Critical care of spinal cord injury

Percutaneous dilational tracheostomy following anterior cervical spine fixation - a retrospective propensity-matched cohort study

PURPOSE

In patients with traumatic, infectious, degenerative, and neoplastic surgical indications in the cervical spine, commonly the anterior approach is used. Often these patients require a tracheostomy necessary due to prolonged mechanical ventilation. The limited spinal mobility and proximity to the surgical site of anterior cervical spine fixation (ACSF) could pose an increased risk for complications of percutaneous dilational tracheostomy (PDT.) Importantly, PDT might raise wound infection rates of the cervical spine approach. The aim of this study is to prove safety of PDT after ACSF.

METHODS

We performed a retrospective, single-center study comparing patients with and without ACSF who underwent Ciaglia-single step PDT. After propensity score matching using logistic regression, we compared intra- and postprocedural complication rates. Furthermore, surgical site infections were evaluated. Putensen's definitions of complications and Clavien-Dindo's classification were used.

RESULTS

A total of 1175 patients underwent PDT between 2009 and 2021. Fifty-seven patients underwent PDT following ACSF and were matched to fifty-seven patients without ACSF. The mean interval between ACSF and PDT was 11.3 days. The overall complication rate was 19.3% in the ACSF group and 21.1% in the non-ACSF group. The mean follow-up was 388 days (± 791) in the ACSF group and 424 days (± 819) in the non-ACSF group. Life-threatening complications (Clavien-Dindo IV to V) were found in 1.8% of ACSF patients and 3.5% of non-ACSF patients. There were no significant differences in complication rates. No surgical site infection of the anterior spine access was detected.

CONCLUSION

PDT is a feasible and safe procedure in patients after ACSF. Complication rates are comparable to patients without ACSF. Surgical site infections of ACSF are very rare.

Quantifying the Association Between Surgical Spine Approach and Tracheostomy Timing After Traumatic Cervical Spinal Cord Injury

BACKGROUND AND OBJECTIVES

Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI.

METHODS

This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation.

RESULTS

The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest.

CONCLUSION

Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach.

Early Prognostication of Critical Patients With Spinal Cord Injury: A Machine Learning Study With 1485 Cases

STUDY DESIGN

A retrospective case-series.

OBJECTIVE

The study aims to use machine learning to predict the discharge destination of spinal cord injury (SCI) patients in the intensive care unit.

SUMMARY OF BACKGROUND DATA

Prognostication following SCI is vital, especially for critical patients who need intensive care.

PATIENTS AND METHODS

Clinical data of patients diagnosed with SCI were extracted from a publicly available intensive care unit database. The first recorded data of the included patients were used to develop a total of 98 machine learning classifiers, seeking to predict discharge destination (eg, death, further medical care, home, etc.). The microaverage area under the curve (AUC) was the main indicator to assess discrimination. The best average-AUC classifier and the best death-sensitivity classifier were integrated into an ensemble classifier. The discrimination of the ensemble classifier was compared with top death-sensitivity classifiers and top average-AUC classifiers. In addition, prediction consistency and clinical utility were also assessed.

RESULTS

A total of 1485 SCI patients were included. The ensemble classifier had a microaverage AUC of 0.851, which was only slightly inferior to the best average-AUC classifier ( P =0.10). The best average-AUC classifier death sensitivity was much lower than that of the ensemble classifier. The ensemble classifier had a death sensitivity of 0.452, which was inferior to the top 8 death-sensitivity classifiers, whose microaverage AUC were inferior to the ensemble classifier ( P <0.05). In addition, the ensemble classifier demonstrated a comparable Brier score and superior net benefit in the DCA when compared with the performance of the origin classifiers.

CONCLUSIONS

The ensemble classifier shows an overall superior performance in predicting discharge destination, considering discrimination ability, prediction consistency, and clinical utility. This classifier system may aid in the clinical management of critical SCI patients in the early phase following injury.

LEVEL OF EVIDENCE

Level 3.

Surgical management of a multilevel thoracolumbar aneurysmal bone cyst

Aneurysmal bone cysts (ABCs) are primary bone tumours that rarely occur in the spine and generally affect one vertebral level in adolescents. Here, we present an unusual case of a multilevel thoracolumbar ABC, which presented a unique surgical challenge due to its infiltrative and destructive nature. A teenage male presented with back pain, paresthesias and a mildly spastic gait. MRI of the thoracolumbar spine revealed an expansive, multicystic mass extending from the left T12-L1 vertebral bodies into adjacent musculature. The patient underwent a two-stage surgical approach with decompression of the spinal cord and instrumentation to stabilise the vertebral column. The first stage involved posterior decompression, laminectomy and facetectomies, followed by pedicle-based instrumentation from T10 to L3. This was followed by a vertebrectomy and anterior stabilisation with an expansile cage from T11 to L2. A gross total resection was achieved with the patient maintaining full neurological function.

High resolution terahertz ATR frequency-domain spectroscopy for monitoring spinal cord injury in rats

Traumatic spinal cord injury (SCI) can lead to permanent neurological impairment, underscoring the urgency of regular therapeutic intervention and monitoring. In this study, we propose a new strategy for monitoring spinal cord injury through serum based on high-resolution THz attenuated total reflection frequency domain spectroscopy (THz-ATR-FDS). We demonstrated serum spectral differences at different time points after experimental SCI in rats. We also studied the relationship between serum lipid concentration and the time of SCI, which revealed the potential of lipid molecules as biomarkers of SCI. In addition, based on the principal component analysis (PCA) and least squares regression (LSR) models, the quantitative relationship between the refractive index spectrum and lipid concentration in serum was automatically analyzed. This work highlights terahertz spectroscopy as a promising tool for label-free, periodic, and efficient monitoring of SCI.

Ventilatory Strategies in Traumatic Cervical Spinal Cord Injury: Controversies and Current Updates

Ventilatory management of patients with traumatic cervical spinal cord injury (CSCI) is a complex and controversial area of critical care medicine. Despite significant advances in our understanding of the pathophysiology of CSCI and the development of novel interventions, there remains a lack of consensus about the optimal approach to ventilatory management in these patients. Some of the key controversies in CSCI ventilatory management include timing of tracheal intubation, non-invasive ventilation versus invasive ventilation, high versus low tidal volume, and early versus late tracheostomy. The objective of this review is to discuss the existing controversies and provide an insight on the current evidence.

The Dose-Response Relationship Between Age and Tracheostomy in Patients with Traumatic Cervical Spinal Cord Injury: A Restricted Cubic Spline Function Analysis

OBJECTIVE

To investigate the continuous relationship between age and tracheostomy in patients with traumatic cervical spinal cord injury (TCSCI).

METHODS

This study comprised 689 TCSCI patients in total. The logistic regression and restricted cubic spline analysis was applied to analyze the possible dose-response relationship between age and tracheostomy. The subgroup analysis was performed for the American Spinal Injury Association (ASIA) grade and neurological level of injury.

RESULTS

The proportion of patients with the age ≥60 was significantly higher in the tracheostomy group than in the non-tracheostomy group (42.2% vs. 19.6%; P < 0.001). Age ≥60 was independently associated with tracheostomy (total: odds ratio = 3.560, 95% confidence interval: 1.892-6.697; P < 0.001) after adjusting for gender, smoking history, dislocation, respiratory complications, ASIA grade, neurological level of injury, preexisting lung disease, brain injury, and thoracic injury. After the relationship was presented in the subgroup analysis, the restricted cubic spline revealed a nonlinear relationship between age and tracheostomy (P-overall < 0.001 and P-nonlinear = 0.021).

