then, secondary mechanisms of injury further propagate the cell dysfunction and cell death over the course of days, weeks, or even months. Among the secondary injury mechanisms, inflammation has been shown to be a key determinant of the secondary injury severity and significantly worsens cell death and functional outcomes. Thus, in addition to surgical management of SCI, selectively targeting the immune response following SCI could substantially decrease the progression of secondary injury and improve patient outcomes. In order to develop such therapies, a detailed molecular understanding of the timing of the immune response following SCI is necessary. Recently, several studies have mapped the cytokine/chemokine and cell proliferation patterns following SCI. In this review, we examine the immune response underlying the pathophysiology of SCI and assess both current and future therapies including pharmaceutical therapies, stem cell therapy, and the exciting potential of extracellular vesicle therapy.

A Bibliometric Analysis of Publications on Spinal Cord Injury Treatment With Glucocorticoids Using VOSviewer

Background

Spinal cord injury (SCI) has devastating physical and social consequences for patients. Systemic administration of methylprednisolone (MP) at a higher dosage though can reduce neurological deficits following acute SCI. Still, this treatment regimen is controversial, owing to the apparent dose-related side effects and relatively minor improvement in neurological function. Therefore, this study aimed at the bibliometric analysis of published literature related to SCI treatment, which may lead to future research trends.

Methods

The literature published relating to SCI and using glucocorticoids for its treatment between 1982 and 2022 was collected and scanned in the Web of Science collection database using the keywords glucocorticoid, dexamethasone, MP, corticosteroids, and SCI, followed by using VOSviewer for bibliometric analysis of these articles.

Results

A total of 1,848 published articles and 7,448 authors on SCI and glucocorticoid usage were identified. The SCI total link strength accounts for 1,341, and MP for 762 has a strong link to neuroprotection and inflammation. The mean citation count for the top 20 most-cited articles was 682 (range: 358–1,828), where most of these were descriptive studies having focused on clinical features. The Journal of Neurotrauma was the highest-ranked journal with 6,010 citations. A total of 69 articles were published by Michael G Fehlings from the University of Toronto with 6,092 citations. The University of Toronto has published 90-related manuscripts with 7,632 citations. In contrast, 800 articles were published in the United States, with 39,633 citations and total link strength of 5,714. The second-ranked country was China, with 241 published articles and 3,403 citations.

Conclusions

The research published on applying MP in treating SCI has increased with time. Although the United States has made a significant global contribution to this important field of research, it requires rigorous clinical trials designed to verify the therapeutic role of MP in SCI and its appropriate dosage to find solutions for neurological recovery.

Established and Emerging Therapies in Acute Spinal Cord Injury

Acute spinal cord injury (SCI) is devastating for patients and their caretakers and has an annual incidence of 20–50 per million people. Following initial assessment with appropriate physical examination and imaging, patients who are deemed surgical candidates should undergo decompression with stabilization. Earlier intervention can improve neurological recovery in the post-operative period while allowing earlier mobilization. Optimized medical management is paramount to improve outcomes. Emerging strategies for managing SCI in the acute period stem from an evolving understanding of the pathophysiology of the injury. General areas of focus include ischemia prevention, reduction of secondary injury due to inflammation, modulation of the cytotoxic and immune response, and promotion of cellular regeneration. In this article, we review established, emerging, and novel experimental therapies. Continued translational research on these methods will improve the feasibility of bench-to-bedside innovations in treating patients with acute SCI.

Premarin Reduces Neurodegeneration and Promotes Improvement of Function in an Animal Model of Spinal Cord Injury

Spinal cord injury (SCI) causes significant mortality and morbidity. Currently, no FDA-approved pharmacotherapy is available for treating SCI. Previously, low doses of estrogen (17β-estradiol, E2) were shown to improve the post-injury outcome in a rat SCI model. However, the range of associated side effects makes advocating its therapeutic use difficult. Therefore, this study aimed at investigating the therapeutic efficacy of Premarin (PRM) in SCI. PRM is an FDA-approved E2 (10%) formulation, which is used for hormone replacement therapy with minimal risk of serious side effects. The effects of PRM on SCI were examined by magnetic resonance imaging, immunofluorescent staining, and western blot analysis in a rat model. SCI animals treated with vehicle alone, PRM, E2 receptor antagonist (ICI), or PRM + ICI were graded in a blinded way for locomotor function by using the Basso–Beattie–Bresnahan (BBB) locomotor scale. PRM treatment for 7 days decreased post-SCI lesion volume and attenuated neuronal cell death, inflammation, and axonal damage. PRM also altered the balance of pro- and anti-apoptotic proteins in favor of cell survival and improved angiogenesis and microvascular growth. Increased expression of estrogen receptors (ERs) ERα and ERβ following PRM treatment and their inhibition by ER inhibitor indicated that the neuroprotection associated with PRM treatment might be E2-receptor mediated. The attenuation of glial activation with decreased inflammation and cell death, and increased angiogenesis by PRM led to improved functional outcome as determined by the BBB locomotor scale. These results suggest that PRM treatment has significant therapeutic implications for the improvement of post-SCI outcome.

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients with TSCI can suffer further secondary damage and experience escalating disability and complications. It is important to quickly assess the patient to identify the location and severity of injury to make a decision to pursue a surgical and/or conservative management. However, there are many conditions that factor into the management of TSCI patients, ranging from the initial presentation of the patient to long-term care for optimal recovery. Here, we provide a comprehensive review of the etiologies of spinal cord injury and the complications that may arise, and present an algorithm to aid in the management of TSCI.

Meta-analysis of the Effectiveness of Steroid Pulse Therapy in Treating Patients with Spinal Cord Injury

Background:

High-dose steroid injection therapy is effective in reducing anti-inflammation and edema and is often used to treat patients with acute spinal cord injury. To evaluate the effectiveness of steroid pulse therapy and identify the factors that affect its effectiveness in patients with acute traumatic spinal cord injury.

Methods:

A comprehensive literature search of the databases Pubmed, Medline, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL was performed on July 31, 2019, with no language and time limits. For analysis, studies conducted within the last 10 years were included to reflect on the recent trend.

Results:

A total of 3 randomized controlled trials and 5 observational studies with 2418 patients were included in this meta-analysis. High-dose steroid injection therapy was found to have a high effect on patients with acute spinal cord injury. The following factors had a strong influence on the effectiveness of high-dose steroid treatment in patients with acute spinal cord injuries: injury, onset ASIA, onset neurological assessment scales, time to start treatment after injury, age, BMI, and gender.

Conclusion:

It is necessary to accurately assess the scope of spinal injury in the early stages and actively provide nursing interventions to identify and mediate factors affecting the treatment effect.

