Incidence and severity of acute complications after spinal cord injury

Incidence, timing, and risk factors for development of gastrointestinal bleeding in acute traumatic spinal cord injury: A systematic review

CONTEXT

Current guidelines recommend four weeks of stress ulcer prophylaxis following traumatic spinal cord injury.

OBJECTIVES

Assess the current literature on the incidence, timing, and risk factors for gastrointestinal bleeding/clinically important gastrointestinal bleeding in the acute setting following a traumatic spinal cord injury and whether the use of stress ulcer prophylaxis has been shown to reduce the rates of gastrointestinal bleeding.

METHODS

A systematic review was performed in PubMed, Embase, Web of Science, and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

A total of 24 articles met the inclusion/exclusion criteria. The average rate of gastrointestinal bleeding among all studies was 5.5% (95% CI = 5.4-5.6%; n = 26,576). The average rate of clinically important gastrointestinal bleeding was 1.8% (95% CI = 1.79-1.82%; n = 3,857). The mean time since injury to when gastrointestinal bleeding occurred ranged from 5 to 22.5 days. For clinically important gastrointestinal bleeding the average time was 16 days or less. Those with cervical injuries had a higher incidence of clinically important gastrointestinal bleeding compared to those with non-cervical injuries (2.7% vs. 0.7%). No study found any difference in the use of stress ulcer prophylaxis in participants with or without gastrointestinal bleeding.

CONCLUSIONS

The overall incidence of clinically important gastrointestinal bleeding among studies was found to be low. Individuals with non-cervical injury were not found to be at high risk of clinically important gastrointestinal bleeding. There was also insufficient evidence to indicate that use of stress ulcer prophylaxis reduces the rate of gastrointestinal bleeding in those with traumatic spinal cord injury.

Data Safety Monitoring Boards: Overview of Structure and Role in Spinal Cord Injury Studies

This paper provides an overview of the history, composition, organization, responsibilities, and regulatory requirements of Data Safety Monitoring Boards (DSMB), with particular reference to the context of clinical trials in spinal cord injury. It is intended to help potential members of such boards and those undertaking the design of new clinical trials to understand the important role of the DSMB in safeguarding the integrity of complex trials, promoting safety, and countering potential bias. An independent DSMB helps to protect research subjects by providing study oversight and serves as an additional step to assure that clinical trials are performed to existing and appropriate standards. The DSMB must meet on a regular schedule, diligently evaluate all the information it receives, and report in a timely and decisive manner. Members must be free of significant conflicts of interest throughout the study and be adequately trained and experienced to serve their roles within the group. DSMB service can be a valuable learning experience and a gratifying opportunity to participate in advancing medicine and helping to maintain and improve the standards of research.

Tracing the evolving dynamics and research hotspots of spinal cord injury and surgical decompression from 1975 to 2024: a bibliometric analysis

Background

Exploration of the benefits and timing of surgical decompression in spinal cord injury (SCI) has been a research hotspot. However, despite the higher volume and increasing emphasis on quality there remains no bibliometric view on SCI and surgical decompression. In this study, we aimed to perform bibliometric analysis to reveal the core countries, affiliations, journals, authors, and developmental trends in SCI and surgical decompression across the past 50 years.

Methods

Articles and reviews were retrieved from web of science core collection between 1975 and 2024. The bibliometrix package in R was used for data analysis and visualizing.

Results

A total of 8,688 documents were investigated, indicating an ascending trend in annual publications. The USA and China played as the leaders in scientific productivity. The University of Toronto led in institutional productions. Core authors, such as Michael G. Fehlings, showed high productivity, and occasional authors showed widespread interests. Core journals like Spine and Spinal Cord served as beacons in this field. The interaction of core authors and international collaboration accentuated the cross-disciplinary feature of the field. Prominent documents emphasized the clinical significance of early decompression in 24 h post SCI.

Conclusion

Based on comprehensive bibliometric analysis and literature review, we identified the hotspots and future directions of this field: (1) further investigation into the molecular and cellular mechanisms to provide pre-clinical evidence for biological effects of early surgical decompression in SCI animal models; (2) further evaluation and validation of the optimal time window of surgical decompression based on large cohort, considering the inherent heterogeneity of subpopulations in complicated immune responses post SCI; (3) further exploration on the benefits of early decompression on the neurological, functional, and clinical outcomes in acute SCI; (4) evaluation of the optimal surgical methods and related outcomes; (5) applications of artificial intelligence-based technologies in spinal surgical decompression.

Protocol for the Chinese Real-World Evidence for Acute Spinal Cord Injury (ChiRES) study: a prospective, observational, multicentre cohort study of acute spinal cord injury

INTRODUCTION

Spinal cord injury (SCI) is a catastrophic event with devastating physical, social and occupational consequences for patients and their families. The number of patients with acute SCI in China continues to grow rapidly, but there have been no large prospective cohort studies of patients with acute SCI. This proposed study aims to establish a multicentre, extensive sample cohort of clinical data and biological samples of patients in China, which would aid the systematisation and standardisation of clinical research and treatment of acute SCI, thus reducing the heavy burden of acute SCI on patients and society.

METHODS AND ANALYSIS

The Chinese Real-World Evidence for Acute Spinal Cord Injury (ChiRES) study is an observational, multicentre cohort study of patients with acute SCI admitted to the Qilu Hospital of Shandong University and other participating centres with prospective collection of their clinical data and biological samples. We aim to recruit 2097 patients in this study. Demographics, disease history, emergency intervention information, motor and sensory examinations, surgical information, medication information and rehabilitation evaluation will be recorded. This will facilitate the development of a prediction model for complications and prognosis of patients with acute SCI and an evaluation of the current management of acute SCI. Among these variables, detailed information on surgical treatment will also be used to assess procedures for acute SCI treatment. Outcome measurements, including the International Standard for Neurological Classification of Spinal Cord Injury examinations, the occurrence of complications and death, will be performed repeatedly during follow-up. We will analyse imaging data and blood samples to develop SCI imaging markers and biomarkers.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Medical Ethics Committee of the Qilu Hospital of Shandong University and all other participating centres. The findings will be disseminated in peer-reviewed journals and academic conferences.

Neurocritical care and neuromonitoring considerations in acute pediatric spinal cord injury

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.

Traumatic Spinal Cord Injury

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.

An Introduction to the North American Clinical Trials Network for Spinal Cord Injury Special Edition: Reflections on Accomplishments and a Look to the Future

The North American Clinical Trials Network (NACTN) has been established as a network of translational clinical research centers focused on traumatic spinal cord injury (SCI) with the goals of facilitating clinical translational research, promotion of enhanced clinical care protocols including the principle of early surgery for SCI, and improving outcomes for individuals with acute SCI. Since its foundation in 2004 by Dr. Robert Grossman, NACTN has evolved into a powerful multi-stakeholder consortium of eight neurosurgical department faculties at university-affiliated institutions in the United States and Canada, a data management center, and a pharmacological center. To date, high-quality data from more than 1000 patients have been prospectively collected, providing us with a strong body of evidence surrounding SCI epidemiology, the natural history, and complications of acute and subacute SCI management. Key accomplishments of NACTN are summarized in this Focus issue. They include the launch, in collaboration with AO Spine, of the international, multi-center, placebo-controlled, Phase III Riluzole in Acute Spinal Cord Injury Study (RISCIS) that recruited 192 patients. While the primary analyses did not achieve the predetermined endpoint of efficacy for Riluzole, likely related to insufficient power, pre-planned secondary analyses demonstrated that all subgroups of cervical SCI subjects (AIS grades A, B and C) treated with Riluzole showed significant gains in functional recovery. The Focus Issue also includes a detailed analysis of the pharmacokinetics and pharmacodynamics of riluzole in the setting of acute SCI (RISCIS-PK study). Additional achievements include key contributions to the evidence supporting the role of early surgery in acute SCI, and a better understanding of the impact of complications on the outcomes of SCI. Future directions of NACTN will build on past accomplishments and focus on enhanced collaborations with other SCI networks, advanced analytics to examine large datasets, and a greater focus on chronic SCI.