CONCLUSIONS

Age and tracheostomy present a dose-response relationship in patients with TCSCI. This finding could help physicians bring assistance in the early identification of tracheostomy and rationalize the allocation of medical resources.

The shoulder abductor strength is a novel predictor of tracheostomy in patients with traumatic cervical spinal cord injury

BACKGROUND

Early prediction of tracheostomy in traumatic cervical spinal cord injury (TCSCI) patients is often difficult. This study aims to clarify the association between shoulder abductor strength (SAS) and tracheostomy in patients with TCSCI.

METHODS

We retrospectively analyzed 513 TCSCI patients who were treated in our hospital. All patients were divided into a tracheostomy group and a non-tracheostomy group. The SAS was assessed using the Medical Research Council (MRC) Scale for Muscle Strength grading. Potential predictors were assessed for their association with tracheostomy in patients. A nomogram was developed based on multivariable logistic regression analysis (MLRA) to visualize the predictive ability of the SAS. Validation of the nomogram was performed to judge whether the nomogram was reliable for visual analysis of the SAS. Receiver operating characteristics curve, specificity, and sensitivity were also performed to assess the predictive ability of the SAS.

RESULTS

The proportion of patients with the SAS grade 0-2 was significantly higher in the tracheostomy group than in the non-tracheostomy group (88.1% vs. 54.8%, p = 0.001). The SAS grade 0-2 was identified as a significant predictor of the tracheostomy (OR: 4.505; 95% CI: 2.080-9.758; p = 0.001). Points corresponding to both the SAS grade 0-2 and the neurological level of injury at C2-C4 were between 60 and 70 in the nomogram. The area under the curve for the SAS grade 0-2 was 0.692. The sensitivity of SAS grade 0-2 was 0.239. The specificity of SAS grade 0-2 was 0.951.

CONCLUSIONS

SAS is a novel predictor of tracheostomy in patients after TCSCI. The SAS grade 0-2 had a good predictive ability of tracheostomy.

Spinal cord injury and degenerative cervical myelopathy

Spinal cord injury (SCI) often results in impaired respiratory function. Paresis or paralysis of inspiratory and expiratory muscles can lead to respiratory dysfunction depending on the level and severity of the injury, which can affect the management and care of SCI patients. Respiratory dysfunction after SCI is more severe in high cervical injuries, with vital capacity (VC) being an essential indicator of overall respiratory health. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Respiratory management includes mechanical ventilation and tracheostomy in high cervical SCI, while noninvasive ventilation is more common in patients with lower cervical and thoracic injuries. Mechanical ventilation can negatively impact the function of the diaphragm and weaning should start as soon as possible. Patients can sometimes be weaned from mechanical ventilation with assistance of electrical stimulation of the phrenic nerve or the diaphragm. Respiratory muscle training regimens may also improve patients' inspiratory function following SCI. Despite the critical advances in preventing, diagnosing, and treating respiratory complications, they continue to significantly affect persons living with SCI. Additional studies of interventions to reduce respiratory complications are likely to further decrease the morbidity and mortality associated with these injuries.

Timely intubation with early prediction of respiratory exacerbation in acute traumatic cervical spinal cord injury

Background

Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in the context of recent advances in multidisciplinary respiratory management, the absolute indication for intubation in patients with CSCI based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation.

Methods

We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regression was performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS).

Results

Among 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE 3.5 days (mean) post-injury; 3 (37.5%) of eight patients with motor-complete CSCI above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48–42.72, P = 0.0144) in multivariate analyses.

Conclusion

Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00530-3.

Comparison of clinical outcomes of tracheotomy in patients with acute cervical spinal cord injury at different timing

Respiratory failure is the leading cause of early death after acute CSCI. Tracheotomy is an effective approach to reduce mortality and improve the clinical outcomes. However, the optimal timing for tracheotomy remains controversial. Hence, the study aimed to compare the clinical outcomes of tracheotomy in patients with acute cervical spinal cord injury (CSCI) at different timing. A retrospectively review was performed of acute CSCI patients who underwent tracheotomy in the intensive care unit of Haian Hospital between January 2014 and June 2019. 124 CSCI patients were included and stratified into three groups based on the timing of tracheotomy: early group (≤4 days from initial intubation), medium group (4-10 days from initial intubation), and late group (≥10 days from initial intubation). The clinical outcomes and functional outcomes were analyzed. No significant intergroup differences in baseline characteristics were observed. The late group needed significantly longer duration of mechanical ventilation, longer ICU stay, and suffered higher ICU mortality, higher pneumonia after tracheotomy than the early and medium groups. More patients in the early and medium groups successfully weaned from mechanical ventilation. The early and medium groups achieved better improvement of JOA and NDI scores than the late group at one year after surgery and at the final follow-up. Early to medium term tracheotomy may lead to better clinical and functional outcomes in patients with acute CSCI who require prolonged mechanical ventilation.

Risk factors for tracheostomy after traumatic cervical spinal cord injury

OBJECTIVE

To determine the risk factors for the need of tracheostomy after cervical spinal cord injury (CSCI) at the acute stage.

METHODS

The authors retrospectively reviewed 294 patients with acute traumatic CSCI in Xinqiao Hospital between 2012 and 2016 and analyzed the factors postulated to increase the risk for tracheostomy, including patient's age, neurological impairment scale grade and level, smoking history, combined injury, and surgical intervention. Logistic regression analysis was used to identify independent risk factor for the need of tracheostomy.

RESULTS

Of 294 patients, 52 patients received tracheostomy (17.7%). The factor identified by demographics and outcomes were smoking history, cause of injury, neurological impairment scale grade and level, and combined dislocation. A multiple logistic regression model demonstrated that age of 60 years older, combined facet dislocation, C4 level high, and the American Spinal Injury Association (ASIA) A and B scale were predictive of need for tracheostomy on 95% occasions.

CONCLUSION

The high age of 60 years, combined facet dislocation, C4 level high, and ASIA A and B scale are indispensable to predict the need for tracheostomy in patients with CSCI at the acute stage.

Early clinical predictors of pneumonia in critically ill spinal cord injured individuals: a retrospective cohort study

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

Pneumonia is the dominant complication following traumatic spinal cord injury (SCI) and profoundly impacts morbidity by prolonging length of stay and worsening neurological outcome. The aims of this study were to determine the key predictors of clinically important pneumonia (CIP); and to examine the impact of CIP on resource utilisation in critically ill acute traumatic SCI individuals between 2010 and 2015.

SETTING

Alfred and Austin Hospitals (Melbourne, Australia).

METHODS

Data were extracted from the medical records of 93 cases of acute traumatic SCI resulting in ISNCSCI C3-L1 level of injury requiring admission to the intensive care unit and aged between 15 and 70 years. Patients with life-threatening injuries, not requiring spinal surgery, palliated within 7 days of injury, diagnosis of traumatic central cord syndrome or with poor general health, were excluded.

