The Importance of Early Surgical Decompression for Acute Traumatic Spinal Cord Injury

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.

Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran

PURPOSE

This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI).

METHODS

The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews.

RESULTS

We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%.

CONCLUSION

Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

Posterior spinal decompression in adults with spinal cord injury without traumatic compromise of the spinal canal: what is the data?

Background

Spinal cord injury (SCI) can be caused by a variety of factors and its severity can range from a mild concussion to a complete severing of the spinal cord. Τreatment depends on the type and severity of injury, the patient's age and overall health. Reduction of dislocated or fractured vertebrae via closed manipulation or surgical procedures, fixation and removal of bony fragments and debris that compromise the spinal canal are indicated for decompression of the spinal cord and stabilization of the spine. However, when there is no obvious traumatic obstruction of spinal canal, the question arises as to whether laminectomy is needed to be performed to improve neurological outcome.

Methods

A literature review covering all indexed studies published between 2013 and 2023 was performed using keywords to identify the patient group of interest (spinal cord injury, SCI, spinal cord trauma, cervical, thoracic, lumbar, thoracolumbar),central cord syndrome (CCS) and the interventions (laminectomy, laminoplasty, decompression, duroplasty).

Results

This review includes6 observational studies investigating the outcome of posterior spinal decompression in patients suffering from spinal cord injury without traumatic spinal cord stenosis. Most patients already had degenerative stenosis. From a total of 202, 151 patients (74.7%) improved neurologically by at least one grade at ASIA scale, after being treated with either laminectomy, laminoplasty, duroplasty or a combination of these techniques.

Conclusion

Early decompression in SCI patients remains a reasonable practice option and can be performed safely, but no specific evidence supports the use of laminectomy alone. There is emerging evidence that intended durotomy followed by extended meningoplasty may improve the neurological outcome in patients suffering from SCI when meta-traumatic edema is apparent. However, the lack of high-quality evidence and results support the need for further research.

A four year experience treating incomplete thoracolumbar spine injuries in an East African country

Background

Traumatic spine injuries are one of the most common causes of disability and mortality.

Objective

To assess post op neurologic status in patients with incomplete thoracic and lumbar spine injuries at two teaching hospitals in Addis Ababa, Ethiopia.

Methods

Institution based retrospective cross-sectional study was conducted among 60 hospitalized patients in these hospitals from February 1, 2017-January 31, 2021.

Results

Forty five (75.0%) of the study participants were males. The mean age was 30.77 years (range: 12-65 year). Only 8(13.3%) patients were operated within 3 days of trauma. The most common injury site was the thoracolumbar junction (T11-L2) in 80.0%. Significant number of patients (56.7%) had sphincters dysfunction. Pedicle screw fixation with or without laminectomy was performed in 98.3%. After minimum six month follow up, 37(61.7%) patients had access to the physiotherapy. Thirty seven (61.7%) patients were non ambulatory (AIS B and C) at presentation, of which 29 (78.4%) were ambulatory on the follow-up. Overall, 54(90%) patients had neurologic improvement on the follow up and 37(61.7%) returned to work. Preoperative neurologic status and sphincter function were found to be significantly associated with treatment outcome with P value 0 .000 and 0.002 respectively.

Conclusion

This study shows despite limited availability of post op physiotherapy, significant number of patientsreturned to work post-surgery. Preoperative neurologic function was an independent predictor of post-operative outcome.

Pre-Clinical Assessment of Roflumilast Therapy in a Thoracic Model of Spinal Cord Injury

The failure of axons to regenerate after a spinal cord injury (SCI) remains one of the greatest challenges in neuroscience. The initial mechanical trauma is followed by a secondary injury cascade, creating a hostile microenvironment, which not only is not permissive to regeneration but also leads to further damage. One of the most promising approaches for promoting axonal regeneration is to maintain the levels of cyclic adenosine monophosphate (cAMP), specifically by a phosphodiesterase-4 (PDE4) inhibitor expressed in neural tissues. Therefore, in our study, we evaluated the therapeutic effect of an FDA-approved PDE4 inhibitor, Roflumilast (Rof), in a thoracic contusion rat model. Results indicate that the treatment was effective in promoting functional recovery. Rof-treated animals showed improvements in both gross and fine motor function. Eight weeks post-injury, the animals significantly recovered by achieving occasional weight-supported plantar steps. Histological assessment revealed a significant decrease in cavity size, less reactive microglia, as well as higher axonal regeneration in treated animals. Molecular analysis revealed that IL-10 and IL-13 levels, as well as VEGF, were increased in the serum of Rof-treated animals. Overall, Roflumilast promotes functional recovery and supports neuroregeneration in a severe thoracic contusion injury model and may be important in SCI treatment.

The pathogenesis of DLD-mediated cuproptosis induced spinal cord injury and its regulation on immune microenvironment

Introduction

Spinal cord injury (SCI) is a severe central nervous system injury that leads to significant sensory and motor impairment. Copper, an essential trace element in the human body, plays a vital role in various biological functions and is strictly regulated by copper chaperones and transporters. Cuproptosis, a novel type of metal ion-induced cell death, is distinct from iron deprivation. Copper deprivation is closely associated with mitochondrial metabolism and mediated by protein fatty acid acylation.

Methods

In this study, we investigated the effects of cuproptosis-related genes (CRGs) on disease progression and the immune microenvironment in acute spinal cord injury (ASCI) patients. We obtained the gene expression profiles of peripheral blood leukocytes from ASCI patients using the Gene Expression Omnibus (GEO) database. We performed differential gene analysis, constructed protein-protein interaction networks, conducted weighted gene co-expression network analysis (WGCNA), and built a risk model.

Results

Our analysis revealed that dihydrolipoamide dehydrogenase (DLD), a regulator of copper toxicity, was significantly associated with ASCI, and DLD expression was significantly upregulated after ASCI. Furthermore, gene ontology (GO) enrichment analysis and gene set variation analysis (GSVA) showed abnormal activation of metabolism-related processes. Immune infiltration analysis indicated a significant decrease in T cell numbers in ASCI patients, while M2 macrophage numbers were significantly increased and positively correlated with DLD expression.

Discussion

In summary, our study demonstrated that DLD affects the ASCI immune microenvironment by promoting copper toxicity, leading to increased peripheral M2 macrophage polarization and systemic immunosuppression. Thus, DLD has potential as a promising biomarker for ASCI, providing a foundation for future clinical interventions.