The Impact of Diffuse Idiopathic Skeletal Hyperostosis on Nutritional Status, Neurological Outcome, and Perioperative Complications in Patients with Cervical Spinal Cord Injury

This retrospective study aimed to investigate the characteristics of patients with cervical spinal cord injuries (CSCI) with diffuse idiopathic skeletal hyperostosis (DISH). We included 153 consecutive patients with CSCI who underwent posterior decompression and fusion surgery. The patients were divided into two groups based on the presence of DISH. Patient characteristics, neurological status on admission, nutritional status, perioperative laboratory variables, complications, neurological outcomes at discharge, and medical costs were compared between the groups. The DISH group (n = 24) had significantly older patients (72.1 vs. 65.9, p = 0.036), more patients with low-impact trauma (62.5% vs. 34.1%, p = 0.009), and a lower preoperative prognostic nutritional index on admission (39.8 vs. 42.5, p = 0.014) than the non-DISH group (n =129). Patients with DISH had significantly higher rates of ventilator management (16.7% vs. 3.1%, p = 0.022) and pneumonia (29.2% vs. 8.5%, p = 0.010). There was no significant difference in medical costs and neurological outcomes on discharge. Patients with CSCI and DISH were older, had poor nutritional status, and were prone to postoperative respiratory complications, while no differences were found between the neurological outcomes of patients with CSCI with and without DISH.

Incidence and risk factors of pneumonia following acute traumatic cervical spinal cord Injury

OBJECTIVES

To elucidate the incidence and risk factors for pneumonia after acute traumatic cervical spinal cord injury (CSCI).

DESIGN

Retrospective cohort study.Setting: Spinal injuries center in Japan.Participants: Of 184 individuals who were admitted within 2 weeks after acute traumatic cervical spinal injuries, 167 individuals who met the criteria were included in this study.Interventions: The occurrence of pneumonia, degree of dysphagia using the Dysphagia Severity Scale, patient age, history of smoking, presence of tracheostomy, vital capacity, level of injury, and the American Spinal Injury Association Impairment Scale (AIS) 2 weeks after injury were assessed.Outcomes: Incidence of pneumonia were analyzed. Moreover, the risk factors of pneumonia were evaluated using logistic regression analysis.

RESULTS

From the 167 individuals who met the criteria, 30 individuals (18%) had pneumonia; in 26 (87%) of these individuals, pneumonia was aspiration related, defined as Dysphagia Severity Scale ≤ 4. The median occurrence of aspiration pneumonia was 11.5 days after injury. A logistic regression analysis revealed that severe AIS and severe Dysphagia Severity Scale scores were significant risk factors of pneumonia after CSCI.

CONCLUSIONS

It was highly likely that the pneumonias following CSCI were related to aspiration based on the Dysphagia Severity Scale. In addition, most of the patients developed aspiration pneumonia within 1 month after injury. Aspiration and severe paralysis were significant risk factors for pneumonia. The treatment of dysphagia in the acute phase should be considered an important indicator to prevent pneumonia.

Evolving Profile of Acute Spinal Cord Injury Demographics, Outcomes, and Surgical Treatment in North America: Analysis of a Prospective Multi-Center Dataset of 989 Patients

Changes in demography and injury patterns have altered the profile and outcome of acute spinal cord injury (SCI) over time. This study sought to describe recent trends in epidemiology and early clinical outcomes using the multi-center North American Clinical Trial Network (NACTN) for Spinal Cord Injury Registry. All participants with blunt acute traumatic SCI (n = 782) were grouped into three five-year time intervals from 2005 to 2019 (2005-2009, 2010-2014, and 2015-2019). Baseline demographics, clinical scores, medical co-morbidities, as well as early clinical outcomes were extracted. Categorical and continuous variables were analyzed to determine between-group differences. Subgroup analysis was performed for participants <50 and ≥50 years of age. Over the duration of the study period, there was an increase in age at presentation (p = 0.0077) as well as a greater incidence of falls as the mechanism of injury. Participants who were ≥50 years of age were more likely to sustain incomplete SCI (<0.0003) and central cord syndrome (< 0.0001). In the most recent period (2015-2019), a greater proportion of NACTN participants underwent surgery within 24 h of injury (63% vs. 41% vs. 41%, p = 0.0001). There was a statistically significant increase in cardiac complications (p < 0.0001) and decrease in pulmonary complications (p < 0.0001) during the study period. Data from the NACTN registry shows that the age of participants with acute SCI is increasing, falls have become the major mechanism of injury, and central cord injury is becoming increasingly prevalent. While early surgical intervention for acute SCI is more common in recent years, cardiac complications are more prevalent while pulmonary complications are less prevalent.

North American Clinical Trials Network for Spinal Cord Injury Registry: Methodology and Analysis

The North American Clinical Trials Network (NACTN) for Spinal Cord Injury (SCI) is a consortium of neurosurgery departments at university affiliated hospitals with medical, nursing, and rehabilitation personnel who are skilled in the assessment, evaluation, and management of SCI. NACTN was established with the goal of consistently advancing the quality of life of people with SCI through clinical trials of new therapies that provide robust evidence of safety and effectiveness. A prospective multi-center Registry was created to collect the natural course of the acute traumatic SCI patient from time of injury to 12 months follow-up. NACTN's network of hospitals enrolls a significant number of patients, defines and adheres to standard protocols, and provides the infrastructure and highly skilled personnel to conduct trials of therapy for SCI. Registry data have been used by academic institutions and by the biotechnology and pharmaceutical sectors to create comparison datasets for Phase I clinical trials of new therapies.

Correlation between Respiratory Dysfunction and Dysphagia in Individuals with Acute Traumatic Cervical Spinal Cord Injury

Introduction

Aspiration pneumonia is one of the most frequent and fatal life-threatening complications among individuals with acute traumatic cervical spinal cord injury (CSCI). However, the mechanism of dysphagia among individuals with CSCI is not well understood. Morbidity and mortality associated with CSCI may result from the interplay between respiratory dysfunction and dysphagia. This study aimed to elucidate the effect of respiratory dysfunction on the swallowing function of individuals with acute traumatic CSCI.

Methods

A prospective cohort study was conducted involving 54 individuals with acute traumatic CSCI who were admitted within 2 weeks following injury. Dysphagia was evaluated using the Dysphagia Severity Scale (DSS) and the Functional Oral Intake Scale (FOIS). Respiratory function was evaluated by measuring the cough peak flow (CPF), forced expiratory volume in 1 s (FEV1.0), FEV1.0/forced vital capacity (FEV1.0%), and percent vital capacity (%VC). We recorded these parameters at weeks 2, 4, 8, and 12 following injury and analyzed pertinent changes over time and significant correlations.

Results

Among 54 individuals (46 men and 8 women) recruited in this study, 48 (88.9%) had restrictive ventilatory impairment and 17 (31.5%) had severe dysphagia (DSS level 1-4) 2 weeks following injury. However, respiratory function and swallowing function significantly improved thereafter. CPF, FEV1.0, and %VC were significantly correlated with the severity of dysphagia during each period.

Conclusions

Restrictive ventilatory impairment, poor cough force, and dysphagia are closely related, and the evaluation of respiratory function plays an important role in evaluating dysphagia.

Complications Associated with Preventive Management to Reduce the Risk of COVID-19 Spread After Surgery for Spinal Cord Injury

BACKGROUND

Preventive management to reduce the risk of coronavirus disease-2019 (COVID-19) spread led to delays in active rehabilitation, which may have negatively impacted the outcomes of patients with traumatic spinal cord injury (SCI). Therefore, the aim of this study was to clarify the influence of preventive management on the rate of perioperative complications after surgical treatment for SCI.

METHODS

This single-center retrospective study examined the cases of 175 patients who had SCI surgery between 2017 and 2021. We could not continue early rehabilitation interventions starting on April 30, 2020, because of our preventive management to reduce the risk of COVID-19 spread. Using a propensity score-matched model, we adjusted for age, sex, American Spinal Injury Association impairment scale score at admission, and risk factors for perioperative complications described in previous studies. Perioperative complication rates were compared between the COVID-19 pandemic and prepandemic groups.

RESULTS

Of the 175 patients, 48 (the pandemic group) received preventive management. The preliminary analysis revealed significant differences between the unmatched pandemic and prepandemic groups with respect to age (75.0 versus 71.2 years, respectively; p = 0.024) and intraoperative estimated blood loss (152 versus 227 mL; p = 0.013). The pandemic group showed significant delays in visiting the rehabilitation room compared with the prepandemic group (10 versus 4 days from hospital admission; p < 0.001). There were significant differences between the pandemic and prepandemic groups with respect to the rates of pneumonia (31% versus 16%; p = 0.022), cardiopulmonary dysfunction (38% versus 18%; p = 0.007), and delirium (33% versus 13%; p = 0.003). With a propensity score-matched analysis (C-statistic = 0.90), 30 patients in the pandemic group and 60 patients in the prepandemic group were automatically selected. There were significant differences between the matched pandemic and prepandemic groups with respect to the rates of cardiopulmonary dysfunction (47% versus 23%; p = 0.024) and deep venous thrombosis (60% versus 35%; p = 0.028).

