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Mahanes D, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mainali S, Meixensberger J, Varelas PN, Weimar C, Westermaier T, Sakowitz OW. Guidelines for neuroprognostication in adults with traumatic spinal cord injury. Neurocrit Care 2024; 40:415-437. [PMID: 37957419 PMCID: PMC10959804 DOI: 10.1007/s12028-023-01845-8] [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: 07/17/2023] [Accepted: 08/17/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (tSCI) impacts patients and their families acutely and often for the long term. The ability of clinicians to share prognostic information about mortality and functional outcomes allows patients and their surrogates to engage in decision-making and plan for the future. These guidelines provide recommendations on the reliability of acute-phase clinical predictors to inform neuroprognostication and guide clinicians in counseling adult patients with tSCI or their surrogates. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development, and Evaluation methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of an appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Timing/Setting question was framed as "When counseling patients or surrogates of critically ill patients with traumatic spinal cord injury, should < predictor, with time of assessment if appropriate > be considered a reliable predictor of < outcome, with time frame of assessment >?" Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four Grading of Recommendations Assessment, Development, and Evaluation criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. Good practice recommendations addressed essential principles of neuroprognostication that could not be framed in the Population/Intervention/Comparator/Outcome/Timing/Setting format. Throughout the guideline development process, an individual living with tSCI provided perspective on patient-centered priorities. RESULTS Six candidate clinical variables and one prediction model were selected. Out of 11,132 articles screened, 369 met inclusion criteria for full-text review and 35 articles met eligibility criteria to guide recommendations. We recommend pathologic findings on magnetic resonance imaging, neurological level of injury, and severity of injury as moderately reliable predictors of American Spinal Cord Injury Impairment Scale improvement and the Dutch Clinical Prediction Rule as a moderately reliable prediction model of independent ambulation at 1 year after injury. No other reliable or moderately reliable predictors of mortality or functional outcome were identified. Good practice recommendations include considering the complete clinical condition as opposed to a single variable and communicating the challenges of likely functional deficits as well as potential for improvement and for long-term quality of life with SCI-related deficits to patients and surrogates. CONCLUSIONS These guidelines provide recommendations about the reliability of acute-phase predictors of mortality, functional outcome, American Spinal Injury Association Impairment Scale grade conversion, and recovery of independent ambulation for consideration when counseling patients with tSCI or their surrogates and suggest broad principles of neuroprognostication in this context.
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Affiliation(s)
- Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, University of Virginia, Charlottesville, VA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Klinikum Dachau, Dachau, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany.
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Jiang SH, Deysher D, Adachi K, Bhaskara M, Almadidy Z, Sadeh M, Mehta AI, Chaudhry NS. Surgical Outcomes in Octogenarians with Central Cord Syndrome: A Propensity-Score Matched Analysis. World Neurosurg 2024; 184:e228-e236. [PMID: 38266996 DOI: 10.1016/j.wneu.2024.01.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE Central cord syndrome (CCS) is a traumatic cervical spine injury that is treated with surgical decompression. In octogenarians (80-89), surgeons often opt for conservative management instead due to fears of postoperative complications and prolonged recovery times. This study aims to assess the in-hospital complications and outcomes in octogenarians undergoing surgery compared to those undergoing nonsurgical management for CCS. METHODS The National Trauma Data Bank was queried from 2017 to 2019 for octogenarians with CCS. Patients who received surgical fusion or decompression were divided into the surgery group and the remaining into the nonsurgical group. The surgery group was sampled and propensity score matched with the non-surgery group. Student t tests and Pearson χ2 tests were used to test for group differences. RESULTS A total of 759 octogenarians with CCS were identified. Following sampling and propensity score matching, 225 patients were identified in each group. The surgery group experienced longer intensive care unit (6.8 days vs. 3.21 days, P < 0.001) and hospital (13.79 days vs. 7.8 days, P < 0.001) lengths of stay and higher rates of deep vein thrombosis (4.89% vs. 0.44%, P = 0.02) and ventilator-associated pneumonia (4% vs. 0%, P = 0.02). Patients did not otherwise differ in mortality rate, other hospital complications, and discharge disposition. CONCLUSIONS Octogenarians undergoing surgery for CCS experience longer length of stay and complications consistent with prolonged hospitalization but otherwise have similar mortality, hospital complications, and discharge disposition compared to non-surgical treatment. Given the relative lack of short-term drawbacks, surgery should be considered first-line management when the long-term benefits are substantive.