Pharmacologic and Cell-Based Therapies for Acute Spinal Cord Injury

This article provides a review of current pharmacologic and cell-based modalities used for the management of acute spinal cord injury (SCI). The literature search was focused on clinical trials performed in the United States and Canada. Despite the significant advance in research, there is no definitive treatment option for SCI. Instead, existing pharmacologic and cell-based modalities provide only minimal neurologic recovery benefits. This can be attributed to the complex pathophysiology of SCI and spinal cord regeneration. Further research is imperative to better understand these mechanisms and discover definitive treatment modalities.

Comparison of Early Surgical Treatment With Conservative Treatment of Incomplete Cervical Spinal Cord Injury Without Major Fracture or Dislocation in Patients With Pre-existing Cervical Spinal Stenosis

STUDY DESIGN

This was a retrospective comparative study.

OBJECTIVE

The objective of this study was to evaluate the clinical outcomes of early surgical treatment (<24 h) and conservative treatment of incomplete cervical spinal cord injury (CSCI) without major fracture or dislocation in patients with pre-existing cervical spinal canal stenosis (CSCS).

SUMMARY OF BACKGROUND DATA

The relative benefits of surgery, especially early surgical treatment, and conservative treatment for CSCI without major fracture or dislocation in patients with pre-existing CSCS remain unclear. Animal models of CSCI have demonstrated that early surgical decompression immediately after the initial insult may prevent or reverse secondary injury. However, the clinical outcomes of early surgery for incomplete CSCI in patients with pre-existing CSCS are still unclear.

MATERIALS AND METHODS

The medical records and radiographic data of 54 patients admitted to our facility between 2005 and 2015 with American Spinal Injury Association (ASIA) impairment scale grade B or C and pre-existing CSCS without major fracture or dislocation were retrospectively reviewed. Thirty-three patients (mean age, 57.4±14.0 y) underwent early surgical treatment within 24 hours after initial trauma (S group), and 21 patients (mean age, 56.9±13.6 y) underwent conservative treatment (C group) performed by 2 spinal surgeons in accordance with their policies. The primary outcome was the degree of improvement in ASIA grade after 2 years.

RESULTS

During the 2-year follow-up period, higher percentages of patients in the S group than in the C group showed ≥1 grade (90.9% vs. 57.1%, P=0.0051) and 2 grade (30.3% vs. 9.5%) improvements in ASIA grade. Multivariate analysis showed that treatment type, specifically early surgical treatment, was the only factor significantly associated with ASIA grade improvement after 2 years (P=0.0044).

CONCLUSIONS

Early surgery yielded better neurological outcomes than conservative treatment in patients with incomplete CSCI without major fracture or dislocation and pre-existing CSCS.

LEVEL OF EVIDENCE

Level III.

Current updates on various treatment approaches in the early management of acute spinal cord injury

Spinal cord injury (SCI) is a debilitating condition which often leads to a severe disability and ultimately impact patient's physical, psychological, and social well-being. The management of acute SCI has evolved over the couple of decades due to improved understanding of injury mechanisms and increasing knowledge of disease. Currently, the early management of acute SCI patient includes pharmacological agents, surgical intervention and newly experimental neuroprotective strategies. However, many controversial areas are still surrounding in the current treatment strategies for acute SCI, including the optimal timing of surgical intervention, early versus delayed decompression outcome benefits, the use of methylprednisolone. Due to the lack of consensus, the optimal standard of care has been varied across treatment centres. The authors have shed a light on the current updates on early treatment approaches and neuroprotective strategies in the initial management of acute SCI in order to protect the early neurologic injury and reduce the future disability.

Zanthoxylum nitidum extract attenuates BMP-2-induced inflammation and hyperpermeability

Bone morphogenetic protein-2 (BMP-2) is commonly applied in spinal surgery to augment spinal fusion. Nevertheless, its pro-inflammatory potential could induce dangerous side effects such as vascular hyper-permeability, posing the need for manners against this condition. The present study aims to investigate the protective effect of Zanthoxylum nitidum (ZN) on BMP-2-related hyperpermeability and inflammation on the human umbilical vein endothelial cells (HUVECs). The results revealed that, in a concentration-dependent manner, BMP-2 enhanced the production of pro-inflammatory cytokines, including interleukin (IL)-1α, IL-1β, and tumor necrosis factor-α, which were, however, suppressed by ZN. ZN inhibited BMP-2-induced inflammatory response by suppressing the phosphorylation of NF-κBp65 and IκB, and the abnormal nuclear translocation of p65. Moreover, the inhibited expression intercellular tight junction protein VE-cadherin and Occludin caused by BMP-2 was blocked by ZN. The hyper-permeability of HUVECs induced by BMP-2, as expressed as the higher fluorescent intensity of dextran, was also reversed by ZN. Overall, these findings demonstrated that ZN antagonized BMP-2-induced inflammation and hyperpermeability. It could be a therapeutic candidate for the treatment of BMP-2-induced side effects during spinal fusion.

Emerging Therapeutic Strategies for Traumatic Spinal Cord Injury

Spinal cord injury (SCI) is a debilitating neurologic condition with tremendous socioeconomic impact on affected individuals and the health care system. The treatment of SCI principally includes surgical treatment and marginal pharmacologic and rehabilitation therapies targeting secondary events with minor clinical improvements. This unsuccessful result mainly reflects the complexity of SCI pathophysiology and the diverse biochemical and physiologic changes that occur in the injured spinal cord. Once the nervous system is injured, cascades of cellular and molecular events are triggered at varying times. Although the cascade of tissue reactions and cell injury develops over a period of days or weeks, the most extensive cell death in SCI occurs within hours of trauma. This situation suggests that early intervention is likely to be the most promising approach to rescue the cord from further and irreversible cell damage. Over the past decades, a wealth of research has been conducted in preclinical and clinical studies with the hope to find new therapeutic strategies. Researchers have identified several targets for the development of potential therapeutic interventions (e.g., neuroprotection, replacement of cells lost, removal of inhibitory molecules, regeneration, and rehabilitation strategies to induce neuroplasticity). Most of these treatments have passed preclinical and initial clinical evaluations but have failed to be strongly conclusive in the clinical setting. This narrative review provides an update of the many therapeutic interventions after SCI, with an emphasis on the underlying pathophysiologic mechanisms.

The safety of pulse corticosteroid therapy- Systematic review and meta-analysis

OBJECTIVE

To amass all available evidence from randomized controlled trials regarding the safety of pulse corticosteroids therapy, in order to establish its safety.

PATIENTS AND METHODS

All electronic databases from 1/1966 up to 02/2019 were reviewed to find all randomized controlled trials comparing pulse corticosteroids to oral corticosteroids or to placebo/no treatment. Two reviewers independently extracted and recorded data regarding type of corticosteroid treatment, dosages, length of treatment and follow-up. Risk ratios (RR) with 95% (CI) for differences between pulse corticosteroids and comparator were pooled using a fixed effect meta-analysis. The primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included any adverse events (AEs), AEs requiring discontinuation, AEs per system involved and all-cause mortality.