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 2 Timing to Surgery

Objective  The objective of the present study was to evaluate the current practice in terms of timing to surgery in acute spinal cord injury (ASCI) patients among spinal surgeons from Iberolatinoamerican countries. Methods  A descriptive cross-sectional study design as a questionnaire was sent by an email for all members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results  A total of 162 surgeons answered questions related to the timing for surgery. Sixty-eight (42.0%) considered that ASCI with complete neurology injury should be treated within 12 hours, 54 (33.3%) performed early decompression within 24 hours, and 40 (24,7%) until the first 48 hours. Regarding ASCI with incomplete neurological injury, 115 (71.0%) would operate in the first 12 hours. There was a significant difference in the proportion of surgeons that would operate ASCI within ≤ 24 hours, regarding the type of injury (complete injury:122 versus incomplete injury:155; p  < 0.01). In the case of patients with central cord syndrome without radiological evidence of instability, 152 surgeons (93.8%) would perform surgical decompression: 1 (0.6%) in the first 12 hours, 63 (38.9%) in 24 hours, 4 (2.5%) in 48 hours, 66 (40.7%) in the initial hospital stay, and 18 (11.1%) after neurologic stabilization. Conclusion  All inquired surgeons favour early decompression, with the majority performing surgery in the first 24 hours. Decompression is performed earlier in cases of incomplete than in complete injuries. In cases of central cord syndrome without radiological evidence of instability, there is a tendency towards early surgical decompression, but the timing is still extremely variable. Future studies are needed to identify the ideal timing for decompression of this subset of ASCI patients.

Pediatric spinal cord injury with radiographic abnormality: the Beijing experience

BACKGROUND CONTEXT

Spinal cord injury (SCI) without radiographic abnormality (SCIWORA) is a syndrome that usually occurs in children primarily because of the unique biomechanics of the pediatric spine. We recently found that the histopathological and behavioral effects of SCI with radiographic abnormality (SCIWRA) and SCIWORA are very different from each other in animal models. Although numerous studies were conducted to understand the epidemiological and clinical characteristics of the overall pediatric SCI population and the pediatric SCIWORA population, the characteristics of the pediatric SCIWRA population and their differences from those of the SCIWORA population are poorly understood.

PURPOSE

To describe the epidemiology and clinical outcomes of pediatric patients with SCIWRA and their differences from those with SCIWORA.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

A total of 47 pediatric SCIWRA patients.

OUTCOME MEASURES

Epidemiological characteristics, injury severities, functional deficits, and management and recovery outcomes.

METHODS

Review of all cases with SCIWRA at Beijing Children's Hospital between July 2007 and December 2019 and comparison between the present data and our previous SCIWORA data.

RESULTS

Of the 187 pediatric SCI patients, 47 had SCIWRA (age: 7.06 ± 3.75 years, male-to-female ratio: 3:2). Main causes of SCIWRA were fall (38%) and traffic accidents (38%). Lesions were often located at multiple levels (62%). Incubation period was 3 ± 18 hours. According to the American Spinal Injury Association impairment scale (AIS), many SCIWRA patients had incomplete impairment (AIS B, 9%; AIS C, 9%; AIS D, 32%). Specifically, many of them had abnormal upper and lower limb muscle powers (55% and 60%), upper and lower limb muscle tones (34% and 49%), sensation (38%), and knee, ankle, and abdominal reflexes (47%, 34%, and 36%). 72% of SCIWRA patients were treated with methylprednisolone, dexamethasone, or both. 81% of them showed neurological improvement before discharge. There was no association between corticosteroid therapy and neurological improvement. Moreover, functional outcomes of their upper and lower limb muscle powers were significantly associated with functional outcomes of their upper and lower limb muscle tones (p < 0.01), respectively. In comparison to the SCIWRA population, the SCIWORA population had a higher ratio of younger and female patients of sports-related thoracic injuries with long incubation period leading to lower-body deficits and complete impairment (p<0.05 or p<0.01). Despite all the differences, their neurological improvement was similar (p>0.05).

CONCLUSIONS

Demographic differences exist in the SCIWRA population. Corticosteroids do not appear to be effective in the different types of pediatric SCI. Limb muscle tone may be used to evaluate the functional status of limb muscle power. The epidemiological and clinical characteristics of SCIWRA and SCIWORA are very different from each other. It is important to formulate tailor-made prevention, evaluation, and management strategies for the pediatric population to optimize the SCI outcomes.

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.

Pathophysiology of Spinal Cord Injury and Tissue Engineering Approach for Its Neuronal Regeneration: Current Status and Future Prospects

A spinal cord injury (SCI) is a very debilitating condition causing loss of sensory and motor function as well as multiple organ failures. Current therapeutic options like surgery and pharmacotherapy show positive results but are incapable of providing a complete cure for chronic SCI symptoms. Tissue engineering, including neuroprotective or growth factors, stem cells, and biomaterial scaffolds, grabs attention because of their potential for regeneration and ability to bridge the gap in the injured spinal cord (SC). Preclinical studies with tissue engineering showed functional recovery and neurorestorative effects. Few clinical trials show the safety and efficacy of the tissue engineering approach. However, more studies should be carried out for potential treatment modalities. In this review, we summarize the pathophysiology of SCI and its current treatment modalities, including surgical, pharmacological, and tissue engineering approaches following SCI in preclinical and clinical phases.

Application of platelet-rich plasma in spinal surgery

With the aging of the population and changes in lifestyle, the incidence of spine-related diseases is increasing, which has become a major global public health problem; this results in a huge economic burden on the family and society. Spinal diseases and complications can lead to loss of motor, sensory, and autonomic functions. Therefore, it is necessary to identify effective treatment strategies. Currently, the treatment of spine-related diseases includes conservative, surgical, and minimally invasive interventional therapies. However, these treatment methods have several drawbacks such as drug tolerance and dependence, adjacent spondylosis, secondary surgery, infection, nerve injury, dural rupture, nonunion, and pseudoarthrosis. Further, it is more challenging to promote the regeneration of the interstitial disc and restore its biomechanical properties. Therefore, clinicians urgently need to identify methods that can limit disease progression or cure diseases at the etiological level. Platelet-rich plasma (PRP), a platelet-rich form of plasma extracted from venous blood, is a blood-derived product. Alpha granules contain a large number of cytokines, such as platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), epidermal growth factor, platelet factor 4 (PF-4), insulin-like growth factor-1 (IGF-1), and transforming growth factor-β (TGF-β). These growth factors allow stem cell proliferation and angiogenesis, promote bone regeneration, improve the local microenvironment, and enhance tissue regeneration capacity and functional recovery. This review describes the application of PRP in the treatment of spine-related diseases and discusses the clinical application of PRP in spinal surgery.