CONCLUSIONS

Even with early surgical intervention, late mobilization and delays in active rehabilitation during the COVID-19 pandemic increased perioperative complications after SCI surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cervical spinal cord injury leads to injury and altered metabolism in the lungs

High-cervical spinal cord injury often disrupts respiratory motor pathways and disables breathing in the affected population. Moreover, cervically injured individuals are at risk for developing acute lung injury, which predicts substantial mortality rates. While the correlation between acute lung injury and spinal cord injury has been found in the clinical setting, the field lacks an animal model to interrogate the fundamental biology of this relationship. To begin to address this gap in knowledge, we performed an experimental cervical spinal cord injury (N = 18) alongside sham injury (N = 3) and naïve animals (N = 15) to assess lung injury in adult rats. We demonstrate that animals display some early signs of lung injury two weeks post-spinal cord injury. While no obvious histological signs of injury were observed, the spinal cord injured cohort displayed significant signs of metabolic dysregulation in multiple pathways that include amino acid metabolism, lipid metabolism, and N-linked glycosylation. Collectively, we establish for the first time a model of lung injury after spinal cord injury at an acute time point that can be used to monitor the progression of lung damage, as well as identify potential targets to ameliorate acute lung injury.

Prognostic value of early magnetic resonance imaging in the morbidity and mortality of traumatic spinal cord injury

OBJECTIVE

To assess in individuals with traumatic spinal cord injury (TSCI) the relationship between mortality and need for ICU and early magnetic resonance imaging (MRI), analyzing spinal parenchymal alterations, disruption of vertebral ligaments (DVL) and spinal cord compression (SCC).

DESIGN

Retrospective study.

SETTING

Third-level hospital, Spinal Cord Injury Unit and ICU.

PATIENTS

Individuals with acute TSCI between 2010 and 2019.

INTERVENTION

Analysis of MRI performed in the first 72 h.

VARIABLES OF INTEREST

Admission to ICU and mortality.

RESULTS

269 cases collected. The pattern that demonstrated higher mortality was cord hemorrhage (16.7%) for 12.5% ​​of single-level edema and 6.5% of multilevel edema (p = 0.125). The same happened with ICU admissions: 69.0% in hemorrhage, 60.2% in multilevel edema and 46.3% in short edema (p = 0.018). Analyzing CCM, mortality was 13.4% with 59.2% of ICU admissions, for 2.2% and 42.2% of individuals without cord compression (p = 0.020 and p = 0.003). The figures of death and ICU admission among cord injuries with DVL were 15.0% and 67.3%, for 6.2% and 44.4% of the individuals without DLV (p < 0.001 and p = 0.013).

CONCLUSIONS

The presence of spinal cord hemorrhage, SCC and DVL was associated with a higher admission in ICU. A significant increase in mortality was observed in cases with SCC and DVL.

Early Decompression in Acute Spinal Cord Injury : Review and Update

Spinal cord injury (SCI) has a significant negative effect on the quality of life due to permanent neurologic damage and economic burden by continuous treatment and rehabilitation. However, determining the correct approach to ensure optimal clinical outcomes can be challenging and remains highly controversial. In particular, with the introduction of the concept of early decompression in brain pathology, the discussion of the timing of decompression in SCI has emerged. In addition to that, the concept of "time is spine" has been added recently, and the mortality and complications caused by SCI have been reduced by providing timely and professional treatment to patients. However, there are many difficulties in establishing international clinical guidelines for the timing of early decompression in SCI because policies for each country and medical institution differ according to the circumstances of medical infrastructure and economic conditions in the surgical treatment of SCI. Therefore, we aim to provide a current review of timing of early decompression in patient with SCI.

A critical appraisal of clinical practice guidelines for management of four common complications after spinal cord injury

BACKGROUND CONTEXT

Complications such as pressure sores, pulmonary infection, urinary tract infection (UTI), and venous thromboembolism (VTE) are common after spinal cord injury (SCI). These have serious consequences for patients' physical, social, and vocational well-being. Several authoritative organizations have developed guidelines for managing these complications after SCI.

PURPOSE

We aim to systematically review and appraise guidelines on the management of four common complications (pressure sores, pulmonary infection, UTI, and VTE) after SCI as well as to summarize relevant recommendations and assess the quality of their supporting evidence.

DESIGN

Systematic review.

METHODS

We searched Medline, Embase, Cochrane, and Web of Science, as well as guideline-specific databases (e.g., National Guideline Clearinghouse) and Google Scholar, from January 2000 to January 2022. We included the most updated guidelines developed by specific authoritative organizations. We evaluated the included guidelines using the Appraisal of Guidelines for Research and Evaluation 2nd edition instrument, which measures six domains (e.g., applicability). Recommendations extracted from guidelines were categorized as for, against, or neither for nor against. An evidence assessment was adopted to classify the quality of supporting evidence as poor, fair, or good.

RESULTS

Eleven guidelines from 2005 to 2020 were included, all of which, among the six domains, scored lowest in the domain of applicability. For pressure sores, guidelines recommended for skin inspection, repositioning, and the use of pressure reduction equipment as preventive measures and dressings, debridement, and surgery as treatment measures. For pulmonary infection, guidelines recommended for physical (e.g., the use of an insufflation-exsufflation device) and pharmacological measures (e.g., the use of bronchodilators). For UTI, guidelines recommended for antibiotics as a treatment measure but recommended against cranberries, methenamine salts, and acidification or alkalinization agents as preventive measures. For VTE prophylaxis, five guidelines recommended for low molecular weight heparin (LMWH). Three guidelines recommended against unfractionated heparin, whereas one guideline recommended for it. Most of the supporting evidence was of poor quality (130/139), and the rest was of fair quality (9/139).

CONCLUSIONS

For pressure sores, pulmonary infection, and UTI, evidence of poor to fair quality indicated consistent recommendations for prevention and treatment measures. For VTE, LMWH was consistently recommended, whereas recommendations on the use of unfractionated heparin were controversial.

Feasibility of gabapentin as an intervention for neurorecovery after an acute spinal cord injury: Protocol

Introduction

This protocol is describing the first ever prospective, mock-efficacy, dose exploration trial design testing the feasibility of administering gabapentin in the acute setting as an intervention for neurorecovery. Gabapentin is an FDA-approved medication for treating seizures and postherpetic neuralgia and is used broadly off-label for neuropathic pain management for many conditions, including spinal cord injury. Emerging data suggests that when given early after spinal cord injury onset and in low-medium doses, gabapentin may have properties that promote recovery of neurological function. The objective of this trial is to assess the feasibility of conducting an efficacy trial in which gabapentin is started early after injury, is restricted in its dose, and is not used for pain management.

Methods and analysis

Forty-two people aged 18 years or older with any level and any severity of spinal cord injury induced by a trauma will be enrolled, randomized, and have the first dose of study medication by 120 h post-injury onset. Participants will be randomly assigned to one of three groups: 600, 1,800 mg/day gabapentin, or placebo. Study medication will be given for a 90-day duration. Blinded assessments will be obtained at 7 days post-injury (baseline), 30 days post-injury (interim), after the 90-day treatment duration/approximately 3 months post-injury (end of treatment), and at 6 months post-injury (end of study). The key analysis parameters will evaluate feasibility of recruitment of target population, delivery of drug treatment protocol, maintenance of blinding, and retention of participants.

Discussion

Outputs from this trial will inform research and clinical practice on the effects of manipulating gabapentin for non-pain management purposes in the acute setting and will guide the development of a properly powered efficacy trial of gabapentin as an intervention for neurorecovery in spinal cord injury.

Ethics and dissemination

The study was approved by the MetroHealth Institutional Review Board (IRB21-00609) and registered at clinicaltrials.gov prior to enrolling any participants. Dissemination will include peer-reviewed publications, presentations at professional conferences and in the community, and through other healthcare and public venues.

Clinical trial registration

www.ClinicalTrials.gov, identifier: NCT05302999; protocol version 1.1 approved 05/23/2022.

Trial funding

National Institute on Disability, Independent Living and Rehabilitation Research.