RESULTS

A total of 64 trials were included: 18 trials which compared pulse corticosteroids to oral corticosteroids and 46 trials which compared pulse corticosteroids to placebo/no intervention. Pulse corticosteroids was not associated with increased risk for SAEs for both comparators: RR 0.77 (95% CI 0.52-1.14), and RR 0.99 (95% CI 0.93-1.06), respectively. Sensitivity analysis based on adequate allocation concealment and use of a valid AE grading did not alter the results. Subgroup analysis revealed no increased risk of specific SAEs or AEs with pulse corticosteroids compared to oral corticosteroids.

CONCLUSION

Pulse corticosteroids was not associated with an increase risk of SAEs and should be regarded as safe.

Therapeutic repair for spinal cord injury: combinatory approaches to address a multifaceted problem

The recent years saw the advent of promising preclinical strategies that combat the devastating effects of a spinal cord injury (SCI) that are progressing towards clinical trials. However, individually, these treatments produce only modest levels of recovery in animal models of SCI that could hamper their implementation into therapeutic strategies in spinal cord injured humans. Combinational strategies have demonstrated greater beneficial outcomes than their individual components alone by addressing multiple aspects of SCI pathology. Clinical trial designs in the future will eventually also need to align with this notion. The scenario will become increasingly complex as this happens and conversations between basic researchers and clinicians are required to ensure accurate study designs and functional readouts.

The safety and efficacy of steroid treatment for acute spinal cord injury: A Systematic Review and meta-analysis

Introduction

The role for steroids in acute spinal cord injury (ASCI) remains unclear; while some studies have demonstrated the risks of steroids outweigh the benefits,a meta-analyses conducted on heterogeneous patient populations have shown significant motor improvement at short-term but not at long-term follow-up. Given the heterogeneity of the patient population in previous meta-analyses and the publication of a recent trial not included in these meta-analyses, we sought to re-assess and update the safety and short-term and long-term efficacy of steroid treatment following ASCI in a more homogeneous patient population.

Materials and methods

A literature search was conducted on PubMed, EMBASE and Cochrane Library through June 2019 for studies evaluating the utility of steroids within the first 8 h following ASCI. Neurological and safety outcomes were extracted for patients treated and not treated with steroids. Pooled effect estimates were calculated using the random-effects model.

Results

Twelve studies, including five randomized controlled trials (RCTs) and seven observational studies (OBSs), were meta-analyzed. Overall, methylprednisolone was not associated with significant short-term or long-term improvements in motor or neurological scores based on RCTs or OBSs. An increased risk of hyperglycemia was shown in both RCTs (RR: 13.7; 95% CI: 1.93, 97.4; 1 study) and OBSs (RR: 2.9; 95% CI: 1.55, 5.41; 1 study). Risk for pneumonia was increased with steroids; while this increase was not statistically significant in the RCTs (pooled RR: 1.16; 95% C.I: 0.59, 2.29; 3 studies), it reached statistical significance in the OBSs (pooled RR: 2.00; 95% C.I: 1.32, 3.02; 6 studies). There was no statistically significant increased risk of gastrointestinal bleeding, decubitus ulcers, surgical site infections, sepsis, atelectasis, venous thromboembolism, urinary tract infections, or mortality among steroid-treated ASCI patients compared to untreated controls in either RCTs or OBSs.

Conclusions

Methylprednisolone therapy within the first 8 h following ASCI failed to show a statistically significant short-term or long-term improvement in patients' overall motor or neurological scores compared to controls who were not administered steroids. For the same comparison, there was an increased risk of pneumonia and hyperglycemia compared to controls. Routine use of methylprednisone following ASCI should be carefully considered in the context of these results.

Current Topics in the Management of Acute Traumatic Spinal Cord Injury

Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.

Epidural Corticosteroids, Lumbar Spinal Drainage, and Selective Hemodynamic Control for the Prevention of Spinal Cord Ischemia in Thoracoabdominal Endovascular Aortic Repair: A New Clinical Protocol

INTRODUCTION

In patients undergoing thoracoabdominal aorta repair, spinal cord ischemia (SCI) remains one of the most common and important complications resulting in transient paraparesis through to permanent flaccid paraplegia. In this manuscript, after a brief introduction to spinal cord ischemia complication and its prevention in thoracoabdominal endovascular aortic repair (TEVAR), we propose a new clinical protocol potentially able to prevent such complication.

METHODS

The proposed protocol suggests the use of high dosages of corticosteroids by epidural route, along with drainage of cerebrospinal fluid and controlled vascular hypertension, to reduce the incidence of SCI in TEVAR. Moreover, we paid particular attention to the control of the hemodynamic parameters to obtain adequate peripheral tissue perfusion (oxygen delivery), including in the spinal cord.

RESULTS

We applied this new protocol in 50 consecutive patients treated with TEVAR for thoracoabdominal aortic aneurysms (TAAs); 47 patients completed the procedure: 27 patients Crawford type I and 20 Crawford type II. Three patients died during surgery because of untreatable aneurysm rupture. The results show that in all patients there were no cases of SCI, after 5 days from TEVAR.

DISCUSSION

To the best of our knowledge, there are no clinical studies on the use of epidural corticosteroids in patients undergoing treatment of aortic syndrome (both in "open surgery" and endovascular aortic repair). This initial study on 50 consecutive patients has shown that the clinical protocol used could be of great interest to prevent one of the worse complications of TEVAR. Its limitations are the low number of patients studied till now, and the non-randomized protocol adopted. Further studies would be necessary.

CONCLUSION

Our experience and the results obtained with this new perioperative protocol with epidural corticosteroid and accurate hemodynamic control have been encouraging and it seems a valid proposal to be explored in future by well-structured prospective, randomized protocols.

Acute cervical myelopathy with quadriparesis after cervical transforaminal epidural steroid injection: A case report

RATIONALE

Cervical transforaminal epidural steroid injection (TFESI), can be an effective tool to improve pain associated with cervical radiculopathy. However, complications related to the procedure have been reported.

PATIENT CONCERNS

A 50-year-old woman who experienced acute cervical myelopathy with quadriparesis after cervical TFESI under fluoroscopic guidance.

DIAGNOSES

The initial post-procedure cervical MRI revealed acute cervical myelopathy INTERVENTIONS:: She received 1000 mg of methylprednisolone was injected intravenously daily for 3 days OUTCOMES:: Improvement in pain, with the only remaining complaints consisting of lingering mild pain in the left hand and occasional hypoesthesia LESSONS:: Cervical TFESI, despite careful fluoroscopic localization, resulted in spinal cord injury. A spinal cord injury may be treated with conservative treatments, such as medication and rehabilitation.

Acute Adverse Events After Spinal Cord Injury and Their Relationship to Long-term Neurologic and Functional Outcomes: Analysis From the North American Clinical Trials Network for Spinal Cord Injury

OBJECTIVES

There are few contemporary, prospective multicenter series on the spectrum of acute adverse events and their relationship to long-term outcomes after traumatic spinal cord injury. The goal of this study is to assess the prevalence of adverse events after traumatic spinal cord injury and to evaluate the effects on long-term clinical outcome.