RESULTS

A total of 33 episodes of CIP were observed. Median time to CIP diagnosis was 65 h (IQR: 42-93) and median time to spinal surgery was 22 h (IQR: 12-32). Four key predictors were identified; male gender (OR: 18.3, CI: 1.9-174.9, p = 0.001), motor complete injury (OR: 10.1, CI: 1.1-92.1, p = 0.011), presence of chest trauma (OR: 4.5, CI: 1.4-14.4, p = 0.007) and delayed intubation (HR: 6.8, CI: 1.6-28.6, p = 0.009).

CONCLUSIONS

This study identifies four key predictors involved in elevated pneumonia risk; male gender, motor complete injury, presence of chest trauma and delayed intubation, enabling the future synthesis of a pneumonia prediction tool for use in the acute postinjury period.

Predictive Values of Magnetic Resonance Imaging Features for Tracheostomy in Traumatic Cervical Spinal Cord Injury

Objective

To evaluate the magnetic resonance (MR) imaging features that have a statistically significant association with the need for a tracheostomy in patients with cervical spinal cord injury (SCI) during the acute stage of injury.

Methods

This study retrospectively reviewed the clinical data of 130 patients with cervical SCI. We analyzed the factors believed to increase the risk of requiring a tracheostomy, including the severity of SCI, the level of injury as determined by radiological assessment, three quantitative MR imaging parameters, and eleven qualitative MR imaging parameters.

Results

Significant differences between the non-tracheostomy and tracheostomy groups were determined by the following five factors on multivariate analysis : complete SCI (p=0.007), the radiological level of C5 and above (p=0.038), maximum canal compromise (MCC) (p=0.010), lesion length (p=0.022), and osteophyte formation (p=0.015). For the MCC, the cut-off value was 46%, and the risk of requiring a tracheostomy was three times higher at an interval between 50–60% and ten times higher between 60–70%. For lesion length, the cut-off value was 20 mm, and the risk of requiring a tracheostomy was two times higher at an interval between 20–30 mm and fourteen times higher between 40–50 mm.

Conclusion

The American Spinal Injury Association grade A, a radiological injury level of C5 and above, an MCC ≥50%, a lesion length ≥20 mm, and osteophyte formation at the level of injury were considered to be predictive values for requiring tracheostomy intervention in patients with cervical SCI.

Risk Analysis Based on the Timing of Tracheostomy Procedures in Patients with Spinal Cord Injury Requiring Cervical Spine Surgery

OBJECTIVE

To determine the optimal moment to perform tracheostomy in a patient requiring anterior cervical fixation.

METHODS

A retrospective observational study conducted over an 18-year period included 56 patients who had been admitted to the intensive care unit with acute spinal cord injury and underwent tracheostomy and surgical fixation. The sample was divided into 2 groups: at-risk group (31 patients who had undergone tracheostomy before cervical surgery or <4 days after surgery) and not-at-risk group (25 patients who had undergone tracheostomy >4 days after fixation surgery). Descriptive and comparative studies were carried out. Overall trend of the collected data was analyzed using cubic splines (graphic methods).

RESULTS

The only infectious complications diagnosed as related to the surgical procedure were infection of the surgical wound in 2 patients in the not-at-risk group (12%) and deep tissue infection in 1 patient in the at-risk group (3.2%). During the study period, we identified a tendency toward performance of early tracheostomies.

CONCLUSIONS

Our results suggest that the presence of a tracheostomy stoma before or immediately after surgery is associated with a low risk of infection of the cervical surgical wound in instrumented spinal fusion.

The Need for Early Tracheostomy in Patients with Traumatic Cervical Cord Injury

Background

In patients who need sustained endotracheal intubation and mechanical ventilation due to respiratory failure after traumatic cervical spinal cord injury, tracheostomy can be performed to reduce the duration of mechanical ventilation and respiratory complications. The purpose of this study was to determine criteria and timing of tracheostomy in patients with severe traumatic cervical spinal cord injury accompanied by motor weakness.

Methods

We reviewed 22 patients who underwent tracheostomy (study group) and 27 patients who did not (control group) from January 2005 to March 2016. We assessed the American Spinal Injury Association (ASIA) impairment scale score and investigated accompanying thoracic injury, paradoxical respiration, postoperative endotracheal intubation and other clinical parameters. The study group was also subdivided into the early tracheostomy group and late tracheostomy group depending on whether the tracheostomy was performed within or later than 7 days after surgery.

Results

Twenty-two patients in the study group had a mean ASIA impairment scale score of 14.1 points, which was lower than the control group's 23.4 points. Paradoxical respiration was observed in 77% of the patients in the study group compared to 18% in the control group. Postoperative intubation was maintained in 68% in the study group; 32% underwent endotracheal intubation due to respiratory failure within 4 days after surgery and had a tracheostomy. In the control group, postoperative intubation was maintained in 22%, and all of them were weaned off intubation within 4 days after surgery. The duration of intensive care unit hospitalization was 11.4 days for the early tracheostomy group, which was shorter than the late tracheostomy group's 19.7 days.

Conclusions

In patients with severe traumatic cervical spinal cord injury, tracheostomy may be needed when the motor grade of the ASIA scale is low, above the C4 segment is injured, or paradoxical respiration occurs after injuries. In addition, if endotracheal extubation is not feasible within 4 days after surgery, an early tracheostomy should be considered.

Fluoroscopic Comparison of Cervical Spine Motion Using LMA CTrach, C-MAC Videolaryngoscope and Macintosh Laryngoscope

Objective

Endotracheal intubation should be performed with care when cervical spine (C-spine) injury is suspected. The aim of this study was to evaluate the movement of the C-spine using fluoroscopy during intubation with Laryngeal Mask Airway (LMA) CTrach, C-MAC videolaryngoscope and Macintosh laryngoscope.

Methods

This was a single-centre, prospective, observational, controlled trial. In total, 22 surgical patients aged 18-65 years planned to undergo operation under general anaesthesia, were enrolled. X-ray images of the C-spine were obtained using fluoroscopy with the patients' head in a neutral position. All patients underwent laryngoscopy using a Macintosh blade, LMA CTrach and C-MAC videolaryngoscope, and fluoroscopic images of the C-spine were obtained. All the patients were intubated at the last laryngoscopy simulation (using the C-MAC). The atlanto-occipital distance (AOD) and angles between C₀C₁, C₀C₂, C₀C₃, C₀C₄, C₁C₂ and C₂C₃ lines were measured and compared between each device.

Results

The mean AOD was measured as 20.4 mm in a neutral position, which decreased to 13.1, 17.2 and 12.3 mm after the insertion of the Macintosh laryngoscope, LMA CTrach and C-MAC videolaryngoscope, respectively. The differences were significant (p<0.001). Moreover, significant difference was noted in C₀C₂, C₀C₃ and C₁C₂ angles with the insertion of the three devices (p<0.001). The LMA CTrach resulted in significantly lesser C-spine movements in C₀C₂, C₀C₃ and C₀C₄ angles compared to the Macintosh laryngoscope and C-MAC videolaryngoscope (p<0.001).

Conclusion

The LMA CTrach resulted in lesser C-spine movements compared to Macintosh laryngoscope and C-MAC videolaryngoscope. In case of the C-spine injury, LMA CTrach may be preferred and may cause fewer traumas during endotracheal intubation.

Classification and regression tree model for predicting tracheostomy in patients with traumatic cervical spinal cord injury

PURPOSE

In patients with cervical spinal cord injury (CSCI), respiratory compromise and the need for tracheostomy are common. The purpose of this study was to identify common risk factors for tracheostomy following traumatic CSCI and develop a decision tree for tracheostomy in traumatic CSCI patients without pulmonary function test.