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Affiliation(s)
- Sam H Jiang
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA.
| | - Daniel Deysher
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Kaho Adachi
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Mounika Bhaskara
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Zayed Almadidy
- Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA
| | - Morteza Sadeh
- Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA
| | - Ankit I Mehta
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA; Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA
| | - Nauman S Chaudhry
- Department of Neurosurgery and Brain Repair, University of South Florida, Lakeland, Florida, USA
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Klockner F, Roch J, Jäckle K, Driesen T, Meier MP, Reinhold M, Lehmann W, Weiser L. [Surgical management of acute traumatic spinal cord injury : Stability vs. functionality]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:756-763. [PMID: 37341733 DOI: 10.1007/s00113-023-01341-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Traumatic spinal cord injuries represent a devastating condition in the lives of those affected, with physical, emotional, and economic burdens for the patients themselves, their social environment, and society as a whole. OBJECTIVE Surgical approach and techniques in traumatic spinal cord injuries. RESULTS Traumatic spinal cord injuries should be surgically treated as soon as possible, but at least within 24 h of injury. If accompanying dural injuries occur, suturing or applying a patch is the primary method of choice. Early surgical decompression is essential, particularly in cervical spinal cord injuries. Stabilization in terms of instrumentation or fusion is inevitable and should be carried out over short segments to maintain the functionality of the cervical spine. Long-distance dorsal instrumentation with prior reduction in thoracolumbar spinal cord injuries provides high stability and preserved functionality in patients. Injuries to the thoracolumbar junction often require a two-stage anterior treatment. CONCLUSION Early surgical decompression, reduction, and stabilization of traumatic spinal cord injuries within 24 h are recommended. While short-segment stabilization is recommended in the cervical spine in addition to decompression, instrumentation should be over long segments in the thoracolumbar spine to provide the necessary stability while maintaining functionality.
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Affiliation(s)
- Friederike Klockner
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland.
| | - Jonathan Roch
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Katharina Jäckle
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Tobias Driesen
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Marc-Pascal Meier
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Maximilian Reinhold
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Wolfgang Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Lukas Weiser
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
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Purkayastha T, Debnath A, Debroy S, Debbarma S. Short-term neurological and functional outcome of surgical intervention in spinal cord injuries: a single center prospective observational study. Pan Afr Med J 2023; 45:138. [PMID: 37790145 PMCID: PMC10543912 DOI: 10.11604/pamj.2023.45.138.37180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 07/03/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction the management of an acute spinal cord injury remains controversial. The patient of acute spinal cord injury undergoes several phases of care beginning with the initial trauma management, surgical intervention, and perioperative medical management. The aim of this study was to evaluate the neurological and functional outcome of operative management of traumatic spinal cord injury patients admitted to a tertiary care centre in Northeast India. Methods thirty patients with spinal cord injury admitted to a tertiary care centre from December 2019 to November 2021, and treated with instrumented stabilisation for spinal cord injury were evaluated until 6 months postoperatively. Patients were evaluated with validated neurological (American Spinal Injury Association scale) and functional outcome measures (Barthel index). Demographic details, mode of injury, morphology, patterns of fractures, neurological level, and management methods in the hospital were recorded and analysed using the Statistical Package for the Social Science (SPSS) version 27.0. Results thoracolumbar spinal cord was more commonly injured with 16 (53.3%) patients compared to cervical spinal cord injury patients at 14 (46.7%). Eight patients had complete recovery, 7 patients had incomplete recovery and 15 patients had no recovery. At 6 months post-injury, 18 (60%) patients had favourable functional outcome. American Spinal Injury Association (ASIA) grade at admission was found to be significantly associated with the functional outcome. Conclusion after surgery half of the patients had an improvement in their neurology, and functional outcome was favorable which suggests that surgery still holds the key to a better functional and rehabilitation outcome.
