1
|
Palati R, Lv J, Yu J, He L, Sun Y. Innovative Computed Tomography-Assisted Intrathecal Nusinersen Injection in a Pediatric Patient. Clin Pediatr (Phila) 2024; 63:746-749. [PMID: 37997668 DOI: 10.1177/00099228231210708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Affiliation(s)
- Reheman Palati
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Jishou Lv
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Jing Yu
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Lei He
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| | - Yan Sun
- Department of Neurology, Children's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Hospital of Beijing Children's Hospital, Urumqi, China
| |
Collapse
|
2
|
Huang J, Feng Y, Wang J, Huang S, Jin J, Xu L, Zhao C, Hua Y, Li X, Xu J, Li H, Zhang H, Zhang Y, Gao F, Mao S. Feasibility analysis of intrathecal administration strategy of nusinersen based on Cobb angle in children with spinal muscular atrophy. Eur J Paediatr Neurol 2023; 46:55-60. [PMID: 37453233 DOI: 10.1016/j.ejpn.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
AIM This retro-prospective observational study described the experience in lumbar puncture procedures in children with spinal muscular atrophy (SMA) with and without neuromuscular scoliosis in a single center. The technical feasibility of intrathecal nusinersen administration was the main limiting factor. STUDY DESIGN A total of 457 technically successful intrathecal injections based on a hierarchical strategy in Cobb angle were reviewed in 81 SMA children aged 0.75-13.5 years who were referred for nusinersen injections in our hospital from October 2019 to December 2022. RESULTS Under local anesthesia, conventional lumbar puncture was performed on 47 patients without spinal deformity (Cobb angle of 0-10°) and 20 patients with moderate scoliosis (Cobb angle of 10-50°). Ultrasound-assisted lumbar puncture was performed on 12 patients with moderate scoliosis but lordosis. A combination of ultrasound imaging and three-dimensional CT under sedation was performed in the remaining 14 patients with severe scoliosis (Cobb angle >50°). No severe complications were found. CONCLUSION Cobb angle is an important basis for intrathecal administration of nusinersen. It is feasible and suitable to carry out intrathecal nusinersen injection under ultrasound combined with three-dimensional CT imaging for children with severe scoliosis.
Collapse
Affiliation(s)
- Jinjin Huang
- Department of Anesthesiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Yijie Feng
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Jia Wang
- Department of Pediatrics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Siyi Huang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Jianing Jin
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Lu Xu
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Congying Zhao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Yi Hua
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Xiaoying Li
- Department of Ultrasonography, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Jingfang Xu
- Department of Orthopedics, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Haibing Li
- Department of Orthopedics, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Huan Zhang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Yi Zhang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Feng Gao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China
| | - Shanshan Mao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, China.
| |
Collapse
|
3
|
Balaji L, Farrar MA, D'Silva AM, Kariyawasam DS. Decision-making and challenges within the evolving treatment algorithm in spinal muscular atrophy: a clinical perspective. Expert Rev Neurother 2023; 23:571-586. [PMID: 37227306 DOI: 10.1080/14737175.2023.2218549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION The clinical application of disease modifying therapies has dramatically changed the paradigm of the management of people with spinal muscular atrophy (SMA), from sole reliance on symptomatic care directed toward the downstream consequences of muscle weakness, to proactive intervention and even preventative care. AREAS COVERED In this perspective, the authors evaluate the contemporary therapeutic landscape of SMA and discuss the evolution of novel phenotypes and the treatment algorithm, including the key factors that define individual treatment choice and treatment response. The benefits achieved by early diagnosis and treatment through newborn screening are highlighted, alongside an appraisal of emerging prognostic methods and classification frameworks to inform clinicians, patients, and families about disease course, manage expectations, and improve care planning. A future perspective of unmet needs and challenges is provided, emphasizing the key role of research. EXPERT OPINION SMN-augmenting therapies have improved health outcomes for people with SMA and powered the practice of personalized medicine. Within this new proactive diagnostic and treatment paradigm, new phenotypes and different disease trajectories are emerging. Ongoing collaborative research efforts to understand the biology of SMA and define optimal response are critical to refining future approaches.