Effects of transcutaneous spinal stimulation on spatiotemporal cortical activation patterns: A proof-of-concept EEG study

OBJECTIVE

Transcutaneous spinal cord stimulation (TSS) has been shown to be a promising non-invasive alternative to epidural spinal cord stimulation (ESS) for improving outcomes of people with spinal cord injury (SCI). However, studies on the effects of TSS on cortical activation are limited. Our objectives were to evaluate the spatiotemporal effects of TSS on brain activity, and determine changes in functional connectivity under several different stimulation conditions. As a control, we also assessed the effects of functional electrical stimulation (FES) on cortical activity.

APPROACH

Non-invasive scalp electroencephalography (EEG) was recorded during TSS or FES while five neurologically intact participants performed one of three lower-limb tasks while in the supine position: (1) A no contraction control task, (2) a rhythmic contraction task, or (3) a tonic contraction task. After EEG denoising and segmentation, independent components were clustered across subjects to characterize sensorimotor networks in the time and frequency domains. Independent components of the event related potentials (ERPs) were calculated for each cluster and condition. Next, a Generalized Partial Directed Coherence (gPDC) analysis was performed on each cluster to compare the functional connectivity between conditions and tasks.

RESULTS

Independent Component analysis of EEG during TSS resulted in three clusters identified at Brodmann areas (BA) 9, BA 6, and BA 4, which are areas associated with working memory, planning, and movement control. Lastly, we found significant (p < 0.05, adjusted for multiple comparisons) increases and decreases in functional connectivity of clusters during TSS, but not during FES when compared to the no stimulation conditions.

SIGNIFICANCE

The findings from this study provide evidence of how TSS recruits cortical networks during tonic and rhythmic lower limb movements. These results have implications for the development of spinal cord-based computer interfaces, and the design of neural stimulation devices for the treatment of pain and sensorimotor deficit.

Pharmacologic and Acute Management of Spinal Cord Injury in Adults and Children

Purpose of Review

This review provides guidance for acute spinal cord injury (SCI) management through an analytical assessment of the most recent evidence on therapies available for treating SCI, including newer therapies under investigation. We present an approach to the SCI patient starting at presentation to acute rehabilitation and prognostication, with additional emphasis on the pediatric population when evidence is available.

Recent Findings

Further studies since the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) demonstrated a potential functional outcome benefit with ultra-early surgical intervention ≤ 8 h post-SCI. Subsequent analysis of the National Acute Spinal Cord Injury Study (NASCIS) II and NASCIS III trials have demonstrated potentially serious complications from intravenous methylprednisolone with limited benefit. Newer therapies actively being studied have demonstrated limited or no benefit in preclinical and clinical trials with insufficient evidence to support use in acute SCI treatment.

Summary

Care for SCI patients requires a multi-disciplinary team. Immediate evaluation and management are focused on preventing additional injury and restoring perfusion to the affected cord. Rapid assessment and intervention involve focused neurological examination, targeted imaging, and surgical intervention when indicated. There are currently no evidence-based recommendations for pathomechanistically targeted therapies.

A prospective multi-center study comparing the complication profile of modest systemic hypothermia versus normothermia for acute cervical spinal cord injury

STUDY DESIGN

Prospective multi-center trial.

OBJECTIVES

To characterize the complication profile associated with modest systemic hypothermia after acute cervical SCI in a prospective multi-center study.

SETTING

Five trauma centers in the United States.

METHODS

We analyzed data from a prospective, multi-center trial on the use of modest systemic hypothermia for acute cervical SCI. Patients with acute cervical SCI were assigned to receive modest systemic hypothermia (33 C) or standard of care medical treatment. Patients in the hypothermia group were cooled to 33 C and maintained at the target temperature for 48 h. Complication profile and the rate of complications within the first 6 weeks after injury were compared between the two groups. Multiple regression analysis was performed to determine risk factors for complications after injury.

RESULTS

Fifty patients (hypothermia: 27, control: 23) were analyzed for this study. Median age was significantly lower in the hypothermia arm (39 vs 59 years, p = 0.02). Respiratory complications were the most common (hypothermia: 55.6% vs control: 52.2%, p = 0.81). The rate of deep vein thrombosis was not significantly different between the two groups (hypothermia: 14.8% vs control 17.4%, p = 0.71). The rate of complications was not statistically different between the two groups.

CONCLUSION

In this prospective multi-center controlled trial, preliminary data show that modest systemic hypothermia was not associated with increased risk of complications within the first 6 weeks after acute cervical SCI.

TRIAL INFORMATION

The study is registered on clinicaltrials.gov NCT02991690. University of Miami IRB (Central IRB) approval No.: 20160758. Emory University IRB #IRB00093786.

Utilizing Pulmonary Function Parameters to Predict Dysphagia in Individuals With Cervical Spinal Cord Injuries

Objective

To utilize pulmonary function parameters as predictive factors for dysphagia in individuals with cervical spinal cord injuries (CSCIs).

Methods

Medical records of 78 individuals with CSCIs were retrospectively reviewed. The pulmonary function was evaluated using spirometry and peak flow meter, whereas the swallowing function was assessed using a videofluoroscopic swallowing study. Participants were divided into the non-penetration-aspiration group (score 1 on the Penetration-Aspiration Scale [PAS]) and penetration-aspiration group (scores 2–8 on the PAS). Individuals with pharyngeal residue grade scores >1 were included in the pharyngeal residue group.

Results

The mean age was significantly higher in the penetration-aspiration and pharyngeal residue groups. In this study, individuals with clinical features, such as advanced age, history of tracheostomy, anterior surgical approach, and higher neurological level of injury, had significantly more penetration-aspiration or pharyngeal residue. Individuals in the penetration-aspiration group had significantly lower peak cough flow (PCF) levels. Individuals in the pharyngeal residue group had a significantly lower forced expiratory volume in 1 second (FEV1). According to the receiver operating characteristic curve analysis of PCF and FEV1 on the PAS, the cutoff value was 140 L/min and 37.5% of the predicted value, respectively.

Conclusion

Low PCF and FEV1 values may predict the risk of dysphagia in individuals with CSCIs. In these individuals, active evaluation of swallowing is recommended to confirm dysphagia.

In-hospital mortality in people with complete acute traumatic spinal cord injury at a tertiary care center in India-a retrospective analysis

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

To analyze the causes and risk factors of mortality in people admitted with complete acute traumatic spinal cord injury (ATSCI).

SETTING

The study was performed at the Indian Spinal Injuries Centre, New Delhi.

METHODS

Data between 2000 and 2016 were retrospectively collected from case records of people with ATSCI. Risk factors for mortality were examined using multivariable logistic regression.

RESULTS

Mortality rate in ATSCI admissions (n = 758) during the study period was 10%. Median (IQR) age of study participants was 34 (21) years with a range of 14-85 years. Respiratory complications, septicemia, and cardiovascular causes were responsible for 42%, 28, and 18% of deaths. Mortality rate in people with paraplegia and tetraplegia was 3% and 22%, respectively. The proportion surviving at 6 weeks was significantly different across people with paraplegia and people with high and low tetraplegia (p < 0.001). Greater age (OR (multivariable models) = 1.03, 95% CI = 1.01-1.06), associated injuries (OR = 2.42, 95% CI = 1.11-5.27), high tetraplegia (OR = 5.09, 95% CI = 2.21-11.72), low tetraplegia (OR = 4.84, 95% CI = 1.29-18.09), need for ventilator support (OR = 31.32, 95% CI = 14.92-65.35), septicemia (OR = 4.60, 95% CI = 1.05-20.07), respiratory complications (OR = 3.46, 95% CI = 1.63-7.33), and cardiovascular causes (OR = 39.03, 95% CI = 8.29-183.89) were significant risk factors associated with mortality.

CONCLUSION

Respiratory complications, septicemia, and cardiovascular causes were the commonest causes of in-hospital mortality in people with complete ATSCI. Greater age, presence of associated injuries, tetraplegia, and ventilator support were risk factors significantly associated with mortality. To reduce morbidity and mortality in the acute phase, there is a need to focus on respiratory management and prevention of infections, especially in tetraplegics.