Time is spine: What's over the horizon

The overarching theme in the early treatment of acute spinal cord injury (SCI) is to reduce the extent of secondary damage to facilitate early neurological and functional recovery. Although multiple studies have brought us innovative and potential new therapies to treat SCI, ameliorating neural damage remains a formidable challenge. Knowledge translation of clinical and basic research studies has shown that surgical intervention is a valuable treatment modality; however, the role, timing and optimal technique in surgery remains a topic of great controversy. While evidence to support the concept of ultra-early surgery for acute SCI continues to emerge, current protocols and international guidelines that encourage reducing time from trauma to surgery support the concept of "Time is Spine". The present article provides a critical narrative review of the current best practice, with a particular focus on the timing of surgical intervention, which shapes our understanding of how time is of the essence in the management of acute SCI.

Does displacement of cervical and thoracolumbar dislocation-translation injuries predict spinal cord injury or recovery?

OBJECTIVE

For patients with cervical and thoracolumbar AO Spine type C injuries, the authors sought to 1) identify whether preoperative vertebral column translation is predictive of a complete spinal cord injury (SCI) and 2) identify whether preoperative or postoperative vertebral column translation is predictive of neurological improvement after surgical decompression.

METHODS

All patients who underwent operative treatment for cervical and thoracolumbar AO Spine type C injuries at the authors' institution between 2006 and 2021 were identified. CT and MRI were utilized to measure vertebral column translation in millimeters prior to and after surgery. A receiver operating characteristic (ROC) curve was generated to predict the probability of sustaining a complete SCI on the basis of the amount of preoperative vertebral column translation. ROC curves were then used to predict the probability of neurological recovery on the basis of preoperative and postoperative vertebral column translation.

RESULTS

ROC analysis of 67 patients identified 6.10 mm (area under the curve [AUC] 0.77, 95% CI 0.650-0.892) of preoperative vertebral column translation as predictive of complete SCI. Additionally, ROC curve analysis found that 10.4 mm (AUC 0.654, 95% CI 0.421-0.887) of preoperative vertebral column translation was strongly predictive of no postoperative neurological improvement. Residual postoperative vertebral column translation after fracture reduction and instrumentation had no predictive value on neurological recovery (AUC 0.408, 95% CI 0.195-0.622).

CONCLUSIONS

For patients with cervical and thoracolumbar AO Spine type C injuries, the amount of preoperative vertebral column translation is highly predictive of complete SCI and the likelihood of postoperative neurological recovery.

Time to Surgery in Spinal Trauma: A Meta-Analysis of the World's Literature Comparing High-Income Countries to Low-Middle Income Countries

OBJECTIVE

We conducted a systematic review and meta-analysis to: 1) compare time from traumatic spinal injury (TSI) to operating room (OR) in high-income countries (HICs) versus low-middle-income countries (LMICs), and 2) evaluate hospital length of stay (LOS) in HICs versus LMICs.

METHODS

A systematic literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving articles of all languages.

INCLUSION CRITERIA

published between 1991 and 2021, spine trauma population, single country/region, and recorded time from injury to OR. The primary outcome was time from injury to OR, and the secondary outcome was LOS. Means and standard deviations were estimated in a random effects model by DerSimonian and Laird methods.

RESULTS

Of 2367 articles, 163 met the inclusion criteria for systematic review. Regarding time from injury to OR, 23 articles were eligible for meta-analysis; 16 studies were conducted in HICs and 7 in LMICs, comprising 3819 patients with TSI. A significantly shorter mean time from injury to OR was found in HICs (1.92 days, 95% confidence interval 1.44-2.41) compared with LMICs (3.27 days, 95% confidence interval 2.27-4.27) (P = 0.020). Regarding length of stay, 14 articles were eligible for meta-analysis, 10 studies were conducted in HICs and 4 in LMICs, comprising 11,003 patients. There was no difference in LOS between HICs and LMICs (25.76 days vs. 20.48 days, P = 0.140).

CONCLUSIONS

Patients with traumatic spinal injuries in HICs were more likely to undergo earlier surgery compared to patients in LMICs. No difference was found in total LOS between HICs and LMICs. While multiple factors can influence time to surgery, these findings draw attention to the global disparity in spinal trauma care.

Differences in the Practice of Traumatic Spinal Cord Injury Management Among Spine Surgeons in Saudi Arabia

BACKGROUND

This study aims to explore the ease of adopting clinical practice guidelines (CPGs) in managing traumatic spinal cord injury (TSCI) among spine surgeons, with particular focus on the use of steroids, high-dependency unit, early spinal cord decompression, and maintaining a target mean arterial blood pressure (MAP).

METHODS

We conducted a cross-sectional study among the practicing spinal surgeons in Saudi Arabia and included surgeons from neurosurgical and orthopedic backgrounds. The study period was from April to June 2020. The respondents provided sociodemographic data, training background, years of experience, and their clinical practices in managing TSCI via a survey tool constructed based on a literature review. The data were analyzed to evaluate the association between a surgeon's demographics and clinical practices.

RESULTS

Ninety-eight spinal surgeons responded, comprising 40% of the practicing spine surgeon population in Saudi Arabia. The only area where the neurosurgical spine and orthopedic spine surgeons' practices differed significantly was maintaining MAP within a target range. Other differences between practices were not statistically significant. The authors also found a significant correlation between the surgeon's school of training and their experience concerning steroids administration. On the other hand, the surgeon experience and volume of treated TSCI cases correlated significantly with admission to a high-dependency unit.

CONCLUSIONS

The adoption of CPGs remains a challenge to many spinal surgeons. Neurosurgeons are more into keeping the MAP at certain target, whereas the school of training and surgeon experience were the largest determinants of the surgeon's practice in managing TSCI in Saudi Arabia.