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Dobran M, Aiudi D, Liverotti V, Fasinella MR, Lattanzi S, Melchiorri C, Iacoangeli A, Campa S, Polonara G. Prognostic MRI parameters in acute traumatic cervical spinal cord injury. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1584-1590. [PMID: 36882580 DOI: 10.1007/s00586-023-07560-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/09/2022] [Accepted: 01/22/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE The aim of this study is to estimate the prognostic value of some features documented on preoperative MRI study in patients with acute cervical spinal cord injury. METHODS The study was conducted in patients operated for cervical spinal cord injury (cSCI) from April 2014 to October 2020. The quantitative analysis on preoperative MRI scans included: length of the spinal cord intramedullary lesion (IMLL the canal diameter at the level of maximal spinal cord compression (MSCC) and the presence of intramedullary hemorrhage. The canal diameter at the MSCC was measured on the middle sagittal FSE-T2W images at the maximum level of injury. The America Spinal Injury Association (ASIA) motor score was used for neurological assessment at hospital admission. At 12-month follow-up all patients were examined with the SCIM questionnaire. RESULTS At linear regression analysis, the length of the spinal cord lesion [β coefficient -10.35, 95% confidence interval (CI)-13.71 to-6.99; p < 0.001], the diameter of the canal at the level of the MSCC (β coefficient 6.99, 95% CI 0.65 to 13.33; p = 0.032), and the intramedullary hemorrhage (β coefficient - 20.76, 95% CI - 38.70 to - 2.82; p = 0.025), were significantly associated with the score at the SCIM questionnaire at one year follow-up: shorter spinal cord lesion, greater diameter of the canal at the level of the MSCC, and absence of intramedullary hemorrhage were predictors of better outcome. CONCLUSION According to the findings of our study, the spinal length lesion, canal diameter at the level of spinal cord compression and intramedullary hematoma documented by the preoperative MRI study were associated with the prognosis of patients with cSCI.
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Affiliation(s)
- M Dobran
- Department of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy.
| | - D Aiudi
- Department of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - V Liverotti
- Department of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - M R Fasinella
- Department of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - S Lattanzi
- Department of Neurology, Università Politecnica delle Marche, Ancona, Italy
| | - C Melchiorri
- Department of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - A Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - S Campa
- Department of Neuroradiology, Università Politecnica delle Marche, Ancona, Italy
| | - G Polonara
- Department of Neuroradiology, Università Politecnica delle Marche, Ancona, Italy
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Pedro KM, Fehlings MG. Time is spine: What's over the horizon. J Clin Orthop Trauma 2022; 35:102043. [PMID: 36340959 PMCID: PMC9634004 DOI: 10.1016/j.jcot.2022.102043] [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: 08/10/2022] [Revised: 09/13/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Karlo M. Pedro
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Yousefifard M, Hashemi B, Forouzanfar MM, Khatamian Oskooi R, Madani Neishaboori A, Jalili Khoshnoud R. Ultra-early Spinal Decompression Surgery Can Improve Neurological Outcome of Complete Cervical Spinal Cord Injury; a Systematic Review and Meta-analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e11. [PMID: 35402995 PMCID: PMC8986504 DOI: 10.22037/aaem.v10i1.1471] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Behrooz Hashemi
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue and Treatment, Police Force, Tehran, Iran
| | - Mohammad Mehdi Forouzanfar
- Men’s Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rozita Khatamian Oskooi
- Emergency Department, Imam Reza Hospital, Birjand University of Medical Sciences, Birjand, Iran
| | - Arian Madani Neishaboori
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.,Corresponding authors1- Reza Jalili Khoshnoud Functional Neurosurgery Research Center, Shohadaye Tajrish Hospital, Shahrdary Avenue, Tajrish Square, Tehran, Iran. Tel: 00989127904684, 2- Arian Madani Neishaboori, Physiology Research Center, Hemmat Highway, P.O Box: 14665-354; Tel: +982186704771 Fax: +982186704771, E-mail:
| | - Reza Jalili Khoshnoud
- Functional Neurosurgery Research Center, Shohadaye Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran. ,Corresponding authors1- Reza Jalili Khoshnoud Functional Neurosurgery Research Center, Shohadaye Tajrish Hospital, Shahrdary Avenue, Tajrish Square, Tehran, Iran. Tel: 00989127904684, 2- Arian Madani Neishaboori, Physiology Research Center, Hemmat Highway, P.O Box: 14665-354; Tel: +982186704771 Fax: +982186704771, E-mail:
