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Horiguchi D, Shin S, Pepino JA, Peterson JT, Kehoe IE, Goldstein JN, Lee J, Kwon BK, Hahn JO, Reisner AT. Hypotension During Vasopressor Infusion Occurs in Predictable Clusters: A Multicenter Analysis. J Intensive Care Med 2024; 39:683-692. [PMID: 38282376 DOI: 10.1177/08850666241226893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Background: Published evidence indicates that mean arterial pressure (MAP) below a goal range (hypotension) is associated with worse outcomes, though MAP management failures are common. We sought to characterize hypotension occurrences in ICUs and consider the implications for MAP management. Methods: Retrospective analysis of 3 hospitals' cohorts of adult ICU patients during continuous vasopressor infusion. Two cohorts were general, mixed ICU patients and one was exclusively acute spinal cord injury patients. "Hypotension-clusters" were defined where there were ≥10 min of cumulative hypotension over a 60-min period and "constant hypotension" was ≥10 continuous minutes. Trend analysis was performed (predicting future MAP using 14 min of preceding MAP data) to understand which hypotension-clusters could likely have been predicted by clinician awareness of MAP trends. Results: In cohorts of 155, 66, and 16 ICU stays, respectively, the majority of hypotension occurred within the hypotension-clusters. Failures to keep MAP above the hypotension threshold were notable in the bottom quartiles of each cohort, with hypotension durations of 436, 167, and 468 min, respectively, occurring within hypotension-clusters per day. Mean arterial pressure trend analysis identified most hypotension-clusters before any constant hypotension occurred (81.2%-93.6% sensitivity, range). The positive predictive value of hypotension predictions ranged from 51.4% to 72.9%. Conclusions: Across 3 cohorts, most hypotension occurred in temporal clusters of hypotension that were usually predictable from extrapolation of MAP trends.
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Affiliation(s)
- Daisuke Horiguchi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Nihon Kohden Innovation Center, LLC, Cambridge, MA, USA
| | - Sungtae Shin
- Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Jeremy A Pepino
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey T Peterson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Iain E Kehoe
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital, Boston MA, USA
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jin-Oh Hahn
- Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Andrew T Reisner
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Stampfl M, DeBlieux P. A Clinical Review of Vasopressors in Emergency Medicine. J Emerg Med 2024; 67:e31-e41. [PMID: 38789351 DOI: 10.1016/j.jemermed.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
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Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, Wisconsin; BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
| | - Peter DeBlieux
- Louisiana State University Medical Center, New Orleans, Louisiana; Tulane University School of Medicine Department of Surgery, New Orleans, Louisiana
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Jiang T, Wang A, Wen G, Qi H, Gu Y, Tang W, Xu C, Ren S, Zhang S, Liu S, He Y. Calycosin promotes axon growth by inhibiting PTPRS and alleviates spinal cord injury. J Mol Neurosci 2024; 74:60. [PMID: 38904846 DOI: 10.1007/s12031-024-02235-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/01/2024] [Indexed: 06/22/2024]
Abstract
Our former studies have identified the alleviating effect of Calycosin (CA) on spinal cord injury (SCI). In this study, our purpose is to explore the influence of CA on SCI from the perspective of promoting axon growth. The SCI animal model was constructed by spinal cord compression, wherein rat primary cortex neuronal isolation was performed, and the axonal growth restriction cell model was established via chondroitin sulfate proteoglycan (CSPG) treatment. The expressions of axon regeneration markers were measured via immunofluorescent staining and western blot, and the direct target of CA was examined using silver staining. Finally, the expression of the protein tyrosine phosphatase receptor type S (PTPRS) was assessed using western blot. CA treatment increased neuronal process outgrowth and the expressions of axon regeneration markers, such as neurofilament H (NF-H), vesicular glutamate transporter 1 (vGlut1), and synaptophysin (Syn) in both SCI model rats and CSPG-treated primary cortical neurons, and PTPRS levels were elevated after SCI induction. In addition, PTPRS was the direct target of CA, and according to in vivo findings, exposure to CA reduced the PTPRS content. Furthermore, PTPRS overexpression inhibited CA's enhancement of axon regeneration marker content and neuronal axon lengths. CA improves SCI by increasing axon development through regulating PTPRS expression.
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Affiliation(s)
- Tianqi Jiang
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China
- Graduate School of Inner Mongolia Medical University, Hohhot, 010000, Inner Mongolia Autonomous Region, China
| | - Aitao Wang
- Department of Anesthesiology, Hohhot First Hospital, Hohhot, 010030, Inner Mongolia Autonomous Region, China
| | - Guangyu Wen
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China
| | - Hao Qi
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China
| | - Yuntao Gu
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China
| | - Wenhai Tang
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China
| | - Chunzhao Xu
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China
| | - Shanwu Ren
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China
| | - Shunli Zhang
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China
| | - Shengxing Liu
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China.
| | - Yongxiong He
- Department of Spine Surgery, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570216, Hainan Province, China.
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Leary OP, Shaaya EA, Chernysh AA, Seidler M, Sastry RA, Persad-Paisley E, Zhu M, Gokaslan ZL, Oyelese AA, Beland MD, Fridley JS. Microbubble Contrast-Enhanced Transcutaneous Ultrasound Enables Real-Time Spinal Cord Perfusion Monitoring Following Posterior Cervical Decompression. World Neurosurg 2024:S1878-8750(24)01035-0. [PMID: 38901475 DOI: 10.1016/j.wneu.2024.06.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Ultrasound imaging is inexpensive, portable, and widely available. The development of a real-time transcutaneous spinal cord perfusion monitoring system would allow more precise targeting of mean arterial pressure goals following acute spinal cord injury (SCI). There has been no prior demonstration of successful real-time cord perfusion monitoring in humans. METHODS Four adult patients who had undergone posterior cervical decompression and instrumentation at a single center were enrolled into this prospective feasibility study. All participants had undergone cervical laminectomies spanning ≥2 contiguous levels ≥2 months prior to inclusion with no history of SCI. The first 2 underwent transcutaneous ultrasound without contrast and the second 2 underwent contrast-enhanced ultrasound (CEUS) with intravenously injected microbubble contrast. RESULTS Using noncontrast ultrasound with or without Doppler (n = 2), the dura, spinal cord, and vertebral bodies were apparent however ultrasonography was insufficient to discern intramedullary perfusion or clear white-gray matter differentiation. With application of microbubble contrast (n = 2), it was possible to quantify differential spinal cord perfusion within and between cross-sectional regions of the cord. Further, it was possible to quantify spinal cord hemodynamic perfusion using CEUS by measuring peak signal intensity and the time to peak signal intensity after microbubble contrast injection. Time-intensity curves were generated and area under the curves were calculated as a marker of tissue perfusion. CONCLUSIONS CEUS is a viable platform for monitoring real-time cord perfusion in patients who have undergone prior cervical laminectomies. Further development has the potential to change clinical management acute SCI by tailoring treatments to measured tissue perfusion parameters.
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Affiliation(s)
- Owen P Leary
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.
| | - Elias A Shaaya
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Alexander A Chernysh
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Michael Seidler
- Department of Diagnostic Imaging, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Rahul A Sastry
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Elijah Persad-Paisley
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Michelle Zhu
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Michael D Beland
- Department of Diagnostic Imaging, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Jared S Fridley
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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Haan BJ, Blackmon SN, Cobb AM, Cohen HE, DeVier MT, Perez MM, Winslow SF. Corticosteroids in critically ill patients: A narrative review. Pharmacotherapy 2024. [PMID: 38872437 DOI: 10.1002/phar.2944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 06/15/2024]
Abstract
Corticosteroids have been utilized in modern medicine for decades. Many indications have been investigated across various treatment settings with both benefit and harm observed. Given the instability of critically ill patients, the increased risk of corticosteroid-related complications, and the pervasive comorbidities, patients who receive corticosteroids must be carefully managed. Common critical care disease states in which corticosteroids have been studied and are routinely utilized include acute respiratory distress syndrome, adrenal insufficiency, angioedema, asthma, chronic obstructive pulmonary disease, community-acquired pneumonia, coronavirus disease 2019, septic shock, and spinal cord injury. Benefits of corticosteroids include an improvement in disease state-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality. The harm of corticosteroids is well documented through adverse effects that include, but are not limited to, hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness. Furthermore, corticosteroids are associated with increased health care costs through adverse effects as well as drug acquisition and administration costs. Given the assortment of agents, dosing, benefits, risks, and utilization in the critical care setting, there may be difficulty with identifying the appropriate places for use of corticosteroids in therapy. There currently exists no comprehensive report detailing the use of corticosteroids in the aforementioned disease states within the critical care setting. This narrative review sets out to describe these in detail.
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Affiliation(s)
- Bradley J Haan
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Samantha N Blackmon
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Alex M Cobb
- Department of Pharmacy, Ascension St. John Medical Center, Tulsa, Oklahoma, USA
| | - Heather E Cohen
- Department of Pharmacy, Ascension Illinois Metro Region, Chicago, Illinois, USA
| | - Margaret T DeVier
- Department of Pharmacy, Ascension Saint Thomas Hospital Midtown, Nashville, Tennessee, USA
| | - Mary M Perez
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Samuel F Winslow
- Department of Pharmacy, Ascension Providence Hospital, Southfield, Michigan, USA
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Zhao W, Jia Z, Bauman WA, Qin Y, Peng Y, Chen Z, Cardozo CP, Wang D, Qin W. Targeted-delivery of nanomedicine-enabled methylprednisolone to injured spinal cord promotes neuroprotection and functional recovery after acute spinal cord injury in rats. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2024; 60:102761. [PMID: 38871068 DOI: 10.1016/j.nano.2024.102761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/17/2024] [Accepted: 06/05/2024] [Indexed: 06/15/2024]
Abstract
To date, no therapy has been proven to be efficacious in fully restoring neurological functions after spinal cord injury (SCI). Systemic high-dose methylprednisolone (MP) improves neurological recovery after acute SCI in both animal and human. MP therapy remains controversial due to its modest effect on functional recovery and significant adverse effects. To overcome the limitation of MP therapy, we have developed a N-(2-hydroxypropyl) methacrylamide copolymer-based MP prodrug nanomedicine (Nano-MP) that can selectively deliver MP to the SCI lesion when administered systemically in a rat model of acute SCI. Our in vivo data reveal that Nano-MP is significantly more effective than free MP in attenuating secondary injuries and neuronal apoptosis. Nano-MP is superior to free MP in improving functional recovery after acute SCI in rats. These data support Nano-MP as a promising neurotherapeutic candidate, which may provide potent neuroprotection and accelerate functional recovery with improved safety for patients with acute SCI.
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Affiliation(s)
- Wei Zhao
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Zhenshan Jia
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - William A Bauman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA; Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Yiwen Qin
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA; GCM Grosvenor, New York, USA
| | - Yuanzhen Peng
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Zihao Chen
- Departments of Biotechnology, Brown University, Providence, RI, USA
| | - Christopher P Cardozo
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA; Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Dong Wang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Weiping Qin
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
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Baroudi M, Rezk A, Daher M, Balmaceno-Criss M, Gregoryczyk JG, Sharma Y, McDonald CL, Diebo BG, Daniels AH. Management of traumatic spinal cord injury: A current concepts review of contemporary and future treatment. Injury 2024; 55:111472. [PMID: 38460480 DOI: 10.1016/j.injury.2024.111472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/03/2024] [Accepted: 02/25/2024] [Indexed: 03/11/2024]
Abstract
Spinal Cord Injury (SCI) is a condition leading to inflammation, edema, and dysfunction of the spinal cord, most commonly due to trauma, tumor, infection, or vascular disturbance. Symptoms include sensory and motor loss starting at the level of injury; the extent of damage depends on injury severity as detailed in the ASIA score. In the acute setting, maintaining mean arterial pressure (MAP) higher than 85 mmHg for up to 7 days following injury is preferred; although caution must be exercised when using vasopressors such as phenylephrine due to serious side effects such as pulmonary edema and death. Decompression surgery (DS) may theoretically relieve edema and reduce intraspinal pressure, although timing of surgery remains a matter of debate. Methylprednisolone (MP) is currently used due to its ability to reduce inflammation but more recent studies question its clinical benefits, especially with inconsistency in recommending it nationally and internationally. The choice of MP is further complicated by conflicting evidence for optimal timing to initiate treatment, and by the reported observation that higher doses are correlated with increased risk of complications. Thyrotropin-releasing hormone may be beneficial in less severe injuries. Finally, this review discusses many options currently being researched and have shown promising pre-clinical results.