Collapse
Affiliation(s)
- Lakshmi Balaji
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
| | - Michelle A Farrar
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
- UNSW Kensington Campus, Sydney, Australia
| | - Arlene M D'Silva
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
- UNSW Kensington Campus, Sydney, Australia
| | - Didu S Kariyawasam
- Department of Neurology, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health UNSW, Sydney, Australia
| |
Collapse
|
4
|
Walter MC, Laforêt P, van der Pol WL, Pegoraro E. 254th ENMC International Virtual Workshop Formation of a European network to initiate a European data collection, along with development and sharing of treatment guidelines for adult SMA patients 28 – 30 January 2022. Neuromuscul Disord 2023; 33:511-522. [PMID: 37245491 DOI: 10.1016/j.nmd.2023.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/14/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023]
|
5
|
Ultrasound-guided interlaminar approach for nusinersen administration in patients with spinal muscular atrophy with spinal fusion or severe scoliosis. Orphanet J Rare Dis 2023; 18:30. [PMID: 36800969 PMCID: PMC9936713 DOI: 10.1186/s13023-023-02630-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 02/06/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Intrathecal injection of medications can be challenging in spinal muscular atrophy (SMA) patients with severe scoliosis or after spine surgery. Here we report our experience with real-time ultrasound (US)-guided intrathecal administration of nusinersen in patients with SMA. METHODS Seven patients (six children and one adult) with either spinal fusion or severe scoliosis were enrolled. We performed intrathecal injections of nusinersen under US guidance. The efficacy and safety of US-guided injection were explored. RESULTS Five patients had undergone spinal fusion, while the other two presented severe scoliosis. Success was achieved in 19/20 lumbar punctures (95%), 15 of which were performed through the near-spinous process approach. The intervertebral space with a designated channel was selected for the five postoperative patients, while the interspaces with the smallest rotation angle were chosen for the other two patients with severe scoliosis. In 89.5% (17/19) of the punctures, the number of insertions was no more than two. No major adverse events were observed. CONCLUSION Given its safety and efficacy, real-time US guidance is recommended for SMA patients with spine surgery or severe scoliosis, and the near-spinous process view can be used as a interlaminar puncture approach for US guidance.
Collapse
|
6
|
Abstract
Spinal muscular atrophy (SMA) is a rare autosomal recessive neuromuscular disorder related to motor neuron degeneration. SMA patients present generally severe muscular weakness and atrophy, which can reduce life expectancy and lead to severe functional disability. In recent years, the management of this condition has been revolutionized by the development of innovative therapies that target alternative splicing of pre-messenger SMN2 RNA by antisense oligonucleotides or small molecules and by the approval of the first vector-based SMN1 gene therapy. The high significance of the trials in children led to fast-tracking of these therapies to all SMA patients despite the absence of data in adults. Real-life data are progressively providing a better understanding of the expected benefits and tolerability. They also highlight the difficulties of evaluating these patients and the need to take into account the patients' reported expectations and outcome. A review of the main data in adult patients is presented. The mechanisms of action of these innovative therapies are discussed as well as the limits of evaluations of these therapies in adults with longstanding severe amyotrophy.
Collapse
Affiliation(s)
- P Cintas
- Service de neurologie, CHU de Toulouse Purpan, centre de référence de pathologie neuromusculaire, place du Docteur Baylac TSA 40031, 31059 Toulouse cedex 9, France.
| |
Collapse
|
7
|
Cone-beam computed tomography guided nusinersen administrations in adult spinal muscular atrophy patients with challenging access: a single- center experience. Radiol Oncol 2022; 56:319-325. [PMID: 35962954 PMCID: PMC9400441 DOI: 10.2478/raon-2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/12/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The challenging anatomic predispositions in adult patients with spinal muscular atrophy (SMA) preclude the conventional lumbar punctures. Consequently, an introduction of alternative method for intrathecal delivery of nusinersen is required. Cone-beam CT (CBCT) allows volumetric display of the area of interest, pre-procedural planning and real time needle guidance which results in accurate anatomic navigation. The aim of the study was to evaluate technical success, safety, and feasibility of CBCT lumbar intrathecal delivery of nusinersen in the adult SMA patients with challenging anatomical access. PATIENTS AND METHODS Thirty-eight adult SMA patients were treated in our institution. Patients with challenging access were selected by multidisciplinary board for image guided administration of nusinersen either due to implantation of the posterior fusion instrumentation, severe scoliosis defined as Cobb's angle > 40º or body mass index over 35. Technical success, radiation exposure and occurrence of adverse events were assessed. RESULTS Twenty patients were selected, and 108 CBCT-guided procedures were performed. Each patient underwent at least 4 administrations. Transforaminal approach was performed in 82% of patients. The technical success was 100%, with primary success of 93.5%. The median radiation effective dose of the administrations was 5 mSv, the mean value equalled 10 mSv. Only mild adverse events were reported in the study. CONCLUSIONS CBCT-guided lumbar intrathecal administrations of nusinersen in an adult SMA population with challenging access was feasible and safe image guided method.
Collapse
|
8
|
Abstract
BACKGROUND The 5q-associated spinal muscular atrophy (SMA) affects ~ 80-120 newborns annually. The disease is characterized by progressive paresis involving the bulbar and respiratory musculatures. The phenotypes are very heterogeneous ranging from severe courses with early death in the first years of life to loss of gait in older age. OBJECTIVE There are now an increasing number of causally targeted therapies available that can either directly interfere with the transcription of the gene causing the disease or replace the homozygous loss of the SMN1 gene. This work aims to elucidate the current state of therapy in different groups of patients with SMA. MATERIAL AND METHODS Presentation of clinical trials and basic studies with a focus on patients with disease onset in adulthood. RESULTS The clinical studies all show improvement or stabilization of motor function; however, in individual cases, the burden of the therapy for severely immobilized patients must be considered in addition to the efficacy in the treatment decision. Even if the drugs show a good safety profile, observations on the long-term efficacy and safety of the new substance classes are still lacking. CONCLUSION The study landscape shows a good efficacy of the currently approved therapies across all degrees of severity and age groups. Due to the lack of comparative studies, the decision on the appropriate therapy should therefore be made according to an individual risk-benefit assessment.