METHODS

Data of 105 trauma patients with CSCI admitted in our institution from April, 2008 to February, 2014 were retrospectively analyzed. Patients who underwent tracheostomy were compared to those who did not. Stepwise logistic regression analysis and classification and regression tree model were used to predict the risk factors for tracheostomy.

RESULTS

Tracheostomy was performed in 20% of patients with traumatic CSCI on median hospital day 4. Patients who underwent tracheostomy tended to be more severely injured (higher Injury Severity Score, lower Glasgow Coma Score, and lower systolic blood pressure on admission) which required more frequent intubation in the emergency room (ER) with a higher rate of complete CSCI compared to those who did not. Upon multiple logistic analysis, Age ≥ 55 years (OR: 6.86, p = 0.037), Car accident (OR: 5.8, p = 0.049), injury above C5 (OR: 28.95, p = 0.009), ISS ≥ 16 (OR: 12.6, p = 0.004), intubation in the ER (OR: 23.87, p = 0.001), and complete CSCI (OR: 62.14, p < 0.001) were significant predictors for the need of tracheostomy after CSCI. These factors can predict whether a new patient needs future tracheostomy with 91.4% accuracy.

CONCLUSIONS

Age ≥ 55 years, injury above C5, ISS ≥ 16, Car accident, intubation in the ER, and complete CSCI were independently associated with tracheostomy after CSCI. CART analysis may provide an intuitive decision tree for tracheostomy.

Respiratory problems and management in people with spinal cord injury

Spinal cord injury (SCI) is characterised by profound respiratory compromise secondary to the level of loss of motor, sensory and autonomic control associated with the injury. This review aims to detail these anatomical and physiological changes after SCI, and outline their impact on respiratory function. Injury-related impairments in strength substantially alter pulmonary mechanics, which in turn affect respiratory management and care. Options for treatments must therefore be considered in light of these limitations.

KEY POINTS

Respiratory impairment following spinal cord injury (SCI) is more severe in high cervical injuries, and is characterised by low lung volumes and a weak cough secondary to respiratory muscle weakness.Autonomic dysfunction and early-onset sleep disordered breathing compound this respiratory compromise.The mainstays of management following acute high cervical SCI are tracheostomy and ventilation, with noninvasive ventilation and assisted coughing techniques being important in lower cervical and thoracic level injuries.Prompt investigation to ascertain the extent of the SCI and associated injuries, and appropriate subsequent management are important to improve outcomes.

EDUCATIONAL AIMS

To describe the anatomical and physiological changes after SCI and their impact on respiratory function.To describe the changes in respiratory mechanics seen in cervical SCI and how these changes affect treatments.To discuss the relationship between injury level and respiratory compromise following SCI, and describe those at increased risk of respiratory complications.To present the current treatment options available and their supporting evidence.

Subclinical respiratory dysfunction in chronic cervical cord compression: a pulmonary function test correlation

OBJECTIVE

Respiratory abnormalities are well documented in acute spinal cord injury; however, the literature available for respiratory dysfunction in chronic compressive myelopathy (CCM) is limited. Respiratory dysfunction in CCM is often subtle and subclinical. The authors studied the pattern of respiratory dysfunction in patients with chronic cord compression by using spirometry, and the clinical and surgical implications of this dysfunction. In this study they also attempted to address the postoperative respiratory function in these patients.

METHODS

A prospective study was done in 30 patients in whom cervical CCM due to either cervical spondylosis or ossification of the posterior longitudinal ligament (OPLL) was diagnosed. Thirty age-matched healthy volunteers were recruited as controls. None of the patients included in the study had any symptoms or signs of respiratory dysfunction. After clinical and radiological diagnosis, all patients underwent pulmonary function tests (PFTs) performed using a standardized Spirometry Kit Micro before and after surgery. The data were analyzed using Statistical Software SPSS version 13.0. Comparison between the 2 groups was done using the Student t-test. The Pearson correlation coefficient was used for PFT results and Nurick classification scores. A p value < 0.05 was considered significant.

RESULTS

Cervical spondylotic myelopathy (prolapsed intervertebral disc) was the predominant cause of compression (n = 21, 70%) followed by OPLL (n = 9, 30%). The average patient age was 45.06 years. Degenerative cervical spine disease has a relatively younger onset in the Indian population. The majority of the patients (n = 28, 93.3%) had compression at or above the C-5 level. Ten patients (33.3%) underwent an anterior approach and discectomy, 11 patients (36.7%) underwent decompressive laminectomy, and the remaining 9 underwent either corpectomy with fusion or laminoplasty.

The mean preoperative forced vital capacity (FVC) (65%) of the patients was significantly lower than that of the controls (88%) (p < 0.001). The mean postoperative FVC (73.7%) in the patients showed significant improvement compared with the preoperative values (p = 0.003). The mean postoperative FVC was still significantly lower than the control value (p = 0.002). The mean preoperative forced expiratory volume in 1 second (FEV1) (72%) of the patients was significantly lower than that of the controls (96%) (p < 0.001). The mean postoperative FEV1 (75.3%) in the cases showed no significant improvement compared with the preoperative values (p = 0.212). The mean postoperative FEV1 was still significantly lower than the control value (p < 0.001). The mean postoperative FEV1/FVC was not significantly different from the control value (p = 0.204). The mean postoperative peak expiratory flow rate was significantly lower than the control value (p = 0.01). The mean postoperative maximal voluntary ventilation was still significantly lower than the control value (p < 0.001). On correlating the FVC and Nurick scores using the Pearson correlation coefficient, a negative correlation was found.

CONCLUSIONS

There is subclinical respiratory dysfunction and significant impairment of various lung capacities in patients with CCM. The FVC showed significant improvement postoperatively. Respiratory function needs to be evaluated and monitored to avoid potential respiratory complications.

A Study of Risk Factors for Tracheostomy in Patients With a Cervical Spinal Cord Injury

STUDY DESIGN

A retrospective, consecutive case series.

OBJECTIVE

To determine the risk factors for a tracheostomy in patients with a cervical spinal cord injury.

SUMMARY AND BACKGROUND DATE

Respiratory status cannot be stabilized in patients with a cervical spinal cord injury (CSCI) for various reasons, so a number of these patients require long-term respiratory care and a tracheostomy. Various studies have described risk factors for a tracheostomy, but none have indicated a relationship between imaging assessment and the need for a tracheostomy. The current study used imaging assessment and other approaches to assess and examine the risk factors for a tracheostomy in patients with a CSCI.

METHODS

Subjects were 199 patients who were treated at the Spinal Injuries Center within 72 hours of a CSCI over 8-year period. Risk factors for a tracheostomy were retrospectively studied. Patients were assessed in terms of 10 items: age, sex, the presence of a vertebral fracture or dislocation, ASIA Impairment Scale, the neurological level of injury (NLI), PaO2, PaCO2, the level of injury on magnetic resonance imaging (MRI), the presence of hematoma-like changes (a hypointense core surrounded by a hyperintense rim in T2-weighted images) on MRI, and the Injury Severity Score.Items were analyzed multivariate logistic regression, and P < 0.05 was considered to indicate a significant difference.