CLINICAL RELEVANCE

As the variability in managment among spine surgeons remains a challenge, international and national spine societies are expected to build clinical practice guidelines from the limited existing literature.

LEVEL OF EVIDENCE: 3

Ultra-early Spinal Decompression Surgery Can Improve Neurological Outcome of Complete Cervical Spinal Cord Injury; a Systematic Review and Meta-analysis

Introduction

Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in current guidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysis aims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12 hours after SCI) in improving patients' neurological status.

Methods

A search was performed in Medline, Embase, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinical trials were included in the present study. Exclusion criteria were absence of an early or late surgery group, failure to report neurological status based on the American spinal injury association impairment scale (AIS) grade, failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Two independent reviewers performed data collection, and risk of bias and certainty of evidence assessments. The outcome was reported as odds ratio (OR) and 95% confidence interval (CI).

Results

Data from 16 articles, which studied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompression surgery significantly improves patients' neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However, ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. Moreover, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86 folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improvement compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83; 95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17).

Conclusion

Current guidelines emphasize that spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and location. However, results of the present study demonstrated that certain considerations may be taken into account when performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should be performed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12 hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than in patients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients with AIS B to D does not significantly affect the neurological outcome.

N-Acetylcysteine alleviates spinal cord injury in rats after early decompression surgery by regulating inflammation and apoptosis

OBJECTIVE

Decompression surgery in patients with spinal cord injury (SCI) has a neuroprotective effect by alleviating secondary injury and improving neurological outcomes. N-Acetylcysteine (NAC), a drug approved by the United States Food and Drug Administration, has been shown to play neuroprotective roles via attenuation of apoptosis and inflammation. The purpose of the present study was to investigate the effects of early or late decompression surgery in combination with NAC administration on acute SCI, as well as investigate the underlying mechanisms of its actions.

METHODS

In this study, an acute SCI model was established in rats. The rats were treated with decompression surgery 24/48 h post-SCI in combination with or without NAC.

RESULTS

The results showed that decompression surgery in combination with NAC lead to a better outcome than decompression alone, as demonstrated by the higher Basso, Beattie, and Bresnahan scores. Histopathological examination demonstrated that early decompression surgery in combination with NAC exerted the best therapeutic effect on spinal cord recovery, which was further confirmed by the extent of inflammation and apoptosis. Additionally, we found that NAC might compensate for a lack of late surgery.

CONCLUSIONS

Collectively, early decompression surgery and NAC could be a promising combination for the treatment of acute SCI, and its therapeutic effects may be associated with the regulation of inflammation and apoptosis.

Ethamsylate Attenuates Mutilated Secondary Pathogenesis and Exhibits a Neuroprotective Role in Experimental Model of Spinal Cord Injury

Deficits in the neuronal connection that succumbs to the impairment of sensory and motor neurons are the hallmarks of spinal cord injury (SCI). Secondary pathogenesis, which initiates after the primary mechanical insult to the spinal cord, depicts a pivotal role in producing inflammation, lesion formation and ultimately causes fibrotic scar formation in the chronic period. This fibrotic scar formed acts as a major hindrance in facilitating axonal regeneration and is one of the root causes of motor impairment. Cascade of secondary events in SCI begins with injury-induced blood spinal cord barrier rupture that promotes increased migration of neutrophils, macrophages, and other inflammatory cells at the injury site to initiate the secondary damages. This phenomenon leads to the release of matrix metalloproteinase, cytokines and chemokines, reactive oxygen species, and other proteolytic enzymes at the lesion site. These factors assist in the activation of the TGF-β1 signaling pathway, which further leads to excessive proliferation of perivascular fibroblast, followed by deposition of collagen and fibronectin matrix, which are the main components of the fibrotic scar. Subsequently, this scar formed inhibits the propagation of action potential from one neuron to adjacent neurons. Ethamsylate, an anti-hemorrhagic drug, has the potential to maintain early hemostasis as well as restore capillary resistance. Therefore, we hypothesized that ethamsylate, by virtue of its anti-hemorrhagic activity, reduces hemorrhagic ischemia-induced neuronal apoptosis, maintains the blood spinal cord barrier integrity, and decreases secondary damage severity, thereby reduce the extent of fibrotic scar formation, and demonstrates a neuroprotective role in SCI.

Early versus Late Surgical Decompression for Traumatic Spinal Cord Injury on Neurological Recovery: A Systematic Review and Meta-Analysis

This study aimed to investigate whether early surgical decompression was associated with favorable neurological recovery in patients with traumatic spinal cord injury (tSCI). We searched PubMed and Embase from the database inception through December 2020 and selected studies comparing the impact of early versus late surgical decompression on neurological recovery as assessed by American Spinal Injury Association Impairment Scale (AIS) for adult patients sustaining tSCI. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Subgroup analysis and meta-regression analysis was conducted to identify significant outcome moderator. We included 26 studies involving 3574 patients in the meta-analysis. The pooled results demonstrated significant association between early surgical decompression and an improvement of at least one AIS grade (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.41-2.41; I2, 48.06%). The benefits of early surgical decompression were consistently observed across different subgroups, including patients with cervical or thoracolumbar injury and patients with complete or incomplete injury. The meta-regression analysis indicated that cut-off timing defining early versus late decompression was a significant effect moderator, with early decompression performed before post-tSCI 8 or 12 h associated with greatest benefits (OR, 3.37; 95% CI, 1.74-6.50; I2, 53.52%). No obvious publication bias was detected by the funnel plot. In conclusion, early surgical decompression was associated with favorable neurological recovery for tSCI patients. However, there was a lack of high-quality evidence and the results need further examination.

Predictors associated with inappropriate transport of near shore spinal injuries

PURPOSE

Spinal injuries resulting in neurological damage cause significant morbidity. Swift neurosurgical intervention can mitigate negative outcomes. However, variable mechanisms of injury may be associated with inappropriate transport (IAT), which may delay necessary surgical interventions. Patients with near shore spinal injuries (NSSI) presented with unique mechanisms, so we investigated factors associated with IAT in patients with NSSI.