Collapse
|
9
|
Rad N, Cai H, Weiss MD. Management of Spinal Muscular Atrophy in the Adult Population. Muscle Nerve 2022; 65:498-507. [PMID: 35218574 DOI: 10.1002/mus.27519] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 01/30/2022] [Accepted: 02/06/2022] [Indexed: 12/14/2022]
Abstract
Spinal muscular atrophy (SMA) is a group of neurodegenerative disorders resulting from the loss of spinal motor neurons. 95% of patients share a pathogenic mechanism of loss of survival motor neuron (SMN) 1 protein expression due to homozygous deletions or other mutations of the SMN1 gene, with the different phenotypes influenced by variable copy numbers of the SMN2 gene. Advances in supportive care, disease modifying treatment and novel gene therapies have led to an increase in the prevalence of SMA, with a third of SMA patients now represented by adults. Despite the growing number of adult patients, consensus on the management of SMA has focused primarily on the pediatric population. As the disease burden is vastly different in adult SMA, an approach to treatment must be tailored to their unique needs. This review will focus on the management of the adult SMA patient as they age and will discuss proper transition of care from a pediatric to adult center, including the need for continued monitoring for osteoporosis, scoliosis, malnutrition, and declining mobility and functioning. As in the pediatric population, multidisciplinary care remains the best approach to the management of adult SMA. Novel and emerging therapies such as nusinersen and risdiplam provide hope for these patients, though these medications are of uncertain efficacy in this population and require additional study.
Collapse
Affiliation(s)
- Nassim Rad
- Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, Washington, USA
| | - Haibi Cai
- Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, Washington, USA
| | - Michael D Weiss
- Department of Neurology, University of Washington, Seattle, Washington, USA
| |
Collapse
|
10
|
Snoj Ž, Salapura V. Ultrasound‐guided transforaminal approach for nusinersen delivery in adult
SMA
patients with challenging access. Muscle Nerve 2022; 65:585-589. [DOI: 10.1002/mus.27518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Ž. Snoj
- Radiology Institute, University Medical Centre Ljubljana, Zaloška 7 Ljubljana Slovenia
- Faculty of Medicine University of Ljubljana, Vrazov trg 2 Ljubljana Slovenia
| | - V. Salapura
- Radiology Institute, University Medical Centre Ljubljana, Zaloška 7 Ljubljana Slovenia
- Faculty of Medicine University of Ljubljana, Vrazov trg 2 Ljubljana Slovenia
| |
Collapse
|
11
|
Sansone VA, Walter MC, Attarian S, Delstanche S, Mercuri E, Lochmüller H, Neuwirth C, Vazquez-Costa JF, Kleinschnitz C, Hagenacker T. Measuring Outcomes in Adults with Spinal Muscular Atrophy - Challenges and Future Directions - Meeting Report. J Neuromuscul Dis 2021; 7:523-534. [PMID: 32538864 DOI: 10.3233/jnd-200534] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Spinal muscular atrophy (SMA) is a progressive autosomal recessive motor neuron disease which affects 1 in 6,000-10,000 live births, caused by loss of the survival motor neuron 1 gene (SMN1). A major focus of therapeutic developments has been on increasing the full-length SMN protein by increasing the inclusion of exon 7 in SMN2 transcripts, enhancing SMN2 gene expression, stabilizing the SMN protein or replacing the SMN1 gene.In June 2017, FDA and EMA have approved the antisense oligonucleotide Nusinersen as the first treatment for all SMA subtypes without age restriction. While prominent treatment effects have been observed in the earlier stages of the disease and in patients up to 15 years of age, there is only limited data from clinical trials in adult SMA patients. First real-world data from neuromuscular clinical centers suggest a therapeutic benefit of nusinersen with a favourable safety profile also in adult SMA patients: in several cases, relevant improvements of motor function is achieved, which might lead to enhanced autonomy in daily life activities and improved quality of life. Systematic follow-up of the motor status with validated instruments is crucial for an adequate monitoring of the therapeutic effects but most of the widely used scales and scores have been developed and evaluated for the pediatric population only. International neuromuscular experts have met in Frankfurt/Main, Germany in May 2019 to discuss relevant aspects of the diagnostic pathway and patient management in adult SMA. The recommendations and challenges in this patient population are discussed.