RESULTS

Twenty-three of the 199 patients required a tracheostomy, accounting for 11.6% of patients with a CSCI. Univariate analyses of the risk factors for tracheostomy revealed significant differences for six items: age, Injury Severity Score, presence of fracture or dislocation, ASIA Impairment Scale A, NLI C4 or above, and MRI scans revealing hematoma-like changes. Multivariate logistic regression analyses revealed significant differences in terms of two items: NLI C4 or above and MRI scans revealing hematoma-like changes. Thirty patients had both an NLI C4 or above and MRI scans revealing hematoma-like changes. Of these, 17 (56.7%) required a tracheostomy.

CONCLUSION

Patients with an NLI C4 or above and MRI scans revealing hematoma-like changes were likely to require a tracheostomy. An early tracheostomy should be considered for patients with both of these characteristics.

LEVEL OF EVIDENCE

3.

Cervical spinal cord injury exacerbates ventilator-induced diaphragm dysfunction

Cervical spinal cord injury (SCI) can dramatically impair diaphragm muscle function and often necessitates mechanical ventilation (MV) to maintain adequate pulmonary gas exchange. MV is a life-saving intervention. However, prolonged MV results in atrophy and impaired function of the diaphragm. Since cervical SCI can also trigger diaphragm atrophy, it may create preconditions that exacerbate ventilator-induced diaphragm dysfunction (VIDD). Currently, no drug therapy or clinical standard of care exists to prevent or minimize diaphragm dysfunction following SCI. Therefore, we first tested the hypothesis that initiating MV acutely after cervical SCI will exacerbate VIDD and enhance proteolytic activation in the diaphragm to a greater extent than either condition alone. Rats underwent controlled MV for 12 h following acute (∼24 h) cervical spinal hemisection injury at C2 (SCI). Diaphragm tissue was then harvested for comprehensive functional and molecular analyses. Second, we determined if antioxidant therapy could mitigate MV-induced diaphragm dysfunction after cervical SCI. In these experiments, SCI rats received antioxidant (Trolox, a vitamin E analog) or saline treatment prior to initiating MV. Our results demonstrate that compared with either condition alone, the combination of SCI and MV resulted in increased diaphragm atrophy, contractile dysfunction, and expression of atrophy-related genes, including MuRF1. Importantly, administration of the antioxidant Trolox attenuated proteolytic activation, fiber atrophy, and contractile dysfunction in the diaphragms of SCI + MV animals. These findings provide evidence that cervical SCI greatly exacerbates VIDD, but antioxidant therapy with Trolox can preserve diaphragm contractile function following acute SCI.

Development of a Novel Alarm System to Improve Adaptation to Non-invasive Ventilation in Patients With High Cervical Spinal Cord Injury

In this case report, we want to introduce a successful way of applying non-invasive ventilation (NIV) with a full face mask in patients with high cervical spinal cord injury through a novel alarm system for communication. A 57-year-old man was diagnosed with C3 American Spinal Injury Association impairment scale (AIS) B. We applied NIV for treatment of hypercapnia. Because of mouth opening during sleep, a full face mask was the only way to use NIV. However, he could not take off the mask by himself, and this situation caused great fear. To solve this problem, we designed a novel alarm system. The best intended motion of the patient was neck rotation. Sensing was performed by a balloon sensor placed under the head of the patient. A beep sound was generated whenever the pressure was above the threshold, and more than three consecutive beeps within 3,000 ms created a loud alarm for caregivers.

Airway complications in traumatic lower cervical spinal cord injury: A retrospective study

OBJECTIVE

To investigate risk factors for pneumonia in patients with traumatic lower cervical spinal cord injury.

DESIGN

Observational study, retrospective study.

SETTING

Spinal cord unit in a maximum care hospital.

METHODS

Thirty-seven patients with acute isolated traumatic spinal cord injury at levels C4-C8 and complete motor function injury (AIS A, B) treated from 2004 to 2010 met the criteria for inclusion in our retrospective analysis. The following parameters were considered: ventilation-specific parameters, re-intubation, creation of a tracheostomy, pneumonia, antibiotic treatment, and length of intensive care unit (ICU) stay and total hospitalization.

RESULTS

Among the patients, 81% had primary invasive ventilation. In 78% of cases a tracheostomy was created; 3% of these cases were discharged with invasive ventilation and 28% with a tracheostomy without ventilation. Pneumonia according to Centers for Disease Control criteria occurred in 51% of cases within 21±32 days of injury, and in 3% at a later date. The number of pre-existing conditions was significantly associated with pneumonia. Length of ICU stay was 25±34 days, and average total hospital duration was 230±144 days. Significant factors affecting the duration of ventilation were the number of pre-existing conditions and tetraplegia-specific complications.

CONCLUSIONS

Our results confirm that patients with traumatic lower cervical spinal cord injuries defined by lesion level and AIS constitute a homogeneous group. This group is characterized by a high rate of pneumonia during the first 4 weeks after injury. The number of pre-existing general conditions and spinal injury-specific comorbidities are the only risk factors identified for the development of pneumonia and/or duration of ventilation.

Mean Arterial Blood Pressure Correlates with Neurological Recovery after Human Spinal Cord Injury: Analysis of High Frequency Physiologic Data

Current guidelines for the care of patients with acute spinal cord injuries (SCIs) recommend maintaining mean arterial pressure (MAP) values of 85-90 mm Hg for 7 days after an acute SCI however, little evidence supports this recommendation. We sought to better inform the relationship between MAP values and neurological recovery. A computer system automatically collected and stored q1 min physiological data from intensive care unit monitors on patients with SCI over a 6-year period. Data for 100 patients with acute SCI were collected. 74 of these patients had American Spinal Injury Association Impairment Scale (AIS) grades determined by physical examination on admission and at time of hospital discharge. Average MAP values as well as the proportion of MAP values below thresholds were explored for values from 120 mm Hg to 40 mm Hg in 1 mm Hg increments; the relationship between these measures and outcome was explored at various time points up to 30 days from the time of injury. A total of 994,875 q1 min arterial line blood pressure measurements were recorded for the included patients amid 1,688,194 min of recorded intensive care observations. A large proportion of measures were below 85 mm Hg despite generally acceptable average MAP values. Higher average MAP values correlated with improved recovery in the first 2-3 days after SCI while the proportion of MAP values below the accepted threshold of 85 mm Hg seemed a stronger correlate, decreasing in strength over the first 5-7 days after injury. This study provides strong evidence supporting a correlation between MAP values and neurological recovery. It does not, however, provide evidence of a causal relationship. Duration of hypotension may be more important than average MAP. It provides support for the notion of MAP thresholds in SCI recovery, and the highest MAP values correlated with the greatest degree of neurological recovery. The results are concordant with current guidelines in suggesting that MAP thresholds >85 mm Hg may be appropriate after acute SCI.

Synergistic impact of acute kidney injury and high level of cervical spinal cord injury on the weaning outcome of patients with acute traumatic cervical spinal cord injury

INTRODUCTION

Respiratory neuromuscular impairment severity is known to predict weaning outcome among patients with cervical spinal cord injury; however, the impact of non-neuromuscular complications remains unexplored. This study was to evaluate possible neuromuscular and non-neuromuscular factors that may negatively impact weaning outcome.

METHODS

From September 2002 to October 2012, acute traumatic cervical spinal cord injury patients who had received mechanical ventilation for >48h were enrolled and divided into successful (n=54) and unsuccessful weaning groups (n=19). Various neuromuscular, non-neuromuscular factors and events during the intensive care unit stay were extracted from medical charts and electronic medical records. Variables presenting with a significant difference (p<0.2) between these two groups were included in the univariate analysis. Following univariate analysis, those significantly different variables (p<0.05) were subjected to multivariate logistic regression to identify independent predictors of unsuccessful weaning.

