Acute complications of spinal cord injuries

Early functional proprioceptive stimulation in high spinal cord injury: a pilot study

Introduction

The first months following a spinal cord injury (SCI) are crucial for promoting recovery. However, patients with high SCIs often require prolonged stays in intensive care units (ICUs), delaying optimal rehabilitation due to limited resources. This study examined the safety, feasibility, and effects on spasticity and muscle atrophy of an early rehabilitation technique using non-invasive sensory stimulation and called functional proprioceptive stimulation (FPS).

Materials and methods

Ten SCI patients were included in this randomized pilot study, with five receiving early FPS and five receiving sham stimulation. Both groups were treated using the Vibramoov, consisting of 12 computer-synchronized vibrators placed on the lower limbs. Treatment sessions lasted 30 min, four times a week, for up to 8 weeks. Spasticity was assessed using the Modified Ashworth Scale, Tardieu Scale, Spinal Cord Assessment Tool for Spastic Reflexes, and a patient self-evaluation with a visual analog scale. Muscle atrophy was evaluated through ultrasonography of rectus femoris thickness and cross-sectional area. The duration of the follow-up period ranged from 6 months to 1 year.

Results

Treatment began early, with a median of 4 days post-injury for both groups. The number of adverse events was similar between groups, with none linked to the intervention. No medium-term effects on spasticity or muscle atrophy could be identified. However, our results show a tendency toward a beneficial short-term effect of FPS on spasticity, observed for all spasticity measurements.

Discussion

This pilot study shows that early FPS is feasible and safe for SCI as early as the intensive care unit stage. We demonstrated that FPS induced a transient relaxation and spasticity reduction that could potentially enhance a rehabilitation session administered shortly after it, but larger studies are needed to determine the medium and long-term effects.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT05094752).

A Comprehensive Proteomic and Bioinformatic Analysis of Human Spinal Cord Injury Plasma Identifies Proteins Associated with the Complement Cascade and Liver Function as Potential Prognostic Indicators of Neurological Outcome

Spinal cord injury (SCI) is a major cause of disability, with complications postinjury often leading to lifelong health issues with the need for extensive treatment. Neurological outcome post-SCI can be variable and difficult to predict, particularly in incompletely injured patients. The identification of specific SCI biomarkers in blood may be able to improve prognostics in the field. This study has utilized proteomic and bioinformatic methodologies to investigate differentially expressed proteins in plasma samples across human SCI cohorts with the aim of identifying candidate prognostic biomarkers and biological pathway alterations that relate to neurological outcome. Blood samples were taken, following informed consent, from American Spinal Injury Association impairment scale (AIS) grade C "improvers" (those who experienced an AIS grade improvement) and "nonimprovers" (no AIS change) and AIS grade A and D at <2 weeks ("acute") and ∼3 months ("subacute") postinjury. The total protein concentration from each sample was extracted, with pooled samples being labeled and nonpooled samples treated with ProteoMiner™ beads. Samples were then analyzed using two 4-plex isobaric tag for relative and absolute quantification (iTRAQ) analyses and a label-free experiment for comparison before quantifying with mass spectrometry. Data are available via ProteomeXchange with identifiers PXD035025 and PXD035072 for the iTRAQ and label-free experiments, respectively. Proteomic datasets were analyzed using OpenMS (version 2.6.0). R (version 4.1.4) and, in particular, the R packages MSstats (version 4.0.1) and pathview (version 1.32.0) were used for downstream analysis. Proteins of interest identified from this analysis were further validated by enzyme-linked immunosorbent assay. The data demonstrated proteomic differences between the cohorts, with the results from the iTRAQ approach supporting those of the label-free analysis. A total of 79 and 87 differentially abundant proteins across AIS and longitudinal groups were identified from the iTRAQ and label-free analyses, respectively. Alpha-2-macroglobulin, retinol-binding protein 4 (RBP4), serum amyloid A1, peroxiredoxin 2 (PRX-2), apolipoprotein A1, and several immunoglobulins were identified as biologically relevant and differentially abundant, with potential as individual candidate prognostic biomarkers of neurological outcome. Bioinformatics analyses revealed that the majority of differentially abundant proteins were components of the complement cascade and most interacted directly with the liver. Many of the proteins of interest identified using proteomics were detected only in a single group and therefore have potential as binary (present or absent) biomarkers, RBP4 and PRX-2 in particular. Additional investigations into the chronology of these proteins and their levels in other tissues (cerebrospinal fluid in particular) are needed to better understand the underlying pathophysiology, including any potentially modifiable targets. Pathway analysis highlighted the complement cascade as being significant across groups of differential functional recovery.

Targeting Nerve Fiber Outgrowth Inhibition After Experimental Spinal Cord Injury: A Systematic Review and Meta-analysis of Chondroitinase ABC

BACKGROUND

Spinal cord injury (SCI) can impair motor, sensory, and autonomic function. The formation of the glial scar comprises protective as well as inhibitory neurite outgrowth properties operated by the deposition of chondroitin sulfate proteoglycans (CSPG). Chondroitinase ABC (ChABC) can degrade CSPG and foster neuroaxonal plasticity as a therapeutic approach to restore locomotor function after SCI.