DESIGN

Multicenter prospective registry.

SETTING

Consortium of 11 university-affiliated medical centers in the North American Clinical Trials Network.

PATIENTS

Eight-hundred one spinal cord injury patients enrolled by participating centers.

INTERVENTIONS

Appropriate spinal cord injury treatment at individual centers.

MEASUREMENTS AND MAIN RESULTS

A total of 2,303 adverse events were recorded for 502 patients (63%). Penalized maximum logistic regression models were fitted to estimate the likelihood of neurologic recovery (ASIA Impairment Scale improvement ≥ 1 grade point) and functional outcomes in subjects who developed adverse events at 6 months postinjury. After accounting for potential confounders, the group that developed adverse events showed less neurologic recovery (odds ratio, 0.55; 95% CI, 0.32-0.96) and was more likely to require assisted breathing (odds ratio, 6.55; 95% CI, 1.17-36.67); dependent ambulation (odds ratio, 7.38; 95% CI, 4.35-13.06) and have impaired bladder (odds ratio, 9.63; 95% CI, 5.19-17.87) or bowel function (odds ratio, 7.86; 95% CI, 4.31-14.32) measured using the Spinal Cord Independence Measure subscores.

CONCLUSIONS

Results from this contemporary series demonstrate that acute adverse events are common and are associated with worsened long-term outcomes after traumatic spinal cord injury.

A Review of Clinical Trials in Spinal Cord Injury Including Biomarkers

Acute traumatic spinal cord injury (SCI) entered the arena of prospective, randomized clinical trials almost 40 years ago, with the undertaking of the National Acute Spinal Cord Study (NASCIS) I trial. Since then, a number of clinical trials have been conducted in the field, spurred by the devastating physical, social, and economic consequences of acute SCI for patients, families, and society at large. Many of these have been controversial and attracted criticism. The current review provides a critical summary of select past and current clinical trials in SCI, focusing in particular on the findings of prospective, randomized controlled trials, the challenges and barriers encountered, and the valuable lessons learned that can be applied to future trials.

High-dose methylprednisolone for acute traumatic spinal cord injury: A meta-analysis

OBJECTIVE

Due to the continuing debates on the utility of high-dose methylprednisolone (MP) early after acute spinal cord injury (ASCI), we aimed to evaluate the therapeutic and adverse effects of high-dose MP according to the second National Acute Spinal Cord Injury Study (NASCIS-2) dosing protocol in comparison to no steroids in patients with ASCI by performing a meta-analysis on the basis of the current available clinical trials.

METHODS

We searched PubMed and Cochrane Library (to May 22, 2018) for studies comparing neurologic recoveries, adverse events, and in-hospital costs between ASCI patients who underwent high-dose MP treatment or not. Data were synthesized with corresponding statistical models according to the degree of heterogeneity.

RESULTS

= 0.78).

CONCLUSIONS

Based on the current evidence, high-dose MP treatment, in comparison to controls, does not contribute to better neurologic recoveries but may increase the risk of adverse events in patients with ASCI. Therefore, we recommend against routine use of high-dose MP early after ASCI.

Management of Acute Traumatic Central Cord Syndrome: A Narrative Review

STUDY DESIGN

Narrative review.

OBJECTIVES

To provide an updated overview of the management of acute traumatic central cord syndrome (ATCCS).

METHODS

A comprehensive narrative review of the literature was done to identify evidence-based treatment strategies for patients diagnosed with ATCCS.

RESULTS

ATCCS is the most commonly encountered subtype of incomplete spinal cord injury and is characterized by worse sensory and motor function in the upper extremities compared with the lower extremities. It is most commonly seen in the setting of trauma such as motor vehicles or falls in elderly patients. The operative management of this injury has been historically variable as it can be seen in the setting of mechanical instability or preexisting cervical stenosis alone. While each patient should be evaluated on an individual basis, based on the current literature, the authors' preferred treatment is to perform early decompression and stabilization in patients that have any instability or significant neurologic deficit. Surgical intervention, in the appropriate patient, is associated with an earlier improvement in neurologic status, shorter hospital stay, and shorter intensive care unit stay.

CONCLUSIONS

While there is limited evidence regarding management of ATCCS, in the presence of mechanical instability or ongoing cord compression, surgical management is the treatment of choice. Further research needs to be conducted regarding treatment strategies and patient outcomes.

Application of Hepatocyte Growth Factor for Acute Spinal Cord Injury: The Road from Basic Studies to Human Treatment

Hepatocyte growth factor (HGF) was first identified as a potent mitogen for mature hepatocytes, and has also gained attention as a strong neurotrophic factor in the central nervous system. We found that during the acute phase of spinal cord injury (SCI) in rats, c-Met, the specific receptor for HGF, increases sharply, while the endogenous HGF up-regulation is relatively weak. Introducing exogenous HGF into the spinal cord by injecting an HGF-expressing viral vector significantly increased the neuron and oligodendrocyte survival, angiogenesis, and axonal regeneration, to reduce the area of damage and to promote functional recovery in rats after SCI. Other recent studies in rodents have shown that exogenously administered HGF during the acute phase of SCI reduces astrocyte activation to decrease glial scar formation, and exerts anti-inflammatory effects to reduce leukocyte infiltration. We also reported that the intrathecal infusion of recombinant human HGF (intrathecal rhHGF) improves neurological hand function after cervical contusive SCI in the common marmoset, a non-human primate. Based on these collective results, we conducted a phase I/II clinical trial of intrathecal rhHGF for patients with acute cervical SCI who showed a modified Frankel grade of A/B1/B2 72 h after injury onset, from June 2014 to May 2018.

[Effect of granulocyte colony-stimulating factor mobilizing bone marrow mesenchymal stell cells homing to injury sites in spinal cord injury of rats]

Objective

To investigate the effect of granulocyte colony-stimulating factor (G-CSF) mobilizing the bone marrow mesenchymal stem cells (BMSCs) homing to the spinal cord injury sites in rats, and to evaluate the feasibility of G-CSF mobilizing the BMSCs home to the injured spinal cord.

Methods

Twenty-four healthy adult female Sprague Dawley rats were injected with 1 mL green fluorescence protein labeled BMSCs (GFP-BMSCs, 1×10 ⁶ cells/mL) into tail vein at 12 hours before operation. They were randomly divided into sham operation group (group A), sham operation+G-CSF group (group B), spinal cord injury group (group C), and spinal cord injury+G-CSF group (group D), with 6 rats in each group. In groups C and D, spinal cord injury model was established by T ₁₀ level spinal cord hemisection. In groups A and B, only laminectomy was performed without injury to the spinal cord. Groups B and D were injected with G-CSF (10 μg/kg·d) at 1 hour after operation for 3 consecutive days, and groups A and C were injected with the same amount of saline. The Basso-Beattie-Bresnahan (BBB) score was used to estimate the neurological function of rats and the expressions of tumor necrosis factor α (TNF-α) and stromal-derived factor 1 (SDF-1) were detected by ELISA method at 1, 3, 7, 14, 21, and 28 days after operation. The spinal cord samples of rats were sacrificed at 28 days after operation for immunohistochemical staining to observe the expression of cytokines, including SDF-1, brain derived neurotrophic factor (BDNF), vascular endothelial growth factor (VEGF), and TNF-α, and immunofluorescence staining to observe GFP-BMSCs positive cells, double-stained fluorescent yellow GFP/neuronal nuclear antigen (NeuN) positive neurons, and GFP/glial fibrillary acidic protein (GFAP) positive neurons. The number of glial cells and apoptosis were detected by TUNEL method.