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Hsieh YL, Tay J, Hsu SH, Chen WT, Fang YD, Liew CQ, Chou EH, Wolfshohl J, d'Etienne J, Wang CH, Tsuang FY. Early versus Late Surgical Decompression for Traumatic Spinal Cord Injury on Neurological Recovery: A Systematic Review and Meta-Analysis. J Neurotrauma 2021; 38:2927-2936. [PMID: 34314253 DOI: 10.1089/neu.2021.0102] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Yu-Lin Hsieh
- Department of Internal Medicine, Danbury Hospital, Danbury, Connecticut, USA
| | - Joyce Tay
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Hsien Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Ting Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-De Fang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiat-Qiao Liew
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Eric H Chou
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, Texas, USA
| | - Jon Wolfshohl
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, Texas, USA
| | - James d'Etienne
- Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University, Taipei, Taiwan
| | - Fon-Yih Tsuang
- Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
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Early Predictors of Neurological Outcomes After Traumatic Spinal Cord Injury: A Systematic Review and Proposal of a Conceptual Framework. Am J Phys Med Rehabil 2021; 100:700-711. [PMID: 34131094 DOI: 10.1097/phm.0000000000001701] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Kim LH, Chen YR. Risk Adjustment Instruments in Administrative Data Studies: A Primer for Neurosurgeons. World Neurosurg 2019; 128:477-500. [DOI: 10.1016/j.wneu.2019.04.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/19/2019] [Accepted: 04/20/2019] [Indexed: 11/25/2022]
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Khorasanizadeh M, Yousefifard M, Eskian M, Lu Y, Chalangari M, Harrop JS, Jazayeri SB, Seyedpour S, Khodaei B, Hosseini M, Rahimi-Movaghar V. Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis. J Neurosurg Spine 2019; 30:683-699. [PMID: 30771786 DOI: 10.3171/2018.10.spine18802] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/11/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance. METHODS A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis. RESULTS A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups. CONCLUSIONS The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.
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Affiliation(s)
| | - Mahmoud Yousefifard
- 2Physiology Research Center and Department of Physiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahsa Eskian
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Yi Lu
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryam Chalangari
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - James S Harrop
- 4Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia
- 5Neurosurgery, Delaware Valley Regional Spinal Cord Injury Center, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | | | - Simin Seyedpour
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Behzad Khodaei
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Mostafa Hosseini
- 6Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Stamegna JC, Sadelli K, Escoffier G, Girard SD, Veron AD, Bonnet A, Khrestchatisky M, Gauthier P, Roman FS. Grafts of Olfactory Stem Cells Restore Breathing and Motor Functions after Rat Spinal Cord Injury. J Neurotrauma 2018; 35:1765-1780. [PMID: 29357739 DOI: 10.1089/neu.2017.5383] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The transplantation of olfactory ecto-mesenchymal stem cells (OEMSCs) could be a helpful therapeutic strategy for spinal cord repair. Using an acute rat model of high cervical contusion that provokes a persistent hemidiaphragmatic and foreleg paralysis, we evaluated the therapeutic effect of a delayed syngeneic transplantation (two days post-contusion) of OEMSCs within the injured spinal cord. Respiratory function was assessed using diaphragmatic electromyography and neuroelectrophysiological recordings of phrenic nerves (innervating the diaphragm). Locomotor function was evaluated using the ladder-walking locomotor test. Cellular reorganization in the injured area was also studied using immunohistochemical and microscopic techniques. We report a substantial improvement in breathing movements, in activities of the ipsilateral phrenic nerve and ipsilateral diaphragm, and also in locomotor abilities four months post-transplantation with nasal OEMSCs. Moreover, in the grafted spinal cord, axonal disorganization and inflammation were reduced. Some grafted stem cells adopted a neuronal phenotype, and axonal sparing was observed in the injury site. The therapeutic effect on the supraspinal command is presumably because of both neuronal replacements and beneficial paracrine effects on the injury area. Our study provides evidence that nasal OEMSCs could be a first step in clinical application, particularly in patients with reduced breathing/locomotor movements.