OBJECTIVES

To systematically review experimental ChABC treatments after SCI and assess their efficacy for locomotor function a comprehensive literature search was conducted following pre-registered Prospero Study protocol, selecting animal studies evaluating neurobehavioral outcomes after traumatic SCI followed by the calculation of normalized effect sizes applying meta-analysis and meta-regression methodology. Additional analyses were performed to investigate the impact of animal type, strain, sex, sample size, injury models, level of injury, and treatment duration.

RESULTS

Within the overall analysis of 1066 animals, a considerable amount of heterogeneity was observed. A subgroup analysis comprising experiments applying the same neurobehavioral measurement (blood-brain barrier/Basso-Mouse-Scale [BMS]-subgroup) demonstrated a 15.9% (95% CI = 11.3%-20.6%) improvement in locomotor outcomes. Different experimental characteristics influenced neurological recovery, including sex, level of injury, used anesthetic, reported dosage of ChABC treatment, the timepoint of assessment and perioperative temperature control. Sensitivity analysis applying Trim and Fill identified 19 hypothetical missing experiments suggestive of reporting bias.

CONCLUSION

Reporting bias in experimental SCI research is prevalent and not limited to a specific intervention. ChABC treatment can exert beneficial effects on locomotor recovery after SCI.

A rare case of respiratory failure associated with spinal cord injury caused by stabbing with scissors and a knife

In forensic practice, spinal cord injury (SCI) resulting in death has rarely been reported. Here, we present the case of a 65-year-old woman who on admission was conscious without dyspnea or dysphagia. Physical examination revealed two sharp objects penetrating the neck: a pair of scissors lodged in the neck on the right side of the thyroid cartilage and a knife embedded in the nuchal region accompanied by minor seepage of bloody exudate. Radiography showed that the scissors and knife were retained in the cervical spine. Despite a series of medical interventions, the patient died 26 days later.

METHOD

A systematic forensic autopsy was performed.

RESULTS

The cause of death was confirmed to be respiratory failure associated with SCI, which was caused by the combination of scissors and a knife.

CONCLUSION

Based on this case, we believe that when there are multiple causes of death, forensic pathologists should determine the primary, immediate, contributory, and other causes of death to ascertain criminal responsibility.

Neuroticism Overestimated? Neuroticism Versus Hypertonia, Pain and Rehabilitation Outcomes in Post-Spinal Cord Injury Patients Rehabilitated Conventionally and with Robotic-Assisted Gait Training

BACKGROUND

The aim of the present study was to analyse the association between neuroticism (one of the Big Five personality traits) and the most common secondary sensorimotor complications occurring in patients after spinal cord injury (SCI), i.e., muscle spasticity (hypertonia) and pain, and to investigate the associations between neuroticism and the effects of conventional rehabilitation (dynamic parapodium) and those using robotic-assisted gait training (RAGT) in this group of patients. In addition, the association of neuroticism with self-efficacy, personal beliefs about pain control, and adopted coping strategies among SCI patients was analysed. These data can be used as a reference for designing effective forms of therapy and support dedicated to this group of patients.

METHODS AND PROCEDURES

Quantitative analysis included 110 patients after SCI. The participants were divided by simple randomisation into a rehabilitation group with RAGT and a rehabilitation group with dynamic parapodium therapy (DPT). The following survey instruments were used for data collection: Revised NEO Personality Inventory (NEO-PI-R); Ashworth Scale; the Spinal Cord Independence Measure III (SCIM III); the Walking Index for Spinal Cord Injury II (WISCI-II); the American Spinal Injury Association Impairment Scale (AIS); the Pain Coping Strategies Questionnaire-CSQ; and the Beliefs about Pain Control Questionnaire-BPCQ.

OUTCOMES AND RESULTS

analyses showed a positive association between neuroticism and spastic tension (rho = 0.39; p < 0.001).

CONCLUSIONS AND IMPLICATIONS

the study showed that a high level of neuroticism correlates with a higher level of spasticity, but no such correlation was observed for pain. Additionally, the study did not show a significant correlation between neuroticism and rehabilitation outcome depending on the rehabilitation modality (RAGT vs. DPT). The results underline the importance of carrying out a psychological diagnosis of patients to provide therapeutic support in the rehabilitation process.

