1
|
Hersh AM, Weber-Levine C, Jiang K, Theodore N. Spinal Cord Injury: Emerging Technologies. Neurosurg Clin N Am 2024; 35:243-251. [PMID: 38423740 DOI: 10.1016/j.nec.2023.10.001] [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: 03/02/2024]
Abstract
The mainstay of treatment for spinal cord injury includes decompressive laminectomy and elevation of mean arterial pressure. However, outcomes often remain poor. Extensive research and ongoing clinical trials seek to design new treatment options for spinal cord injury, including stem cell therapy, scaffolds, brain-spine interfaces, exoskeletons, epidural electrical stimulation, ultrasound, and cerebrospinal fluid drainage. Some of these treatments are targeted at the initial acute window of injury, during which secondary damage occurs; others are designed to help patients living with chronic injuries.
Collapse
Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-113, Baltimore, MD 21287, USA. https://twitter.com/AndrewMHersh
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-113, Baltimore, MD 21287, USA
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-113, Baltimore, MD 21287, USA. https://twitter.com/kellyjjiang
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-113, Baltimore, MD 21287, USA; Orthopaedic Surgery & Biomedical Engineering, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
2
|
Kwon BK, Tetreault LA, Martin AR, Arnold PM, Marco RAW, Newcombe VFJ, Zipser CM, McKenna SL, Korupolu R, Neal CJ, Saigal R, Glass NE, Douglas S, Ganau M, Rahimi-Movaghar V, Harrop JS, Aarabi B, Wilson JR, Evaniew N, Skelly AC, Fehlings MG. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management. Global Spine J 2024; 14:187S-211S. [PMID: 38526923 DOI: 10.1177/21925682231202348] [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: 03/27/2024] Open
Abstract
STUDY DESIGN Clinical practice guideline development following the GRADE process. OBJECTIVES Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets. METHODS A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences. RESULTS The GDG suggested that MAP should be augmented to at least 75-80 mmHg as the "lower limit," but not actively augmented beyond an "upper limit" of 90-95 mmHg in order to optimize spinal cord perfusion in acute traumatic SCI. The quality of the evidence around the "target MAP" was very low, and thus the strength of this recommendation is weak. For duration of hemodynamic management, the GDG "suggested" that MAP be augmented for a duration of 3-7 days. Again, the quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence. CONCLUSION We provide new recommendations for blood pressure management after acute SCI that acknowledge the limitations of the current evidence on the relationship between MAP and neurologic recovery. It was felt that the low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines. While important knowledge gaps still remain regarding hemodynamic management, these recommendations represent current perspectives on the role of MAP augmentation for acute SCI.
Collapse
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
| | | | - Allan R Martin
- Department of Neurological Surgery, University of California, Davis, CA, USA
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Virginia F J Newcombe
- University Division of Anaesthesia and PACE, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | | | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, Houston, TX, USA
| | - Chris J Neal
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Rajiv Saigal
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Nina E Glass
- Department of Surgery, Rutgers, New Jersey Medical School, University Hospital, Newark, NJ
| | - Sam Douglas
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Mario Ganau
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jefferson R Wilson
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | | | - Michael G Fehlings
- 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
| |
Collapse
|
3
|
Fehlings MG, Moghaddamjou A, Evaniew N, Tetreault LA, Alvi MA, Skelly AC, Kwon BK. The 2023 AO Spine-Praxis Guidelines in Acute Spinal Cord Injury: What Have We Learned? What Are the Critical Knowledge Gaps and Barriers to Implementation? Global Spine J 2024; 14:223S-230S. [PMID: 38526926 DOI: 10.1177/21925682231196825] [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: 03/27/2024] Open
Abstract
STUDY DESIGN Narrative summary of the 2023 AO Spine-Praxis clinical practice guidelines for management in acute spinal cord injury (SCI). OBJECTIVES The objective of this article is to summarize the key findings of the clinical practice guidelines for the optimal management of traumatic and intraoperative SCI (ISCI). This article will also highlight potential knowledge translation opportunities for each recommendation and discuss important knowledge gaps and areas of future research. METHODS Systematic reviews were conducted according to accepted methodological standards to evaluate the current body of evidence and inform the guideline development process. The summarized evidence was reviewed by a multidisciplinary guidelines development group that consisted of international multidisciplinary stakeholders. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to rate the certainty of the evidence for each critical outcome and the "evidence to recommendation" framework was used to formulate the final recommendations. RESULTS The key recommendations regarding the timing of surgical decompression, hemodynamic management, and the prevention, diagnosis, and management of ISCI are summarized. While a strong recommendation was made for early surgery, further prospective research is required to define what constitutes sufficient surgical decompression, examine the role of ultra-early surgery, and assess the impact of early surgery in different SCI phenotypes, including central cord syndrome. Furthermore, additional investigation is required to evaluate the impact of mean arterial blood pressure targets on neurological recovery and to determine the utility of spinal cord perfusion pressure measurements. Finally, there is a need to examine the role of neuroprotective agents for the treatment of ISCI and to prospectively validate the new AO Spine-Praxis care pathway for the prevention, diagnosis, and management of ISCI. To optimize the translation of these guidelines into practice, important barriers to their implementation, particularly in underserved areas, need to be explored. Ultimately, these recommendations will help to establish more personalized approaches to care for SCI patients. CONCLUSIONS The recommendations from the 2023 AO Spine-Praxis guidelines not only highlight the current best practice in the management of SCI, but reveal critical knowledge gaps and barriers to implementation that will help to guide further research efforts in SCI.