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Affiliation(s)
- Makeen Baroudi
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Anna Rezk
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mohammad Daher
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mariah Balmaceno-Criss
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jerzy George Gregoryczyk
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Yatharth Sharma
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher L McDonald
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Podell JE, Morris NA. Traumatic Brain Injury and Traumatic Spinal Cord Injury. Continuum (Minneap Minn) 2024; 30:721-756. [PMID: 38830069 DOI: 10.1212/con.0000000000001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury. LATEST DEVELOPMENTS Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated. ESSENTIAL POINTS Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.
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9
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Sharma A, Jaiswal A, Marathe N, Singh V, Shakya A, Mangale N, Mhatre P. Does Elevated Mean-Arterial Pressure Lead to Better Outcomes in Degenerative Cervical Myelopathy?- A Prospective, Pilot Randomized Control Trial. Global Spine J 2024:21925682241256350. [PMID: 38798232 DOI: 10.1177/21925682241256350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
STUDY DESIGN Randomized Control Trial. OBJECTIVE DCM refers to compression of spinal cord either due to static/dynamic causes or commonly, a result of combination of both. Number of variables exist, which determine prognosis post-surgery. Role of intra-operative blood pressure has not been analyzed in depth in current literature. Elevating MAP post SCI is widely practiced and forms a recommendation of AANS/CNS Joint Committee Guidelines. This led us to investigate role played by elevated MAP during surgery for DCM, in order to optimize outcomes. METHODS This prospective randomized comparative pilot study was conducted at a tertiary care spine centre. 84 patients were randomly divided in two groups. Group 1 had intra-operative MAP in normal range. Group 2, had intra-operative BP 20 mmHg higher than preoperative average MAP with a variation of + 5 mmHg. Outcomes were recorded at 3 months, 6 months and 1 year by mJOA, VAS and ASIA scale. RESULTS Neurological improvement was documented in 19/30 (63.3%) patients of hypertensive group compared to 16/30 (53.3%) patients of normotensive group. Improvements in mJOA scores were better for hypertensive group during the 1-year follow-up. Improvement in VAS scores were comparable between two groups, but at 1-year follow-up the VAS score of hypertensive groups was significantly lower. CONCLUSION MAP should be individualized according to preoperative average blood pressure assessment of patient. Keeping intraoperative MAP at higher level (preoperative MAP + 20 mmHg) during surgery for DCM can result in better outcomes.
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Affiliation(s)
- Ayush Sharma
- Department of Orthopedic and Spine Surgery, Dr. Babasaheb Ambedkar Central Railway Hospital, Mumbai, India
| | - Ajay Jaiswal
- Department of Orthopedic and Spine Surgery, Dr. Babasaheb Ambedkar Central Railway Hospital, Mumbai, India
| | | | - Vijay Singh
- Department of Orthopedic and Spine Surgery, Dr. Babasaheb Ambedkar Central Railway Hospital, Mumbai, India
| | - Akash Shakya
- Department of Orthopedic and Spine Surgery, Dr. Babasaheb Ambedkar Central Railway Hospital, Mumbai, India
| | - Nilesh Mangale
- Department of Orthopedic and Spine Surgery, Dr. Babasaheb Ambedkar Central Railway Hospital, Mumbai, India
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Fischer G, Bättig L, Stienen MN, Curt A, Fehlings MG, Hejrati N. Advancements in neuroregenerative and neuroprotective therapies for traumatic spinal cord injury. Front Neurosci 2024; 18:1372920. [PMID: 38812974 PMCID: PMC11133582 DOI: 10.3389/fnins.2024.1372920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/10/2024] [Indexed: 05/31/2024] Open
Abstract
Traumatic spinal cord injuries (SCIs) continue to be a major healthcare concern, with a rising prevalence worldwide. In response to this growing medical challenge, considerable scientific attention has been devoted to developing neuroprotective and neuroregenerative strategies aimed at improving the prognosis and quality of life for individuals with SCIs. This comprehensive review aims to provide an up-to-date and thorough overview of the latest neuroregenerative and neuroprotective therapies currently under investigation. These strategies encompass a multifaceted approach that include neuropharmacological interventions, cell-based therapies, and other promising strategies such as biomaterial scaffolds and neuro-modulation therapies. In addition, the review discusses the importance of acute clinical management, including the role of hemodynamic management as well as timing and technical aspects of surgery as key factors mitigating the secondary injury following SCI. In conclusion, this review underscores the ongoing scientific efforts to enhance patient outcomes and quality of life, focusing on upcoming strategies for the management of traumatic SCI. Each section provides a working knowledge of the fundamental preclinical and patient trials relevant to clinicians while underscoring the pathophysiologic rationale for the therapies.
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Affiliation(s)
- Gregor Fischer
- Department of Neurosurgery, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
| | - Linda Bättig
- Department of Neurosurgery, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
| | - Martin N. Stienen
- Department of Neurosurgery, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Nader Hejrati
- Department of Neurosurgery, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Medical School of St.Gallen, St.Gallen, Switzerland
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11
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Lee KZ, Liu TT, Chen RY. Therapeutic efficacy of adrenergic agents on systemic and spinal hemodynamics in an acute cervical spinal cord injury rodent model. Spine J 2024:S1529-9430(24)00191-8. [PMID: 38679076 DOI: 10.1016/j.spinee.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Cervical spinal cord injury usually results in cardiorespiratory dysfunctions due to interruptions of the bulbospinal pathways innervating the cervical phrenic motoneurons and thoracic sympathetic preganglionic neurons. PURPOSE The present study aimed to evaluate the therapeutic effects of adrenergic agents on systemic and spinal hemodynamics during acute cervical spinal cord injury. STUDY DESIGN In vivo animal study. METHODS The cardiorespiratory function and spinal cord blood flow and oxygenation level were monitored in response to cervical spinal cord contusion and intravenous infusion of three types of adrenergic agents (phenylephrine, dobutamine, and norepinephrine). RESULTS Cervical spinal cord contusion resulted in immediate reduction of respiratory airflow, arterial blood pressure, and spinal cord blood flow. The arterial blood pressure and spinal cord blood flow remained lower than the pre-injury value in contused animals infused with saline at 60 min post-injury. Infusion of phenylephrine (500, 1000, and 2000 μg/kg) and norepinephrine (125, 250, and 500 μg/kg) significantly increased the arterial blood pressure, while only norepinephrine augmented the spinal cord blood flow. Conversely, dobutamine (1000 and 2000 μg/kg) reduced both arterial blood pressure and spinal cord blood flow. Notably, administration of adrenergic agents tended to increase spinal cord hemorrhage in contused animals. CONCLUSIONS Infusion of norepinephrine can effectively maintain the blood pressure and improve spinal cord blood flow during acute spinal cord injury. CLINICAL SIGNIFICANCE Norepinephrine may be a superior medicine for hemodynamic management; however, the potential hemorrhage should be considered when utilizing the vasopressor to regulate systemic and spinal hemodynamics at the acute injured stage.
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Affiliation(s)
- Kun-Ze Lee
- Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Tzu-Ting Liu
- Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Rui-Yi Chen
- Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
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12
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Mergoum AM, Rhone AR, Larson NJ, Dries DJ, Blondeau B, Rogers FB. A Guide to the Use of Vasopressors and Inotropes for Patients in Shock. J Intensive Care Med 2024:8850666241246230. [PMID: 38613381 DOI: 10.1177/08850666241246230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.
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Affiliation(s)
| | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
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Sun C, Xu G, Wang H, Nie C, Xu G, Liu D, Yang Y, Wang X, Xie L, Li L, Ma X, Lu F, Jiang J, Wang H. A Study on Interobserver and Intraobserver Reliability of the Huashan Radiologic Classification System for Cervical Spinal Cord Injury Without Fracture and Dislocation. Clin Spine Surg 2024:01933606-990000000-00290. [PMID: 38637922 DOI: 10.1097/bsd.0000000000001621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 02/28/2024] [Indexed: 04/20/2024]
Abstract
STUDY DESIGN Observational study. OBJECTIVE To assess the reproducibility and reliability of the system. BACKGROUND The Huashan radiologic classification system for cervical spinal cord injury without fracture and dislocation (CSCIWFD) was recently proposed and found useful for clinical practice. PATIENTS AND METHODS Patients diagnosed with CSCIWFD between 2015 and 2021 were recruited. Six spine surgeons from different institutions, three experienced and other inexperienced respectively, were trained as observers of the system, and these surgeons classified the recruited patients using the system. Then, 8 weeks later, they repeated the classification on the same patients in a different order. The interobserver and intraobserver agreement between the results was analyzed using percentage agreement, weighted kappa, and Cohen kappa (κ) statistics. RESULTS A total of 60 patients were included in the analysis. Type I was the most frequent type (29 cases, 48.3%), followed by type II (13 cases, 21.7%), type III (12 cases, 20%), and type IV (6 cases, 10%). For all the observers, experienced observers, and inexperienced observers, the overall agreement percentages were 77.6% (κ = 0.78), 84.4% (κ = 0.84), and 72.8% (κ = 0.74), respectively, indicating substantial to nearly perfect interobserver reproducibility. A higher level of agreement was found for differentiating type I from other types, with the percentage agreement ranging from 87.8% to 94.4% (κ= 0.74-0.88). For distinguishing compression on the spinal cord (types I and II vs types III and IV) among the different groups of observers, the percentage agreement was 97.8% (κ = 0.94), indicating nearly perfect reproducibility. As for intraobserver agreement, the percentage agreement ranged from 86.7% to 96.7% (κ = 0.78-0.95), indicating at least substantial reliability. CONCLUSIONS The Huashan radiologic classification system for CSCIWFD was easy to learn and apply in a clinical environment, showing excellent reproducibility and reliability. Therefore, it would be promising to apply and promote this system for the precise evaluation and personalized treatment strategy.
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Affiliation(s)
- Chi Sun
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
| | - Guangyu Xu
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
| | - Hongwei Wang
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
| | - Cong Nie
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
| | - Guanhua Xu
- Department of Spine Surgery, Nantong First People's Hospital, Nantong University, Nantong
| | - Dayong Liu
- Department of Spine Surgery, Weifang People's Hospital, Weifang Medical University, Weifang
| | - Yong Yang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou University, Lanzhou
| | - Xiandi Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu
| | - Lin Xie
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Linli Li
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
| | - Xiaosheng Ma
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
| | - Feizhou Lu
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
- Department of Orthopaedics, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Jianyuan Jiang
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
| | - Hongli Wang
- Department of Orthopaedics, Huashan Hospital, Fudan University, Shanghai
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Adegeest C, Moayeri N, Muijs S, ter Wengel P. Spinal cord injury: Current trends in acute management. BRAIN & SPINE 2024; 4:102803. [PMID: 38618228 PMCID: PMC11010802 DOI: 10.1016/j.bas.2024.102803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/05/2024] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
Introduction Traumatic spinal cord injury (tSCI) is a profoundly debilitating condition necessitating prompt intervention. However, the optimal acute treatment strategy remains a subject of debate. Research question The aim of this overview is to elucidate prevailing trends in the acute tSCI management. Material and Methods We provided an overview using peer-reviewed studies. Results Early surgical treatment (<24h after trauma) appears beneficial compared to delayed surgery. Nonetheless, there is insufficient evidence supporting a positive influence of ultra-early surgery on neurological outcome in tSCI. Furthermore, the optimal surgical approach to decompress the spinal cord remains unclear. These uncertainties extend to a growing aging population suffering from central cord syndrome (CCS). Additionally, there is a paucity of evidence supporting the beneficial effects of strict hemodynamic management. Discussion and Conclusion This overview highlights the current literature on surgical timing, surgical techniques and hemodynamic management during the acute phase of tSCI. It also delves into considerations specific to the elderly population experiencing CCS.
