Concomitant Brain Injury and Spinal Cord Injury Management Strategies: A Narrative Review

Risk of Parkinson's disease in spinal cord injury: a nationwide cohort study in South Korea

Despite the association between spinal cord injury (SCI) and various neurological diseases, the risk of Parkinson's disease (PD) in SCI is not elucidated yet. Especially, the role of SCI severity and injury level in the risk of PD development is not investigated. Based on the nation-wide cohort data the Korean National Health Insurance Service between 2010 and 2018, we investigated the incidence of PD in 7,182 patients with SCI compared with 24,844 age- and sex-matched controls. Adjusted hazard ratio and 95% confidence interval (CI) were calculated using Cox proportional hazards regression. We compared the risk of PD based on the degree of disability (without disability, mild, severe) and SCI level (cervical, thoracic, and lumbar). During the mean follow-up duration of 4.31 years, patients with SCI had a higher risk of PD compared with matched controls. The PD risk was greater among patients with SCI with disability than in those without disability, especially those with mild disability. Additionally, cervical-level injury was associated with the highest risk in patients with SCI without disability, while thoracic-level injury was associated with the highest risk in those with disability. Our study found patients with SCI have increased risk of PD, particularly those with disability and thoracic-level injuries.

Pharmacological management of secondary chronic spinal cord injury: a systematic review

INTRODUCTION

Spinal cord injury (SCI) may bring lifelong consequences for affected patients and a high financial burden to the health care system.

SOURCE OF DATA

Published peer-reviewed scientific articles identified from EMBASE, Google Scholar, PubMed and Scopus.

AREAS OF AGREEMENT

Surgery and blood pressure management are the main targets in acute SCI to avoid secondary damage.

AREAS OF CONTROVERSY

The management of secondary chronic SCI is challenging, with unpredictable outcomes.

GROWING POINTS

Given the lack of consensus on pharmacological therapy for acute and secondary chronic SCI, the present study analyses the currently available drugs and treatment options to manage secondary chronic SCI.

AREAS TIMELY FOR DEVELOPING RESEARCH

Different approaches exist for the pharmacological management of secondary chronic SCI. One of the most investigated drugs, 4-aminopyridine, improves central motor conduction and shows improvement in neurological signs. Positive results in different areas have been observed in patients receiving the anti-spastic drugs tizanidine and baclofen or Granulocyte colony-stimulating factor. Growth hormone showed only minimal or no significant effects, and the therapy of secondary chronic SCI with riluzole has been poorly researched to date.

The epidemiology of spinal fractures: A nationwide data-based study in Iran

Background

Blunt trauma is a physical injury to a part of the body, mainly caused by road accidents, direct blows, attacks, sports injuries, and falls in elderly people. Spinal fractures are observed only in a small percentage of injured patients. Accordingly, the present study was conducted on collected data between 2018 and 2022 to determine the frequency of spinal fractures in blunt trauma in Iran while also considering the mechanism of injury as a secondary outcome of interest.

Methods

In this retrospective study, blunt trauma patients with spinal fractures, regardless of age were included by the census sampling method. Data were obtained from the National Trauma Registry of Iran. Means and standard deviations were used for continuous variables, and the chi-square test was used to assess the relationship between the variables.

Results

Among 25,986 cases of all-cause trauma patients, 1,167 cases (4.5%) of blunt trauma and spinal fracture were included in the study. Gender, the severity of injury, and the cause of trauma showed a significant difference among different age groups (p < 0.05). Significant differences were found in the injury mechanisms across various spine regions (p < 0.05). The majority of patients (68.2%) had lumbar spinal fractures. Road traffic collisions were the most common cause of spinal cord injuries, accounting for 58.3% of cases, followed by falls (36.1%). The injury severity score was higher in younger patients (under 18 years old), with a mean of 4.4 ± 3.5, and in patients with cervical injuries. The majority of injuries occurred in the lumbar area (68.2%), followed by the thoracic area. Furthermore, notable variations existed in Emergency Room (ER) stay duration, overall hospitalization, Intensive Care Unit (ICU) stay duration, and injury severity levels, all influenced by the spinal regions (p < 0.05). Distinctively, ICU stay durations and ER stay duration showed significant differences, particularly in relation to injuries in the lumbar and thoracic regions (p < 0.05).

Conclusion

According to the results of the present study, trauma is more severe, and cervical injuries are more common in young people, which is a critical finding that underscores the need for targeted interventions to mitigate the severity of trauma in this age group. Additionally, the majority of cervical injuries occurred in young people, which is a particularly concerning finding given the potential for long-term disability and impact on quality of life. Our findings suggest that strategies to reduce cervical injuries, such as speed control, seat belt use, and phone-free driving, are crucial interventions for mitigating the severity of trauma and promoting patient outcomes in young people.