METHODS

We performed a multicenter retrospective study of all adult patients transported from a beach resort to 3 hospitals for suspected NSSI between 2006 - 2017. We excluded patients transferred to other facilities, and those not injured in the water. Primary outcome was IAT, defined as patients with NSSI requiring transfer to another trauma center. To avoid heterogeneity in our analysis, we further excluded patients without NSSI who were inappropriately transported to a level I trauma center. We used multivariable logistic regression to assess association of independent variables (such as demographic, environmental, and clinical factors) with outcome.

RESULTS

We analyzed 278 patients with suspected NSSI, and found 14 (5.0%) had IAT. Compared to appropriately transported patients, diving was associated with higher percentages of IAT (28.6% vs. 3.9%, p = 0.014) and more were transported by air (50.0% vs. 20.6%, p = 0.01). In multivariable regression, patients' oxygenation saturation (odds ratio [OR] = 0.8, 95% confidence intervals [CI]: 077-0.98) and diving (OR = 7.5, 95% CI: 1.2-46) were significantly associated with IAT.

CONCLUSION

Rate of IAT for patients with NSSI was low. However, first responders and emergency medicine providers should be aware that diving is associated with a higher likelihood of IAT.

Early Predictors of Neurological Outcomes After Traumatic Spinal Cord Injury: A Systematic Review and Proposal of a Conceptual Framework

BACKGROUND

Neurological outcomes after traumatic spinal cord injury are variable and depend on patient-, trauma-, and treatment-related factors as well as on spinal cord injury characteristics, imaging, and biomarkers.

OBJECTIVE

The aims of the study were to identify and classify the early predictors of neurological outcomes after traumatic spinal cord injury.

DATA SOURCES

The Medline, PubMed, Embase, and the Cochrane Central Database were searched using medical subject headings. The search was extended to the reference lists of identified studies.

STUDY ELIGIBILITY CRITERIA

The study eligibility criteria were assessment of neurological outcomes as primary or secondary outcome, predictors collected during the acute phase after traumatic spinal cord injury, and multivariate design.

PARTICIPANTS

The participants were adult patients with traumatic spinal cord injury followed at least 3 mos after injury.

STUDY APPRAISAL AND SYNTHESIS METHODS

The quality of studies was assessed by two independent reviewers using the Study Quality Assessment Tools for Observational Cohort and Cross-sectional Studies. The studies' narrative synthesis relied on a classification of the predictors according to quantity, quality, and consistency of the evidence. Results were summarized in a conceptual framework.

RESULTS

Forty-nine articles were included. The initial severity of traumatic spinal cord injury (American Spinal Injury Association Impairment Scale, motor score, and neurological level of injury) was the strongest predictor of neurological outcomes: patients with more severe injury at admission presented poor neurological outcomes. Intramedullary magnetic resonance imaging signal abnormalities were also associated with neurological outcomes, as the presence of intramedullary hemorrhage was a factor of poor prognosis. Other largely studied predictors, such as age and surgical timing, showed some inconsistency in results depending on cutoffs. Younger age and early surgery were generally associated with good outcomes. Although widely studied, other factors, such as vertebral and associated injuries, failed to show association with outcomes. Cerebrospinal fluid inflammatory biomarkers, as emerging factors, were significantly associated with outcomes.

CONCLUSIONS

This study provides a comprehensive review of predictors of neurological outcomes after traumatic spinal cord injury. It also highlights the heterogeneity of outcomes used by studies to assess neurological recovery. The proposed conceptual framework classifies predictors and illustrates their relationships with outcomes.

Bioinformatic Analysis of the Proteome in Exosomes Derived From Plasma: Exosomes Involved in Cholesterol Metabolism Process of Patients With Spinal Cord Injury in the Acute Phase

Spinal cord injury (SCI) is a common but severe disease caused by traffic accidents. Coronary atherosclerotic heart disease (CHD) caused by dyslipidemia is known as the leading cause of death in patients with SCI. However, the quantitative analysis showed that the cholesterol and lipoprotein concentrations in peripheral blood (PB) did not change significantly within 48 h after SCI. Due to the presence of the Blood spinal cord barrier (BSCB), there are only few studies concerning the plasma cholesterol metabolism in the acute phase of SCI. Exosomes have a smaller particle size, which enables them relatively less limitation of BSCB. This study uses exosomes derived from the plasma of 43 patients in the acute phase of SCI and 71 patients in the control group as samples. MS proteomics and bioinformatics analysis found 590 quantifiable proteins, in which 75 proteins were upregulated and 153 proteins were downregulated, and the top 10 differentially expressed proteins are those including downregulating proteins: HIST1H4A, HIST2H3A, HIST2H2BE, HCLS1, S100A9, HIST1H2BM, S100A8, CALM3, YWHAH, and SFN, and upregulating proteins: SERPIND1, C1QB, SPTLC3, IGHV4-28, C4A, IGHV4-38-2, IGHV4-30-2, SLC15A1, C4B, and ACTG2. Enrichment analysis showed that the largest part of proteins was related to cholesterol metabolism among the downregulated proteins. The main components of cholesterol [ApoB-48 and ApoB-100 increased, ApoA-I, ApoA-II, ApoA-IV, ApoC, ApoE, and Apo(a) decreased] were changed in exosomes derived from plasma of patients. ELISA analysis showed that some components were disordered in the acute phase of SCI. These results suggested that the exosomes might be involved in cholesterol metabolism regulation in the acute phase of SCI.

Emergent spine surgery during COVID-19 pandemic: 10 Months experience in Dr. Sardjito general hospital, Indonesia a case series

Background

During the COVID-19 pandemic, the spine surgeon had to deal with some new challenges in treating emergency spine cases. This paper aimed to report our experience with spine emergency surgery during the pandemic, with already limited resources for surgery.

Methods

This was a retrospective, single-center study, involving all patients admitted to our hospital during a period of 1st March - 31^st December 2020 and underwent emergent spinal surgery. The data were collected from the patients' medical records.

Results

We found 15 patients who met the inclusion criteria. Four patients were suspected to be infected by COVID-19, but none of them was confirmed to be infected by COVID-19 based on the PCR test. All patients had a history of injury: fell from height (53.3%), traffic accident (40%), and direct trauma (6.7%). The average time interval from injury to hospital admission was 38.6 h, from admission to surgery was 6.3 days, and from injury to surgery was 8.1 days. The patient who was suspected to be infected with COVID-19 has a significantly greater time interval from admission to surgery (p = 0.012). The surgery lasted for 3-6 h, with an average of 4.6 h. The average hospital stay duration was 13.3 days and it has a significant positive correlation with the time interval from admission to surgery (p = 0.001). Three months post-operatively, seven patients experienced an improvement in the Frankel grade, 4 patients had no changes in Frankel grade, and 2 patients died.