Collapse
Affiliation(s)
- Michael G Fehlings
- 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
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ali Moghaddamjou
- 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
| | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | | | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - 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
| |
Collapse
|
4
|
Asif H, Tsan SEH, Zoumprouli A, Papadopoulos MC, Saadoun S. Evolving trends in the surgical, anaesthetic, and intensive care management of acute spinal cord injuries in the UK. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1213-1222. [PMID: 38217717 DOI: 10.1007/s00586-023-08085-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE We surveyed the treatment of acute spinal cord injuries in the UK and compared current practices with 10 years ago. METHODS A questionnaire survey was conducted amongst neurosurgeons, neuroanaesthetists, and neurointensivists that manage patients with acute spinal cord injuries. The survey gave two scenarios (complete and incomplete cervical spinal cord injuries). We obtained opinions on the speed of transfer, timing and aim of surgery, choice of anaesthetic, intraoperative monitoring, targets for physiological parameters, and drug treatments. RESULTS We received responses from 78.6% of UK units that manage acute spinal cord injuries (33 neurosurgeons, 56 neuroanaesthetists/neurointensivists). Most neurosurgeons operate within 12 h for incomplete (82%) and complete (64%) injuries. There is a significant shift from 10 years ago, when only 61% (incomplete) and 30% (complete) of neurosurgeons operated within 12 h. The preferred anaesthetic technique in 2022 is total intravenous anaesthesia (TIVA), used by 69% of neuroanaesthetists. Significantly more intraoperative monitoring is now used at least sometimes, including bispectral index (91%), non-invasive cardiac output (62%), and neurophysiology (73-77%). Methylprednisolone is no longer used by surgeons. Achieving at least 80 mmHg mean arterial blood pressure is recommended by 70% neurosurgeons, 62% neuroanaesthetists, and 75% neurointensivists. CONCLUSIONS Between 2012 and 2022, there was a paradigm shift in managing acute spinal cord injuries in the UK with earlier surgery and more intraoperative monitoring. Variability in practice persists due to lack of high-quality evidence and consensus guidelines.
Collapse
Affiliation(s)
- Hasan Asif
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, SW17 0RE, UK
| | | | - Argyro Zoumprouli
- Neurointensive Care Unit, St. George's Hospital, London, SW17 0QT, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, SW17 0RE, UK
| | - Samira Saadoun
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, SW17 0RE, UK.
| |
Collapse
|
5
|
Chryssikos T, Tawil ME, Ambati VS, Macki M, DiGiorgio AM, Mummaneni PV, Tan L. Real-Time Intraoperative Ultrasound Using a Minimally Invasive Transducer During Anterior Cervical Spine Surgery. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01034. [PMID: 38295396 DOI: 10.1227/ons.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/01/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intraoperative ultrasound (IOUS) during anterior cervical surgery is hindered by large transducer size and small operative corridor. We hypothesized that a linear (minimally invasive) transducer designed for transsphenoidal surgery can visualize the spinal cord, nerve roots, and surrounding structures during anterior cervical approaches, facilitating intraoperative assessment of central and foraminal decompression. METHODS IOUS was used to evaluate 26 levels in 17 patients (15 anterior cervical discectomy and fusion, 1 corpectomy, 1 arthroplasty) with a linear probe (7 × 6-mm end-fire transducer, 150-mm length, 12-15 MHz). After pin-based distraction, discectomy, and posterior longitudinal ligament resection, IOUS assessed adequacy of cord decompression and, following proximal foraminotomy or uncinectomy, nerve root decompression. If indicated, additional decompression was completed. Criteria for adequate central and foraminal decompression were visualization of subarachnoid space around the cord and cerebrospinal fluid pulsatility along the root sleeve/absence of nerve root compression distal to the root sleeve, respectively. RESULTS IOUS successfully visualized the cord, nerve roots, and surrounding structures in all 26 levels and influenced management in 11 levels (42.3%). IOUS indicated persistent cord and nerve root compression in 2 and 7 levels, respectively. Planned uncinectomy was aborted in 2 levels after IOUS demonstrated adequate nerve root decompression with intervertebral distraction/proximal foraminotomy alone. IOUS identified persistent nerve root compression after initial proximal foraminotomy in 4 levels and uncinectomy in 2 levels. An unplanned uncinectomy was performed in 1 level after IOUS showed persistent nerve root compression after multiple iterations of proximal foraminotomy. At follow-up (mean 3.1 months), the mean improvement in Numeric Rating Scale neck and arm pain, Neck Disability Index, and modified Japanese Orthopedic Association was 4.0%, 3.2%, 3.7%, and 0.7%, respectively. CONCLUSION The neural elements and their relationships to surrounding bone/soft tissue can be visualized using a minimally invasive IOUS transducer during anterior cervical surgery without having to remove pin-based distraction. This allows surgeons to intraoperatively verify the extent of central and foraminal decompression.