Development and validation of a nomogram for predicting heterotopic ossification following spinal cord injury

OBJECTIVE

Heterotopic ossification (HO) following spinal cord injury (SCI) can severely compromise patient mobility and quality of life. Precise identification of SCI patients at an elevated risk for HO is crucial for implementing early clinical interventions. While the literature presents diverse correlations between HO onset and purported risk factors, the development of a predictive model to quantify these risks is likely to bolster preventive approaches. This study is designed to develop and validate a nomogram-based predictive model that estimates the likelihood of HO in SCI patients, utilizing recognized risk factors to expedite clinical decision-making processes.

METHODS

We recruited a total of 145 patients with SCI and presenting with HO who were hospitalized at the China Rehabilitation Research Center, Beijing Boai Hospital, from June 2016 to December 2022. Additionally, 337 patients with SCI without HO were included as controls. Comprehensive data were collected for all study participants, and subsequently, the dataset was randomly partitioned into training and validation groups. Using Least Absolute Shrinkage and Selection Operator regression, variables were meticulously screened during the pretreatment phase to formulate the predictive model. The efficacy of the model was then assessed using metrics including receiver-operating characteristic (ROC) analysis, calibration assessment, and decision curve analysis.

RESULTS

The final prediction model incorporated age, sex, complete spinal cord injury status, spasm occurrence, and presence of deep vein thrombosis (DVT). Notably, the model exhibited commendable performance in both the training and validation groups, as evidenced by areas under the ROC curve (AUCs) of 0.756 and 0.738, respectively. These values surpassed the AUCs obtained for single variables, namely age (0.636), sex (0.589), complete spinal cord injury (0.681), spasm occurrence (0.563), and DVT presence (0.590). Furthermore, the calibration curve illustrated a congruence between the predicted and actual outcomes, indicating the high accuracy of the model. The decision curve analysis indicated substantial net benefits associated with the application of the model, thereby underscoring its practical utility.

CONCLUSIONS

HO following SCI correlates with several identifiable risk factors, including male gender, youthful age, complete SCI, spasm occurrence and DVT. Our predictive model effectively estimates the likelihood of HO development by leveraging these factors, assisting physicians in identifying patients at high risk. Subsequently, correct positioning to prevent spasm-related deformities and educating healthcare providers on safe lower limb mobilization techniques are crucial to minimize muscle injury risks from rapid iliopsoas muscle extension. Additionally, the importance of early DVT prevention through routine screening and anticoagulation is emphasized to further reduce the incidence of HO.

Heterotopic ossification of the elbow joint in a child: Successful surgical resection - A case report

Background

This case report describes the occurrence of a rare heterotopic ossification of the elbow joint in a child, caused by inappropriate movement after trauma. A successful operation to remove heterotopic ossification was described in the report with satisfactory results.

Case presentation

A 7-year-old boy suffered a supracondylar fracture of the humerus after an accidental fall, and after immobilization with a cast, improper movement resulted in heterotopic ossification of the elbow joint, which severely affected joint function. The heterotopic ossification was surgically removed and a complete recovery was demonstrated at 18 months follow-up. The heterotopic ossification was successfully removed with good elbow function and no recurrence at 18 months follow-up.

Conclusions

The purpose of this report is to show the good results with surgical treatment of heterotopic ossification of the elbow joint in children,when conservative treatment does not work.

Concomitant Traumatic Brain Injury Delays Surgery in Patients With Traumatic Spinal Cord Injury

BACKGROUND AND OBJECTIVES

Growing evidence supports prompt surgical decompression for patients with traumatic spinal cord injury (tSCI). Rates of concomitant tSCI and traumatic brain injury (TBI) range from 10% to 30%. Concomitant TBI may delay tSCI diagnosis and surgical intervention. Little is known about real-world management of this common injury constellation that carries significant clinical consequences. This study aimed to quantify the impact of concomitant TBI on surgical timing in a national cohort of patients with tSCI.

METHODS

Patient data were obtained from the National Trauma Data Bank (2007-2016). Patients admitted for tSCI and who received surgical intervention were included. Delayed surgical intervention was defined as surgery after 24 hours of admission. Multivariable hierarchical regression models were constructed to measure the risk-adjusted association between concomitant TBI and delayed surgical intervention. Secondary outcome included favorable discharge status.