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Affiliation(s)
- Jean-Claude Stamegna
- 1 Institut de Neurophysiopathologie, Aix-Marseille Université , Marseille, France
| | - Kevin Sadelli
- 1 Institut de Neurophysiopathologie, Aix-Marseille Université , Marseille, France
| | - Guy Escoffier
- 1 Institut de Neurophysiopathologie, Aix-Marseille Université , Marseille, France
| | - Stéphane D Girard
- 1 Institut de Neurophysiopathologie, Aix-Marseille Université , Marseille, France
| | - Antoine D Veron
- 1 Institut de Neurophysiopathologie, Aix-Marseille Université , Marseille, France .,2 IRSEA, Research Institute in Semiochemistry and Applied Ethology , Apt, France
| | - Amandine Bonnet
- 1 Institut de Neurophysiopathologie, Aix-Marseille Université , Marseille, France
| | | | - Patrick Gauthier
- 3 Laboratoire de Neurosciences et Cognitives, Aix-Marseille Université , Marseille, France
| | - François S Roman
- 1 Institut de Neurophysiopathologie, Aix-Marseille Université , Marseille, France
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Clinical and psychological outcome after surgery for lumbar spinal stenosis: A prospective observational study with analysis of prognostic factors. Neurol Neurochir Pol 2017; 52:70-74. [PMID: 29246564 DOI: 10.1016/j.pjnns.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 12/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The identification of psychological risk factors is important for the selection of patients before spinal surgery. Moreover, the effect of surgical decompression in lumbar spinal stenosis (LSS) on psychological outcome is not previously well analyzed. AIM OF PAPER to investigate clinical and psychological outcome after surgery for LSS and the effect of depressive symptoms and anxiety on the clinical outcome. MATERIALS AND METHODS A total of 25 patients with symptomatic LSS underwent decompressive surgery with or without spinal stabilization were prospectively enrolled in this observational surgery. The Symptom Checklist-90-Revised (SCL-90-R) was used to assess global psychological distress with a summary score termed Global Severity Index (GSI) and single psychological disorders including depression (DEP) and anxiety (ANX). The clinical outcome of surgery was evaluated with the Oswestry Disability Index (ODI) and visual analogue scale (VAS) pain assessment. RESULTS Compared with baseline, there was a statistically significant improvement in VAS, ODI and GSI after surgery (p<0.05) in all patients. Univariate analysis revealed that patients with high GSI and anxiety and depression scores had significantly higher ODI and VAS scores in the follow-up with a bad outcome. CONCLUSIONS Surgery for spinal stenosis was effective to treat pain and disability. In this prospective study baseline global psychological distress, depression and anxiety were associated with poorer clinical outcome.