Spinal Cord Signal Change on Magnetic Resonance Imaging May Predict Worse Clinical In- and Outpatient Outcomes in Patients with Spinal Cord Injury: A Prospective Multicenter Study in 459 Patients

Prognostic factors for clinical outcome after spinal cord (SC) injury (SCI) are limited but important in patient management and education. There is a lack of evidence regarding magnetic resonance imaging (MRI) and clinical outcomes in SCI patients. Therefore, we aimed to investigate whether baseline MRI features predicted the clinical course of the disease. This study is an ancillary to the prospective North American Clinical Trials Network (NACTN) registry. Patients were enrolled from 2005-2017. MRI within 72 h of injury and a minimum follow-up of one year were available for 459 patients. Patients with American Spinal Injury Association impairment scale (AIS) E were excluded. Patients were grouped into those with (n = 354) versus without (n = 105) SC signal change on MRI T2-weighted images. Logistic regression analysis adjusted for commonly known a priori confounders (age and baseline AIS). Main outcomes and measures: The primary outcome was any adverse event. Secondary outcomes were AIS at the baseline and final follow-up, length of hospital stay (LOS), and mortality. A regression model adjusted for age and baseline AIS. Patients with intrinsic SC signal change were younger (46.0 (interquartile range (IQR) 29.0 vs. 50.0 (IQR 20.5) years, p = 0.039). There were no significant differences in the other baseline variables, gender, body mass index, comorbidities, and injury location. There were more adverse events in patients with SC signal change (230 (65.0%) vs. 47 (44.8%), p < 0.001; odds ratio (OR) = 2.09 (95% confidence interval (CI) 1.31-3.35), p = 0.002). The most common adverse event was cardiopulmonary (186 (40.5%)). Patients were less likely to be in the AIS D category with SC signal change at baseline (OR = 0.45 (95% CI 0.28-0.72), p = 0.001) and in the AIS D or E category at the final follow-up (OR = 0.36 (95% CI 0.16-0.82), p = 0.015). The length of stay was longer in patients with SC signal change (13.0 (IQR 17.0) vs. 11.0 (IQR 14.0), p = 0.049). There was no difference between the groups in mortality (11 (3.2%) vs. 4 (3.9%)). MRI SC signal change may predict adverse events and overall LOS in the SCI population. If present, patients are more likely to have a worse baseline clinical presentation (i.e., AIS) and in- or outpatient clinical outcome after one year. Patients with SC signal change may benefit from earlier, more aggressive treatment strategies and need to be educated about an unfavorable prognosis.

A Prognostic Factor for Prolonged Mechanical Ventilator-Dependent Respiratory Failure after Cervical Spinal Cord Injury : Maximal Canal Compromise on Magnetic Resonance Imaging

Objective

The period of mechanical ventilator (MV)-dependent respiratory failure after cervical spinal cord injury (CSCI) varies from patient to patient. This study aimed to identify predictors of MV at hospital discharge (MVDC) due to prolonged respiratory failure among patients with MV after CSCI.

Methods

Two hundred forty-three patients with CSCI were admitted to our institution between May 2006 and April 2018. Their medical records and radiographic data were retrospectively reviewed. Level and completeness of injury were defined according to the American Spinal Injury Association (ASIA) standards. Respiratory failure was defined as the requirement for definitive airway and assistance of MV. We also evaluated magnetic resonance imaging characteristics of the cervical spine. These characteristics included : maximum canal compromise (MCC); intramedullary hematoma or cord transection; and integrity of the disco-ligamentous complex for assessment of the Subaxial Cervical Spine Injury Classification (SLIC) scoring. The inclusion criteria were patients with CSCI who underwent decompression surgery within 48 hours after trauma with respiratory failure during hospital stay. Patients with Glasgow coma scale 12 or lower, major fatal trauma of vital organs, or stroke caused by vertebral artery injury were excluded from the study.

Results

Out of 243 patients with CSCI, 30 required MV during their hospital stay, and 27 met the inclusion criteria. Among them, 48.1% (13/27) of patients had MVDC with greater than 30 days MV or death caused by aspiration pneumonia. In total, 51.9% (14/27) of patients could be weaned from MV during 30 days or less of hospital stay (MV days : MVDC 38.23±20.79 vs. MV weaning, 13.57±8.40; p<0.001). Vital signs at hospital arrival, smoking, the American Society of Anesthesiologists classification, Associated injury with Injury Severity Score, SLIC score, and length of cord edema did not differ between the MVDC and MV weaning groups. The ASIA impairment scale, level of injury within C3 to C6, and MCC significantly affected MVDC. The MCC significantly correlated with MVDC, and the optimal cutoff value was 51.40%, with 76.9% sensitivity and 78.6% specificity. In multivariate logistic regression analysis, MCC >51.4% was a significant risk factor for MVDC (odds ratio, 7.574; p=0.039).

Conclusion

As a method of predicting which patients would be able to undergo weaning from MV early, the MCC is a valid factor. If the MCC exceeds 51.4%, prognosis of respiratory function becomes poor and the probability of MVDC is increased.

A Systematic Review of Safety Reporting in Acute Spinal Cord Injury Clinical Trials: Challenges and Recommendations

Accurate safety information in published clinical trials guides the assessment of risk-benefit, as well as the design of future clinical trials. Comprehensive reporting of adverse events, toxicity, and discontinuations from acute spinal cord injury clinical trials is an essential step in this process. Here, we sought to assess the degree of "satisfactoriness" of reporting in past clinical trials in spinal cord injury. A review of citations from MEDLINE and EMBASE identified eligible clinical trials in acute (within 30 days) spinal cord injury. English language studies, published between 1980 and 2020, with sensory, motor, or autonomic neurological assessments as the primary outcome measure were eligible for inclusion. Criteria were then established to qualify the safety reporting as satisfactory (i.e., distinguished severe/life-threatening events), partially satisfactory, or unsatisfactory (i.e., only mentioned in general statements, or reported but without distinguishing severe events). A total of 40 trials were included. Satisfactory reporting for clinical adverse events was observed in 30% of trials; partially satisfactory was achieved by 10% of the trials, and the remaining 60% were unsatisfactory. The majority of trials were determined to be unsatisfactory for the reporting of laboratory-defined toxicity (82.5%); only 17.5% were satisfactory. Discontinuations were satisfactorily reported for the majority of trials (80%), with the remaining partially satisfactory (5%) or unsatisfactory (15%). Reporting of safety in clinical trials for acute spinal cord injury is suboptimal. Due to the complexities of acute spinal cord injury (e.g., polytrauma, multiple systems affected), tailored and specific standards for tracking adverse events and safety reporting should be established.

hucMSCs transplantation promotes locomotor function recovery, reduces apoptosis and inhibits demyelination after SCI in rats

AIMS

Spinal cord injury (SCI) can cause a variety of cells apoptosis, neurodegeneration, and eventually permanent paralysis. This study aimed to examine whether transplanting human umbilical cord mesenchymal stem cells (hucMSCs) can promote locomotor function recovery, reduce apoptosis and inhibit demyelination in SCI models.

MAIN METHODS

Rats were allocated into Sham group (spinal cord exposure only), SCI + PBS group (spinal cord impact plus phosphate-buffered saline (PBS) injections), SCI + hucMSCs group (spinal cord impact plus hucMSCs injections) groups. Behavioral tests, Basso-Beattie-Bresnahan locomotion scores (BBB scores), were carried out at 0, 3, 7, 14, 21, 28 days after SCI surgery. Hematoxylin-eosin staining observed spinal cord morphology. Nissl staining detected the number of nissl bodies. Myelin basic protein (MBP) and oligodendrocyte (CNPase) were examed by immunohistochemical staining. The apoptosis of oligodendrocyte and neurons were detected by immunofluorescence.

RESULTS

The 28-day behavioral test showed that the BBB score of rats in the SCI + hucMSCs group increased significantly, comparing to the SCI + PBS group. The numbers of nissl bodies and myelin sheath in the damaged area of SCI + hucMSCs group were also significantly increased compared to the SCI + PBS group. HucMSCs transplanting decreased the expression of protein level of Caspase-3 and Bax and increased the Bcl-2, MBP and CNPase, rescued the apoptosis of neurons and the oligodendrocyte.

CONCLUSION

These results showed that hucMSCs can improve motor function, tissue repairing and reducing apoptosis in SCI rats.