RESULTS

Compared to successful weaning patients, unsuccessful weaning patients were older; more often had high level of cervical spinal cord injury (C1-3), lower pulse rates, and lower Glasgow Coma Scale score on admission, higher peak blood urea nitrogen, lower trough albumin, and lower trough blood leukocyte counts. Furthermore, unsuccessful weaning patients had a higher incidence of pneumonia, acute respiratory distress syndrome, shock and acute kidney injury during the intensive care unit stay. Multivariate logistic regression analysis revealed acute kidney injury and high level of cervical spinal cord injury were independent risk factors for failure of weaning. Importantly, patients with both risk factors showed a large increase in odds ratio for unsuccessful weaning from mechanical ventilation (p<0.001).

CONCLUSIONS

The presence of acute kidney injury during the intensive care unit stay and high level of cervical spinal injury are two independent risk factors that synergistically work together producing a negative impact on weaning outcome.

Translating mechanisms of neuroprotection, regeneration, and repair to treatment of spinal cord injury

One of the big challenges in neuroscience that remains to be understood is why the central nervous system is not able to regenerate to the extent that the peripheral nervous system does. This is especially problematic after traumatic injuries, like spinal cord injury (SCI), since the lack of regeneration leads to lifelong deficits and paralysis. Treatment of SCI has improved during the last several decades due to standardized protocols for emergency medical response teams and improved medical, surgical, and rehabilitative treatments. However, SCI continues to result in profound impairments for the individual. There are many processes that lead to the pathophysiology of SCI, such as ischemia, vascular disruption, neuroinflammation, oxidative stress, excitotoxicity, demyelination, and cell death. Current treatments include surgical decompression, hemodynamic control, and methylprednisolone. However, these early treatments are associated with modest functional recovery. Some treatments currently being investigated for use in SCI target neuroprotective (riluzole, minocycline, G-CSF, FGF-2, and polyethylene glycol) or neuroregenerative (chondroitinase ABC, self-assembling peptides, and rho inhibition) strategies, while many cell therapies (embryonic stem cells, neural stem cells, induced pluripotent stem cells, mesenchymal stromal cells, Schwann cells, olfactory ensheathing cells, and macrophages) have also shown promise. However, since SCI has multiple factors that determine the progress of the injury, a combinatorial therapeutic approach will most likely be required for the most effective treatment of SCI.

Management of acute traumatic spinal cord injury

OPINION STATEMENT

Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90 mm Hg should be kept for at least 1 week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72 h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72 h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.

Reprint of "Drawing breath without the command of effectors: the control of respiration following spinal cord injury"

The maintenance of blood gas and pH homeostasis is essential to life. As such breathing, and the mechanisms which control ventilation, must be tightly regulated yet highly plastic and dynamic. However, injury to the spinal cord prevents the medullary areas which control respiration from connecting to respiratory effectors and feedback mechanisms below the level of the lesion. This trauma typically leads to severe and permanent functional deficits in the respiratory motor system. However, endogenous mechanisms of plasticity occur following spinal cord injury to facilitate respiration and help recover pulmonary ventilation. These mechanisms include the activation of spared or latent pathways, endogenous sprouting or synaptogenesis, and the possible formation of new respiratory control centres. Acting in combination, these processes provide a means to facilitate respiratory support following spinal cord trauma. However, they are by no means sufficient to return pulmonary function to pre-injury levels. A major challenge in the study of spinal cord injury is to understand and enhance the systems of endogenous plasticity which arise to facilitate respiration to mediate effective treatments for pulmonary dysfunction.

Pulmonary management of the acute cervical spinal cord injured patients

A traumatic spinal cord injury is a catastrophic event associated with physiologic disruptions to the motor, sensory, cardiovascular, and respiratory systems. Respiratory complications are a common cause of morbidity and mortality in patients with acute cervical spinal cord injury and treatments must be initiated immediately. The longer it takes for a patient to receive pulmonary treatments and mobility activities, the higher the morbidity and mortality and the longer the length of stay. Disrupted pulmonary mechanics and respiratory complications are frequent and are influenced by the level of injury.

Acute and chronic respiratory failure

Respiratory failure (RF) can be attributed to a plethora of neuromuscular diseases (NMDs) and manifests clinically in a multitude of overt or more subtle ways. The basic principles of pathophysiology, diagnosis and treatment of neurologic diseases and of RF apply concomitantly to this subset of patients. Various entities should be approached according to the latest evidence-based recommendations. Treatment follows the natural disease progression, from minimal respiratory assistance to mechanical ventilation (MV). A comprehensive treatment plan has to be formulated that takes into consideration the patient's wishes.

Cardiac arrhythmias associated with spinal cord injury

CONTEXT/OBJECTIVES

To review the current literature to reveal the incidence of cardiac arrhythmias and its relation to spinal cord injury (SCI).

DATA SOURCE

MEDLINE database, 304 hits, and 32 articles were found to be relevant. The relevant articles all met the inclusion criteria: (1) contained original data (2) on cardiac arrhythmias (3) in humans with (4) traumatic SCI.

RESULTS

In the acute phase of SCI (1-14 days after injury) more cranial as well as more severe injuries seemed to increase the incidence of bradycardia. Articles not covering the first 14 days after injury, thus describing the chronic phase of SCI, showed that individuals with SCI did not have a higher incidence of cardiac arrhythmias compared with able-bodied controls. Furthermore, their heart rate did not differ significantly. Penile vibro-stimulation was the procedure investigated most likely to cause bradycardia, which in turn was associated with episodes of autonomic dysreflexia. The incidence of bradycardia was found to be 17-77% for individuals with cervical SCI. For individuals with thoracolumbar SCI, the incidence was 0-13%.

CONCLUSION

Bradycardia was commonly seen in the acute stage after SCI as well as during procedures such as penile vibro-stimulation and tracheal suction. These episodes of bradycardia were seen more often in individuals with cervical injuries. Longitudinal studies with continuous electrocardiogram recordings are needed to uncover the true relation between cardiac arrhythmias and SCI.

The Effectiveness of Early Tracheostomy (within at least 10 Days) in Cervical Spinal Cord Injury Patients

Objective

This study aimed to determine the optimal time for tracheostomy by evaluating the benefits and safety of early versus late tracheostomy in spinal cord injury (SCI) patients.

Methods

We retrospectively reviewed a total of 254 patients with spinal cord injury. Of them, we selected 21 spinal cord injury patients who required tracheostomy due to long-term mechanical ventilation and analyzed their medical records. The patients were categorized into two groups. Early tracheostomy was performed day 1-10 from intubation in 10 patients and the late tracheostomy was performed after day 10 in 11 cases. We also evaluated the duration of mechanical ventilation, stay in the ICU and complications related to tracheostomy, the injury level of and clinical severity. All data was analyzed using SPSS 18.0/WIN.

Results

The early tracheostomy offered clear advantages for shortening the total ICU stay (20.8 day vs. 38.0 day, p=0.010). There was also statistically significant reduction in the total length of time on mechanical ventilation (5.2 day vs. 29.2 day, p=0.009). However, the reductions in the incidence of pneumonia (40% vs. 82%) and the length of ICU stay post to tracheostomy (6 day vs. 15 day) were found to be statistically not significant. There were also no statistically significant differences in the injury level and clinical severity between the groups.