RESULTS

We identified 14 964 patients with surgically managed tSCI across 377 North American trauma centers, of whom 2444 (16.3%) had concomitant TBI and 4610 (30.8%) had central cord syndrome (CCS). The median time to surgery was 20.0 hours for patients without concomitant TBI and 24.8 hours for patients with concomitant TBI. Hierarchical regression modeling revealed that concomitant TBI was independently associated with delayed surgery in patients with tSCI (odds ratio [OR], 1.3; 95% CI, 1.1-1.6). Although CCS was associated with delayed surgery (OR, 1.5; 95% CI, 1.4-1.7), we did not observe a significant interaction between concomitant TBI and CCS. In the subset of patients with concomitant tSCI and TBI, patients with severe TBI were significantly more likely to experience a surgical delay than patients with mild TBI (OR, 1.4; 95% CI, 1.0-1.9).

CONCLUSION

Concomitant TBI delays surgical management for patients with tSCI. This effect is largest for patients with tSCI with severe TBI. These findings should serve to increase awareness of concomitant TBI and tSCI and the likelihood that this may delay time-sensitive surgery.

Bowel dysfunctions after acquired brain injury: a scoping review

Bowel dysfunction is a common consequence of neurological diseases and has a major impact on the dignity and quality of life of patients. Evidence on neurogenic bowel is focused on spinal cord injury and multiple sclerosis; few studies have focused on patients with acquired brain injury (ABI). Neurogenic bowel dysfunction is related to a lifelong condition derived from central neurological disease, which further increases disability and social deprivation. The manifestations of neurogenic bowel dysfunction include fecal incontinence and constipation. Almost two out of three patients with central nervous system disorder have bowel impairment. This scoping review aims to comprehend the extent and type of evidence on bowel dysfunction after ABI and present conservative treatment. For this scoping review, the PCC (population, concept, and context) framework was used: patients with ABI and bowel dysfunction; evaluation and treatment; and intensive/extensive rehabilitation path. Ten full-text articles were included in the review. Oral laxatives are the most common treatment. The Functional Independence Measure (FIM) subscale is the most common scale used to assess neurogenic bowel disease (60%), followed by the Rome II and III criteria, and the colon transit time is used to test for constipation; however, no instrumental methods have been used for incontinence. An overlapping between incontinence and constipation, SCI and ABI increase difficulties to manage NBD. The need for a consensus between the rehabilitative and gastroenterological societies on the diagnosis and medical care of NBD.

Systematic review registration

Open Science Framework on August 16, 2022 https://doi.org/10.17605/OSF.IO/NEQMA.

Polytrauma patients with severe cervical spine injuries are different than with severe TBI despite similar AIS scores

Traumatic cervical spine injuries (TCSI) are rare injuries. With increasing age the incidence of TCSI is on the rise. TCSI and traumatic brain injury (TBI) are often associated. Both TCSI and TBI are allocated to the Abbreviated Injury Scale (AIS) head region. However, the nature and outcome of these injuries are potentially different. Therefore, the aim of this study was to investigate the epidemiology, demographics and outcome of severely injured patients with severe TCSI, and compare them with polytrauma patients with severe TBI in the strict sense. Consecutive polytrauma patients aged ≥ 15 years with AIShead ≥ 3 who were admitted to a level-1 trauma center Intensive Care Unit (ICU) from 2013 to 2021 were included. Demographics, treatment, and outcome parameters were analyzed for patients who had AIShead ≥ 3 based on TCSI and compared to patients with AIShead ≥ 3 based on proper TBI. Data on follow-up were collected for TCSI patients. Two hundred eighty-four polytrauma patients (68% male, Injury Severity Score (ISS) 33) with AIShead ≥ 3 were included; Thirty-one patients (11%) had AIShead ≥ 3 based on TCSI whereas 253 (89%) had AIShead ≥ 3 based on TBI. TCSI patients had lower systolic blood pressure in the Emergency Department (ED) and stayed longer in ICU than TBI patients. There was no difference in morbidity and mortality rates. TCSI patients died due to high cervical spine injuries or respiratory insufficiency, whereas TBI patients died primarily due to TBI. TCSI was mainly located at C2, and 58% had associated spinal cord injury. Median follow-up time was 22 months. Twenty-two percent had improvement of the spinal cord injury, and 10% died during follow-up. In this study the incidence of severe TCSI in polytrauma was much lower than TBI. Cause of death in TCSI was different compared to TBI demonstrating that AIShead based on TCSI is a different entity than based on TBI. In order to avoid data misinterpretation injuries to the cervical spine should be distinguished from TBI in morbidity and mortality analysis.

Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers

Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.