Collapse
Affiliation(s)
- V A Sansone
- The NEMO Clinical Center, Milan - Neurorehabilitation Unit, University of Milan, Italy
| | - M C Walter
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - S Attarian
- Reference Center for Neuromuscular Disorders and ALS, CHU La Timone, Aix-Marseille University, Marseille, France
| | - S Delstanche
- Department of Neurology, University of Liege, Belgium
| | - E Mercuri
- Department of Pediatrics, Catholic University of Rome, Roma, Italy.,Department of Woman and Child Health and Public Health, Paediatric Neurology and Neuromuscular Omnicentre Clinical Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy
| | - H Lochmüller
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.,Department of Medicine, The Ottawa Hospital, and Brain and Mind Research Institute, University of Ottawa, Ottawa, Canada
| | - C Neuwirth
- Muskelzentrum ALS Clinic, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - J F Vazquez-Costa
- Instituto de Investigacion Sanitaria la Fe (IIS La Fe), Neuromuscular Research Unit, Valencia, Spain.,Department of Neurology, ALS Unit, Hospital Universitario y Politecnico La Fe, Valencia, Spain.,Centro de Investigacion Biomedica en Red de EnfermedadesRaras (CIBERER), Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - C Kleinschnitz
- Department of Neurology, University of Essen, Essen, Germany
| | - T Hagenacker
- Department of Neurology, University of Essen, Essen, Germany
| |
Collapse
|
12
|
Johannsen J, Weiss D, Schlenker F, Groth M, Denecke J. Intrathecal Administration of Nusinersen in Pediatric SMA Patients with and without Spine Deformities: Experiences and Challenges over 3 Years in a Single Center. Neuropediatrics 2021; 52:179-185. [PMID: 33276405 DOI: 10.1055/s-0040-1718916] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Spinal muscular atrophy (SMA) is a rare neurodegenerative disease leading to progressive muscular atrophy, respiratory failure, and premature death. Secondary thorax and spine deformities are frequent. In July 2017, the antisense oligonucleotide nusinersen (Spinraza) was approved for the recurrent lifelong intrathecal treatment of SMA in Europe. Lumbar punctures are challenging especially in SMA patients with severe spine deformities and after spine surgery. In the light of alternative SMA therapies that are available or are expected to be available soon and which are administered orally or via one-time infusion, an appraisal of the established therapy is significant. Discussion about which therapy is the best for each individual patient will have to include not only the safety and efficacy of data but also the application form and its burden for the patient and the health care system. Therefore, we analyzed our 3-year experiences and challenges with 478 lumbar puncture procedures in 61 pediatric SMA patients with and without spine deformities or instrumentation.
Collapse
Affiliation(s)
- Jessika Johannsen
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Deike Weiss
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friderike Schlenker
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Groth
- Department of Pediatric Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Denecke
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
13
|
Mendonça RDH, Fernandes HDS, Pinto RBS, Matsui Júnior C, Polido GJ, Silva AMSD, Grossklauss LF, Reed UC, Zanoteli E. Managing intrathecal administration of nusinersen in adolescents and adults with 5q-spinal muscular atrophy and previous spinal surgery. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:127-132. [PMID: 33759979 DOI: 10.1590/0004-282x-anp-2020-0200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/05/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a neurodegenerative disease of lower motor neurons associated with frequent occurrence of spinal deformity. Nusinersen is an antisense oligonucleotide that increases SMN protein level and is administrated by frequent intrathecal lumbar injections. Thus, spinal deformities and previous spinal surgery are important challenges for drug delivery in SMA. OBJECTIVE To report imaging methods used for Nusinersen injection in SMA patients. METHODS Nusinersen injection procedures in SMA types 2 and 3 patients who had previous spinal surgery were analyzed retrospectively to describe the imaging and puncture procedures, as well as the occurrence of complications. RESULTS Nine SMA patients (14 to 50 years old) underwent 57 lumbar punctures for nusinersen injection. Six patients had no interlaminar space available; in five of them, a transforaminal approach was used, and another one underwent a surgery to open a posterior bone window for the injections. Transforaminal puncture was performed using CT scan in three cases and fluoroscopy in the other two, with a similar success rate. One patient in the transforaminal group had post-procedure radiculitis, and another one had vagal reaction (hypotension). In three cases, with preserved interlaminar space, injections were performed by posterior interlaminar puncture, and only one adverse event was reported (post-puncture headache). CONCLUSION In SMA patients with previous spinal surgery, the use of imaging-guided intervention is necessary for administering intrathecal nusinersen. Transforaminal technique is indicated in patients for whom the interlaminar space is not available, and injections should always be guided by either CT or fluoroscopy.
Collapse
Affiliation(s)
| | | | | | - Ciro Matsui Júnior
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Graziela Jorge Polido
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Luis Fernando Grossklauss
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão Neuromusculares, São Paulo SP, Brazil
| | - Umbertina Conti Reed
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Edmar Zanoteli
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| |
Collapse
|
14
|
Kim AR, Lee JM, Min YS, Lee H, Kim D, Hwang SK, Kwon S, Lee YJ. Clinical Experience of Nusinersen in a Broad Spectrum of Spinal Muscular Atrophy: A Retrospective Study. Ann Indian Acad Neurol 2021; 23:796-801. [PMID: 33688130 PMCID: PMC7900722 DOI: 10.4103/aian.aian_524_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 05/31/2020] [Accepted: 06/09/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Nusinersen has recently been approved and more widely used as first-line treatment of spinal muscular atrophy (SMA). This study aimed to evaluate the real-world experience of nusinersen use for patients with a broad spectrum of SMA. Methods: We reviewed consecutive patients with SMA treated with nusinersen from April 2018 to April 2020. Data collected included clinical and diagnostic characteristics, molecular genetics, functional motor outcomes, and adverse events. Results: Seven patients including four with SMA type 1 and three with SMA type 2 were treated with nusinersen. The median disease duration at the time of the first dose and the median follow-up duration were 37 months (range: 0.5–254 months) and 6.1 months (range: 2.1–22.1 months), respectively. Of the 41 lumbar punctures (LPs), seven fluoroscopy-guided LPs were successfully performed for two patients without sedation. All patients showed improvement in motor function even though the current tools for motor assessment seemed unable to detect subtle subjective improvement. All patients maintained a stable respiratory status. No patient has experienced a severe adverse event or discontinued treatment so far. Conclusion: Although the number of patients in this study was small, our results suggest that nusinersen is effective even in patients with a later stage of the disease. Additional long-term prospective studies with more number of patients having a broad spectrum of diseases are needed to identify meaningful improvement in the motor function and quality of life after nusinersen treatment.