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Traumatic Spinal Cord Injury: Long-Term Motor, Sensory, and Urinary Outcomes. Asian Spine J 2017; 11:412-418. [PMID: 28670409 PMCID: PMC5481596 DOI: 10.4184/asj.2017.11.3.412] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 09/29/2016] [Accepted: 10/18/2016] [Indexed: 11/09/2022] Open
Abstract
Study Design Retrospective study. Purpose To evaluate how motor, sensory, and urinary outcomes of spinal cord injury (SCI) patients were influenced in the long term. Overview of Literature SCI is a potentially disabling and devastating neurological outcome that can occur because of spinal column fractures. Most studies have not evaluated or have failed to show the influence of different surgical approaches and other parameters on neurological recovery. Methods A thorough history regarding sensory, motor, and urinary complaints was taken from 103 patients with SCI due to vertebral fracture; patients were followed by a thorough neurological examination. Subsequently, all medical records of patients, including neurological state after trauma, trauma mechanism, treatment protocol, surgical protocol, and imaging findings, were evaluated. Results Of the 103 patients, 73.8% were survivors of a major earthquake and 26.2% were victims of vehicle accidents; 92.2% patients were surgically treated, while 7.8% underwent conservative management. The mean follow-up duration was 10.3 years. In follow-up visits, 67.0%, 12.6%, 13.6%, and 6.8% patients showed no, partial, substantial, and complete motor improvement, respectively; 68.0%, 26.2%, and 5.8% showed no, mild, and substantial sensory improvement, respectively; and 73.8%, 17.5%, and 8.7% showed no, substantial, and complete urinary improvement, respectively. Logistic regression analysis showed that sex, age at injury time, follow-up duration, trauma mechanism, and stem cell therapy had no effect on motor, sensory, and urinary improvement. Higher initial scores on the American Spinal Injury Association (ASIA) classification, lumbar fracture level, and performance of laminectomy improved motor outcome; higher initial ASIA scores improved urinary and sensory outcomes. Conclusions The initial ASIA score is the most important factor for prognosticating motor, sensory, and urinary improvement in SCI patients. Lumbar (L3–L5) and thoracic (T1–T10) fractures have the best and worst prognosis, respectively, in terms of motor recovery. Laminectomy during surgery improves motor function.
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DOBRAN M, MARINI A, GLADI M, NASI D, COLASANTI R, BENIGNI R, MANCINI F, IACOANGELI M, SCERRATI M. Deep spinal infection in instrumented spinal surgery: diagnostic factors and therapy. G Chir 2017; 38:124-129. [PMID: 29205141 PMCID: PMC5726498 DOI: 10.11138/gchir/2017.38.3.124] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Postoperative surgical site infections (SSI) are complication of spinal surgery. These complications may lead to a poor outcome with neurological deficits, spinal deformity and chronic pain. The purpose of this study is to explore the statistical value of diagnostic parameters and the proper therapy. METHOD We retrospectively reviewed 550 patients who underwent spinal instrumentation at our department from January 2011 to December 2015. The SSI was present in 16 patients out of 550 operated. Diagnostic criteria of SSI were the positivity of the surgical wound swab or blood culture, the clinical findings, positivity of laboratory tests and radiological elements. All patients had peri-operative antibiotic prophylaxis. Diagnostic laboratory findings were compared with a homogeneous control group of 16 patients and analyzed by univariate statistical analysis with Chi-square test for the discrete variables. P<0,05 was considered statistically significant. RESULTS Matching the SSI patients with a group of control, fever was not statistically significant for diagnosis as number of leukocytes, neutrophils and lymphocytes. On the contrary values of ESR and CRP were statistically significant with p <0, 01. The hardware was removed only in 3 patients (18%) out of 16 SSI patients. CONCLUSION In this study the statistically significant parameters to diagnose SSI are ESR and CRP values. The leucocytes count, number of lymphocytes and presence of fever integrates the data of ESR and CRP with no statistical significance. Most patients with SSI reach clinical healing with favorable outcome by means of target antibiotic therapy without hardware removal.