Submandibular Push Exercise Using Visual Feedback from a Pressure Sensor in Patients with Swallowing Difficulties: A Pilot Study

Objectives: We aimed to determine the usefulness and effectiveness of a submandibular push exercise with visual feedback from a pressure sensor in patients with dysphagia through continuous exercise sessions. Methods: Twelve patients with dysphagia of various etiologies were included. A total of five exercise sessions (every 3 or 4 days) over three weeks were conducted. During the submandibular push exercise, patients were instructed to maintain a maximum force for 3 s, repeated for 1 min to measure the number of exercises, the maximum pressure, and the area of the pressure-time graph. We statistically compared the values of each exercise trial. Results: Among the 12 patients, eight completed the exercise sessions. As the number of exercise trials increased, the maximum pressure and the area in the pressure-time graph showed a significant increase compared to the previous attempt (p < 0.05). The maximum pressure and the area of the pressure-time graph improved from the first to the fourth session (p < 0.05). The values were maintained after the fourth session, and there was no significant difference between the fourth and the fifth exercise (p > 0.05). There was no significant difference between successful and non-successful groups, except for the Modified Barthel Index (p < 0.05). Conclusion: Through repetitive exercise training, the submandibular push exercise using visual feedback from a pressure sensor can be applied as an exercise method to strengthen swallowing related muscles, such as the suprahyoid and infrahyoid muscles. However, additional studies including more patients and a long-term study period are warranted to evaluate the effects of the exercise for improvement of dysphagia.

Mechanism of Dysphagia after Acute Traumatic Cervical Spinal Cord Injury

Swallowing dysfunction, which may cause aspiration pneumonia, is one of the most important complications of treatment of traumatic cervical spinal cord injury (CSCI); however, the mechanism of dysphagia is not well understood. No previous studies have reported the association between morphological changes of the soft tissue and dysphagia. We aimed to determine the factors associated with severity of dysphagia after CSCI and elucidate its mechanism. We conducted a prospective analysis of patients with acute traumatic CSCI who were admitted within 2 weeks of the injury. Dysphagia was evaluated using the Dysphagia Severity Scale (DSS) 2 weeks after the injury. The widths of the retropharyngeal and retrotracheal spaces were measured to assess soft tissue damage owing to the injury using sagittal images of computed tomography. We also assessed age, surgery of the injured cervical spine, presence of tracheostomy, osteophyte behind the pharynx, level of injury, and motor score 2 weeks after the injury. A total of 136 persons met our criteria. Given that 44 persons were categorized under grades <5 of the DSS, which were defined as different types of aspirations, the incidence of aspiration was 32%. The multiple regression analysis revealed that age, motor score, tracheostomy, and retropharyngeal space were significantly associated with DSS. Severe paresis, tracheostomy, old age, and swelling of the retropharyngeal space were significantly affected by dysphagia after CSCI. Morphological changes in the pharynx, situated right behind the larynx, after the injury affects the mechanism of dysphagia.

Serum albumin as a predictor of neurological recovery after spinal cord injury: a replication study

STUDY DESIGN

This was a secondary analysis on an observational cohort study.

OBJECTIVE

To determine if serum albumin significantly associates with long-term neurological outcome (i.e., 1-year post-injury) in a contemporary cohort of individuals with spinal cord injury.

SETTING

Six rehabilitation centers across the United States.

METHODS

A secondary analysis of neurological outcomes and serum albumin concentrations was performed on data from the Spinal Cord Injury Rehabilitation study. Data was accessed from the Archive of Data on Disability to Enable Policy and research (ADDEP). The primary analysis applied unbiased recursive partitioning to examine the relationship between serum albumin, injury severity, and long-term outcomes. The analysis is accessible via https://rpubs.com/AnhKhoaVo/586028 .

RESULTS

Serum albumin concentration was significantly associated with lower extremity motor scores (LEMS) and American Spinal Injury Association Impairment Scale (AIS) grade at admission to rehabilitation. Serum albumin concentrations alone were also significantly associated with change of LEMS and marked recovery (improvement of at least 2 AIS grades and/or recovery to walking) at 1-year post injury. However, after adjusting for admission to rehabilitation LEMS and AIS grade, serum albumin was not significant.

CONCLUSION

The current study partially confirms our previous observations that serum albumin concentrations are associated with neurological outcome after spinal cord injury. As a crude prognostic biomarker, serum albumin concentration could be useful in cases where injury severity cannot be accurately assessed.

The Impact of a Comorbid Spinal Cord Injury on Cognitive Outcomes of Male and Female Patients with Traumatic Brain Injury

INTRODUCTION

Evidence of the effect of comorbid spinal cord injury (SCI) on cognitive outcomes in persons undergoing rehabilitation following newly diagnosed traumatic brain injury (TBI) is limited. We conducted a population-based study to investigate this effect.

OBJECTIVE

To compare cognitive outcomes in patients with TBI with and without a comorbid SCI.

SETTING/PARTICIPANTS

Adult patients diagnosed with TBI were identified and followed for 1 year through provincial health administrative data; those who entered inpatient rehabilitation were studied.

DESIGN

A retrospective matched cohort study using the National Rehabilitation Reporting System data of all acute care and freestanding rehabilitation hospitals in Ontario, Canada.

MAIN MEASURES

The exposure was a comorbid SCI in patients with diagnosed TBI. Exposed patients were matched to unexposed (TBI-only) on sex, age, injury severity, and income, in a ratio of one to two. Gain differences in the cognitive subscale of the Functional Independence Measure were compared between exposed and unexposed patients using multivariable mixed linear model, controlling for comorbidity propensity score, gains in motor function, and rehabilitation care indicators.

RESULTS

Over the first year post injury, 12 750 (0.84%) of all TBI patients entered inpatient rehabilitation, of whom 1359 (10.66%) had a comorbid SCI. A total of 1195 exposed patients (65.4% male, mean age 50.9 ± 20.6 for male and 61.8 ± 21.8 for female patients) were matched to 2390 unexposed patients. Controlling for confounding, exposed patients had lower cognitive gain (beta -0.43; 95% CI -0.72, -0.15), for both male (beta -0.39; 95% CI -0.75, -0.03) and female (beta -0.51; 95% CI -0.97, -0.05) patients. The adverse effects of comorbid SCI were driven largely by lower gains in problem solving and comprehension.

CONCLUSIONS

Adult patients with TBI and comorbid SCI showed a lower cognitive domain response to inpatient rehabilitation than patients with TBI alone. Identifying patients at risk for worse cognitive outcomes may facilitate the development of targeted strategies that improve cognitive outcomes.

Ferroptosis in Acute Central Nervous System Injuries: The Future Direction?

Acute central nervous system (CNS) injuries, such as stroke, traumatic brain injury (TBI), and spinal cord injury (SCI) present a grave health care challenge worldwide due to high morbidity and mortality, as well as limited clinical therapeutic strategies. Established literature has shown that oxidative stress (OS), inflammation, excitotoxicity, and apoptosis play important roles in the pathophysiological processes of acute CNS injuries. Recently, there have been many studies on the topic of ferroptosis, a form of regulated cell death characterized by the accumulation of iron-dependent lipid peroxidation. Some studies have revealed an emerging connection between acute CNS injuries and ferroptosis. Ferroptosis, induced by the abnormal metabolism of lipids, glutathione (GSH), and iron, can accelerate acute CNS injuries. However, pharmaceutical agents, such as iron chelators, ferrostatin-1 (Fer-1), and liproxstatin-1 (Lip-1), can inhibit ferroptosis and may have neuroprotective effects after acute CNS injuries. However, the specific mechanisms underlying this connection has not yet been clearly elucidated. In this paper, we discuss the general mechanisms of ferroptosis and its role in stroke, TBI, and SCI. We also summarize ferroptosis-related drugs and highlight the potential therapeutic strategies in treating various acute CNS injuries. Additionally, this paper suggests a testable hypothesis that ferroptosis may be a novel direction for further research of acute CNS injuries by providing corresponding evidence.

Impact of complications at admission to rehabilitation on the functional status of patients with spinal cord lesion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Aim of the study is to evaluate the impact of complications at admission on the functional status of spinal cord lesions patients.

SETTING

Rehabilitation hospital in Italy.

METHODS

Two hundred and seven patients with complications (mostly pressure ulcers) at admission to rehabilitation were matched for neurological level of injury and AIS grade with 207 patients without complications.

MEASURES

International Standards for Neurological Classification of Spinal Cord Injury, Spinal Cord Independence Measure, Rivermead Mobility Index, and Walking Index for Spinal Cord Injury. These measures were recorded at admission to rehabilitation and at discharge. We also recorded length of acute and rehabilitation stay and discharge destination.

STATISTICS

Student's T test for paired samples, McNemar's chi-square test.