Collapse
Affiliation(s)
- Ae Ryoung Kim
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Jong-Mok Lee
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Yu-Sun Min
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Hoseok Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Dongsub Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Su-Kyeong Hwang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Soonhak Kwon
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Yun Jeong Lee
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| |
Collapse
|
15
|
Pediatric SMA patients with complex spinal anatomy: Implementation and evaluation of a decision-tree algorithm for administration of nusinersen. Eur J Paediatr Neurol 2021; 31:92-101. [PMID: 33711792 DOI: 10.1016/j.ejpn.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/23/2022]
Abstract
The approval of nusinersen for the treatment of spinal muscular atrophy (SMA) has significantly changed the natural history of the disease. Nevertheless, scoliosis secondary to axial muscle weakness occurs at some point in most of patients with SMA and a conventional posterior interlaminar approach for intrathecal administration of nusinersen can be particularly challenging to perform in patients with severe scoliosis and/or previous spine fusion surgeries. We developed a protocol for the administration of nusinersen in pediatric patients, which includes a decision-tree algorithm that categorizes patients according to the estimated technical difficulty for the intrathecal administration. Complex spine patients were defined as those with a Cobb angle greater than 50° and/or a history of spinal surgery, while the rest of patients were considered non-complex. Nusinersen was successfully administered through a conventional non-CT-guided lumbar puncture in all 14 non-complex spine patients (110 out of 110 procedures; 100%). The feasibility of the intrathecal injection in the 15 complex spine patients was assessed by 3D CT. Administration was considered unfeasible in 7 out of these 15 patients according to imaging. In the 8 complex spine patients in whom the administration was considered feasible, conventional non-CT-guided lumbar punctures were successful only in 19 out of 53 procedures (36%). The remaining 34 procedures (64%) were guided by CT scan, all successful. Our work demonstrates that a cut-off point of 50° in Cobb angle and history of spinal surgery can reliably be used to anticipate the need for CT guidance in nusinersen administration.
Collapse
|
16
|
Rosiak G, Lusakowska A, Milczarek K, Konecki D, Fraczek A, Rowinski O, Kostera-Pruszczyk A. Ultra-low radiation dose protocol for CT-guided intrathecal nusinersen injections for patients with spinal muscular atrophy and severe scoliosis. Neuroradiology 2021; 63:539-545. [PMID: 33512541 PMCID: PMC7965851 DOI: 10.1007/s00234-021-02643-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
Purpose Intrathecal injection of nusinersen is an approved treatment of spinal muscular atrophy (SMA). CT-guided injection is a method of nusinersen administration in patients with severe scoliosis, in whom standard lumbar puncture is not feasible. The injections are repeated every 4 months for life, and accumulated radiation doses absorbed by the patient can increase the risk of cancer. In this study, we present the results of CT-guided intrathecal nusinersen injections with an ultra-low radiation dose protocol. Methods Eighteen patients (15 adults and three children) in whom standard lumbar puncture was not feasible due to severe scoliosis or spinal stabilization were included in this retrospective study. The first 23 injections were performed with a standard radiation dose protocol and the next 42 injections with an ultra-low-dose protocol. The radiation doses, measured as total dose length product (DLP), were acquired and compared between the protocols. Results Injections were successful in 100% of patients with both ultra-low-dose and standard protocols. The radiation dose, measured as DLP, was 111.2–1100.7 (Me = 248.1) mGy*cm for the standard protocol. For the ultra-low-dose protocol, the dose range was 5.0–54.4 (Me = 26.7) mGy*cm, which was significantly lower than with the standard protocol (p < 0.001, η2 = 0.67). Conclusion Radiation doses can be significantly decreased in the CT-guided injection of nusinersen. The proposed protocol allows for effective CT-guided intrathecal nusinersen administration in patients with SMA and severe scoliosis.