Conclusion

We concluded that the early tracheostomy (at least 10 days) is beneficial for SCI patients who are likely to require prolonged mechanical ventilation.

Respiratory management in the patient with spinal cord injury

Spinal cord injuries (SCIs) often lead to impairment of the respiratory system and, consequently, restrictive respiratory changes. Paresis or paralysis of the respiratory muscles can lead to respiratory insufficiency, which is dependent on the level and completeness of the injury. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Vital capacity (VC) is an indicator of overall pulmonary function; patients with severely impaired VC may require assisted ventilation. It is best to proceed with intubation under controlled circumstances rather than waiting until the condition becomes an emergency. Mechanical ventilation can adversely affect the structure and function of the diaphragm. Early tracheostomy following short orotracheal intubation is probably beneficial in selected patients. Weaning should start as soon as possible, and the best modality is progressive ventilator-free breathing (PVFB). Appropriate candidates can sometimes be freed from mechanical ventilation by electrical stimulation. Respiratory muscle training regimens may improve patients' inspiratory function following a SCI.

LMA C Trach aided endotracheal intubation in simulated cases of cervical spine injury: A series of 30 cases

Background:

Laryngeal mask airway (LMA) C Trach is a novel device designed to intubate trachea without conventional laryngoscopy. The aim of the study was to evaluate the clinical efficacy of C trach in the simulated scenario of cervical spine injury where conventional laryngoscopy is not desirable.

Methods:

This prospective pilot study was carried out in 30 consenting adults of either gender, ASAPS I or II, scheduled for surgery requiring endotracheal intubation. An appropriate sized rigid cervical collar was positioned around the patient's neck to restrict the neck movements and simulate the scenario of cervical spine injury. After induction of anesthesia, various technical aspects of C Trach facilitated endotracheal intubation, changes in hemodynamic variables, and complications were recorded.

Results:

Mask ventilation was easy in all the patients. Successful insertion of C Trach was achieved in 27 patients at first attempt, while 3 patients required second attempt. Majority of patients required one of the adjusting maneuvers to obtain acceptable view of glottis (POGO score >50%). Intubation success rate was 100% with 26 patients intubated at first attempt and the rest required second attempt. Mean intubation time was 69.8±27.40 sec. With experience, significant decrease in mean intubation time was observed in last 10 patients as compared to first 10 (46±15.77 sec vs. 101.3±22.91 sec). Minor mucosal injury was noted in four patients.

Conclusion:

LMA C Trach facilitates endotracheal intubation under direct vision and can be a useful technique in patients with cervical spine injury with cervical collar in situ.

Effectiveness of pseudoephedrine as adjunctive therapy for neurogenic shock after acute spinal cord injury: a case series

STUDY OBJECTIVE

To evaluate the effectiveness of pseudoephedrine as adjunctive therapy for neurogenic shock in patients with acute spinal cord injury (SCI).

DESIGN

Case series.

SETTING

Academic medical center.

PATIENTS

Thirty-eight patients admitted to the trauma intensive care unit between September 2005 and October 2012 with an acute SCI and who received more than 1 day of pseudoephedrine for one or more of the following: treatment of bradycardia (heart rate ≤ 50 beats/min), treatment of hypotension (systolic blood pressure < 90 mm Hg), or were receiving intravenous vasopressor support.

MEASUREMENTS AND MAIN RESULTS

The effect of adjunctive pseudoephedrine (PSE) was categorized as a success if vasopressors were discontinued after the initiation of PSE or improvement in the number of episodes of bradycardia was noted after the initiation of PSE as evidenced by decreased use of atropine. The effect of pseudoephedrine was categorized as a failure if it did not meet one of the criteria for success. The effect of pseudoephedrine was categorized as inconclusive if there were confounding factors such as vasopressors being restarted for another indication after initial discontinuation. Pseudoephedrine was successful in 31/38 (82%) patients, failed in 2/38 (5%) patients, and had inconclusive results in 5/38 (13%) patients. The mean ± SD time to successful weaning of intravenous vasopressors was 7 ± 7 days. Daily maximum pseudoephedrine doses ranged from 60-720 mg. Mean ± SD duration of pseudoephedrine therapy was 32 ± 23 days (range 2-135 days), with 64.5% of surviving patients discharged while receiving pseudoephedrine.

CONCLUSION

These data suggest that pseudoephedrine is an effective adjunctive therapy in facilitating the discontinuation of intravenous vasopressors and/or atropine in patients with acute SCI with neurogenic shock, although patients will typically require long durations of therapy.

Timing of tracheostomy after anterior cervical spine fixation

BACKGROUND

Patients with cervical spinal cord injury frequently undergo early anterior cervical spine fixation (ACSF) and tracheostomy procedures to reduce further deterioration, to reduce risk of pulmonary complications, and to improve patient mobilization. However, tracheostomy is often delayed because of the risk of cross contamination as a result of the proximity to the ACSF incision site. Currently, there is a paucity of studies evaluating this outcome to determine the safety of early tracheostomy after ACSF. In this study, we have evaluated the outcomes and complications associated with early tracheostomy placement.

METHODS

We performed a retrospective review of all patients who underwent tracheostomy placement and ACSF during the same hospitalization between 2005 and 2010. A variety of patient and procedural data were collected, including demographics, timing of ACSF and tracheostomy, length of hospitalization, indication for surgery, American Spinal Injuries Association and Glasgow Coma Scale scores on admission, reason for tracheostomy, method of tracheostomy, and complications.

RESULTS

Of the 1,184 patients who underwent an ACSF, 20 (1.7%) required a postfixation tracheostomy. Tracheostomy was performed at mean (SD) of 6.9 (4.2) days after ACSF, ranging from 0 to 17 days. Although nearly half of all patients underwent postfixation tracheostomy within 6 days, no wound or implant infection was seen to occur in any patient. Ten patients (50%) developed ventilator-associated pneumonia, with most cases occurring before tracheostomy (90% vs. 10%, p < 0.0001). Univariate analysis only revealed late tracheostomy to significantly increase the risk of complications (odds ratio, 9.33; 95% confidence interval, 1.19-73.0; p = 0.033). Analysis of all studies in the literature revealed a 1% cross-infection rate, with no cases involving implant contamination.

CONCLUSION

Our findings suggest that early tracheostomy can be performed safely after cervical spine fixation surgery, with no patients developing incisional or implant infections. As the risk of cross contamination is only 1%, early tracheostomy should be strongly considered because of its potential benefits.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Management of acute spinal cord injury in the neurocritical care unit

Acute spinal cord injury (SCI) is associated with widespread disturbances not only affecting neurologic function but also leading to hemodynamic instability and respiratory failure. Traumatic SCI rarely occurs in isolation, and frequently is accompanied by trauma to other organ systems. Management of individuals with SCI is complex, requiring aggressive monitoring and prompt treatment when complications arise. Typically this level of care is provided in the neurocritical care unit. This article reviews the pathophysiology of the neurologic, cardiovascular, and pulmonary derangements following traumatic SCI and their management in the critical care setting.

Characterizing the need for tracheostomy placement and decannulation after cervical spinal cord injury

PURPOSE

There have been few reports on the risk factors for tracheostomy and the possibility of patients for decannulation. The purpose of this study was to identify factors necessitating tracheostomy after cervical spinal cord injury (SCI) and detect features predictive of successful decannulation in tracheostomy patients.