Conclusion

To our experience, the lack of human and material resources during the pandemic caused some delay in surgery. However, surgery performed later than 24 h during the pandemic might still bring benefit to the patient.

Regenerative replacement of neural cells for treatment of spinal cord injury

Introduction: Traumatic Spinal Cord Injury (SCI) results from primary physical injury to the spinal cord, which initiates a secondary cascade of neural cell death. Current therapeutic approaches can attenuate the consequences of the primary and secondary events, but do not address the degenerative aspects of SCI. Transplantation of neural stem/progenitor cells (NPCs) for the replacement of the lost/damaged neural cells is suggested here as a regenerative approach that is complementary to current therapeutics.Areas Covered: This review addresses how neurons, oligodendrocytes, and astrocytes are impacted by traumatic SCI, and how current research in regenerative-NPC therapeutics aims to restore their functionality. Methods used to enhance graft survival, as well as bias progenitor cells towards neuronal, oligodendrogenic, and astroglia lineages are discussed.Expert Opinion: Despite an NPC's ability to differentiate into neurons, oligodendrocytes, and astrocytes in the transplant environment, their potential therapeutic efficacy requires further optimization prior to translation into the clinic. Considering the temporospatial identity of NPCs could promote neural repair in region specific injuries throughout the spinal cord. Moreover, understanding which cells are targeted by NPC-derived myelinating cells can help restore physiologically-relevant myelin patterns. Finally, the duality of astrocytes is discussed, outlining their context-dependent importance in the treatment of SCI.

Adult Spinal Cord Injury without Major Bone Injury: Effects of Surgical Decompression and Predictors of Neurological Outcomes in American Spinal Injury Association Impairment Scale A, B, or C

The cervical spine can be injured even in the absence of radiographic abnormality, and the best surgical treatment for adult spinal cord injury without bone injury is debated. The aim of this study was to retrospectively investigate the effect of surgical decompression for severe adult spinal cord injury without major bone injury and to establish predictors of good neurological outcome. We analyzed 11 patients who underwent surgical decompression in severe adult spinal cord injury without major bone injury patients classified as American Spinal Injury Association Impairment Scale (AIS) grade A, B, or C. Neurological assessments were performed using AIS at preoperative and postoperative 1-year follow-up. Radiological evaluations were performed using cervical magnetic resonance imaging (MRI) at preoperative. Seven cases were classified as AIS grade A; two cases as AIS grade B; and two cases as AIS grade C. Five of 11 (45.5%) patients showed improved neurological grade 1-year postoperatively. Intramedullary lesion length (IMLL) (p = 0.047) and compression rate (p = 0.045) had the most powerful effect on AIS grade conversion. This study shows that the fate of the injured spinal cord is determined at the time of the injury, but adequate decompression may have limited contribution to the recovery of neurological function. Compression rate and IMLL on MRI can be used as a predictor of neurological recovery.

Comparison of anterior-only versus combined anterior and posterior fusion for unstable subaxial cervical injuries: a meta-analysis of biomechanical and clinical studies

OBJECTIVE

The purpose of the present study was to perform a meta-analysis comparing biomechanical and clinical outcomes between anterior-only and combined anterior and posterior fusions to determine which method of cervical fusion yielded better results for unstable cervical injuries.

METHODS

The MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and SCOPUS electronic databases were searched for relevant articles published through 2000-2019 that compared the biomechanical and clinical outcomes of anterior-only and combined anterior and posterior fusion for unstable cervical fracture.

RESULTS

Eight biomechanical and four clinical studies were included in the analysis. There were significant biomechanical differences between the groups with respect to flexion-extension, axial rotation and lateral bending. Combined fusion provided better biomechanical stability for unstable cervical injuries than anterior-only fusion, regardless of the number of corpectomies or the presence of a posterior column injury. However, despite significant biomechanical differences, there were no significant differences in clinical outcomes, such as the degree of neurologic improvement and complications between the two groups.

CONCLUSION

Anterior-only and combined anterior and posterior fusions for unstable subaxial cervical injuries can both restore cervical stability. Although combined fusion might have some advantages in terms of stability biomechanically, there were no significant differences in clinical outcomes, such as the degree of neurologic improvement and perioperative complications. Therefore, rather than the routine use of combined fusion for unstable cervical injuries, the selective use of anterior-only or combined fusion according to the type of injury is recommended.

Bibliometric and Visualized Analysis of Scientific Publications on Ossification of the Posterior Longitudinal Ligament Based on Web of Science

BACKGROUND

In recent years, there has been increasing study of ossification of the posterior longitudinal ligament (OPLL), leading to many articles on this topic. We aimed to identify trends in OPLL-related research and to analyze the most highly cited scientific articles on OPLL.

METHODS

We searched the Web of Science Core Collection database for all articles on OPLL. The years of publication, countries, journals, institutions, and total citations were extracted and analyzed. Results related to countries, institutions, and keywords were subjected to co-occurrence analysis using VOSviewer software. The top 100 most-cited articles on OPLL were analyzed.

RESULTS

A total of 876 articles related to OPLL were identified. The frequency of publication on OPLL has increased substantially over time. Among all countries, Japan has contributed the most articles on OPLL (n = 349). The most productive institution has been Hirosaki University (n = 57). Spine topped the list of journals and has published 120 OPLL-related articles, which received 4221 total citations. The surgical treatment of OPLL has been the most common research focus in the OPLL literature.

CONCLUSIONS

The scientific literature on OPLL has rapidly expanded in recent years. This study represents the first bibliometric analysis of scientific articles on OPLL and can serve as a useful guide to clinicians and researchers in the field.

Current updates on various treatment approaches in the early management of acute spinal cord injury

Spinal cord injury (SCI) is a debilitating condition which often leads to a severe disability and ultimately impact patient's physical, psychological, and social well-being. The management of acute SCI has evolved over the couple of decades due to improved understanding of injury mechanisms and increasing knowledge of disease. Currently, the early management of acute SCI patient includes pharmacological agents, surgical intervention and newly experimental neuroprotective strategies. However, many controversial areas are still surrounding in the current treatment strategies for acute SCI, including the optimal timing of surgical intervention, early versus delayed decompression outcome benefits, the use of methylprednisolone. Due to the lack of consensus, the optimal standard of care has been varied across treatment centres. The authors have shed a light on the current updates on early treatment approaches and neuroprotective strategies in the initial management of acute SCI in order to protect the early neurologic injury and reduce the future disability.