RESULTS

Patients with complications at admission suffered more often from a traumatic lesions. The functional status at admission and discharge of the patients without complications was significantly better than the functional status of patients with complications (Spinal Cord Independence Measure mean difference between the two groups 5.7 (CI 2.8-8.5) at admission, and 10 (CI 5.3-14.7) at discharge). Length of stay was significantly higher in patients with complications. Patients with complications were more often institutionalized than their counterparts (46/161 vs. 20/187, odds ratio 0.4 (CI 0.2-0.7)).

CONCLUSIONS

Complications seem to be more frequent in patients with traumatic lesions. The presence of complications has a negative effect on patients' functional status at discharge and length of stay, and it determines a higher risk of being institutionalized.

Current Topics in the Management of Acute Traumatic Spinal Cord Injury

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

Quality and Safety Improvement in Spine Surgery

STUDY DESIGN

Review article.

OBJECTIVES

A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery.

METHODS

A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review.

RESULTS

Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature.

CONCLUSION

Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.

A Two-decade Assessment of Changing Practice for Surgical Decompression and Fixation after Traumatic Spinal Cord Injury – Impact on Healthcare Utilization and Cost

Early surgery after traumatic spinal cord injury (TSCI) has been associated with a greater neurological recovery and reduced secondary complications. In this study, we aimed to evaluate the trend of early TSCI surgery (within 24 hours) over two decades and the effect on length of hospitalization, complications, and hospital charges. We extracted emergency admissions of adults diagnosed with TSCI from the National Inpatient Sample database (1998-2016). We analyzed the trend of early surgery and concurrent trends of complication rate, length of stay (LOS) and hospital charges. These outcomes were then compared between early and late surgery cohorts. There were 3942 (53%) TSCI patients who underwent early surgery, and 3446 (47%) were operated after 24 hours. The combined patient group characteristics consisted of median age 43 years (IQR: 29-59), 73% males, 72% white, 44% private payer, 18% Medicare, 17% Medicaid, 51% cervical, 30% thoracic, 75% from large hospitals, and 79% from teaching hospitals. The trend of early surgery, adjusted for annual case-mix, increased from 45% in 1998 to 64% in 2016. Each year was associated with 1.60% more patients undergoing early surgery than the previous year (p-value <0.05). During these years, the total LOS decreased, while hospital charges increased. Patients who underwent early surgery spent four fewer days in the hospital, accrued $28,705 lower in hospital charges and had 2.8% fewer complications than those with delay surgery. We found that the rate of early surgery has significantly increased from 1998 to 2016. However, as of 2016, one-third of patients still did not undergo spinal surgery within 24 hours. Late surgery is associated with higher complications, longer stays, and higher charges. The causes of delayed surgery are undoubtedly justified in some situations but require further delineation. Surgeons should consider performing surgery within 24 hours on patients with TSCI whenever feasible. 

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

OBJECTIVES

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

DESIGN

Multicenter prospective registry.

SETTING

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

PATIENTS

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

INTERVENTIONS

Appropriate spinal cord injury treatment at individual centers.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

SCING-Spinal Cord Injury Neuroprotection with Glyburide: a pilot, open-label, multicentre, prospective evaluation of oral glyburide in patients with acute traumatic spinal cord injury in the USA

INTRODUCTION

Acute traumatic spinal cord injury (tSCI) is a devastating neurological disorder with no pharmacological neuroprotective strategy proven effective to date. Progressive haemorrhagic necrosis (PHN) represents an increasingly well-characterised mechanism of secondary injury after tSCI that negatively impacts neurological outcomes following acute tSCI. Preclinical studies evaluating the use of the Food and Drug Administration-approved sulfonylurea receptor 1-transient receptor potential melastatin 4 channel blocker glyburide in rodent models have shown reduced secondary microhaemorrhage formation and the absence of capillary fragmentation, the pathological hallmark of PHN.

METHODS AND ANALYSIS

In this initial phase multicentre open-label pilot study, we propose to enrol 10 patients with acute cervical tSCI to primarily assess the feasibility, and safety of receiving oral glyburide within 8 hours of injury. Secondary objectives include pharmacokinetics and preliminary evaluations on neurological recovery as well as blood and MRI-based injury biomarkers. Analysis will be performed using the descriptive and non-parametric statistics.

ETHICS AND DISSEMINATION

Glyburide has been shown as an effective neuroprotective agent in preclinical tSCI models and in the treatment of ischaemic stroke with the additional risk of a hypoglycaemic response. Given the ongoing secondary injury and the traumatic hyperglycaemic stress response seen in patients with tSCI, glyburide; thus, offers an appealing neuroprotective strategy to supplement standard of care treatment. The study protocol was approved by the Ohio State University Biomedical Institutional Review Board. The protocol was amended in February 2017 with changes related to study feasibility and patient recruitment. Specifically, the route of administration was changed to the oral form to allow for streamlined and rapid drug administration, and the injury-to-drug time window was extended to 8 hours in an effort to further enhance enrolment. Participants or legally authorised representatives are informed about the trial and its anticipated risks orally and in written form using an approved informed consent form prior to inclusion. The findings of this study will be disseminated to the participants and to academic peers through scientific conferences and peer-reviewed journal publications.

TRIAL REGISTRATION NUMBERS

NCT02524379 and 2014H0335.

Critical Care Management of Acute Spinal Cord Injury-Part II: Intensive Care to Rehabilitation

Spinal cord injury is devastating to those affected due to the loss of motor and sensory function, and, in some cases, cardiovascular collapse, ventilatory failure, and bowel and bladder dysfunction. Primary trauma to the spinal cord is exacerbated by secondary insult from the inflammatory response to injury. Specialized intensive care of patients with acute spinal cord injury involves the management of multiple systems and incorporates evidence-based practices to reduce secondary injury to the spinal cord. Patients greatly benefit from early multidisciplinary rehabilitation for neurologic and functional recovery. Treatment of acute spinal cord injury may soon incorporate novel molecular agents currently undergoing clinical investigation to assist in neuroprotection and neuroregeneration.

The time course of dysphagia following traumatic cervical spinal cord injury: a prospective cohort study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To elucidate serial changes in dysphagia and elucidate the critical period for dysphagia following acute traumatic cervical spinal cord injury (CSCI).

SETTING

Spinal Injuries Center, Fukuoka, Japan.

METHODS

We prospectively examined individuals with acute traumatic CSCI admitted within 2 weeks after injury. Severity of dysphagia was evaluated using both the dysphagia severity scale (DSS) and functional oral intake scale (FOIS) at 2 weeks, 1 month, 2 months, and 3 months after injury. Condition of oral intake before injury was assessed by history taking. American Spinal Injury Association (ASIA) impairment scale grade and motor scores were also assessed at the same timepoints, and the correlation between dysphagia and paresis was analyzed.

RESULTS

Sixty-five individuals with CSCI were assessed consecutively for 3 months after injury. Swallowing function, evaluated using both the DSS and FOIS, was significantly decreased at 2 weeks after injury, but significantly improved thereafter. Significant correlations between severity of dysphagia (DSS and FOIS scores) and motor scores were found at 2 weeks after injury (r_s = 0.66 and 0.61; p < 0.001 and p < 0.001, respectively), indicating that individuals with lower motor scores had more severe swallowing dysfunction.

CONCLUSIONS

Dysphagia occurred immediately after injury, but gradually improved over time. Individuals with more severe paralysis had significantly more severe dysphagia. Special attention for dysphagia should be paid to individuals with severe paralysis in acute phase.

Severe pressure ulcers requiring surgery impair the functional outcome after acute spinal cord injury

STUDY DESIGN

Retrospective matched cohort study.

OBJECTIVES

Assessing the influence of surgically managed grade 3 and 4 pressure ulcers (PU) in the acute phase after spinal cord injury (SCI) on the neurological and functional outcome after 1 year.

SETTING

Specialized SCI-unit within a level 1 trauma center in Murnau, Germany.

METHODS

We performed a retrospective matched cohort study. For every patient with acute SCI and a PU requiring surgery, we identified matched controls within our database in a 1:3 ratio. Matching criteria were: AIS-grade (American Spinal Injury Association Impairment Scale), neurological level and age. The scores of the SCIM-III (Spinal Cord Independence Measure) and the ISNCSCI (International Standards for Neurological Classification of Spinal Cord Injury) as well as the total length of stay (LOS) at the hospital were used as outcome parameters. We applied a stratified analysis using a conditional logistic regression to test for group differences in each outcome parameter of the study.