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Affiliation(s)
- C.Y. Adegeest
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - N. Moayeri
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - S.P.J. Muijs
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P.V. ter Wengel
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
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15
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Thomas AX, Erklauer JC. Neurocritical care and neuromonitoring considerations in acute pediatric spinal cord injury. Semin Pediatr Neurol 2024; 49:101122. [PMID: 38677801 DOI: 10.1016/j.spen.2024.101122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/26/2024] [Accepted: 03/18/2024] [Indexed: 04/29/2024]
Abstract
Management of pediatric spinal cord injury (SCI) is an essential skill for all pediatric neurocritical care physicians. In this review, we focus on the evaluation and management of pediatric SCI, highlight a novel framework for the monitoring of such patients in the intensive care unit (ICU), and introduce advancements in critical care techniques in monitoring and management. The initial evaluation and characterization of SCI is crucial for improving outcomes as well as prognostication. While physical examination and imaging are the main stays of the work-up, we propose the use of somatosensory evoked potentials (SSEPs) and transcranial magnetic stimulation (TMS) for challenging clinical scenarios. SSEPs allow for functional evaluation of the dorsal columns consisting of tracts associated with hand function, ambulation, and bladder function. Meanwhile, TMS has the potential for informing prognostication as well as response to rehabilitation. Spine stabilization, and in some cases surgical decompression, along with respiratory and hemodynamic management are essential. Emerging research suggests that targeted spinal cerebral perfusion pressure may provide potential benefits. This review aims to increase the pediatric neurocritical care physician's comfort with SCI while providing a novel algorithm for monitoring spinal cord function in the ICU.
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Affiliation(s)
- Ajay X Thomas
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, TX, USA.
| | - Jennifer C Erklauer
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, TX, USA; Department of Pediatrics, Division of Pediatric Critical Care Medicine, Baylor College of Medicine at Texas Children's Hospital, Houston, TX, USA
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Irrgang S, Himmelhaus S, Allek K, Debecker I, Gemperli A, Kynast K, von Reumont A, Scheel-Sailer A. Assessments and interventions on body functions, structures and activity to prepare adults with acute spinal cord injury or disease for participation: a scoping review. FRONTIERS IN REHABILITATION SCIENCES 2024; 5:1272682. [PMID: 38601217 PMCID: PMC11004486 DOI: 10.3389/fresc.2024.1272682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 03/18/2024] [Indexed: 04/12/2024]
Abstract
Introduction In the acute phase after a spinal cord injury or disease (SCI/D), various therapeutic assessments and interventions are applied with the goal of restoring structures, preventing complications and preparing the patient as best as possible for further activity and finally participation. The goal was to identify and evaluate the available evidence on assessments and interventions for body functions and structures to prepare adults with acute spinal cord SCI/D for activity and participation during the first 14 days. Methods A scoping review was conducted. The search was performed on June 19, 2023 using the databases PubMed, PEDro, Cochrane library and Embase. These were screened for studies including patients with acute SCI/D and physiotherapeutic or occupational therapy assessments and interventions. Only studies in English or German published between 2012 and 2023 were included. Results Twelve publications met the inclusion criteria, namely three systematic reviews, two randomized controlled trials, two observational studies and five clinical practice guidelines. Assessments as the Spinal Cord Independence Measure, as well as exercises such as daily passive mobilization of body structures against contractures were used in the entire population, while others were only applied in subgroups of SCI/D such as the Graded Redefined Assessment of Strength, Sensation and Prehension or functional electrical stimulation with and without additional movements. The methodological quality of the studies found varied greatly from good to very poor. Discussion Heterogeneity in research design and study population as well as lack of high-quality studies do not cover the standard of clinical management in the acute phase and further comprehensive research is needed.
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Affiliation(s)
- Sophie Irrgang
- Health Services and Clinical Care Group, Swiss Paraplegic Research, Nottwil, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Sandra Himmelhaus
- Health Services and Clinical Care Group, Swiss Paraplegic Research, Nottwil, Switzerland
| | - Kirstin Allek
- Spinal Cord Injury Center, Zentralklinik Bad Berka, Bad Berka, Germany
| | | | - Armin Gemperli
- Health Services and Clinical Care Group, Swiss Paraplegic Research, Nottwil, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Karen Kynast
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Anne von Reumont
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Anke Scheel-Sailer
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Center, Nottwil, Switzerland
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17
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Ko CC, Lee PH, Lee JS, Lee KZ. Spinal decompression surgery may alleviate vasopressor-induced spinal hemorrhage and extravasation during acute cervical spinal cord injury in rats. Spine J 2024; 24:519-533. [PMID: 37793474 DOI: 10.1016/j.spinee.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Cervical spinal injury often disrupts the supraspinal vasomotor pathways projecting to the thoracic sympathetic preganglionic neurons, leading to cardiovascular dysfunction. The current guideline is to maintain the mean arterial blood pressure at 85 to 90 mmHg using a vasopressor during the first week of the injury. Some studies have demonstrated that this treatment might be beneficial to alleviate secondary injury and improve neurological outcomes; however, elevation of blood pressure may exacerbate spinal hemorrhage, extravasation, and edema, exacerbating the initial injury. PURPOSE The present study was designed to (1) examine whether vasopressor administration exacerbates spinal hemorrhage and extravasation; (2) evaluate whether spinal decompression surgery relieves vasopressor-induced spinal hemorrhage and extravasation. STUDY DESIGN In vivo animal study. METHODS Animals received a saline solution or a vasopressor (phenylephrine hydrochloride, 500 or 1000 μg/kg, 7 mL/kg/h) after mid-cervical contusion with or without spinal decompression (ie, incision of the dura and arachnoid mater). Spinal cord hemorrhage and extravasation were examined by expression of Evans blue within the spinal cord section. RESULTS The results demonstrated that cervical spinal contusion significantly reduced the mean arterial blood pressure and induced spinal hemorrhage and extravasation. Phenylephrine infusion significantly elevated the mean arterial blood pressure to the preinjury level within 15 to 60 minutes postcontusion; however, spinal hemorrhage and extravasation were more extensive in animals that received phenylephrine than in those that received saline. Notably, spinal decompression mitigated spinal hemorrhage and extravasation in contused rats who received phenylephrine. CONCLUSIONS These data indicate that, although phenylephrine can prevent hypotension after cervical spinal injury, it also causes excess spinal hemorrhage and extravasation. CLINICAL SIGNIFICANCE Spinal decompressive surgery seemed to minimize the side effect of phenylephrine as vasopressor treatment during acute spinal cord injury.
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Affiliation(s)
- Chia-Chen Ko
- Department of Biological Sciences, National Sun Yat-sen University, No. 70, Lien-Hai Rd., Kaohsiung city 804, Taiwan
| | - Po-Hsuan Lee
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, No. 138, Sheng-Li Rd., Tainan city 704, Taiwan
| | - Jung-Shun Lee
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, No. 138, Sheng-Li Rd., Tainan city 704, Taiwan; Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, No.1, University Rd., Tainan city 701, Taiwan; Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, No.1, University Rd., Tainan city 701, Taiwan
| | - Kun-Ze Lee
- Department of Biological Sciences, National Sun Yat-sen University, No. 70, Lien-Hai Rd., Kaohsiung city 804, Taiwan; Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Rd., Kaohsiung city 807, Taiwan.
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18
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Zama D, Candela E, Pagano G, Venturelli F, Melchionda F, Toni F, Zucchelli M, Pession A. Pediatric non-Hodgkin lymphoma as a rare cause of spinal cord injury: When lymphoma hides in the canal. Clin Case Rep 2024; 12:e7789. [PMID: 38523827 PMCID: PMC10959824 DOI: 10.1002/ccr3.7789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 03/26/2024] Open
Abstract
Key Clinical Message Spinal cord compression from non-Hodgkin lymphoma (NHL) should be considered as a potential diagnosis in cases of acute signs of myelopathy in pediatric patients. Abstract Spinal cord compression in pediatric non-Hodgkin lymphoma (NHL) is a rare presentation with potential diagnostic challenges. We report on two pediatric patients with NHL who exhibited myelopathy signs as initial presentation. Considering NHL as a differential diagnosis in pediatric patients presenting with spinal cord compression is crucial for optimizing the outcome of these patients.
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Affiliation(s)
- Daniele Zama
- Pediatric Emergency UnitIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
- Department of Medical and Surgical Sciences, Alma Mater StudiorumUniversity of BolognaBolognaItaly
| | - Egidio Candela
- Department of Medical and Surgical Sciences, Alma Mater StudiorumUniversity of BolognaBolognaItaly
- Pediatric UnitIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Gennaro Pagano
- Specialty School of Paediatrics ‐ Alma Mater StudiorumUniversity of BolognaBolognaItaly
| | - Francesco Venturelli
- Department of Medical and Surgical Sciences, Alma Mater StudiorumUniversity of BolognaBolognaItaly
- Pediatric Oncology and Hematology Unit "Lalla Seràgnoli"IRCCS Azienda Ospedaliera‐Universitaria di BolognaBolognaItaly
| | - Fraia Melchionda
- Pediatric Oncology and Hematology Unit "Lalla Seràgnoli"IRCCS Azienda Ospedaliera‐Universitaria di BolognaBolognaItaly
| | - Francesco Toni
- Neuroradiology UnitIRCCS Istituto delle scienze Neurologiche di BolognaBolognaItaly
| | - Mino Zucchelli
- Pediatric Neurosurgery, Institute of Neurological ScienceIRCCS Bellaria HospitalBolognaItaly
| | - Andrea Pession
- Department of Medical and Surgical Sciences, Alma Mater StudiorumUniversity of BolognaBolognaItaly
- Pediatric UnitIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
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19
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Du JY, Shafi K, Blackburn CW, Chapman JR, Ahn NU, Marcus RE, Albert TJ. Resource Utilization following Anterior Versus Posterior Cervical Decompression and Fusion for Acute Central Cord Syndrome. Clin Spine Surg 2024:01933606-990000000-00272. [PMID: 38446594 DOI: 10.1097/bsd.0000000000001598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 12/06/2023] [Indexed: 03/08/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination. SUMMARY OF BACKGROUND DATA Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear. METHODS Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed. RESULTS There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 (P<0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P<0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P<0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P<0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P<0.001). CONCLUSIONS For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.
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Affiliation(s)
- Jerry Y Du
- Division of Spine Surgery, Hospital for Special Surgery, New York City, NY
| | - Karim Shafi
- Division of Spine Surgery, Hospital for Special Surgery, New York City, NY
| | - Collin W Blackburn
- Department of Orthopedics, University Hospitals/Cleveland Medical Center, Cleveland, OH
| | - Jens R Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA
| | - Nicholas U Ahn
- Department of Orthopedics, University Hospitals/Cleveland Medical Center, Cleveland, OH
| | - Randall E Marcus
- Department of Orthopedics, University Hospitals/Cleveland Medical Center, Cleveland, OH
| | - Todd J Albert
- Division of Spine Surgery, Hospital for Special Surgery, New York City, NY
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20
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Tetreault LA, Kwon BK, Evaniew N, Alvi MA, Skelly AC, Fehlings MG. A Clinical Practice Guideline on the Timing of Surgical Decompression and Hemodynamic Management of Acute Spinal Cord Injury and the Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury: Introduction, Rationale, and Scope. Global Spine J 2024; 14:10S-24S. [PMID: 38632715 PMCID: PMC10964894 DOI: 10.1177/21925682231183969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
STUDY DESIGN Protocol for the development of clinical practice guidelines following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. OBJECTIVES Acute SCI or intraoperative SCI (ISCI) can have devastating physical and psychological consequences for patients and their families. The treatment of SCI has dramatically evolved over the last century as a result of preclinical and clinical research that has addressed important knowledge gaps, including injury mechanisms, disease pathophysiology, medical management, and the role of surgery. In an acute setting, clinicians are faced with critical decisions on how to optimize neurological recovery in patients with SCI that include the role and timing of surgical decompression and the best strategies for hemodynamic management. The lack of consensus surrounding these treatments has prevented standardization of care across centers and has created uncertainty with respect to how to best manage patients with SCI. ISCI is a feared complication that can occur in the best of hands. Unfortunately, there are no systematic reviews or clinical practice guidelines to assist spine surgeons in the assessment and management of ISCI in adult patients undergoing spinal surgery. Given these limitations, it is the objective of this initiative to develop evidence-based recommendations that will inform the management of both SCI and ISCI. This protocol describes the rationale for developing clinical practice guidelines on (i) the timing of surgical decompression in acute SCI; (ii) the hemodynamic management of acute SCI; and (iii) the prevention, identification, and management of ISCI in patients undergoing surgery for spine-related pathology. METHODS Systematic reviews were conducted according to PRISMA standards in order to summarize the current body of evidence and inform the guideline development process. The guideline development process followed the approach proposed by the GRADE working group. Separate multidisciplinary, international groups were created to perform the systematic reviews and formulate the guidelines. All potential conflicts of interest were vetted in advance. The sponsors exerted no influence over the editorial process or the development of the guidelines. RESULTS This process resulted in both systematic reviews and clinical practice guidelines/care pathways related to the role and timing of surgery in acute SCI; the optimal hemodynamic management of acute SCI; and the prevention, diagnosis and management of ISCI. CONCLUSIONS The ultimate goal of this clinical practice guideline initiative was to develop evidence-based recommendations for important areas of controversy in SCI and ISCI in hopes of improving neurological outcomes, reducing morbidity, and standardizing care across settings. Throughout this process, critical knowledge gaps and future directions were also defined.