Cellular therapy for treatment of spinal cord injury in Zebrafish model

Spinal cord injury is a serious problem with a high rate of morbidity and mortality for all persons, especially young people (15-25 years old). Due to the large burden and the costs incurred on the government, finding the best therapeutic approach is necessary. In this respect, treatment strategies based on the disease mechanism can be effective. After the first trauma of spinal cord cascades, cellular events happen one after the other known as secondary trauma. The mechanism of secondary events of spinal cord injury could be helpful for target therapy as trying to stop the secondary trauma. Herein, some medical and surgical therapy has been introduced and cell therapy strategy was considered as a recent method. Actually, cell therapy is defined as the application of different cells including mesenchymal stem cells, embryonic stem cells, induced pluripotent stem cells, and some others to replace or reconstruct the damaged tissues and restore their functions. However, as a newly emerged therapeutic method, cell therapy should be used through various subclinical studies in animal models to assess the efficacy of the treatment under controlled conditions. In this review, the role of Zebrafish as a recommended model has been discussed and combinatory approach as the probably most useful treatment has been suggested.

Early Management of Spinal Cord Injury: WFNS Spine Committee Recommendations

Scientific knowledge today is being generated more rapidly than we can assimilate thus requiring continuous review of gold-standards for diagnosis and treatment of specific pathologies. The aim of this paper is to provide an update on the best early management of spinal cord injury (SCI), in order to produce acceptable worldwide recommendations to standardize clinical practice as much as possible.The WFNS Spine Committee voted recommendations regarding management of SCI based on literature review of the last 10 years. The committee stated 9 recommendations on 3 main topics: (1) clinical assessment and classification of SCI; (2) emergency care and early management; (3) cardiopulmonary management. American Spinal Injury Association impairment scale, Spinal Cord Independence Measure, and International Spinal Cord Injury Basic Pain Data Set are considered the most useful and feasible in emergency evaluation and follow-up in case of SCI. Magnetic resonance imaging is the most indicated examination to evaluate patients with symptomatic SCI. In early phase, correction of hypotension (systolic blood pressure < 90 mmHg), and bradycardia are strongly recommended. Surgical decompression should be performed as soon as possible with the ideal surgical time being within 8 hours for both complete and incomplete lesions.

Human Pluripotent Stem Cells for Spinal Cord Injury

Spinal cord injury (SCI) as a serious public health issue and neurological insult is one of the most severe cause of long-term disability. To date, a variety of techniques have been widely developed to treat central nervous system injury. Currently, clinical treatments are limited to surgical decompression and pharmacotherapy. Because of their negative effects and inefficiency, novel therapeutic approaches are required in the management of SCI. Improvement and innovation of stem cell-based therapies have a huge potential for biological and future clinical applications. Human pluripotent stem cells (hPSCs) including embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs) are defined by their abilities to divide asymmetrically, self-renew and ultimately differentiate into various cell lineages. There are considerable research efforts to use various types of stem cells, such as ESCs, neural stem cells (NSCs), and mesenchymal stem cells (MSCs) in the treatment of patients with SCI. Moreover, the use of patient-specific iPSCs holds great potential as an unlimited cell source for generating in vivo models of SCI. In this review, we focused on the potential of hPSCs in treating SCI.

Cervical foraminal stenosis causing unilateral diaphragmatic paralysis without neurologic manifestation: A case report and review of the literature

RATIONALE

Unilateral diaphragmatic paralysis due to cervical spondylosis has rarely been reported. We present the first case of unilateral diaphragmatic paralysis without radicular pain or motor weakness due to cervical foraminal stenosis and a review of the related literature.

PATIENT CONCERNS

A 59-year-old man presented with dyspnea and fever. His chest radiograph revealed right hemidiaphragmatic paralysis.

DIAGNOSES

The differential diagnosis of phrenic nerve palsy excluded mediastinal and neurodegenerative diseases. Imaging studies showed right foraminal stenosis caused by cervical spondylosis at C3-4 and C4-5.

INTERVENTIONS

The patient underwent foraminotomy at C3-4 and C4-5 on the right side. The operative findings revealed a severe compression of the C4 root.

OUTCOMES

At 3 months postoperatively, the unilateral diaphragmatic paralysis and dyspnea were recovered.

LESSONS

Hemidiaphragmatic paralysis deserves careful evaluation for the presence of cervical spondylosis, even without concomitant neurologic manifestations.

Early Predictors of Near-Shore Spinal Injuries Among Emergency Department Patients

BACKGROUND

Spinal injuries (SIs) can pose a significant burden to patients and family; delayed surgical intervention, associated with interhospital transfer, results in worse outcomes.

OBJECTIVE

This study aimed to identify early patient-centered factors associated with risk for near-shore SIs to assist clinicians with expeditious medical decision-making.

METHODS

We performed a multicenter retrospective study of all adults transported from Ocean City, Maryland to two emergency departments (EDs) and one regional trauma center for evaluation of suspected SIs from 2006 to 2017. Outcomes were any SI and any spinal cord injury (SCI). Multivariable logistic regression was performed for association of environmental and clinical factors with outcomes.

RESULTS

We analyzed 278 records, 102 patients (37%) were diagnosed with any SI and 41 (15%) were diagnosed with SCIs. Compared with patients without SI, patients with SI were more likely to be older (48 vs. 39 years), male (90% vs. 70%), with pre-existing spinal condition (62% vs. 33%), and injury caused by diving (11% vs. 2%). Multivariable logistic regression showed age (odd ratio [OR] 1.07; 95% confidence interval [CI] 1.04-1.11), diving (OR 3.5; 95% CI 3-100+), and wave height (OR 4.5; 95% CI 1.35-15.2) were associated with any SI, and a chief complaint of extremity numbness or tingling (OR 5.73; 95% CI 1.2-27.9) was associated with SCI.

CONCLUSIONS

We identified older age, diving, and higher wave height as risk factors for any SI and symptoms of numbness and tingling were associated with SCIs. Clinicians should consider expediting these patients' transfers to a trauma center with neurosurgical capability.