METHODS

One hundred and sixty four patients with cervical fracture/dislocation were retrospectively reviewed. The patients comprised 142 men and 22 women with a mean age of 44.9 years. The clinical records were reviewed for patients' demographic data, smoking history, level of cervical spine injury, injury patterns, neurological status, evidence of direct thoracic trauma and head injury, tracheostomy placement, and decannulation. Risk factors necessitating tracheostomy and factors predicting decannulation were statistically analysed.

RESULTS

Twenty-five patients (15.2%) required tracheostomy. Twenty-one patients were successfully decannulated. Smoking history (relative risk [RR], 3.05; p = 0.03) and complete SCI irrespective of injury level (C1-4 complete SCI: RR, 67.55; p < 0.001, C5-7 complete SCI: RR, 57.88; p < 0.001) were significant risk factors necessitating tracheostomy. C1-4 complete SCI was more frequent among those who could not be decannulated. However, even in patients with high cervical complete SCI at the time of injury, patients regaining sufficient movement to shrug their shoulders within 3 weeks after injury could later be decannulated.

CONCLUSIONS

The risk factors for tracheostomy after complete SCI were a history of smoking and complete paralysis irrespective of the level of injury. High cervical level complete SCI was found to be a risk factor for the failure of decannulation in patients without shoulder shrug within 3 weeks after injury.

Analysis of the risk factors for tracheostomy in traumatic cervical spinal cord injury

STUDY DESIGN

A retrospective, consecutive case series.

OBJECTIVE

To determine the risk factors that have a statistically significant association with the need of tracheostomy in patients with cervical spinal cord injury (CSCI) at the acute stage.

SUMMARY OF BACKGROUND DATA

Respiratory complications remain a major cause of further morbidity and mortality in patients with CSCI. Although several risk factors for tracheostomy have been postulated in these patients, no definitive factors have yet been established according to a multivariate analysis. The use of vital capacity was considered as a single global measure of respiratory function in patients with spinal cord injury, but there are very few studies in which the forced vital capacity was investigated as a risk factor for tracheostomy.

METHODS

This study that reviewed the clinical data of 319 patients with CSCI, who were evaluated for their neurological impairment within 2 days after injury, was performed. We analyzed the factors postulated to increase the risk for tracheostomy, including patient's age, neurological impairment scale grade and level, smoking history, pre-existing medical comorbidities, respiratory diseases, Injury Severity Score, forced vital capacity, and percentage of vital capacity to the predicted value (%VC), using a multiple logistic regression model and classification and regression tree analysis.

RESULTS

Of 319 patients, 32 patients received tracheostomy (10.03%). The factors identified using a multiple logistic regression model were high age (69 years of age or older), severe neurological impairment scale, low forced vital capacity (≤ 500 mL), and low percentage of vital capacity to the predicted value (<16.3%). The decision tree analysis demonstrated that forced vital capacity, the severe neurological impairment scale, and high patient age were predictive of need for tracheostomy on 94.4% occasions.

CONCLUSION

The measurement of forced vital capacity is indispensable to predict the need for tracheostomy in patients with CSCI at the acute stage.

Advances in the management of spinal cord and spinal column injuries

Spinal cord injury (SCI) is a significant public problem, with recent data suggesting that over 1 million people in the U.S.A. alone are affected by paralysis resulting from SCI. Recent advances in prehospital care have improved survival as well as reduced incidence and severity of SCI following spine trauma. Furthermore, increased understanding of the secondary mechanisms of injury following SCI has provided improvements in critical care and acute management in patients suffering from SCI, thus limiting morbidity following injury. In addition, improved technology and biomechanical understanding of the mechanisms of spine trauma have allowed further advances in available techniques for spinal decompression and stabilization. In this chapter we review the most recent data and salient literature regarding SCI and address current controversies, including the use of pharmacological adjuncts in the setting of acute SCI. We will also attempt to provide a reader with basic understanding of the classifications of SCI and spinal column injury. Finally, we review advances in spinal column stabilization including improvements in instrumented fusion and minimally invasive surgery.

Complications of tracheostomy after anterior cervical spine fixation surgery

PURPOSE

Cervical traumatic spinal cord-injured patients often way require both anterior cervical spine stabilization and tracheostomy in the first few days after the injury. The infectious complication of tracheostomy can interfere with the evolution of the fixation surgery. The aim of our study was to evaluate the safety of tracheostomy performed early after anterior cervical spine stabilization.

MATERIALS AND METHODS

We reviewed the clinical records of 28 patients admitted to our hospital intensive care unit. In all cases, percutaneous tracheostomy was performed using the percutaneous dilation technique.

RESULTS

The average time interval between the fixation surgery and tracheostomy was 8.25 ± 5.57 days. We had complications in tracheostomy in only 3 cases: minor bleeding occurred in 1 patient and stomal infection, not propagated to the fixation surgery wound, was observed in 2 patients. Two patients died without causal relation to these interventions.

CONCLUSIONS

The early performance of tracheostomy after cervical spinal fixation surgery is safe, still realized early and nearly this, at least if the tracheostomy is performed by percutaneous method.

Severity of locomotor and cardiovascular derangements after experimental high-thoracic spinal cord injury is anesthesia dependent in rats

Anesthetics affect outcomes from central nervous system (CNS) injuries differently. This is the first study to show how two commonly used anesthetics affect continuously recorded hemodynamic parameters and locomotor recovery during a 2-week period after two levels of contusion spinal cord injury (SCI) in rats. We hypothesized that the level of cardiovascular depression and recovery of locomotor function would be dependent upon the anesthetic used during SCI. Thirty-two adult female rats were subjected to a sham, 25-mm or 50-mm SCI at T3-4 under pentobarbital or isoflurane anesthesia. Mean arterial pressure (MAP) and heart rate (HR) were telemetrically recorded before, during, and after SCI. Locomotor function recovered best in the 25-mm-injured isoflurane-anesthetized animals. There was no significant difference in locomotor recovery between the 25-mm-injured pentobarbital-anesthetized animals and the 50-mm-injured isoflurane-anesthetized animals. White matter sparing and extent of intermediolateral cell column loss appeared larger in animals anesthetized with pentobarbital, but this was not significant. There were no differential effects of anesthetics on HR and MAP before SCI, but recovery from anesthesia was significantly slower in pentobarbital-anesthetized animals. At the time of SCI, MAP was acutely elevated in the pentobarbital-anesthetized animals, whereas MAP decreased in the isoflurane-anesthetized animals. Hypotension occurred in the pentobarbital-anesthetized groups and in the 50-mm-injured isoflurane-anesthetized group. In pentobarbital-anesthetized animals, SCI resulted in acute elevation of HR, although HR remained low. Return of HR to baseline was much slower in the pentobarbital-anesthetized animals. Severe SCI at T3 produced significant chronic tachycardia that was injury severity dependent. Although some laboratories monitor blood pressure, HR, and other physiological variables during surgery for SCI, inherently few have monitored cardiovascular function during recovery. This study shows that anesthetics affect hemodynamic parameters differently, which in turn can affect functional outcome measures. This supports the need for a careful evaluation of cardiovascular and other physiological measures in experimental models of SCI. Choice of anesthetic should be an important consideration in experimental designs and data analyses.