RESULTS

In a 6-year period (2010-2015) 28 patients required flap surgery due to 3-4° PU in the acute phase after SCI. Of these patients, 15 had complete data sets according to the EMSCI (European Multicenter Study about Spinal Cord Injury) protocol. Patients with severe PUs during the acute SCI phase had a significantly impaired functional outcome. After 1 year the improvement of the SCIM score was significantly lower in the PU group compared to the control group (17.4 versus 30.5; p < 0.006). However, the change in AIS grade after 1 year was not significantly affected. The LOS was prolonged by a mean of 48 days in the PU group (p < 0.006).

CONCLUSIONS

Severe PUs requiring surgery in the acute phase after SCI impair the functional outcome and increase LOS. Preventive measures should be applied to all acute SCI patients. Patients should be transferred to specialized SCI-centers as soon as possible.

Association of Pneumonia, Wound Infection, and Sepsis with Clinical Outcomes after Acute Traumatic Spinal Cord Injury

 < 0.001). There were no statistical differences between participants with or without PWS with respect to time from injury to surgery, and administration of steroids. Dominance analysis showed injury level, baseline AIS grade, and subject pre-morbid medical status collectively accounted for 77.7% of the predicted variance of PWS. Regression analysis indicated subjects with PWS demonstrated higher odds for respiratory (odds ratio [OR] 3.91, 95% confidence interval [CI]: 1.42-10.79) and ambulatory (OR 3.94, 95% CI: 1.50-10.38) support at 6 month follow-up in adjusted analysis. This study has shown an association between PWS occurring during acute admission and poorer functional outcomes following SCI.

Nutritional status in chronic spinal cord injury: a systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

The objective was to investigate nutritional status in chronic spinal cord injury (SCI), and compare macronutrient and micronutrient intake to the recommended values by the United States Department of Agriculture (USDA) 2015-2020 Dietary Guidelines for Americans.

SETTING

United States of America.

METHODS

A MEDLINE/PubMed, Google Scholar, Scopus, and Web of Science search was performed, identifying 268 papers. All papers included were English-language papers examining adults with chronic SCI. A meta-analysis was performed to produce weighted averages and 95% confidence intervals (CI) when summary statistics were provided.

RESULTS

The systematic review included 15 articles, while the meta-analysis included 12. Resting metabolic rate (1492 kcal/day; CI: 1414-1569) fell below the able-bodied average, and total energy (1876 kcal/day; CI: 1694-2059) and fiber (17 g/day; CI: 14-20) intake were below USDA guidelines. Protein (319 kcal/day; CI: 294-345) and carbohydrate (969 kcal/day; CI: 851-1087) intake were above guidelines. Fat intake (663 kcal/day; CI: 590-736) was within USDA guidelines. Vitamins A, B5, B7, B9, D, E, potassium, and calcium were deficient, while vitamins B1, B2, B3, B12, C, K, sodium, phosphorus, copper, and zinc were in excess according to USDA guidelines. Vitamin B6, iron, and magnesium were within USDA guidelines.

CONCLUSION

Findings indicate greater energy intake relative to energy needs in those with chronic SCI, and an imbalance in fiber intake and micronutrients compared to the USDA guidelines. Future research examining nutritional health status is needed in order to establish evidence-based, SCI-specific dietary guidelines.

Traumatic spinal cord injury in the north-east Tanzania - describing incidence, etiology and clinical outcomes retrospectively

Background: Causes, magnitude and consequences of traumatic spinal cord injury depend largely on geography, infrastructure, socioeconomic and cultural activities of a given region. There is a scarcity of literature on profile of traumatic spinal cord injury to inform prevention and rehabilitation of this health condition in African rural settings, particularly Tanzania.

Objective: To describe the incidence, etiology and clinical outcomes of traumatic spinal cord injury and issues related to retrospective study in underdeveloped setting.

Methods: Records for patients with traumatic spinal cord injury for five consecutive years (2010–2014) were obtained retrospectively from the admission wards and health records archives of the Kilimanjaro Christian Medical Center. Sociodemographic, cause, complications and patients’ condition on discharge were recorded and analyzed descriptively.

Results: The admission books in the wards registered 288 new traumatic spinal cord injury cases from January 2010 to December 2014. Of the 288 cases registered in the books, 224 were males and 64 females with mean age 39.1(39.1 ± 16.3) years and the majority of individuals 196(68.1%) were aged between 16 and 45 years. A search of the hospital archives provided 213 full patient records in which the leading cause of injury was falls 104(48.8%) followed by road traffic accidents 73(34.3%). Cervical 81(39.9%) and lumbar 71(34.74%) spinal levels were the most affected. The annual incidence for the Kilimanjaro region (population 1,640,087) was estimated at more than 26 persons per million population. The most documented complications were pressure ulcers 42(19.7%), respiratory complications 32(15.0%) and multiple complications 28(13.1%). The mean length of hospital stay was 64.2 ± 54.3 days and the mortality rate was 24.4%.

Conclusion: Prevention of traumatic spinal cord injury in North-east Tanzania should consider falls (particularly from height) as the leading cause, targeting male teenagers and young adults. Pressure ulcers, respiratory complications, in-hospital mortality and availability of wheelchairs should be addressed.

The impact of acute management on the occurrence of medical complications during the specialized spinal cord injury acute hospitalization following motor-complete cervical spinal cord injury

CONTEXT/OBJECTIVE

Determine the impact of early admission and complete perioperative management in a specialized spinal cord injury (SCI) trauma center (SCI-center) on the occurrence of medical complications following tetraplegia.

DESIGN

A retrospective comparative cohort study of prospectively collected data involving 116 individuals was conducted. Group 1 (N=87) was early managed in a SCI-center promptly after the trauma, whereas Group 2 (N=29) was surgically and preoperatively managed in a non-specialized (NS) center before being transferred to the SCI-center. Bivariate comparisons and multivariate logistic regression analyses were used to assess the relationship between the type of acute care facility and the occurrence of medical complications. Length of stay (LOS) in acute care was also compared.

SETTING

Single Level-1 trauma center.

PARTICIPANTS

Individuals with acute traumatic motor-complete cervical SCI.

INTERVENTIONS

Not applicable Outcome measures: The occurrence of complications during the SCI-center stay.

RESULTS

There was a similar rate of complications between the two groups. However, the LOS was greater in Group 2 (p=0.04). High cervical injuries (C1-C4) showed an important tendency to increase the likelihood of developing a complication, while high cervical injuries and increased trauma severity increased the odds of developing respiratory complications.

CONCLUSION

Although complication rates were similar in non-specialized and specialized centers, peri-operative management in a non-specialized center required a longer length of stay. Prompt transfer to a SCI-center may optimize the care trajectory by favoring earlier transfer to rehabilitation.

First-in-Man Intrathecal Application of Neurite Growth-Promoting Anti-Nogo-A Antibodies in Acute Spinal Cord Injury

Background. Neutralization of central nervous system neurite growth inhibitory factors, for example, Nogo-A, is a promising approach to improving recovery following spinal cord injury (SCI). In animal SCI models, intrathecal delivery of anti-Nogo-A antibodies promoted regenerative neurite growth and functional recovery. Objective. This first-in-man study assessed the feasibility, safety, tolerability, pharmacokinetics, and preliminary efficacy of the human anti-Nogo-A antibody ATI355 following intrathecal administration in patients with acute, complete traumatic paraplegia and tetraplegia. Methods. Patients (N = 52) started treatment 4 to 60 days postinjury. Four consecutive dose-escalation cohorts received 5 to 30 mg/2.5 mL/day continuous intrathecal ATI355 infusion over 24 hours to 28 days. Following pharmacokinetic evaluation, 2 further cohorts received a bolus regimen (6 intrathecal injections of 22.5 and 45 mg/3 mL, respectively, over 4 weeks). Results. ATI355 was well tolerated up to 1-year follow-up. All patients experienced ≥1 adverse events (AEs). The 581 reported AEs were mostly mild and to be expected following acute SCI. Fifteen patients reported 16 serious AEs, none related to ATI355; one bacterial meningitis case was considered related to intrathecal administration. ATI355 serum levels showed dose-dependency, and intersubject cerebrospinal fluid levels were highly variable after infusion and bolus injection. In 1 paraplegic patient, motor scores improved by 8 points. In tetraplegic patients, mean total motor scores increased, with 3/19 gaining >10 points, and 1/19 27 points at Week 48. Conversion from complete to incomplete SCI occurred in 7/19 patients with tetraplegia. Conclusions. ATI335 was well tolerated in humans; efficacy trials using intrathecal antibody administration may be considered in acute SCI.