Novel Role of HAX-1 in Neurons Protection After Spinal Cord Injury Involvement of IRE-1

Spinal cord injury (SCI) is one of the diseases with high probability of causing disability in human beings, and there is no reliable treatment at present. Neuronal apoptosis is a vital component of secondary injury and plays a critical role in the development of neurological dysfunction after spinal cord injury. In this study, we found that the expression and distribution of HAX-1 in neurons increased 1 day after SCI. PC12 cells overexpressing HAX-1 showed decreased apoptosis and PC12 cells are more likely to undergo apoptosis after down-regulating HAX-1, which was confirmed via TUNEL experiments. We found GRP94 showed the same trend as HAX-1 in expression and interacted with HAX-1 and IRE-1 in both spinal cord tissue and PC12 cells, and this interaction seems to be enhanced after SCI. When the expression of HAX-1 was up-regulated, GRP94 also increased, but IRE-1 did not change at all. Further studies showed that overexpression of HAX-1 decreased the expression of pIRE-1, rather than IRE-1, and downstream proteins of the IRE signaling pathway (Caspase12, pJNK and CHOP) were significantly reduced, and vice versa. In animals treated with HAX-1 expressing adenovirus there are more neuronal cells remaining in the damaged spinal cord tissue, and hindlimb motor function of rats was significantly improved. So, we speculate that HAX-1 might play a role in protecting neurons from apoptosis after SCI by regulating the IRE-1 signaling pathway via promoting the dissociation of GRP94 from IRE-1. This may provide a theoretical basis and a potential therapeutic target for clinical improvement of neural function recovery after SCI.

Correlation of history and physical examination with imaging in traumatic near-shore aquatic head and spinal injury

OBJECTIVE

It remains unclear whether clinicians can rely on specific symptoms and signs to detect or exclude serious head and spinal injury sustained during near-shore aquatic activities. Our study investigated patients' history of present illness (HPI) and physical examination (PE) for their utility in detecting serious head and spinal injury.

METHODS

We conducted a multicenter retrospective comparative analysis of adult patients who were transported from the beach in Ocean City, Maryland, to three nearby emergency departments for possible spinal injury from 2006 through 2017. Patients suspected to have any spinal injury from beach activities were eligible. We excluded patients who could not verbalize their symptoms or with insufficient emergency department records. We compared components of each patient's HPI and PE with radiologic evidence of spinal injury. We calculated sensitivity, specificity, and negative and positive likelihood ratios (LRs).

RESULTS

We analyzed 278 patients with suspected spinal injury. Midline spinal tenderness was associated with increased likelihood of thoracic (LR+ 2.6) and lumbar spinal fractures (LR+ 3.5). HPI complaints of paralysis (LR+ 13.9) and sensory loss (LR+ 5.8) had strong associations with spinal cord injuries. Weakness found through PE was also associated with spinal cord injury (LR+ 5.3).

CONCLUSIONS

We identified several components of the clinical evaluation that had clinically significant association with spinal injuries from beach-related trauma. While prospective studies are needed to confirm our observations, clinicians may consider these high-risk features in patients with beach-related trauma and adjust testing and level of care appropriately.

The Impact of Urgent (<8 Hours) Decompression on Neurologic Recovery in Traumatic Spinal Cord Injury: A Meta-Analysis

OBJECTIVE

The relationship between urgent decompression and neurologic recovery for traumatic spinal cord injury (TSCI) remains controversial. This meta-analysis was conducted to determine the beneficial effects of surgery within 8 hours for patients with TSCI.

METHODS

A systematic search in EMBASE, MEDLINE, Cochrane Library, and PubMed for relevant studies was conducted from the earliest records until December 2019. Studies that compared outcomes of early (<8 hours) surgery versus late (≥8 hours) surgery for patients with TSCI were selected for analysis.

RESULTS

Nine cohort studies involving 716 participants met the eligibility criteria. Early (<8 hours) surgery for patients showed a more significant improvement in American Spinal Injury Association scores (standardized mean difference, 0.75, 95% confidence interval [CI], 0.51-0.99; P < 0.05). Especially for patients with initial complete TSCI, neurologic improvement rate significantly increased in the early surgery group (relative ratio [RR], 3.96; 95% CI, 2.02-7.76; P < 0.05), whereas in patients with initial incomplete TSCI, no significant differences were found between the 2 groups in neurologic improvement rate (RR, 1.41; 95% CI, 0.95-2.10; P > 0.05). There were no significant differences between the 2 groups in length of hospital stay (standardized mean difference, 0.34; 95% CI, -0.24 to 0.92; P > 0.05) and complications (RR, 0.92; 95% CI, 0.70-1.22; P > 0.05).

CONCLUSIONS

This meta-analysis provides evidence of benefits from urgent (<8 hours) decompression for patients with TSCI in terms of neurologic recovery. The improvement effect is more definite in patients with initial complete TSCI.

French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury

OBJECTIVES

To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury.

DESIGN

A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology.

RESULTS

The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations.

CONCLUSIONS

There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

Molecular Pathophysiology of Ossification of the Posterior Longitudinal Ligament (OPLL)

Ossification of the posterior longitudinal ligament (OPLL) can be defined as an ectopic ossification in the tissues of spinal ligament showing a hyperostotic condition. OPLL is developed mostly in the cervical spine and clinical presentations of OPLL are majorly myelopathy and/or radiculopathy, with serious neurological pathology resulting in paralysis of extremities and disturbances of motility lowering the quality of life. OPLL is known to be an idiopathic and multifactorial disease, which genetic factors and non-genetic factors including diet, obesity, physical strain on the posterior longitudinal ligament, age, and diabetes mellitus, are involved into the pathogenesis. Up to now, surgical management by decompressing the spinal cord is regarded as standard treatment for OPLL, although there might be the risk of development of reprogression of ossification. The molecular pathogenesis and efficient therapeutic strategy, especially pharmacotherapy and/or preventive intervention, of OPLL has not been clearly elucidated and suggested. Therefore, in this review, we tried to give an overview to the present research results on OPLL, in order to shed light on the potential pharmacotherapy based on molecular pathophysiologic aspect of OPLL, especially on the genetic/genomic factors involved into the etiology of OPLL.