Collapse
Affiliation(s)
- Grzegorz Rosiak
- II Department of Radiology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Anna Lusakowska
- Department of Neurology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Krzysztof Milczarek
- II Department of Radiology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Dariusz Konecki
- II Department of Radiology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Anna Fraczek
- Department of Neurology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | - Olgierd Rowinski
- II Department of Radiology, Warsaw Medical University, Banacha 1a, 02-097 Warszawa, Poland
| | | |
Collapse
|
17
|
Flotats-Bastardas M, Hahn A, Schwartz O, Linsler S, Meyer S, Kolodziej M, Koehler C. Multicenter Experience with Nusinersen Application via an Intrathecal Port and Catheter System in Spinal Muscular Atrophy. Neuropediatrics 2020; 51:401-406. [PMID: 33091940 DOI: 10.1055/s-0040-1715481] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Nusinersen, an antisense oligonucleotide enhancing the production of the survival motor neuron protein, is approved for the treatment of spinal muscular atrophy (SMA) but requires repetitive lumbar punctures. Application via a subcutaneous port connected to a permanent intrathecal catheter has been proposed as an alternative for patients with severe scoliosis, spinal fusion, or comorbidities, rendering serial interlaminar punctures complicated and risky. Since experience with this technique is sparse and follow-up data are lacking, we assessed feasibility, safety, and tolerability of this approach in eight patients with SMA II/SMA III receiving Nusinersen in a multicenter study. Median age at port implantation was 21 years (range: 10-30 years), and median follow-up time thereafter was 19 months (range: 7-24 months). Leakage of the port catheter occurred in two patients, promptly resolving after resuturing. No further complications such as infection, dislocation, kinking, or obstruction of the port were noted in any of the patients. These findings suggest that application via an intrathecal port and catheter system represents a safe and feasible option for Nusinersen treatment in subjects with SMA. However, to detect rare adverse events longer term follow-up in a larger study cohort is warranted.
Collapse
Affiliation(s)
| | - Andreas Hahn
- Department of Child Neurology, University Hospital Giessen, Giessen, Germany
| | - Oliver Schwartz
- Department of Neuropediatrics, Münster University Hospital, Münster, Germany
| | - Steffan Linsler
- Department of Neurosurgery, University Children's Hospital of Saarland, Homburg, Germany
| | - Sascha Meyer
- Department of Neuropediatrics, University Children's Hospital of Saarland, Homburg, Germany
| | | | - Cornelia Koehler
- Department of Neuropediatrics, University Hospitals of the Ruhr University of Bochum, Bochum, Germany
| |
Collapse
|
18
|
Veiga-Canuto D, Cifrián-Pérez M, Pitarch-Castellano I, Vázquez-Costa JF, Aparici F. Ultrasound-guided lumbar puncture for nusinersen administration in spinal muscular atrophy patients. Eur J Neurol 2020; 28:676-680. [PMID: 33051940 DOI: 10.1111/ene.14586] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/16/2020] [Accepted: 10/08/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE The purpose was to report the results of ultrasound-guided lumbar puncture for the administration of nusinersen in spinal muscular atrophy (SMA) patients with complex spines. METHODS Eighteen SMA patients (five children, five adolescents and eight adults) with either severe scoliosis or spondylodesis were evaluated for ultrasound-guided lumbar puncture. Ultrasound was performed with a 3.5 MHz transducer to guide a 22 gauge × 15 mm needle, which was placed in the posterior lumbar space following a parasagittal interlaminar approach. RESULTS Twelve patients had undergone spinal instrumentation (nine growing rods and three spinal fusion) whilst the other six showed severe scoliosis. Success was achieved in 91/94 attempts (96.8%), in 14/18 patients (77.8%), including 100% of children and adolescents and 50% of adult patients. In two of the unsuccessfully treated patients, computed tomography and fluoroscopy-guided transforaminal lumbar punctures were also tried without success. After a median follow-up of 14 months, only few adverse events, mostly mild, were observed. CONCLUSION The ultrasound-guided lumbar puncture, following an interlaminar parasagittal approach, is a safe and effective approach for intrathecal treatment with nusinersen in children, adolescents and carefully selected adult SMA patients with complex spines and could be considered the first option in them.
Collapse
Affiliation(s)
- D Veiga-Canuto
- Radiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - M Cifrián-Pérez
- Radiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - I Pitarch-Castellano
- Neuromuscular Research Unit, Instituto de Investigación Sanitaria la Fe, Valencia, Spain.,Pediatrics Department, Pediatric Neurology Section, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J F Vázquez-Costa
- Neuromuscular Research Unit, Instituto de Investigación Sanitaria la Fe, Valencia, Spain.,Motor Neuron Disease Unit, Department of Neurology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - F Aparici
- Radiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| |
Collapse
|
19
|
Khadilkar SV, Singh RK. Nusinersen and Spinal Muscular Atrophies: Where are we in 2020? Ann Indian Acad Neurol 2020; 23:743-744. [PMID: 33688120 PMCID: PMC7900727 DOI: 10.4103/aian.aian_887_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 08/14/2020] [Accepted: 08/15/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Satish V. Khadilkar
- Department of Neurology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Rakesh K. Singh
- Department of Neurology, Grant Medical College and Sir J J Group of Hospitals, Mumbai, Maharashtra, India
| |
Collapse
|
20
|
Smeriglio P, Langard P, Querin G, Biferi MG. The Identification of Novel Biomarkers Is Required to Improve Adult SMA Patient Stratification, Diagnosis and Treatment. J Pers Med 2020; 10:jpm10030075. [PMID: 32751151 PMCID: PMC7564782 DOI: 10.3390/jpm10030075] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
Spinal muscular atrophy (SMA) is currently classified into five different subtypes, from the most severe (type 0) to the mildest (type 4) depending on age at onset, best motor function achieved, and copy number of the SMN2 gene. The two recent approved treatments for SMA patients revolutionized their life quality and perspectives. However, upon treatment with Nusinersen, the most widely administered therapy up to date, a high degree of variability in therapeutic response was observed in adult SMA patients. These data, together with the lack of natural history information and the wide spectrum of disease phenotypes, suggest that further efforts are needed to develop precision medicine approaches for all SMA patients. Here, we compile the current methods for functional evaluation of adult SMA patients treated with Nusinersen. We also present an overview of the known molecular changes underpinning disease heterogeneity. We finally highlight the need for novel techniques, i.e., -omics approaches, to capture phenotypic differences and to understand the biological signature in order to revise the disease classification and device personalized treatments.