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Affiliation(s)
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - Michael G Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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21
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Hejrati N, Moghaddamjou A, Pedro K, Alvi MA, Harrop JS, Guest JD, Kwon BK, Fehlings MG. Current Practice of Acute Spinal Cord Injury Management: A Global Survey of Members from the AO Spine. Global Spine J 2024; 14:546-560. [PMID: 36036628 PMCID: PMC10802552 DOI: 10.1177/21925682221116888] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Cross-sectional, international survey. OBJECTIVES To examine current international practices as well as knowledge, adoption, and barriers to guideline implementation for acute spinal cord injury (SCI) management. METHODS A survey was distributed to members of AO Spine. The questionnaire was structured to obtain demographic data and preferred acute SCI practices surrounding steroid use, hemodynamic management, and timing of surgical decompression. RESULTS 593 members completed the survey including orthopaedic surgeons (54.3%), neurosurgeons (35.6%), and traumatologists (8.4%). Most (61.2%) respondents were from low and middle-income countries (LMICs). 53.6% of physicians used steroids for the treatment of acute SCIs. Respondents from LMICs were more likely to administer steroids than HICs (178 vs. 78; P < .001). 331 respondents (81.5%) answered that patients would receive mean arterial pressure (MAP) targeted treatment. In LMICs, SCI patients were less likely to be provided with MAP-targeted treatment (76.9%) as compared to HICs (89%; P < .05). The majority of respondents (87.8%) reported that patients would benefit from early decompression. Despite overwhelming evidence and surgeons' responses that would offer early surgery, 62.4% of respondents stated they encounter logistical barriers in their institutions. This was particularly evident in LMICs, where 57.9% of respondents indicated that early intervention was unlikely to be accomplished, while only 21.1% of respondents from HICs stated the same (P < .001). CONCLUSION This survey highlights challenges in the implementation of standardized global practices in the management of acute SCI. Future research efforts will need to refine SCI guidelines and address barriers to guideline implementation.
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Affiliation(s)
- Nader Hejrati
- Division of Neurosurgery and Spine Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ali Moghaddamjou
- Division of Neurosurgery and Spine Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Karlo Pedro
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - James S. Harrop
- Department of Neurological and Orthopedic Surgery, Division of Spine and Peripheral Nerve Surgery, Delaware Valley SCI Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - James D. Guest
- Neurological Surgery and the Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Brian K. Kwon
- Department of Orthopaedics, International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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Raisch P, Pflästerer J, Kreinest M, Vetter SY, Grützner PA, Jung MK. Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02458-2. [PMID: 38363327 DOI: 10.1007/s00068-024-02458-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/22/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors. METHODS Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant. RESULTS Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions. CONCLUSION sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.
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Affiliation(s)
- Philipp Raisch
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Jan Pflästerer
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Michael Kreinest
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Sven Y Vetter
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Paul A Grützner
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Matthias K Jung
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany.
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23
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Carabini LM, Koski TR, Bebawy JF. Perioperative Management for Complex Spine Fusion Surgery. Anesthesiology 2024; 140:293-303. [PMID: 38048486 DOI: 10.1097/aln.0000000000004744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Complex spine surgeries performed worldwide continue to increase in number, as do the age and comorbidity of patients undergoing these operations. Perioperative care protocols related to blood management, postoperative pain control, and intraoperative measures to mitigate morbidity may improve clinical workflows and patient outcomes.
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Affiliation(s)
- Louanne M Carabini
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tyler R Koski
- Departments of Neurological Surgery and Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John F Bebawy
- Departments of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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24
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Izzy S. Traumatic Spinal Cord Injury. Continuum (Minneap Minn) 2024; 30:53-72. [PMID: 38330472 PMCID: PMC10869103 DOI: 10.1212/con.0000000000001392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article provides a review of the initial clinical and radiologic evaluation and treatment of patients with traumatic spinal cord injuries. It specifically highlights essential knowledge for neurologists who encounter patients with these complex injuries. LATEST DEVELOPMENTS There has been improvement in the care of patients with traumatic spinal cord injuries, particularly in the prehospital evaluation, approach for immediate immobilization, standardized spinal clearance, efficient triage, and transportation of appropriate patients to traumatic spinal cord injury specialized centers. Advancements in spinal instrumentation have improved the surgical management of spinal fractures and the ability to manage patients with spinal mechanical instability. The clinical evidence favors performing early surgical decompression and spine stabilization within 24 hours of traumatic spinal cord injuries, regardless of the severity or location of the injury. There is no evidence that supports the use of neuroprotective treatments to improve outcomes in patients with traumatic spinal cord injuries. The administration of high-dose methylprednisolone, which is associated with significant systemic adverse effects, is strongly discouraged. Early and delayed mortality rates continue to be high in patients with traumatic spinal cord injuries, and survivors often confront substantial long-term physical and functional impairments. Whereas the exploration of neuroregenerative approaches, such as stem cell transplantation, is underway, these methods remain largely investigational. Further research is still necessary to advance the functional recovery of patients with traumatic spinal cord injuries. ESSENTIAL POINTS Traumatic spinal cord injury is a complex and devastating condition that leads to long-term neurologic deficits with profound physical, social, and vocational implications, resulting in a diminished quality of life, particularly for severely affected patients. The initial management of traumatic spinal cord injuries demands comprehensive interdisciplinary care to address the potentially catastrophic multisystem effects. Ongoing endeavors are focused on optimizing and customizing initial management approaches and developing effective therapies for neuroprotection and neuroregeneration to enhance long-term functional recovery.
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25
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Raisch P, Pflästerer J, Kreinest M, Vetter SY, Grützner PA, Jung MK. Secondary Dislocations in Type B and C Injuries of the Subaxial Cervical Spine: Risk Factors and Treatment. J Clin Med 2024; 13:700. [PMID: 38337392 PMCID: PMC10856098 DOI: 10.3390/jcm13030700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/07/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION This study analyzed the incidence of secondary dislocations (sDLs) after surgical stabilization of AO Spine type B and C injuries of the subaxial cervical spine (sCS). MATERIALS AND METHODS Patients treated for injuries of the sCS from 2010 to 2020 were retrospectively analyzed for the incidence of sDL within 60 days after first surgery. A univariate analysis of variables potentially influencing the risk of sDL was performed. Patients with solitary anterior stabilization underwent subgroup analysis. The treatment of sDLs was described. RESULTS A total of 275 patients were included. sDLs occurred in 4.0% of patients (n = 11) in the total sample, most frequently after solitary anterior stabilization with 8.0% (n = 10, p = 0.010). Only one sDL occurred after combined stabilization and no sDLs after posterior stabilization. In the total sample and the anterior subgroup, variables significantly associated with sDL were older age (p = 0.001) and concomitant unstable facet joint injury (p = 0.020). No neurological deterioration occurred due to sDL and most patients were treated with added posterior stabilization. sDL is frequent after solitary anterior stabilization and rare after posterior or combined stabilization. DISCUSSION Patients of higher age and with unstable facet joint injuries should be followed up diligently to detect sDLs in time. Neurological deterioration does not regularly occur due to sDL, and most patients can be treated with added posterior stabilization.
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Affiliation(s)
| | | | | | | | | | - Matthias K. Jung
- Department for Trauma and Orthopaedic Surgery, University of Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany; (P.R.); (J.P.); (M.K.); (S.Y.V.); (P.A.G.)
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26
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Routkevitch D, Soulé Z, Kats N, Baca E, Hersh AM, Kempski-Leadingham KM, Menta AK, Bhimreddy M, Jiang K, Davidar AD, Smit C, Theodore N, Thakor NV, Manbachi A. Non-contrast ultrasound image analysis for spatial and temporal distribution of blood flow after spinal cord injury. Sci Rep 2024; 14:714. [PMID: 38184676 PMCID: PMC10771432 DOI: 10.1038/s41598-024-51281-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/03/2024] [Indexed: 01/08/2024] Open
Abstract
Ultrasound technology can provide high-resolution imaging of blood flow following spinal cord injury (SCI). Blood flow imaging may improve critical care management of SCI, yet its duration is limited clinically by the amount of contrast agent injection required for high-resolution, continuous monitoring. In this study, we aim to establish non-contrast ultrasound as a clinically translatable imaging technique for spinal cord blood flow via comparison to contrast-based methods and by measuring the spatial distribution of blood flow after SCI. A rodent model of contusion SCI at the T12 spinal level was carried out using three different impact forces. We compared images of spinal cord blood flow taken using both non-contrast and contrast-enhanced ultrasound. Subsequently, we processed the images as a function of distance from injury, yielding the distribution of blood flow through space after SCI, and found the following. (1) Both non-contrast and contrast-enhanced imaging methods resulted in similar blood flow distributions (Spearman's ρ = 0.55, p < 0.0001). (2) We found an area of decreased flow at the injury epicenter, or umbra (p < 0.0001). Unexpectedly, we found increased flow at the periphery, or penumbra (rostral, p < 0.05; caudal, p < 0.01), following SCI. However, distal flow remained unchanged, in what is presumably unaffected tissue. (3) Finally, tracking blood flow in the injury zones over time revealed interesting dynamic changes. After an initial decrease, blood flow in the penumbra increased during the first 10 min after injury, while blood flow in the umbra and distal tissue remained constant over time. These results demonstrate the viability of non-contrast ultrasound as a clinical monitoring tool. Furthermore, our surprising observations of increased flow in the injury periphery pose interesting new questions about how the spinal cord vasculature reacts to SCI, with potentially increased significance of the penumbra.
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Affiliation(s)
- Denis Routkevitch
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Zoe Soulé
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Nicholas Kats
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Emily Baca
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew M Hersh
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kelley M Kempski-Leadingham
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Arjun K Menta
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Meghana Bhimreddy
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kelly Jiang
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - A Daniel Davidar
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Constantin Smit
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nitish V Thakor
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Amir Manbachi
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
- HEPIUS Innovation Laboratory, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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27
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Adegeest CY, Ter Wengel PV, Peul WC. Traumatic spinal cord injury: acute phase treatment in critical care. Curr Opin Crit Care 2023; 29:659-665. [PMID: 37909371 DOI: 10.1097/mcc.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW Surgical timing in traumatic spinal cord injury (t-SCI) remains a point of debate. Current guidelines recommend surgery within 24 h after trauma; however, earlier timeframes are currently intensively being investigated. The aim of this review is to provide an insight on the acute care of patients with t-SCI. RECENT FINDINGS Multiple studies show that there appears to be a beneficial effect on neurological recovery of early surgical decompression within 24 h after trauma. Currently, the impact of ultra-early surgery is less clear as well as lacking evidence for the most optimal surgical technique. Nevertheless, early surgery to decompress the spinal cord by whatever method can impact the occurrence for perioperative complications and potentially expedite rehabilitation. There are clinical and socioeconomic barriers in achieving timely and adequate surgical interventions for t-SCI. SUMMARY In this review, we provide an overview of the recent insights of surgical timing in t-SCI and the current barriers in acute t-SCI treatment.
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Affiliation(s)
- Charlotte Y Adegeest
- University Neurosurgical Center Holland (UNCH), LUMC | HMC | HAGA, Leiden-The Hague, the Netherlands
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28
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Botchway-Commey E, Muscara F, Greenham M, D'Cruz K, Bonyhady B, Anderson V, Scheinberg A, Knight S. Rehabilitation models of care for children and youth with traumatic brain and/or spinal cord injuries: A focus on service structure, service organization, and the barriers and facilitators of rehabilitation service provision. Neuropsychol Rehabil 2023; 33:1697-1727. [PMID: 36423210 DOI: 10.1080/09602011.2022.2147196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/08/2022] [Indexed: 11/25/2022]
Abstract
To understand the systems underlying current rehabilitation models of care used with children and youth (0-21years) who sustain traumatic brain and/or spinal cord injuries. This study gathered qualitative data on service structures, service organization, and the barriers and facilitators of service provision in selected medical rehabilitation service(s) (MRS) and community-based rehabilitation service(s) (CBRS). Informants from 11 rehabilitation services were interviewed using a semi-structured interview guide. Interviews were analysed in NVivo using content analysis method. Experiences shared by the service representatives indicated that most services supported children and youth with brain injury, with a limited number also specializing in spinal cord injuries. MRS often delivered care in inpatient or outpatient settings, while CBRS offered home/community-based services. Care planning often started either prior to or shortly after admission from acute care settings, using either multidisciplinary or interdisciplinary teamwork models. Strengths of the services included innovation and provision of family-centred care; while challenges experienced included difficulty translating evidence into practice and poor team communication. Models of care were similar across services, with a focus on providing family-centred care. Several shared challenges were described, and service representatives expressed interest in forming partnerships and collaborations to address these challenges through innovative initiatives.