Results

The BBB score of groups A and B had no significant change at each time point after operation. At 1 day after operation, the BBB score of groups C and D decreased to the lowest level, and then gradually increased. The BBB score of group D was significantly higher than that of group C at all time points except 1 day after operation ( P<0.05). At 3, 7, 14, 21, 28 days after operation, the levels of TNF-α and SDF-1 in groups C and D were significantly higher than those in groups A and B ( P<0.05), but the levels of TNF-α in group D were significantly lower than those in group C at each time point, and the levels of SDF-1 were significantly higher than those in group C ( P<0.05). Immunohistochemical staining showed that the expressions of SDF-1, BDNF, VEGF, and TNF-α in groups C and D were significantly higher than those in groups A and B ( P<0.05); the expressions of SDF-1, BDNF, and VEGF in group D were significantly higher than those in group C, and the expression of TNF-α was significantly lower than that in group C ( P<0.05). Immunofluorescence staining showed that the number of GFP-BMSCs, GFP/NeuN, and GFP/GFAP positive cells in groups C and D were significantly higher than those in groups A and B, and in group D than in group C ( P<0.05). TUNEL assay showed that the number of apoptotic cells in groups C and D was significantly lower than that in groups A and B, and in group D than in group C ( P<0.05).

Conclusion

G-CSF can mobilize BMSCs to the spinal cord injury site and promote repair effect by down-regulating TNF-α to promote the anti-apoptosis function and up-regulating SDF-1, BDNF, VEGF to promote BMSCs migration.

Steroids in Acute Spinal Cord Injury: All But Gone Within 5 Years

BACKGROUND

Spinal cord injury (SCI) is a devastating event often leading to poor neurologic outcomes. One of the most widely practiced treatments has been the administration of methylprednisolone. However, today its use has been called into question over concerns of efficacy and safety. The present study evaluated the changes in the practice of steroid administration in acute SCI among members of the National Spinal Society in Poland in comparison with the results of the survey conducted in 2013.

METHODS

The questionnaire, comprising 5 questions, was distributed among 240 spinal surgeons, members of the Polish Society of Spinal Surgery; of these, 97 (40%) responded. The results were compared with data from the previous survey conducted in 2013.

RESULTS

Over a period of 5 years, the prevalence of steroid administration in acute SCI has completely reversed; the proportion of steroid users declined from 73% to 27%. The main rationale for using it was belief in efficacy, rather than fear of litigation. The differences between specialization and age groups were not statistically significant in both administrations.

CONCLUSIONS

A significant decrease was observed in the number of surgeons using steroids in the acute SCI, similar to that reported in the literature. The critical appraisal of the existing clinical evidence, as well as the formulation of guidelines by professional organizations, exerted a profound impact on the practice pattern.

Effect evaluation of methylprednisolone plus mitochondrial division inhibitor-1 on spinal cord injury rats

PURPOSE

To investigate the combination effect of methylprednisolone (MP) and mitochondrial division inhibitor-1 (Mdivi-1) on the neurological function recovery of rat spinal cord injury (SCI) model.

METHODS

The weight-drop method was used to establish the rat SCI model; then, rats were randomized into sham group, SCI group, MP group, Mdivi-1 group and MP+Mdivi-1 group. Motor function scores were quantified to evaluate locomotor ability; HE staining was used to assess spinal cord histopathology; tissue water content, oxidative stress, tissue mitochondrial function, neurons apoptosis, and apoptosis-related protein expression were detected.

RESULTS

From the third day after SCI, BBB score of the MP+Mdivi-1 group was obviously higher than the other experimental groups (p < 0.05). Compared with the SCI group, tissue water content of the Mdivi-1 group and MP+Mdivi-1 group reduced obviously (p < 0.05), mitochondrial membrane potential (MMP) level and ATP content in the Mdivi-1 group and MP+Mdivi-1 group were both higher (p < 0.05). Meanwhile, three kinds of treatment all reduced apoptosis significantly, while MP plus Mdivi-1 exhibited the best inhibition effect on apoptosis (p < 0.05). The expression levels of Drp1, cytochrome c, and caspase-3 were all upregulated obviously; Mdivi-1 could inhibit Drp1 upregulation induced by SCI; for the upregulation of cytochrome c and caspase-3, the inhibition effect of Mdivi-1 approached MP. When MP combined with Mdivi-1, there was the best inhibition effect.

CONCLUSIONS

MP combined with Mdivi-1 may produce better neurological function recovery, through improving functional status of mitochondria and inhibiting lipid peroxidation in damaged tissue of SCI rats, and thus alleviating apoptosis.

Anti-Inflammatory Peptide Attenuates Edema and Promotes BMP-2-Induced Bone Formation in Spine Fusion

Recombinant human bone morphogenic protein-2 (BMP-2)-loaded absorbable collagen sponges (ACS) have been successfully used to enhance bone formation and to induce spinal fusion in humans. However, side effects, such as soft tissue edema and inflammation, have been reported. NEMO binding domain peptide (NBD) inhibits activation of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), a central regulator of immune response. In this study, we investigated NBD's potential to reduce BMP-2-induced soft tissue inflammation without affecting BMP-2-mediated spinal fusion in rat. For evaluation of soft tissue inflammation, ACS containing BMP-2, BMP-2+NBD, NBD, or ACS only were implanted into intramuscular paraspinal sites of 32 rats. At day 2 postsurgery, edema formation at the implant sites was assessed using magnetic resonance imaging. T2-weighted relaxation time (T2-RT) values were increased in the BMP-2 group compared with BMP-2+NBD, NBD, and ACS groups. No difference in T2-RT values was detected between BMP-2+NBD versus NBD and ACS controls. Postsacrifice, histological analysis of the implant-surrounding zones showed increased mononuclear cell infiltration in the BMP-2 group compared with BMP-2+NBD and controls. The presence of BMP-2 increased relative NF-κB binding and gene expression of inflammatory markers, interleukin (IL)1β, IL6, IL18, and chemokine ligand (CCL)2 and CCL3 compared with controls. In the BMP-2+NBD group, cytokine expression was blocked. No differences were found between BMP-2+NBD and control groups. For evaluation of spinal fusion, posterolateral intertransverse lumbar fusion procedures were performed on 16 rats. ACS were loaded with BMP-2 or BMP-2+NBD. After sacrifice at week 12, microcomputed tomographic assessment of the fusion site detected a higher bone volume and reduced trabecular spacing in the BMP-2+NBD group compared with BMP-2. Histological analysis did not show any differences in newly formed bone microarchitecture. In summary, addition of NBD to BMP-2-loaded ACS reduces BMP-2-induced soft tissue edema formation and mononuclear cell infiltration, diminishes NF-κB binding, and thus blocks transcription of NF-κB-regulated cytokines in rat. Furthermore, NBD stimulates bone formation in BMP-2-mediated spinal fusion, possibly through crosstalk of the NF-κB pathway with other pathways. The results of this study might provide the basis to develop new therapeutic bone grafting approaches with combinatory administration of BMP-2 and NBD for spinal fusion.