Collapse
Affiliation(s)
- Piera Smeriglio
- Centre of Research in Myology, Institute of Myology, Sorbonne Université, INSERM, 75013 Paris, France; (P.L.); (G.Q.)
- Correspondence: (P.S.); (M.G.B.)
| | - Paul Langard
- Centre of Research in Myology, Institute of Myology, Sorbonne Université, INSERM, 75013 Paris, France; (P.L.); (G.Q.)
| | - Giorgia Querin
- Centre of Research in Myology, Institute of Myology, Sorbonne Université, INSERM, 75013 Paris, France; (P.L.); (G.Q.)
- Association Institut de Myologie, Plateforme Essais Cliniques Adultes, 75013 Paris, France
- APHP, Service de Neuromyologie, Hôpital Pitié-Salpêtrière, 75013 Paris, France
| | - Maria Grazia Biferi
- Centre of Research in Myology, Institute of Myology, Sorbonne Université, INSERM, 75013 Paris, France; (P.L.); (G.Q.)
- Correspondence: (P.S.); (M.G.B.)
| |
Collapse
|
21
|
Spiliopoulos S, Reppas L, Zompola C, Palaiodimou L, Papadopoulou M, Filippiadis D, Palialexis K, Ploussi A, Efstathopoulos E, Tsivgoulis G, Brountzos E. Computed-tomography-guided transforaminal intrathecal nusinersen injection in adults with spinal muscular atrophy type 2 and severe spinal deformity. Feasibility, safety and radiation exposure considerations. Eur J Neurol 2020; 27:1343-1349. [PMID: 32250518 DOI: 10.1111/ene.14245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE The purpose was to investigate our centre's experience on computed-tomography-guided (CT-guided), transforaminal, intrathecal administration of nusinersen in adult subjects with spinal muscular atrophy (SMA) type 2 and severe spinal deformity. METHOD This is a retrospective, single-centre study investigating the feasibility and safety of CT-guided, transforaminal, lumbar puncture for the intrathecal administration of nusinersen (Spinranza®; Biogen; Cambridge, MA, USA) in a cohort of adult subjects with SMA type 2, severe neuromuscular scoliosis and previous spinal surgery. Between January 2019 and October 2019, five male, adult, SMA type 2 subjects were eligible to be treated in our centre with nusinersen. The mean age of the patients was 31 ± 9 years (range 19-43 years). The study's outcome measures were technical success, adverse events and radiation exposure. RESULTS In total, four patients completed the four loading doses, whilst the fifth patient received only one loading dose; two patients also received their first maintenance doses. Overall, 20 consecutive transforaminal, intrathecal treatments were analysed. Technical success was 100% (20/20 intrathecal infusions). No adverse events were documented following the procedures. Mean dose-length product (DLP) value per injection was 665.4 ± 715.5 mGy*cm. Estimated mean effective dose per injection was 12.7 ± 12.9 mSv. Subgroup analysis between the chronologically first 10 versus subsequent 10 procedures demonstrated a clear trend towards less radiation exposure in the latter, although this difference did not reach statistical significance (DLP: 984.7 ± 903.3 vs. 436.7 ± 321.5 mGy*cm, P = 0.165; respectively). CONCLUSIONS In this retrospective series, CT-guided transforaminal access for intrathecal injection of nusinersen was proven feasible and safe. A decrease in radiation dose over time was noted. Protocols to minimize radiation exposure are essential.
Collapse
Affiliation(s)
- S Spiliopoulos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - L Reppas
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - C Zompola
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - L Palaiodimou
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - M Papadopoulou
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - D Filippiadis
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - K Palialexis
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - A Ploussi
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - E Efstathopoulos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| | - G Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - E Brountzos
- Second Department of Radiology, Division of Interventional Radiology, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' University General Hospital, Athens, Greece
| |
Collapse
|
22
|
Cartwright MS, Ward ZT, White EP, West TG. Intrathecal delivery of nusinersen in individuals with complicated spines. Muscle Nerve 2020; 62:114-118. [PMID: 32319101 DOI: 10.1002/mus.26899] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/12/2020] [Accepted: 04/16/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The treatment of spinal muscular atrophy (SMA) with nusinersen requires intrathecal medication administration, which can be challenging in individuals with complicated spines. This retrospective case series reviews the nusinersen treatment experience at one academic medical center with children and adults with SMA and complicated spines. METHODS Twenty medical records of individuals receiving nusinersen were reviewed and administration methods summarized and assessed. RESULTS Ten children and 10 adults were treated, and 55% had complicated spines. In total, 163 treatments were given, 91 in those with complicated spines. In the complicated spines, 74% of treatments were done by means of fluoroscopic lumbar puncture, 22% by means of intrathecal Ommaya reservoir, 3% by means of palpation, and < 1% by means of computed tomography-guided transforaminal approach. CONCLUSIONS A large majority of individuals with complicated spines can receive intrathecal nusinersen using fluoroscopic guidance in the lumbar region. Other delivery methods are available but less frequently used.