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Affiliation(s)
- Edith Botchway-Commey
- Brain and Mind, Clinical Sciences, Murdoch Children's Research Institute, Parkville, Australia
- The Royal Children's Hospital, Parkville, Australia
| | - Frank Muscara
- Brain and Mind, Clinical Sciences, Murdoch Children's Research Institute, Parkville, Australia
- The Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Mardee Greenham
- Brain and Mind, Clinical Sciences, Murdoch Children's Research Institute, Parkville, Australia
| | - Kate D'Cruz
- Department of Occupational Therapy, Social Work and Social Policy, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
| | - Bruce Bonyhady
- Melbourne Disability Institute, University of Melbourne, Melbourne, Australia
| | - Vicki Anderson
- Brain and Mind, Clinical Sciences, Murdoch Children's Research Institute, Parkville, Australia
- The Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Adam Scheinberg
- Brain and Mind, Clinical Sciences, Murdoch Children's Research Institute, Parkville, Australia
- The Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
- Victorian Paediatric Rehabilitation Service, Parkville, Australia
| | - Sarah Knight
- Brain and Mind, Clinical Sciences, Murdoch Children's Research Institute, Parkville, Australia
- The Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
- Victorian Paediatric Rehabilitation Service, Parkville, Australia
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29
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Zhou Q, He W, Lv J, Liu H, Yang H, Zhang J, Liu T. Benefits of Early Surgical Treatment for Patients with Multilevel Cervical Canal Stenosis of Acute Traumatic Central Cord Syndrome. Orthop Surg 2023; 15:3092-3100. [PMID: 37771121 PMCID: PMC10694011 DOI: 10.1111/os.13904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/27/2023] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Currently, there exists considerable debate surrounding the optimal treatment approaches for different subtypes of patients with spinal cord injury (SCI). The purpose of this study was to conduct a comparative analysis of the benefits associated with conservative treatment and treatments with different surgical periods for patients diagnosed with acute traumatic central cord syndrome (ATCCS) and multilevel cervical canal stenosis (CCS). METHODS A retrospective cohort study was conducted, and 93 patients who met inclusion and exclusion criteria in our hospital between 2015 and 2020 were followed for a minimum duration of 2 years. Among them, 30 patients (Group A) received conservative treatment, 18 patients (Group B) received early surgery (≤7 days), and 45 patients (Group C) received late surgery (>7 days). The American Spinal Injury Association (ASIA) grade, Japanese Orthopedic Association (JOA) score, and recovery rate (RR) were evaluated. Multivariate linear regression was used to analyze prognostic determinants. Cost-utility analysis was performed based on the EQ-5D scale. RESULTS The ASIA grade, JOA score, and RR of all three groups improved compared with the previous evaluation (P < 0.05). During follow-up, the ASIA grade, JOA score, and RR of Group B were all better than for Group A and Group C (P < 0.05), while there was no significant difference between Group A and C (P > 0.05). The EQ-5D scale in Group B was optimal at the last follow-up. The incremental cost-utility ratio (ICUR) of Group A was the lowest, while that of Group B compared to Group A was less than the threshold of patients' willingness to pay. Age, initial ASIA grade, and treatment types significantly affected the outcomes. CONCLUSIONS Both conservative and surgical treatments yield good results. Compared with patients who received conservative treatment and late surgery, patients who received early surgery had better clinical function and living quality. Despite the higher cost, early surgery is cost-effective when compared to conservative treatment. Younger age, initial better ASIA grade, and earlier surgery were associated with better prognosis.
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Affiliation(s)
- Quan Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Wei He
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Jiaheng Lv
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Hao Liu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Huilin Yang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Junxin Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
| | - Tao Liu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow UniversitySoochow UniversitySuzhouChina
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30
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Kijima K, Ono G, Kobayakawa K, Saiwai H, Hara M, Yoshizaki S, Yokota K, Saito T, Tamaru T, Iura H, Haruta Y, Kitade K, Utsunomiya T, Konno D, Edgerton VR, Liu CY, Sakai H, Maeda T, Kawaguchi K, Matsumoto Y, Okada S, Nakashima Y. Zinc deficiency impairs axonal regeneration and functional recovery after spinal cord injury by modulating macrophage polarization via NF-κB pathway. Front Immunol 2023; 14:1290100. [PMID: 38022538 PMCID: PMC10666775 DOI: 10.3389/fimmu.2023.1290100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Spinal cord injury (SCI) is a devastating disease that results in permanent paralysis. Currently, there is no effective treatment for SCI, and it is important to identify factors that can provide therapeutic intervention during the course of the disease. Zinc, an essential trace element, has attracted attention as a regulator of inflammatory responses. In this study, we investigated the effect of zinc status on the SCI pathology and whether or not zinc could be a potential therapeutic target. Methods We created experimental mouse models with three different serum zinc concentration by changing the zinc content of the diet. After inducing contusion injury to the spinal cord of three mouse models, we assessed inflammation, apoptosis, demyelination, axonal regeneration, and the number of nuclear translocations of NF-κB in macrophages by using qPCR and immunostaining. In addition, macrophages in the injured spinal cord of these mouse models were isolated by flow cytometry, and their intracellular zinc concentration level and gene expression were examined. Functional recovery was assessed using the open field motor score, a foot print analysis, and a grid walk test. Statistical analysis was performed using Wilcoxon rank-sum test and ANOVA with the Tukey-Kramer test. Results In macrophages after SCI, zinc deficiency promoted nuclear translocation of NF-κB, polarization to pro-inflammatory like phenotype and expression of pro-inflammatory cytokines. The inflammatory response exacerbated by zinc deficiency led to worsening motor function by inducing more apoptosis of oligodendrocytes and demyelination and inhibiting axonal regeneration in the lesion site compared to the normal zinc condition. Furthermore, zinc supplementation after SCI attenuated these zinc-deficiency-induced series of responses and improved motor function. Conclusion We demonstrated that zinc affected axonal regeneration and motor functional recovery after SCI by negatively regulating NF-κB activity and the subsequent inflammatory response in macrophages. Our findings suggest that zinc supplementation after SCI may be a novel therapeutic strategy for SCI.
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Affiliation(s)
- Ken Kijima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Neurorestoration Center, University of Southern California, Los Angeles, CA, United States
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Gentaro Ono
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazu Kobayakawa
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirokazu Saiwai
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masamitsu Hara
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shingo Yoshizaki
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuya Yokota
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeyuki Saito
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuya Tamaru
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirotaka Iura
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yohei Haruta
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuki Kitade
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Utsunomiya
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daijiro Konno
- Department of Energy and Materials, Faculty of Science and Engineering, Kindai University, Osaka, Japan
| | - V. Reggie Edgerton
- Neurorestoration Center, University of Southern California, Los Angeles, CA, United States
- Rancho Research Institute, Los Amigos National Rehabilitation Center, Downey, CA, United States
- Institut Guttmann. Hospital de Neurorehabilitació, Institut Universitari adscrit a la Universitat Autònoma de Barcelona, Barcelona, Badalona, Spain
| | - Charles Y. Liu
- Neurorestoration Center, University of Southern California, Los Angeles, CA, United States
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Rancho Research Institute, Los Amigos National Rehabilitation Center, Downey, CA, United States
| | - Hiroaki Sakai
- Department of Orthopaedic Surgery, Spinal Injuries Center, Iizuka, Japan
| | - Takeshi Maeda
- Department of Orthopaedic Surgery, Spinal Injuries Center, Iizuka, Japan
| | - Kenichi Kawaguchi
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Fukushima Medical University, Fukushima, Japan
| | - Seiji Okada
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasuharu Nakashima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Lv Q, Zhang X, Guo K, Hu D, Deng Z. Risk Factors for Pulmonary Infection and Nursing Interventions Post-Tracheostomy in Patients with Spinal Cord Injury. Infect Drug Resist 2023; 16:6691-6701. [PMID: 37854469 PMCID: PMC10581007 DOI: 10.2147/idr.s418894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/21/2023] [Indexed: 10/20/2023] Open
Abstract
Objective We analyzed the characteristics and risk factors for pulmonary infection in patients with spinal cord injury who underwent tracheostomy and propose measures to help in early detection and intervention to reduce mortality and improve prognosis. Methods We collected data retrospectively from January 1, 2018, to December 31, 2022. The inclusion criteria were: Patients aged 18 years or more with a spinal cord injury who underwent tracheostomy, were treated with mechanical ventilation for over 48 hours, and were diagnosed as having a pulmonary infection. Sputum samples were cultured and analyzed. Results 101 cases of pulmonary infection were analyzed, and the incidence was 32.17%. Diabetes (OR 2.302, 95% CI 1.285-3.972), hypoproteinemia (OR 1.992, 95% CI 1.125-3.101), administration of glucocorticoids (OR 2.934, 95% CI 1.412-4.661), ASIA grade A (OR 3.672, 95% CI 1.988-5.046), mechanical ventilation for ≥ 6 days (OR 2.108, 95% CI 1.385-4.751), and length of hospital stay for ≥ 20 days (OR 2.137, 95% CI 1.092-3.842) were risk factors for pulmonary infection in patients with spinal cord injury post-tracheostomy. Among 213 pathogenic bacteria, 52 (51.48%) were Gram-negative and 24 (23.76%) were Gram-positive. Klebsiella pneumoniae (15.84%) and Staphylococcus aureus (8.91%) were the most common pathogenic bacteria. The mortality rate of patients with gram-positive infection was higher than that of patients with gram-negative infection. K. pneumoniae and S. aureus were sensitive to cefoperazone, meropenem, and levofloxacin. Conclusion Pulmonary infection is a complication post-tracheostomy in patients with spinal cord injury. Diabetes, hypoproteinemia, administration of glucocorticoids, mechanical ventilation for ≥ 6 days, length of hospital stay for ≥ 20 days were risk factors for pulmonary infection. Pulmonary infection was mainly caused by gram-negative bacteria. Timely and effective measures for managing risk factors are essential for improving the prognosis of pulmonary infection post-tracheostomy in patients with spinal cord injuries.
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Affiliation(s)
- Qin Lv
- Department of Emergency, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050051, People’s Republic of China
| | - Xinliang Zhang
- Department of Emergency, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050051, People’s Republic of China
| | - Kucun Guo
- Department of Emergency, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050051, People’s Republic of China
| | - Dezheng Hu
- Department of Emergency, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050051, People’s Republic of China
| | - Zhuojun Deng
- Department of General Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province, 050000, People’s Republic of China
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Cloney MB, Texakalidis P, Roumeliotis AG, Tecle NE, Dahdaleh NS. Atlas fractures with and without simultaneous dens fractures differ with respect to clinical, demographic, and management characteristics. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:418-425. [PMID: 38268695 PMCID: PMC10805171 DOI: 10.4103/jcvjs.jcvjs_126_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 10/16/2023] [Indexed: 01/26/2024] Open
Abstract
Background Patients with simultaneous fractures of the atlas and dens have traditionally been managed according to the dens fracture's morphology, but data supporting this practice are limited. Methods We retrospectively examined all patients with traumatic atlas fractures at our institution between 2008 and 2016. We used multivariable regression and propensity score matching to compare the presentation, management, and outcomes of patients with isolated atlas fractures to patients with simultaneous atlas-dens fractures. Results Ninety-nine patients were identified. Patients with isolated atlas fractures were younger (61 ± 22 vs. 77 ± 14, P = 0.0003), had lower median Charlson Comorbidity Index (3 vs. 5, P = 0.0005), had better presenting Nurick myelopathy scores (0 vs. 3, P < 0.0001), and had different mechanisms of injury (P = 0.0011). Multivariable regression showed that having a simultaneous atlas-dens fracture was independently associated with older age (odds ratio [OR] =1.59 [1.22, 2.07], P = 0.001), worse presenting myelopathy (OR = 3.10 [2.04, 4.16], P < 0.001), and selection for surgery (OR = 4.91 [1.10, 21.97], P = 0.037). Propensity score matching yielded balanced populations (Rubin's B = 23.3, Rubin's R = 1.96) and showed that the risk of atlas fracture nonunion was no different among isolated atlas fractures compared to simultaneous atlas-dens fractures (P = 0.304). Age was the only variable independently associated with atlas fracture nonunion (OR = 2.39 [1.15, 5.00], P = 0.020), having a simultaneous atlas-dens fracture was not significant (P = 0.2829). Conclusions Among patients with atlas fractures, simultaneous fractures of the dens occur in older patients and confer an increased risk of myelopathy and requiring surgical stabilization. Controlling for confounders, the risk of atlas fracture nonunion is equivalent for isolated atlas fractures versus simultaneous atlas-dens fractures.