The Comprehensive Therapy of Electroacupuncture Promotes Regeneration of Nerve Fibers and Motor Function Recovery in Rats after Spinal Cord Injury

The present study aimed to evaluate the role of the combination treatment of methylprednisolone (MP) and electroacupuncture (EA) in regeneration of nerve fibers and functional recovery in rats with spinal cord injury (SCI). Female Wistar rats were used for an SCI model by using a weight-drop hammer at levels T₁₀ (spinal cord segment corresponding to the 10th thoracic vertebra). Four groups received different treatments for the study: SCI control, MP, MP and EA, and Sham. The growth of nerve fibers was examined by counting fluorescein positive nerve fibers. The motor functional recovery was evaluated by Basso, Beattie, Bresnahan (BBB) score, and electrophysiology analysis. We found that, compared to MP groups, there were more well-oriented and paralleled fluorescein positive nerve fibers in MP and EA group. Both latencies and amplitudes of the Motor Evoked Potential (MEP) in the combination therapy of MP and EA were higher than MP group. Additionally, recovered hindlimb movements were sustained in most rats in the MP and EA group. Our study indicated that combination therapies could become a powerful treatment for SCI in rats.

Study protocol for the G-SPIRIT trial: a randomised, placebo-controlled, double-blinded phase III trial of granulocyte colony-stimulating factor-mediated neuroprotection for acute spinal cord injury

INTRODUCTION

Granulocyte colony-stimulating factor (G-CSF) is generally used for neutropaenia. Previous experimental studies revealed that G-CSF promoted neurological recovery after spinal cord injury (SCI). Next, we moved to early phase of clinical trials. In a phase I/IIa trial, no adverse events were observed. Next, we conducted a non-randomised, non-blinded, comparative trial, which suggested the efficacy of G-CSF for promoting neurological recovery. Based on those results, we are now performing a phase III trial.

METHODS AND ANALYSIS

The objective of this study is to evaluate the efficacy of G-CSF for acute SCI. The study design is a prospective, multicentre, randomised, double-blinded, placebo-controlled comparative study. The current trial includes cervical SCI (severity of American Spinal Injury Association (ASIA) Impairment Scale B/C) within 48 hours after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group is administered 400 µg/m²/day×5 days of G-CSF in normal saline via intravenous infusion for 5 consecutive days. The placebo group is similarly administered a placebo. Our primary endpoint is changes in ASIA motor scores from baseline to 3 months. Each group includes 44 patients (88 total patients).

ETHICS AND DISSEMINATION

The study will be conducted according to the principles of the World Medical Association Declaration of Helsinki and in accordance with the Japanese Medical Research Involving Human Subjects Act and other guidelines, regulations and Acts. Results of the clinical study will be submitted to the head of the respective clinical study site as a report after conclusion of the clinical study by the sponsor-investigator. Even if the results are not favourable despite conducting the clinical study properly, the data will be published as a paper.

TRIAL REGISTRATION NUMBER

UMIN000018752.

Stem Cells Therapy for Spinal Cord Injury

Spinal cord injury (SCI), a serious public health issue, most likely occurs in previously healthy young adults. Current therapeutic strategies for SCI includes surgical decompression and pharmacotherapy, however, there is still no gold standard for the treatment of this devastating condition. Inefficiency and adverse effects of standard therapy indicate that novel therapeutic strategies are required. Because of their neuroregenerative and neuroprotective properties, stem cells are a promising tool for the treatment of SCI. Herein, we summarize and discuss the promising therapeutic potential of human embryonic stem cells (hESC), induced pluripotent stem cells (iPSC) and ependymal stem/progenitor cells (epSPC) for SCI.

Engraftment, neuroglial transdifferentiation and behavioral recovery after complete spinal cord transection in rats

Background:

Proof of the efficacy and safety of a xenogeneic mesenchymal stem cell (MSCs) transplant for spinal cord injury (SCI) may theoretically widen the spectrum of possible grafts for neuroregeneration.

Methods:

Twenty rats were submitted to complete spinal cord transection. Ovine bone marrow MSCs, retrovirally transfected with red fluorescent protein and not previously induced for neuroglial differentiation, were applied in 10 study rats (MSCG). Fibrin glue was injected in 10 control rats (FGG). All rats were evaluated on a weekly basis and scored using the Basso–Beattie–Bresnahan (BBB) locomotor scale for 10 weeks, when the collected data were statistically analyzed. The spinal cords were then harvested and analyzed with light microscopy, immunohistochemistry, and immunofluorescence.

Results:

Ovine MSCs culture showed positivity for Nestin. MSCG had a significant and durable recovery of motor functions (P <.001). Red fluorescence was found at the injury sites in MSCG. Positivity for Nestin, tubulin βIII, NG2 glia, neuron-specific enolase, vimentin, and 200 kD neurofilament were also found at the same sites.

Conclusions:

Xenogeneic ovine bone marrow MSCs proved capable of engrafting into the injured rat spinal cord. Transdifferentiation into a neuroglial phenotype was able to support partial functional recovery.

The Investigation of the Cox-2 Selective Inhibitor Parecoxib Effects in Spinal Cord Injury in Rat

Aim: Today, spinal cord injury (SCI) can be rehabilitated but cannot be treated adequately. This experimental study was conducted to investigate possible beneficial effects of methylprednisolone and parecoxib in treatment of SCI. Materials and methods: Forty-eight male Wistar albino rats were assigned into CONTROL, acute (MP-A, PX-A, and PXMP-A), and subacute (MP-S, PX-S, and PXMP-S) stage groups. Then, to induce SCI, a temporary aneurysm clip was applied to the spinal cord following T7-8 laminectomy, except in the CONTROL group. Four hours later parecoxib, methylprednisolone, or their combination was administered to rats intraperitoneally except CONTROL, SHAM-A, and SHAM-S groups. Rats in the acute stage group were sacrificed 72 h later, and whereas rats in the subacute stage were sacrificed 7 days later for histopathological and biochemical investigation and for gene-expression analyses. Results: Parecoxib and methylprednisolone and their combination could not improve histopathological grades in any stage. They also could not decrease malondialdehyde or caspase-3, myeloperoxidase levels in any stage. Parecoxib and methylprednisolone could decrease the TNF-α gene expression in subacute stage. Methylprednisolone could increase TGF-1β gene-expression level in acute stage. Conclusion: Neither of the experimental drugs, either alone or in combination, did not show any beneficial effects in SCI model in rats.