Collapse
Affiliation(s)
- Timothy Chryssikos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael E Tawil
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Vardhaan S Ambati
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Mohamed Macki
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Lee Tan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
6
|
Kenechi Nwawka O, Cha N, Ko LM, LaSala VR. Visibility of Prevertebral Soft Tissues in the Neck Using Ultrasonography: A Feasibility Study. Int J Spine Surg 2023; 17:824-827. [PMID: 37813455 PMCID: PMC10753337 DOI: 10.14444/8546] [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: 10/17/2023] Open
Abstract
OBJECTIVE To aid emergent diagnosis of postoperative retropharyngeal hematoma in anterior cervical spine surgery patients, this study investigates ultrasonography's potential role by evaluating the visibility of retropharyngeal and prevertebral soft tissues in the neck using ultrasound and potential correlations with body habitus. METHODS The visibility of the anterior vertebral bodies and the prevertebral soft tissues in both sides of the neck was recorded and analyzed with 95% CI using the Wilson method. Body mass index, neck circumference, and neck length were measured. A point-biserial correlation was performed to compare body habitus with visibility of vertebrae and prevertebral tissues. RESULTS Longus colli muscle and C3 to C6 were successfully visualized in all 10 (100%) cases on both sides. C2 was only visible in 6 (60%) on both sides. C7 was visible in 9 (90%) on the right and 7 (70%) on the left. The esophagus was visible in 7 (70%) on the right and 10 (100%) on the left. There was a significant negative correlation with neck circumference and C2 visibility on the right side, r(8) = -0.76, P = 0.011. CONCLUSIONS Ultrasonography was successful in visualizing prevertebral tissues, with a trend of obstructed visibility with wider and longer necks. CLINICAL RELEVANCE Ultrasonography has potential to aid early detection of postoperative retropharyngeal hematoma after cervical spine surgery. LEVEL OF EVIDENCE: 4
Collapse
Affiliation(s)
- O Kenechi Nwawka
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Noah Cha
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Lydia M Ko
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Vincent R LaSala
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| |
Collapse
|
7
|
Srikandarajah N, Alvi MA, Fehlings MG. Current insights into the management of spinal cord injury. J Orthop 2023; 41:8-13. [PMID: 37251726 PMCID: PMC10220467 DOI: 10.1016/j.jor.2023.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/28/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023] Open
Abstract
Background Traumatic spinal cord injury (SCI) is a serious disorder that results in severe impairment of neurological function as well as disability, ultimately reducing a patient's quality of life. The pathophysiology of SCI involves a primary and secondary phase, which causes neurological injury. Methods Narrative review on current clinical management of spinal cord injury and emerging therapies. Results This review explores the management of SCI through early decompressive surgery, optimizing mean arterial pressure, steroid therapy and focused rehabilitation. These management strategies reduce secondary injury mechanisms to prevent the propagation of further neurological damage. The literature regarding emerging research is also explored in cell-based, gene, pharmacological and neuromodulation therapies, which aim to repair the spinal cord following the primary injury mechanism. Conclusions Outcomes for patients with SCI can be enhanced and improved if primary and secondary phases of SCI can be addressed.
Collapse
Affiliation(s)
- Nisaharan Srikandarajah
- 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
| | - Michael G. Fehlings
- 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
- Division of Genetics and Development, Krembil Brain Institute, University Health Network, Toronto, ON, Canada
| |
Collapse
|