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Affiliation(s)
- Michael Brendan Cloney
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Pavlos Texakalidis
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Anastasios G Roumeliotis
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Najib El Tecle
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Nader S. Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
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Garside T, Stanford R, Flower O, Li T, Dababneh E, Hammond N, Bass F, Middleton J, Tang J, Ball J, Delaney A. Acute assessment of spinal cord injury in New South Wales: A retrospective study of current practice in two spinal cord injury referral centers. J Spinal Cord Med 2023:1-8. [PMID: 37707355 DOI: 10.1080/10790268.2023.2247625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Interventions provided in the early phases after spinal cord injury (SCI) may improve neurological recovery and provide for best possible functional outcomes. Knowing this relies on early and clear documentation of the level and grade of the spinal cord injury. Guidelines advocate for early documentation of neurological status within 72 h of injury to allow early prognostication and to help guide initial management. It is unclear whether this is current practice in New South Wales (NSW). METHODS Patients with acute SCI who were admitted to two SCI referral centers during 2018-2019 in NSW were included. Data relating to documentation of neurological status, timing of imaging, surgery and transfer to spinal cord injury center were collected and summarized using descriptive statistics. RESULTS Only 18 percent of patients had an acceptable neurological examination according to the International Standards for Classification of Spinal Cord Injury (ISNCSCI) within 72 h of injury (either not done, or unable to determine the neurological level of injury). At the first neurological examination, the neurological level of injury and grade was unable to be determined in 26.8% of patients and 29.9% of patients respectively. At discharge from acute care and transfer to rehabilitation, the neurological level was undetermined in 28.9% of patients and grade undetermined in 26.8%. ISNCSCI examination was most commonly performed by spinal rehabilitation doctors after patients were discharged from the intensive care unit (ICU). CONCLUSIONS Documentation of neurological level and grade of SCI within 72 h of injury is not being performed in the large majority of this cohort, which may impede evaluation of neurological improvement in response to acute treatment, and hinder prognostication.
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Affiliation(s)
- Tessa Garside
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - Ralph Stanford
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Oliver Flower
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Trent Li
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Edward Dababneh
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - Frances Bass
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
| | - James Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and The University of Sydney, Sydney, Australia
| | - Jonathan Tang
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Jonathan Ball
- Department of Neurosurgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- The George Institute, Newtown, New South Wales, Australia
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Zhou Z, Luo H, Yu H, Liu Z, Zhong J, Xiong J, Cao K. Ferrostatin-1 facilitated neurological functional rehabilitation of spinal cord injury mice by inhibiting ferroptosis. Eur J Med Res 2023; 28:336. [PMID: 37697399 PMCID: PMC10494332 DOI: 10.1186/s40001-023-01264-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/03/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND To seek the potential therapy for spinal cord injury, Ferrostatin-1, the first ferroptosis inhibitor, was administrated in spinal cord injury mice to identify the therapeutic effect. METHODS Spinal cord injury model was established by a modified Allen's method. Then, ferrostatin-1 was administrated by intraspinal injection. Cortical evoked motor potential and BMS were indicated to assess the neurological function rehabilitation. H&E, Nissl's staining, NeuN, and GFAP immunofluorescence were used to identify the histological manifestation on the mice with the injured spinal cord. Spinosin, a selective small molecule activator of the Nrf2/HO-1 signaling pathway, was administrated to verify the underlying mechanism of ferrostatin-1. RESULTS Ferrostatin-1 promoted the rehabilitation of cortical evoked motor potential and BMS scores, synchronized with improvement in the histological manifestation of neuron survival and scar formation. Spinosin disturbed the benefits of ferrostatin-1 administration on histological and neurobehavioral manifestation by deranging the Nrf2/HO-1 signaling pathway. CONCLUSIONS Ferrostatin-1 improved the rehabilitation of spinal cord injury mice by regulating ferroptosis through the Nrf2/HO-1 signaling pathway.
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Affiliation(s)
- Zhenhai Zhou
- The Orthopaedic Hospital, The First Affiliated Hospital of Nanchang University, #1519 Dongyue Avenue, Nanchang, 330052, China
- Institute of Spine and Spinal Cord, Nanchang University, Nanchang, China
| | - Hao Luo
- The Orthopaedic Hospital, The First Affiliated Hospital of Nanchang University, #1519 Dongyue Avenue, Nanchang, 330052, China
| | - Honggui Yu
- The Orthopaedic Hospital, The First Affiliated Hospital of Nanchang University, #1519 Dongyue Avenue, Nanchang, 330052, China
- Institute of Spine and Spinal Cord, Nanchang University, Nanchang, China
| | - Zhiming Liu
- The Orthopaedic Hospital, The First Affiliated Hospital of Nanchang University, #1519 Dongyue Avenue, Nanchang, 330052, China
| | - Junlong Zhong
- The Orthopaedic Hospital, The First Affiliated Hospital of Nanchang University, #1519 Dongyue Avenue, Nanchang, 330052, China
- Institute of Spine and Spinal Cord, Nanchang University, Nanchang, China
| | - Jiachao Xiong
- The Orthopaedic Hospital, The First Affiliated Hospital of Nanchang University, #1519 Dongyue Avenue, Nanchang, 330052, China
- Institute of Spine and Spinal Cord, Nanchang University, Nanchang, China
| | - Kai Cao
- The Orthopaedic Hospital, The First Affiliated Hospital of Nanchang University, #1519 Dongyue Avenue, Nanchang, 330052, China.
- Institute of Spine and Spinal Cord, Nanchang University, Nanchang, China.
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Zhou R, Li J, Wang R, Chen Z, Zhou F. The neurovascular unit in healthy and injured spinal cord. J Cereb Blood Flow Metab 2023; 43:1437-1455. [PMID: 37190756 PMCID: PMC10414016 DOI: 10.1177/0271678x231172008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/09/2023] [Accepted: 03/24/2023] [Indexed: 05/17/2023]
Abstract
The neurovascular unit (NVU) reflects the close temporal and spatial link between neurons and blood vessels. However, the understanding of the NVU in the spinal cord is far from clear and largely based on generalized knowledge obtained from the brain. Herein, we review the present knowledge of the NVU and highlight candidate approaches to investigate the NVU, particularly focusing on the spinal cord. Several unique features maintain the highly regulated microenvironment in the NVU. Autoregulation and neurovascular coupling ensure regional blood flow meets the metabolic demand according to the blood supply or local neural activation. The blood-central nervous system barrier partitions the circulating blood from neural parenchyma and facilitates the selective exchange of substances. Furthermore, we discuss spinal cord injury (SCI) as a common injury from the perspective of NVU dysfunction. Hopefully, this review will help expand the understanding of the NVU in the spinal cord and inspire new insights into SCI.
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Affiliation(s)
- Rubing Zhou
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Neuroscience Research Institute and Department of Neurobiology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Junzhao Li
- Neuroscience Research Institute and Department of Neurobiology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Ruideng Wang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Zhengyang Chen
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Fang Zhou
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
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Lambrechts MJ, Issa TZ, Hilibrand AS. Updates in the Early Management of Acute Spinal Cord Injury. J Am Acad Orthop Surg 2023; 31:e619-e632. [PMID: 37432977 DOI: 10.5435/jaaos-d-23-00281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future.
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Affiliation(s)
- Mark J Lambrechts
- From the Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
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Quddusi A, Pedro KM, Alvi MA, Hejrati N, Fehlings MG. Early surgical intervention for acute spinal cord injury: time is spine. Acta Neurochir (Wien) 2023; 165:2665-2674. [PMID: 37468659 DOI: 10.1007/s00701-023-05698-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/28/2023] [Indexed: 07/21/2023]
Abstract
Acute traumatic spinal cord injury (tSCI) is a devastating occurrence that significantly contributes to global morbidity and mortality. Surgical decompression with stabilization is the most effective way to minimize the damaging sequelae that follow acute tSCI. In recent years, strong evidence has emerged that supports the rationale that early surgical intervention, within 24 h following the initial injury, is associated with a better prognosis and functional outcomes. In this review, we have summarized the evidence and elaborated on the nuances of this concept. Additionally, we have reviewed further concepts that stem from "time is spine," including earlier cutoffs less than 24 h and the challenging entity of central cord syndrome, as well as the emerging concept of adequate surgical decompression. Lastly, we identify barriers to early surgical care for acute tSCI, a key aspect of spine care that needs to be globally addressed via research and policy on an urgent basis.
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Affiliation(s)
- Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Karlo M Pedro
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nader Hejrati
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.
- Toronto Western Hospital, 399 Bathurst Street, Suite 4WW-449, Toronto, ON, M5T 2S8, Canada.
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Cunha NSC, Malvea A, Sadat S, Ibrahim GM, Fehlings MG. Pediatric Spinal Cord Injury: A Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1456. [PMID: 37761417 PMCID: PMC10530251 DOI: 10.3390/children10091456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023]
Abstract
A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.
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Affiliation(s)
| | - Anahita Malvea
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON M5T 2S8, Canada;
| | - Sarah Sadat
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - George M. Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON M5G 1E8, Canada;
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON M5T 2S8, Canada;
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
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Wathen CA, Ghenbot YG, Ozturk AK, Cullen DK, O’Donnell JC, Petrov D. Porcine Models of Spinal Cord Injury. Biomedicines 2023; 11:2202. [PMID: 37626699 PMCID: PMC10452184 DOI: 10.3390/biomedicines11082202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/23/2023] [Accepted: 07/29/2023] [Indexed: 08/27/2023] Open
Abstract
Large animal models of spinal cord injury may be useful tools in facilitating the development of translational therapies for spinal cord injury (SCI). Porcine models of SCI are of particular interest due to significant anatomic and physiologic similarities to humans. The similar size and functional organization of the porcine spinal cord, for instance, may facilitate more accurate evaluation of axonal regeneration across long distances that more closely resemble the realities of clinical SCI. Furthermore, the porcine cardiovascular system closely resembles that of humans, including at the level of the spinal cord vascular supply. These anatomic and physiologic similarities to humans not only enable more representative SCI models with the ability to accurately evaluate the translational potential of novel therapies, especially biologics, they also facilitate the collection of physiologic data to assess response to therapy in a setting similar to those used in the clinical management of SCI. This review summarizes the current landscape of porcine spinal cord injury research, including the available models, outcome measures, and the strengths, limitations, and alternatives to porcine models. As the number of investigational SCI therapies grow, porcine SCI models provide an attractive platform for the evaluation of promising treatments prior to clinical translation.
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Affiliation(s)
- Connor A. Wathen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Yohannes G. Ghenbot
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Ali K. Ozturk
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
| | - D. Kacy Cullen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - John C. O’Donnell
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Dmitriy Petrov
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.A.W.); (Y.G.G.); (A.K.O.); (D.K.C.); (J.C.O.)