Lessons learned from administration of high-dose methylprednisolone sodium succinate for acute pediatric spinal cord injuries

OBJECTIVE Methylprednisolone sodium succinate (MPSS) has been studied as a pharmacological adjunct that may be given to patients with acute spinal cord injury (ASCI) to improve neurological recovery. MPSS treatment became the standard of care in adults despite a lack of evidence supporting clinical benefit. More recently, new guidelines from neurological surgeon groups recommended no longer using MPSS for ASCI, due to questionable clinical benefit and known complications. However, little information exists in the pediatric population regarding MPSS use in the setting of ASCI. The aim of this paper was to describe steroid use and side effects in patients with ASCI at the authors' Level 1 pediatric trauma center in order to inform other hospitals that may still use this therapy. METHODS A retrospective chart review was conducted to determine adherence in ordering and delivery according to the guideline of the authors' institution and to determine types and frequency of complications. Inclusion criteria included age < 17 years, blunt trauma, physician concern for ASCI, and admission for ≥ 24 hours or treatment with high-dose intravenous MPSS. Exclusion criteria included penetrating trauma, no documentation of ASCI, and incomplete medical records. Charts were reviewed for a predetermined list of complications. RESULTS A total of 602 patient charts were reviewed; 354 patients were included in the study. MPSS was administered in 59 cases. In 34 (57.5%) the order was placed correctly. In 13 (38.2%) of these 34 cases, MPSS was administered according to the recommended timeline protocol. Overall, only 13 (22%) of 59 patients received the therapy according to protocol with regard to accurate ordering and administration. Among the patients with ASCI, 20 (55.6%) of the 36 who received steroids had complications, which was a significantly higher rate than in those who did not receive steroids (8 [24.2%] of 33, p = 0.008). Among the patients without ASCI, 10 (43.5%) of the 23 who received steroids also experienced significantly more complications than patients who did not receive steroids (50 [19.1%] of 262, p = 0.006). CONCLUSIONS High-dose MPSS for ASCI was not delivered to pediatric patients according to protocol with a high degree of reliability. Patients receiving steroids for pediatric ASCI were significantly more likely to experience complications than patients not receiving steroids. The findings presented, including complications of steroid use, support removal of high-dose MPSS as a treatment option for pediatric ASCI.

Granulocyte Colony-Stimulating Factor (G-CSF) for the Treatment of Spinal Cord Injury

Spinal cord injury (SCI) is a common medical condition with a poor prognosis for recovery and catastrophic effects on a patient's quality of life. Available treatments for SCI are limited, and the evidence suggesting their harmful side effects is more consistent than any suggestion of clinical benefit. Developing novel safe and effective therapeutic options for SCI is crucial. Granulocyte colony-stimulating factor (G-CSF) is a hematopoietic cytokine with known multifaceted effects on the central nervous system. Herein, we review the accumulating preclinical evidence for the beneficial effects of G-CSF on functional and structural outcomes after SCI. Meanwhile we present and discuss multiple mechanisms for G-CSF's neuroprotective and neuroregenerative actions through the results of these studies. In addition, we present the available clinical evidence indicating the efficacy and safety of G-CSF administration for the treatment of acute and chronic traumatic SCI, compression myelopathy, and SCI-associated neuropathic pain. Our review indicates that although the quality of clinical evidence regarding the use of G-CSF in SCI is inadequate, the encouraging available preclinical and clinical data warrant its further clinical development, and bring new hope to the longstanding challenge that is treatment of SCI.

Efficacy and Safety of Methylprednisolone Sodium Succinate in Acute Spinal Cord Injury: A Systematic Review

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The objective of this study was to conduct a systematic review to assess the comparative effectiveness and safety of high-dose methylprednisolone sodium succinate (MPSS) versus no pharmacological treatment in patients with traumatic spinal cord injury (SCI).

METHODS

A systematic search was performed in PubMed and the Cochrane Collaboration Library for literature published between January 1956 and June 17, 2015. Included studies were critically appraised, and Grades of Recommendation Assessment, Development and Evaluation methods were used to determine the overall quality of evidence for primary outcomes. Previous systematic reviews on this topic were collated and evaluated using the Assessment of Multiple Systematic Reviews scoring system.

RESULTS

The search yielded 723 citations, 13 of which satisfied inclusion criteria. Among these, 6 were primary research articles and 7 were previous systematic reviews. Based on the included research articles, there was moderate evidence that the 24-hour NASCIS II (National Acute Spinal Cord Injury Studies) MPSS regimen has no impact on long-term neurological recovery when all postinjury time points are considered. However, there is also moderate evidence that subjects receiving the same MPSS regimen within 8 hours of injury achieve an additional 3.2 points (95% confidence interval = 0.10 to 6.33; P = .04) of motor recovery compared with patients receiving placebo or no treatment.

CONCLUSION

Although safe to administer, a 24-hour NASCIS II MPSS regimen, when all postinjury time points are considered, has no impact on indices of long-term neurological recovery. When commenced within 8 hours of injury, however, a high-dose 24-hour regimen of MPSS confers a small positive benefit on long-term motor recovery and should be considered a treatment option for patients with SCI.

A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope

Acute spinal cord injury (SCI) is a traumatic event that results in disturbances to normal sensory, motor, or autonomic function and ultimately affects a patient's physical, psychological, and social well-being. The management of patients with SCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding available management strategies for the treatment of SCI, including the use of corticosteroids such as methylprednisolone sodium succinate, the optimal timing of surgical intervention, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and among the various disciplines that encounter patients with SCI. The objective of this guideline is to form evidence-based recommendations for these areas of controversy and outline how to best manage patients with SCI. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.

"Direct vision" operation of posterior atlantoaxial transpedicular screw fixation for unstable atlantoaxial fractures: A retrospective study

BACKGROUND

The posterior screw fixation in atlas via posterior arch and lateral mass, also called C1 "pedicle" screw, combined with C2 pedicle screw fixiation has shown better biomechanical stability in unstable atlantoaxial fractures. However, its popularization has to fulfill the limitation imposed by anatomical characteristics. The aim of this study was to explore the manipulation, effect, and safety of the atlantoaxial transpedicular screw fixation under "direct vision" for the treatment of unstable atlantoaxial fracture.

METHODS

All the patients diagnosed with unstable atlantoaxial fracture, who received surgery treatment of C1,C2 internal fixation from January 2012 to December 2014 were reviewed. Only these patients that were diagnosed with atlantoaxial unstability secondary to trauma and were treated with atlantoaxial transpedicular screw fixation under "direct vision" and iliac autograft were included. The safety of transpedicular screw placement, postoperative outcome, atlantoaxial stability, autograft fusion, and complications was observed and analyzed retrospectively. The pain visual analog scale (VAS) and the Japanese Orthopedic Association (JOA) score were used as surgical curative effect evaluation standards.