Collapse
Affiliation(s)
- Michael S Cartwright
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Zachary T Ward
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Eric P White
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Thomas G West
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
23
|
Song JY, Kim HS, Park SJ, Lee J, Lee J. Nusinersen Administration in Spinal Muscular Atrophy Patients with Severe Scoliosis: Interlaminar Approaches at the Lumbar Level. ANNALS OF CHILD NEUROLOGY 2020. [DOI: 10.26815/acn.2020.00045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
|
24
|
Wan HWY, Carey KA, D'Silva A, Vucic S, Kiernan MC, Kasparian NA, Farrar MA. Health, wellbeing and lived experiences of adults with SMA: a scoping systematic review. Orphanet J Rare Dis 2020; 15:70. [PMID: 32164772 PMCID: PMC7068910 DOI: 10.1186/s13023-020-1339-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a neurodegenerative disease that has a substantial and multifaceted burden on affected adults. While advances in supportive care and therapies are rapidly reshaping the therapeutic environment, these efforts have largely centered on pediatric populations. Understanding the natural history, care pathways, and patient-reported outcomes associated with SMA in adulthood is critical to advancing health policy, practice and research across the disease spectrum. The aim of this study was to systematically review research investigating the healthcare, well-being and lived experiences of adults with SMA. METHODS In accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analysis guidelines, seven electronic databases were systematically searched until January 2020 for studies examining clinical (physical health, natural history, treatment) and patient-reported (symptoms, physical function, mental health, quality of life, lived experiences) outcomes in adults with SMA. Study risk of bias and the level of evidence were assessed using validated tools. RESULTS Ninety-five articles met eligibility criteria with clinical and methodological diversity observed across studies. A heterogeneous clinical spectrum with variability in natural history was evident in adults, yet slow declines in motor function were reported when observational periods extended beyond 2 years. There remains no high quality evidence of an efficacious drug treatment for adults. Limitations in mobility and daily activities associated with deteriorating physical health were commonly reported, alongside emotional difficulties, fatigue and a perceived lack of societal support, however there was no evidence regarding effective interventions. CONCLUSIONS This systematic review identifies the many uncertainties regarding best clinical practice, treatment response, and long-term outcomes for adults with SMA. This comprehensive identification of the current gaps in knowledge is essential to guide future clinical research, best practice care, and advance health policy with the ultimate aim of reducing the burden associated with adult SMA.
Collapse
Affiliation(s)
- Hamish W Y Wan
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia
| | - Kate A Carey
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia
| | - Arlene D'Silva
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia
| | - Steve Vucic
- Department of Neurology, Westmead Hospital and Western Clinical School, University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Brain & Mind Centre, University of Sydney, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, NSW, 2006, Australia
| | - Nadine A Kasparian
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia.,Cincinnati Children's Center for Heart Disease and the Developing Mind, Heart Institute and the Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children's Hospital, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michelle A Farrar
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia. .,Department of Neurology, Sydney Children's Hospital, Randwick, NSW, 2031, Australia.
| |
Collapse
|
25
|
Radiation dose reduction for CT-guided intrathecal nusinersen administration in adult patients with spinal muscular atrophy. Sci Rep 2020; 10:3406. [PMID: 32099042 PMCID: PMC7042284 DOI: 10.1038/s41598-020-60240-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/24/2020] [Indexed: 12/18/2022] Open
Abstract
Intrathecal administration of nusinersen in adult spinal muscular atrophy (SMA) patients with scoliosis and spondylodesis requires image guidance, which is preferably achieved with multi-detector computed tomography (MDCT). As long-term treatment is necessary and patients are young, radiation doses should be reduced to a minimum whilst a sufficient image quality for precise interventional performance should be kept. We compared 44 MDCT standard-dose scans (133.0–200.0 mA) with a hybrid iterative reconstruction (iDose4) to 20 low-dose scans (20.0–67.0 mA) with iterative model reconstruction (IMR), which were performed for procedure planning of intrathecal nusinersen administration in 13 adult patients with SMA and complex spinal conditions. Qualitative image evaluation, including confidence for intervention planning, was performed by two neuroradiologists for standard- and low-dose scans. All 64 MDCT-guided intrathecal administrations of nusinersen were successful. The dose length product (DLP) was significantly lower when using low-dose scanning with IMR (median DLP of standard-dose scans: 92.0 mGy•cm vs. low-dose scans: 34.5 mGy•cm; p < 0.0001). Image quality was significantly reduced for low-dose compared to standard-dose scanning. However, bone/soft tissue contrast and confidence for intervention planning were not significantly impaired in low-dose MDCT according to both readers, showing good inter-reader agreement. Thus, we hereby demonstrate a low-dose MDCT protocol combined with advanced image reconstruction for scanning during procedure planning as a viable option for image guidance in intrathecal nusinersen treatment of adult SMA patients with complex spinal conditions.
Collapse
|