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Song Y, Guo L, Jiang X, Dong M, Xiang D, Wen M, He S, Yuan Y, Lin F, Zhao G, Liu L, Liao J. Meglumine cyclic adenylate improves cardiovascular hemodynamics and motor-function in a rat model of acute T4 thoracic spinal cord injury. Spinal Cord 2023; 61:422-429. [PMID: 37402893 DOI: 10.1038/s41393-023-00909-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 05/26/2023] [Accepted: 06/26/2023] [Indexed: 07/06/2023]
Abstract
STUDY DESIGN Animal experimental study. OBJECTIVES Spinal cord injury (SCI) at or above the T6 level causes cardiovascular dysfunction. Maintaining cAMP levels with cAMP analogs can facilitate neurological recovery. In the present study, the effects of meglumine cyclic adenylate (MCA), a cAMP analog and approved cardiovascular drug, on cardiovascular and neurological recovery in acute T4-SCI in rats were investigated. SETTING Hospital in Kunming, China. METHODS Eighty rats were randomly allocated to five groups, and groups A-D received SCI: (A) a group administered MCA at 2 mg/kg/d iv qd, (B) a group administered dopamine at 2.5 to 5 μg/kg/min iv to maintain mean arterial pressure above 85 mm Hg, (C) a group administered atropine at 1 mg/kg iv bid, (D) a group receiving an equal volume of saline iv qd for 3 weeks after SCI and (E) a group undergoing laminectomy only. The cardiovascular and behavioral parameters of the rats were examined, and spinal cord tissues were processed for hematoxylin and eosin staining, Nissl staining, electron microscopy, and analysis of cAMP levels. RESULTS Compared with dopamine or atropine, MCA significantly reversed the decrease in cAMP levels in both myocardial cells and the injured spinal cord; improved hypotension, bradycardia and behavioral parameters at 6 weeks; and improved spinal cord blood flow and histological structure at 7 days post-SCI. The regression analysis suggested spinal cord motor-function improved as decreased heart rate and mean arterial pressure were stopped post-SCI. CONCLUSIONS MCA may be an effective treatment for acute SCI by sustaining cAMP-dependent reparative processes and improving post-SCI cardiovascular dysfunction. SPONSORSHIP N/A.
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Affiliation(s)
- Yueming Song
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Limin Guo
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Xingxiong Jiang
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Minglin Dong
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Dong Xiang
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Ming Wen
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Shaoxuan He
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Yong Yuan
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Feng Lin
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Gang Zhao
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Luping Liu
- Department of Orthopedic Surgery, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Jingwu Liao
- Orthopedic-Traumatology Department, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China.
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Böcklein M, Beck M, Shmygalev S. [Distributive shock]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01304-1. [PMID: 37493826 DOI: 10.1007/s00101-023-01304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 07/27/2023]
Abstract
In shock there is a significant mismatch between oxygen supply and consumption. In recent years the classification of forms of shock has been established based on pathophysiological and clinical aspects. The term distributive shock includes septic, anaphylactic and neurogenic shock. All these forms share a distinct vasoplegia with a relative volume deficiency. The adequate treatment of patients with distributive shock includes a rapid diagnosis and a consistent emergency treatment consisting of volume and catecholamine administration as well as additional specific emergency procedures when necessary.
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Affiliation(s)
- M Böcklein
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland.
| | - M Beck
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland
| | - S Shmygalev
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Deutschland
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Montoto-Meijide R, Meijide-Faílde R, Díaz-Prado SM, Montoto-Marqués A. Mesenchymal Stem Cell Therapy in Traumatic Spinal Cord Injury: A Systematic Review. Int J Mol Sci 2023; 24:11719. [PMID: 37511478 PMCID: PMC10380897 DOI: 10.3390/ijms241411719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Recovery from a traumatic spinal cord injury (TSCI) is challenging due to the limited regenerative capacity of the central nervous system to restore cells, myelin, and neural connections. Cell therapy, particularly with mesenchymal stem cells (MSCs), holds significant promise for TSCI treatment. This systematic review aims to analyze the efficacy, safety, and therapeutic potential of MSC-based cell therapies in TSCI. A comprehensive search of PUBMED and COCHRANE databases until February 2023 was conducted, combining terms such as "spinal cord injury," "stem cells," "stem cell therapy," "mesenchymal stem cells," and "traumatic spinal cord injury". Among the 53 studies initially identified, 22 (21 clinical trials and 1 case series) were included. Findings from these studies consistently demonstrate improvements in AIS (ASIA Impairment Scale) grades, sensory scores, and, to a lesser extent, motor scores. Meta-analyses further support these positive outcomes. MSC-based therapies have shown short- and medium-term safety, as indicated by the absence of significant adverse events within the studied timeframe. However, caution is required when drawing generalized recommendations due to the limited scientific evidence available. Further research is needed to elucidate the long-term safety and clinical implications of these advancements. Although significant progress has been made, particularly with MSC-based therapies, additional studies exploring other potential future therapies such as gene therapies, neurostimulation techniques, and tissue engineering approaches are essential for a comprehensive understanding of the evolving TSCI treatment landscape.
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Affiliation(s)
- Rodrigo Montoto-Meijide
- Complejo Hospitalario Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain
| | - Rosa Meijide-Faílde
- Grupo de Investigación en Terapia Celular y Medicina Regenerativa, Instituto de Investigación Biomédica de A Coruña (INIBIC), Centro Interdisciplinar de Química y Biología (CICA), Universidade da Coruña, 15071 A Coruña, Spain
- Departamento de Fisioterapia, Medicina y Ciencias Biomédicas, Universidade da Coruña, 15071 A Coruña, Spain
| | - Silvia María Díaz-Prado
- Grupo de Investigación en Terapia Celular y Medicina Regenerativa, Instituto de Investigación Biomédica de A Coruña (INIBIC), Centro Interdisciplinar de Química y Biología (CICA), Universidade da Coruña, 15071 A Coruña, Spain
- Departamento de Fisioterapia, Medicina y Ciencias Biomédicas, Universidade da Coruña, 15071 A Coruña, Spain
| | - Antonio Montoto-Marqués
- Departamento de Fisioterapia, Medicina y Ciencias Biomédicas, Universidade da Coruña, 15071 A Coruña, Spain
- Unidad de Lesionados Medulares, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña, 15006 A Coruña, Spain
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Tao JW, Fan X, Zhou JY, Huo LY, Mo YJ, Bai HZ, Zhao Y, Ren JP, Mu XH, Xu L. Granulocyte colony-stimulating factor effects on neurological and motor function in animals with spinal cord injury: a systematic review and meta-analysis. Front Neurosci 2023; 17:1168764. [PMID: 37449274 PMCID: PMC10338098 DOI: 10.3389/fnins.2023.1168764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Spinal cord injury (SCI) is a severe neurological injury for which no effective treatment exists. Granulocyte colony-stimulating factor (G-CSF) is used to treat autologous bone marrow transplantation, chemotherapy-induced granulocytopenia, Acquired Immune Deficiency Syndrome (AIDS), etc. Recent research has revealed the potential application of G-CSF on neuroprotective effectiveness. In central nervous system diseases, G-CSF can be used to alleviate neuronal injury. Objective To investigate the effects of G-CSF on Basso, Beattie, and Bresnahan (BBB) scale score, inclined plane test, electrophysiologic exam, quantitative analysis of TUNEL-positive cells, and quantitative analysis of glial fibrillary acidic protein (GFAP) immunostaining images in animal models of SCI. Methods We searched PubMed, Web of Science, and Embase databases for all articles on G-CSF intervention with animal models of SCI reported before November 2022. A total of 20 studies met the inclusion criteria. Results Results revealed that G-CSF intervention could improve the BBB scale score in both groups at 3, 7, 14, 28, and 35 days [at 35 days, weighted mean differences (WMD) = 2.4, 95% CI: 1.92-2.87, p < 0.00001, I2 = 69%]; inclined plane test score; electrophysiologic exam; quantitative analysis of TUNEL-positive cell numbers; quantitative analysis of GFAP immunostaining images in animal models of SCI. Subgroup analysis revealed that treatment with normal saline, phosphate-buffered saline, and no treatment resulted in significantly different neurological function effectiveness compared to the G-CSF therapy. SD rats and Wistar rats with SCI resulted in significant neurological function effectiveness. C57BL/6 mice showed no difference in the final effect. The T9-T10 or T10 segment injury model and the T8-T9 or T9 segment injury model resulted in significant neurological function effectiveness. The BBB score data showed no clear funnel plot asymmetry. We found no bias in the analysis result (Egger's test, p = 0.42). In our network meta-analysis, the SUCRA ranking showed that 15 mg/kg-20 mg/kg was an optimal dose for long-term efficacy. Conclusion Our meta-analysis suggests that G-CSF therapy may enhance the recovery of motor activity and have a specific neuroprotective effect in SCI animal models.Systematic review registration: PROSPERO, identifier: CRD42023388315.
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Affiliation(s)
- Jing-Wei Tao
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Xiao Fan
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
- Qingdao Municipal Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Jing-Ya Zhou
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
| | - Lu-Yao Huo
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
| | - Yan-Jun Mo
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
| | - Hui-Zhong Bai
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
| | - Yi Zhao
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
| | - Jing-Pei Ren
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
| | - Xiao-Hong Mu
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
| | - Lin Xu
- Center for Orthopedic Surgery, Beijing University of Chinese Medicine Dongzhimen Hospital, Beijing, China
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Hu X, Xu W, Ren Y, Wang Z, He X, Huang R, Ma B, Zhao J, Zhu R, Cheng L. Spinal cord injury: molecular mechanisms and therapeutic interventions. Signal Transduct Target Ther 2023; 8:245. [PMID: 37357239 DOI: 10.1038/s41392-023-01477-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/22/2023] [Accepted: 05/07/2023] [Indexed: 06/27/2023] Open
Abstract
Spinal cord injury (SCI) remains a severe condition with an extremely high disability rate. The challenges of SCI repair include its complex pathological mechanisms and the difficulties of neural regeneration in the central nervous system. In the past few decades, researchers have attempted to completely elucidate the pathological mechanism of SCI and identify effective strategies to promote axon regeneration and neural circuit remodeling, but the results have not been ideal. Recently, new pathological mechanisms of SCI, especially the interactions between immune and neural cell responses, have been revealed by single-cell sequencing and spatial transcriptome analysis. With the development of bioactive materials and stem cells, more attention has been focused on forming intermediate neural networks to promote neural regeneration and neural circuit reconstruction than on promoting axonal regeneration in the corticospinal tract. Furthermore, technologies to control physical parameters such as electricity, magnetism and ultrasound have been constantly innovated and applied in neural cell fate regulation. Among these advanced novel strategies and technologies, stem cell therapy, biomaterial transplantation, and electromagnetic stimulation have entered into the stage of clinical trials, and some of them have already been applied in clinical treatment. In this review, we outline the overall epidemiology and pathophysiology of SCI, expound on the latest research progress related to neural regeneration and circuit reconstruction in detail, and propose future directions for SCI repair and clinical applications.
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Affiliation(s)
- Xiao Hu
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Wei Xu
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Yilong Ren
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Zhaojie Wang
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Xiaolie He
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Runzhi Huang
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Bei Ma
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Jingwei Zhao
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China
| | - Rongrong Zhu
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China.
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China.
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China.
| | - Liming Cheng
- Division of Spine, Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, 200065, Shanghai, China.
- Key Laboratory of Spine and Spinal cord Injury Repair and Regeneration (Tongji University), Ministry of Education, 200065, Shanghai, China.
- Clinical Center For Brain And Spinal Cord Research, Tongji University, 200065, Shanghai, China.
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Sekar A, Datta D, Lakha A, Jena SS, Bansal S, Sahu RN. Oral Midodrine as an Adjunct in Rapid Weaning of Intravenous Vasopressor Support in Spinal Cord Injury. Asian J Neurosurg 2023; 18:306-311. [PMID: 37397051 PMCID: PMC10310436 DOI: 10.1055/s-0043-1769755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Background Majority of acute cervical spinal cord injury end up requiring long-term stay in intensive care unit (ICU). During the initial few days after spinal cord injury, most patients are hemodynamically unstable requiring intravenous vasopressors. However, many studies have noted that long-term intravenous vasopressors remain the main reason for prolongation of ICU stay. In this series, we report the effect of using oral midodrine in reducing the amount and duration of intravenous vasopressors in patients with acute cervical spinal cord injury. Materials and Methods Five adult patients with cervical spinal cord injury after initial evaluation and surgical stabilization are assessed for the need for intravenous vasopressors. If patients continue to need intravenous vasopressors for more than 24 hours, they were started on oral midodrine. Its effect on weaning of intravenous vasopressors was assessed. Results Patients with systemic and intracranial injury were excluded from the study. Midodrine helped in weaning of intravenous vasopressors in the first 24 to 48 hours and helped in complete weaning of intravenous vasopressors. The rate of reduction was between 0.5 and 2.0 µg/min. Conclusion Oral midodrine does have an effect in reduction of intravenous vasopressors for patients needing prolonged support after cervical spine injury. The real extent of this effect needs to be studied with collaboration of multiple centers dealing with spinal injuries. The approach seems to be a viable alternative to rapidly wean intravenous vasopressors and reduce duration of ICU stay.