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Affiliation(s)
- M. DOBRAN
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - A. MARINI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - M. GLADI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - D. NASI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - R. COLASANTI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - R. BENIGNI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - F. MANCINI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - M. IACOANGELI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - M. SCERRATI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
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Yousefifard M, Rahimi-Movaghar V, Baikpour M, Ghelichkhani P, Hosseini M, Jafari A, Aziznejad H, Tafakhori A. Early versus late spinal decompression surgery in treatment of traumatic spinal cord injuries; a systematic review and meta-analysis. EMERGENCY (TEHRAN, IRAN) 2017; 5:e37. [PMID: 28286844 PMCID: PMC5325907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Despite the vast number of surveys, no consensus has been reached on the optimum timing of spinal decompression surgery. This systematic review and meta-analysis aimed to compare the effects of early and latespinal decompression surgery on neurologic improvement and post-surgical complications in patients with traumatic spinal cord injuries. METHODS Two independent reviewers carried out an extended search in electronic databases. Data of neurological outcome and post-surgery complication were extracted. Finally, pooled relative risk (RR) with a 95% confidence interval (CI) was reported for comparing of efficacy of early and late surgical decompression. RESULTS Eventually 22 studies were included. The pooled RRwas 0.77 (95% CI: 0.68-0.89)for at least one grade neurological improvement, and 0.84 (95% CI: 0.77-0.92)for at least two grade improvement. Pooled RR for surgical decompression performed within 12 hours after the injury was 0.26 (95% CI: 0.13-0.52; p<0.001), while it was 0.75 (95% CI: 0.63-0.90; p=0.002) when the procedure was performed within 24 hours, and 0.93 (95% CI: 0.76-1.14; p=0.48) when it was carried out in the first 72 hours after the injury. Surgical decompression performed within 24 hours after injury was found to be associated with significantly lower rates of post-surgical complications (RR=0.77; 95% CI: 0.68-0.86; p<0.001). CONCLUSION The findings of this study indicate that early spinal decompression surgery can improve neurologic recovery and is associated with less post-surgical complications. The optimum efficacy is observed when the procedure is performed within 12 hours of the injury.
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Affiliation(s)
- Mahmoud Yousefifard
- Sina Trauma and Surgery Research Center, Tehran University ofMedical Sciences, Tehran, Iran
- Physiology Research Center and Department of Physiology, Faculty ofMedicine, Iran University ofMedical Sciences, Tehran, Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University ofMedical Sciences, Tehran, Iran
| | - Masoud Baikpour
- Department ofMedicine, School ofMedicine, Tehran University ofMedical Sciences, Tehran, Iran
| | - Parisa Ghelichkhani
- Department of Intensive Care Nursing, School of Nursing andMidwifery, Tehran University ofMedical Sciences, Tehran, Iran
| | - Mostafa Hosseini
- Sina Trauma and Surgery Research Center, Tehran University ofMedical Sciences, Tehran, Iran
- Pediatric Chronic Kidney Diseases Research Center, Children’s HospitalMedical Center, Tehran University ofMedical Sciences, Tehran, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University ofMedical Sciences, Tehran, Iran
| | - AliMoghadas Jafari
- Department of EmergencyMedicine, School ofMedicine, Bushehr University ofMedical Sciences, Bushehr, Iran
| | - Heidar Aziznejad
- The Persian Gulf TropicalMedicine Research Center, Bushehr University ofMedical Sciences, Bushehr, Iran
| | - Abbas Tafakhori
- Department of Neurology, School ofMedicine, Imam Khomeini Hospital, Tehran University ofMedical Sciences, Tehran, Iran
- Iranian Center of Neurological Research, Tehran University ofMedical Sciences, Tehran, Iran
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Kreinest M, Ludes L, Biglari B, Küffer M, Türk A, Grützner PA, Matschke S. Influence of Previous Comorbidities and Common Complications on Motor Function after Early Surgical Treatment of Patients with Traumatic Spinal Cord Injury. J Neurotrauma 2016; 33:2175-2180. [DOI: 10.1089/neu.2016.4416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michael Kreinest
- Department of Trauma Surgery and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Lisa Ludes
- Department of Trauma Surgery and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Bahram Biglari
- Department of Paraplegiology, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | | | - Ansgar Türk
- Department of Paraplegiology, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Paul A. Grützner
- Department of Trauma Surgery and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Stefan Matschke
- Department of Trauma Surgery and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
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Analysis of prehospital care and emergency room treatment of patients with acute traumatic spinal cord injury: a retrospective cohort study on the implementation of current guidelines. Spinal Cord 2016; 55:16-19. [DOI: 10.1038/sc.2016.84] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 04/05/2016] [Accepted: 04/10/2016] [Indexed: 11/08/2022]
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