RESULTS

We reviewed a total of 92 patients diagnosed with unstable atlantoaxial fracture, who received surgery treatment of C1,C2 internal fixation from January 2012 to December 2014, and 87 patients were treated with atlantoaxial transpedicular screw fixation under "direct vision" and were included this analysis. A total of 306 transpedicular screws in atlas and axis were placed successfully. All cases were followed-up >12 months. The overall breach rate was 11.36%. None of the breaches resulted in new-onset neurological sequela. The neurological status in cases with bilateral upper extremities numbness and lower extremities weakness had improved after surgery. At the latest follow-up, the neck VAS and JOA scores were significantly improved (P < .01) than those preoperatively. No cases demonstrated implantation failure and bone graft absorption on the postoperative x-ray films and CT scans.

CONCLUSION

Atlantoaxial transpedicular screw fixation under "direct vision" and iliac autograft for the treatment of unstable atlantoaxial fracture has shown simple manipulation and efficient performance. Thus, the technique of C1-C2 fixation is feasible in treating unstable atlantoaxial fracture.

Methylprednisolone Administration Following Spinal Cord Injury Reduces Aquaporin 4 Expression and Exacerbates Edema

Spinal cord injury (SCI) is an incapacitating condition that affects motor, sensory, and autonomic functions. Since 1990, the only treatment administered in the acute phase of SCI has been methylprednisolone (MP), a synthetic corticosteroid that has anti-inflammatory effects; however, its efficacy remains controversial. Although MP has been thought to help in the resolution of edema, there are no scientific grounds to support this assertion. Aquaporin 4 (AQP4), the most abundant component of water channels in the CNS, participates in the formation and elimination of edema, but it is not clear whether the modulation of AQP4 expression by MP plays any role in the physiopathology of SCI. We studied the functional expression of AQP4 modulated by MP following SCI in an experimental model in rats along with the associated changes in the permeability of the blood-spinal cord barrier. We analyzed these effects in male and female rats and found that SCI increased AQP4 expression in the spinal cord white matter and that MP diminished such increase to baseline levels. Moreover, MP increased the extravasation of plasma components after SCI and enhanced tissue swelling and edema. Our results lend scientific support to the increasing motion to avoid MP treatment after SCI.

Neuroprotective effect of combining tanshinone IIA with low-dose methylprednisolone following acute spinal cord injury in rats

The present study compared the potential neuroprotective effect of tanshinone IIA (TIIA) monotherapy, methylprednisolone (MP) monotherapy and combined treatment in an adult acute spinal cord injury (ASCI) rat model. The current study used the weight-drop method (Allen's Impactor) in the rat model and the mechanical scratch method in primary spinal cord neuron culture to determine whether the combined treatment was able to reduce the required dosage of MP in the treatment of ASCI to produce a similar or improved therapeutic effect. In vivo male Sprague Dawley rats (n=60) were randomly divided into 5 groups, of which 12 rats were selected for the sham group and T9-T11 laminectomies, leading to ASCI, were performed on 48 of the 60 rats using a 10 g ×25 mm weight-drop at the level of T10 spinal cord. Therefore, the ASCI group (n=12) included the 'laminectomy and weight-drop'. The remaining 36 ASCI model animals were subdivided into 3 groups (n=12 each group): TIIA group (30 mg/kg/day), MP group (30 mg/kg) and combined treatment group (TIIA 30 mg/kg/day + MP 20 mg/kg). Neuronal function following ASCI was evaluated using the Basso Beattie Bresnahan (BBB) locomotor rating scale. Levels of the anti-apoptotic factor B-cell lymphoma-2 (Bcl-2), the pro-apoptotic factors Bcl-2 associated protein X (Bax) and caspase-3, and the inflammatory associated factor nuclear factor-κB, were analyzed by western blot analysis. Immunohistochemistry was used to detect caspase-3. To investigate the underlying mechanism, the anti-oxidative effect of combination TIIA and MP treatment was assessed by measuring the activity of malondialdehyde (MDA) and superoxide dismutase (SOD) in ASCI. In agreement with the experiment in vivo, primary neurons were prepared from the spinal cord of one-day-old Sprague-Dawley rats' and co-cultured with astrocytes from the brain cortex. The injury of neurons was induced by mechanical scratch and levels of apoptosis factors were analyzed by western blot analysis. The results of the current study indicated that injured animals in the combined treatment group exhibited a significant increase in BBB scores (P<0.05). TIIA + MP combined treatment and MP treatment was observed to reduce the expression of pro-apoptotic factors and promote neuron survival in vivo and in vitro. Combined treatment may promote neuroprotection through reduced apoptosis and inflammation caused by ASCI, similar to MP alone. Combined treatment reversed the decrease of SOD and the increase of MDA level caused by ASCI. In addition, combined treatment decreased the expression of caspase-3 in the neurons following ASCI in rats, as indicated by immunofluorescence double labeling. Overall, the present study indicates that the combined treatment of TIIA and MP may protect the neurons by stimulating the rapid initiation of neuroprotection following ASCI and reduce the dosage of MP in the treatment of ASCI required to produce the same or improved neuroprotective effects in vivo and in vitro.

Management of acute traumatic spinal cord injuries

Acute traumatic spinal cord injury (SCI) is a devastating disease process affecting tens of thousands of people across the USA each year. Despite the increase in primary prevention measures, such as educational programs, motor vehicle speed limits, automobile running lights, and safety technology that includes automobile passive restraint systems and airbags, SCIs continue to carry substantial permanent morbidity and mortality. Medical measures implemented following the initial injury are designed to limit secondary insult to the spinal cord and to stabilize the spinal column in an attempt to decrease devastating sequelae. This chapter is an overview of the contemporary management of an acute traumatic SCI patient from the time of injury through the stay in the intensive care unit. We discuss initial triage, immobilization, and transportation of the patient by emergency medical services personnel to a definitive treatment facility. Upon arrival at the emergency department, we review initial trauma protocols and the evidence-based recommendations for radiographic evaluation of the patient's vertebral column. Finally, we outline closed cervical spine reduction and various aggressive medical therapies aimed at improving neurologic outcome.

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.

Emergency Neurological Life Support: Traumatic Spine Injury

Traumatic spine injuries (TSIs) carry significantly high risks of morbidity, mortality, and exorbitant health care costs from associated medical needs following injury. For these reasons, TSI was chosen as an ENLS protocol. This article offers a comprehensive review on the management of spinal column injuries using the best available evidence. Alhough the review focuses primarily on cervical spinal column injuries, thoracolumbar injuries are briefly discussed as well. The initial emergency department clinical evaluation of possible spinal fractures and cord injuries, along with the definitive early management of confirmed injuries, is also covered.