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Affiliation(s)
- Arunkumar Sekar
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Debajyoti Datta
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Avinash Lakha
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Sritam Swaroop Jena
- Department of Anesthesiology, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Sumit Bansal
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Rabi Narayan Sahu
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
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Ramadoss R, Sekar D, Rameesh M, Saibaba J, Raman D. Clinical Profile, Corticosteroid Usage and Predictors of Mortality in Near-hanging Patients: A Five-year, Single-center Retrospective Study. Indian J Crit Care Med 2023; 27:403-410. [PMID: 37378362 PMCID: PMC10291671 DOI: 10.5005/jp-journals-10071-24477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/12/2023] [Indexed: 06/29/2023] Open
Abstract
Background Hanging is the most common method of suicide in India. When near-hanging patients reach the hospital for treatment, their neurological outcome ranges from full recovery to severe neurological impairment or death. This study looked at the clinical profile, usage of corticosteroids and predictors of mortality in near-hanging patients. Materials and methods This retrospective study was conducted from May 2017 to April 2022. Demographic, clinical, and treatment details were collected from case records. Neurological outcome at discharge was assessed using the Glasgow Outcome Scale (GOS). Results The study involved 323 patients, 60% of men with a median (interquartile range) age of 30 (20-39). At the time of admission, the Glasgow Coma Scale (GCS) ≤8 in 110 (34%) patients, hypotension was present in 43 (13.3%) of patients, and 21 (6.5%) had hanging-induced cardiac arrest. About 101 patients required intensive care unit care. Corticosteroid therapy was given to 219 patients (67.8%) as part of anti-cerebral edema measures. Good neurological recovery was found (GOS-5) in 84.2% of patients, and the death rate (GOS-1) was 9.3%. Univariate logistic regression showed that usage of corticosteroids is significantly associated with poor survival (p < 0.02, odds ratio 4.7). In the multivariable logistic regression analysis, GCS ≤8, hypotension, need for intensive care, hanging-induced cardiac arrest, aspiration pneumonia, and severe cerebral edema were found to be significantly associated with mortality. Conclusion The majority of near-hanging patients had a good neurological recovery. Corticosteroids were used in two-thirds of the study population. There were multiple variables associated with mortality. How to cite this article Ramadoss R, Sekar D, Rameesh M, Saibaba J, Raman D. Clinical Profile, Corticosteroid Usage and Predictors of Mortality in Near-hanging Patients: A Five-year, Single-center Retrospective Study. Indian J Crit Care Med 2023;27(6):403-410.
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Affiliation(s)
- Ramu Ramadoss
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Dineshbabu Sekar
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Mohamed Rameesh
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Jayaram Saibaba
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Divya Raman
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
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Aarabi B, Neal CJ, Hersh DS, Harrop JS, Fehlings MG, Toups EG, Guest JD, Ugiliweneza B, Akhtar-Danesh N, Kurpad SN, Grossman RG. Mortality in ASIA Impairment Scale grade A to D Patients With Odontoid Fracture and Magnetic Resonance Imaging Evidence of Spinal Cord Injury. Neurotrauma Rep 2023; 4:375-383. [PMID: 37350794 PMCID: PMC10282967 DOI: 10.1089/neur.2023.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
Odontoid fractures are common, often presenting in the elderly after a fall and infrequently associated with traumatic spinal cord injury (tSCI). The goal of this study was to analyze predictors of mortality and neurological outcome when odontoid fractures were associated with signal change on magnetic resonance imaging (MRI) at admission. Over an 18-year period (2001-2019), 33 patients with odontoid fractures and documented tSCI on MRI were identified. Mean age was 65.3 years (standard deviation [SD] = 17.2), and 21 patients were male. The mechanism of injury was falls in 25 patients, motor vehicle accidents in 5, and other causes in 3. Mean Injury Severity Score (ISS) was 40.5 (SD = 30.2), Glasgow Coma Scale (GCS) score was 13 (SD = 3.4), and American Spinal Injury Association (ASIA) motor score (AMS) was 51.6 (SD = 42.7). ASIA Impairment Scale (AIS) grade was A, B, C, and D in 9, 2, 3, and 19 patients, respectively. Mean intramedullary lesion length was 32.3 mm (SD = 18.6). The odontoid peg was displaced ventral or dorsal in 15 patients. Twenty patients had surgical intervention: anterior odontoid screw fixation in 7 and posterior spinal fusion in 13. Eleven (33.3%) patients died in this series: withdrawal of medical care in 5; anoxic brain injury in 4; and failure of critical care management in 2. Univariate logistic regression indicated that GCS score (p < 0.014), AMS (p < 0.002), AIS grade (p < 0.002), and ISS (p < 0.009) were risk factors for mortality. Multi-variate regression analysis indicated that only AMS (p < 0.002) had a significant relationship with mortality when odontoid fracture was associated with tSCI (odds ratio, 0.963; 95% confidence interval, 0.941-0.986).
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher J. Neal
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David S. Hersh
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut, USA
| | - James S. Harrop
- Department of Neurosurgery, Jefferson Medical College, Philadelphia, Pennsylvania, USA
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G. Toups
- Department of Neurosurgery, University of Texas, Houston at Methodist Hospital, Houston, Texas, USA
| | - James D. Guest
- Department of Neurological Surgery, the Miami Project to Cure Paralysis, Miami, Florida, USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, Kentucky Spinal Cord Injury Research Center, Louisville, Kentucky, USA
| | - Noori Akhtar-Danesh
- School of Nursing and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert G. Grossman
- Department of Neurosurgery, University of Texas, Houston at Methodist Hospital, Houston, Texas, USA
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Meyer BP, Lee SY, Kurpad SN, Budde MD. Differential Trajectory of Diffusion and Perfusion Magnetic Resonance Imaging of Rat Spinal Cord Injury. J Neurotrauma 2023; 40:918-930. [PMID: 36226406 PMCID: PMC10150724 DOI: 10.1089/neu.2022.0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic spinal cord injury causes rapid neuronal and vascular injury, and predictive biomarkers are needed to facilitate acute patient management. This study examined the progression of magnetic resonance imaging (MRI) biomarkers after spinal cord injury and their ability to predict long-term neurological outcomes in a rodent model, with an emphasis on diffusion-weighted imaging (DWI) markers of axonal injury and perfusion-weighted imaging of spinal cord blood flow (SCBF). Adult Sprague-Dawley rats received a cervical contusion injury of varying severity (injured = 30, sham = 9). MRI at 4 h, 48-h, and 12-weeks post-injury included T1, T2, perfusion, and DWI. Locomotor outcome was assessed up to 12 weeks post-injury. At 4 h, the deficit in SCBF was larger than the DWI lesion, and although SCBF partially recovered by 48 h, the DWI lesion expanded. At 4 h, the volume of the SCBF deficit (R2 = 0.56, padj < 0.01) was significantly correlated with 12-week locomotor outcome, whereas DWI (R2 = 0.30, padj < 0.01) was less predictive of outcome. At 48 h, SCBF (R2 = 0.41, padj < 0.01) became less associated with outcome, and DWI (R2 = 0.38, padj < 0.01) lesion volume became more closely related to outcome. Spinal cord perfusion has unique spatiotemporal dynamics compared with diffusion measures of axonal damage and highlights the importance of acute perfusion abnormalities. Perfusion and diffusion offer complementary and clinically relevant insight into physiological and structural abnormalities following spinal cord injury beyond those afforded by T1 or T2 contrasts.
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Affiliation(s)
- Briana P. Meyer
- Neuroscience Doctoral Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Seung-Yi Lee
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew D. Budde
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Clement J. Zablocki Veterans' Affairs Medical Center, Milwaukee, Wisconsin, USA
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Balasuberamaniam P, Wasim A, Shrikumar M, Chen T, Anthony T, Phillips A, Nathens A, Chapman M, Crawford E, Schwartz CE, Finkelstein J. Predictors of hospital-acquired pressure injuries in patients with complete spinal cord injury: a retrospective case-control study. BMC Musculoskelet Disord 2023; 24:329. [PMID: 37101130 PMCID: PMC10131324 DOI: 10.1186/s12891-023-06369-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 03/24/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Despite current best practices, pressure injuries (PI) remain a devastating and prevalent hospital-acquired complication for patients with acute traumatic spinal cord injuries (SCIs). This study examined associations between risk factors for PI development in patients with complete SCI, such as norepinephrine dose and duration, and other demographic factors or lesion characteristics. METHODS This case-control study included adults with acute complete SCIs ASIA-A, who were admitted to a level-one trauma center between 2014-18. A retrospective review was implement using data on patient and injury characteristics, including age, gender, level of SCI (cervical vs. thoracic), Injury Severity Score (ISS), length of stay (LOS) and mortality; presence/absence of PI during their acute hospital stay; and treatment factors such as spinal surgery, mean arterial pressure (MAP) targets, and vasopressor treatment. Multivariable logistic regression evaluated associations with PI. RESULTS Eighty-two out of 103 eligible patients had complete data, and 30 (37%) developed PIs. Patient and injury characteristics, including age (Mean: 50.6; SD:21.3), location of SCI (48 cervical, 59%) and ISS (Mean 33.1; SD:11.8), did not differ between PI and non-PI groups. Logistic regression analysis revealed that male gender (OR:34.1; CI95:2.3-506.5, p = 0.010) and increased LOS (log-transformed; OR:20.5, CI95:2.8-149.9, p = 0.003) were associated with increased risk of PI. Having an order for a MAP > 80mmg (OR:0.05; CI95:0.01-0.30, p = 0.001) was associated with a reduced risk of PI. There were no significant associations between PI and duration of norepinephrine treatment. CONCLUSIONS Norepinephrine treatment parameters were not associated with development of PI, suggesting that MAP targets should be a focus for future investigations for SCI management. Increasing LOS should highlight the need for high-risk PI prevention and vigilance.
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Affiliation(s)
| | - Abeer Wasim
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mopina Shrikumar
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Tan Chen
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Tracey Anthony
- Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrea Phillips
- Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Avery Nathens
- Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Martin Chapman
- Critical Care Medicine and Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Eric Crawford
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Carolyn E Schwartz
- DeltaQuest Foundation, 31 Mitchell Road, Concord, MA, 01742, USA.
- Departments of Medicine and Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA, USA.
| | - Joel Finkelstein
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Onder C, Onder C, Akesen S, Yumusak E, Akesen B. Riluzole is Effective on Spinal Decompression for Treating Acute Spinal Injury When Compared With Methylprednisolone and the Combination of Two Drugs: In Vivo Rat Model. Global Spine J 2023:21925682231159068. [PMID: 36812057 DOI: 10.1177/21925682231159068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
STUDY DESIGN Randomized controlled animal experiment. OBJECTIVES To determine and compare the efficacy of riluzole, MPS and the combination of two drugs in a rat model with acute spinal trauma, electrophysiologically and histopathologically. METHODS 59 rats were divided into 4 groups as control, riluzole (6 mg/kg, every 12 hours for 7 days), MPS (30 mg/kg, 2nd and 4th hours after injury) and riluzole + MPS. Spinal trauma was created and the subjects were followed for 7 days. Electrophysiological recordings were made via neuromonitoring. The subjects were sacrificed and histopathological examination was made. RESULTS For the amplitude values, mean alteration in the period from the spinal cord injury to the end of the 7th day is 15.89 ± 20.00%, 210.93 ± 199.44%, 24.75% ± 10.13% increase and 18.91 ± 30.01% decrease for the control, riluzole, riluzole + MPS and MPS groups, respectively. Although the riluzole treatment group produced the greatest increase in amplitude, it was observed that no treatment provided a significant improvement compared to the control group, in terms of latency and amplitude. It was observed that there was significantly less cavitation area in the riluzole treatment group compared to the control group (P = .020). (P < .05). CONCLUSIONS Electrophysiologically, no treatment was found to provide significant improvement. Histopathologically, it was observed that riluzole provided significant neural tissue protection.
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Affiliation(s)
- Cem Onder
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Uludağ University, Bursa, Turkey
| | - Cigdem Onder
- Department of Physical Therapy and Rehabilitation, Sehitkamil Hospital, Gaziantep, Turkey
| | - Selcan Akesen
- Faculty of Medicine, Department of Anesthesiology and Reanimation, Uludağ University, Bursa, Turkey
| | - Ezgi Yumusak
- Faculty of Veterinary Medicine, Department of Pathology, Uludağ University, Bursa, Turkey
| | - Burak Akesen
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Uludağ University, Bursa, Turkey
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