Epidemiology of demographic, clinical characteristics and hospital course of patients with spinal cord injury associated with vertebral fracture in a large private health care system in the United States

Objectives: To evaluate the demographics, clinical characteristics, hospital course, and factors associated with outcomes in patients with spinal cord injury associated with vertebral fracture (SCI-VF).Design: Retrospective analysis of data collected from electronic health record.Setting: A large for-profit United States health care system.Participants: 2219 inpatients with SCI-VF between 2014 and 2020 identified using International Classification of Disease codes.Main Outcome Measure: In-hospital mortality, and disposition (home vs. no-home discharge) after hospitalization.Results: The mean age of patients admitted with a diagnosis of SCI-VF was 54.80 ± 20.85 years with 68.27% identified as male. The cervical spine was the most prevalent site of fracture, displaced vertebral fracture was the most common radiographic diagnosis, and the majority of injuries were classified as incomplete. 836 (37.67% of all 2219) patients were discharged home and had a shorter length of stay (7.56 ± 13.58 days) when compared to the average of the total study population (11.56 ± 19.2 days). The most common hospital-acquired complication (HAC) was falls (n = 259, 11.67%). Characteristics associated with in-hospital mortality in the 96 patients (6.94% of 1,383 patients with no-home discharge) included initial respiratory failure, ICU stay, increased medical comorbidity index value, insulin use, and presence of cardiovascular, pulmonary, and gastrointestinal HACs.Conclusions: A large observational study of patients with SCI-VF can add to the knowledge of SCI characteristics in the U.S. population. Recognizing the common hospital-acquired conditions and clinical characteristics associated with increased in-hospital mortality can be helpful to improve the care of patients with SCI-VF.

Exploring and prioritizing content to include in a medication self-management toolkit for persons with spinal cord injury/dysfunction: A concept mapping approach

BACKGROUND

Adults with spinal cord injury/dysfunction (SCI/D) face challenges with medications they take to manage their secondary conditions (e.g., pain, urinary tract infections, autonomic dysreflexia). With many healthcare providers typically involved in care, there are additional challenges with care fragmentation and self-management. Prior research emphasized the desire for more support with medication self-management among this population.

OBJECTIVE

To explore what content should be included in a medication self-management resource (i.e., toolkit) for adults with SCI/D, as well as considerations for delivery from the perspectives of adults with SCI/D, caregivers, healthcare providers, and representatives from community organizations.

METHODS

A concept mapping study was conducted. Participants took part in one or more of three activities: brainstorming; sorting and rating; and mapping. Participants generated ideas about the content to include in a medication self-management toolkit. Participants sorted the statements into conceptual piles and assigned a name to each. All statements were rated on a five-point Likert-type scale on importance and realistic to include in the toolkit. Participants decided on the final cluster map, rearranged statements, and assigned a name to each cluster to create visual representations of the data.

RESULTS

Forty-four participants took part in this study. The final map contained eight clusters: 1) information-sharing and communication; 2) healthcare provider interactions and involvement; 3) peer and community connections; 4) supports and services for accessing prescription medications and medication information; 5) information on non-prescription medication and medication supplies; 6) safety and lifestyle considerations; 7) general medication information; and 8) practical information and strategies related to medication-taking. Safety and lifestyle considerations was rated as the most important and realistic to include in the toolkit.

CONCLUSIONS

Given the limited tools to help adults with SCI/D with managing their medications, there is great potential to better support this population across all areas of medication self-management.

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

INTRODUCTION

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

SOURCE OF DATA

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

AREAS OF AGREEMENT

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

AREAS OF CONTROVERSY

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

GROWING POINTS

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

AREAS TIMELY FOR DEVELOPING RESEARCH

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

Stem Cell-Derived Exosomes as a Therapeutic Option for Spinal Cord Injuries; a Systematic Review and Meta-Analysis

Introduction

Exosomes function as cell signaling carriers and have drawn much attention to the cell-free treatments of regenerative medicine. This meta-analysis aimed to investigate the efficacy of mesenchymal stem cell-derived (MSC-derived) exosomes in animal models of spinal cord injuries (SCI).

Method

A comprehensive search was conducted in Medline, Embase, Scopus, and Web of Science to attain related articles published by January 31, 2023. The eligible keywords were correlated with the spinal cord injury and MSC-derived exosomes. The evaluated outcomes were locomotion, cavity size, cell apoptosis, inflammation, neuro-regeneration, and microglia activation. A standardized mean difference was calculated for each sample and a pooled effect size was reported.

Results

65 papers fully met the inclusion criteria. Treatment with MSC-derived exosomes ultimately improved locomotion and shrunk cavity size (p<0.0001). The administration of MSC-derived exosomes enhanced the expression of beta-tubulin III, NF200, and GAP-43, and increased the number of NeuN-positive and Nissl-positive cells, while reducing the expression of glial fibrillary acidic protein (p<0.0001). The number of apoptotic cells in the treatment group decreased significantly (p<0.0001). Regarding the markers of microglia activation, MSC-derived exosomes increased the number of CD206- and CD68-positive cells (p=0.032 and p<0.0001, respectively). Additionally, MSC-derived exosome administration significantly increased the expression of the anti-inflammatory interleukin (IL)-10 and IL-4 (p<0.001 and p=0.001, respectively) and decreased the expression of the inflammatory IL-1b, IL-6, and TNF-a (p<0.0001).

Conclusion

MSC-derived exosome treatment resulted in a significantly improved locomotion of SCI animals through ameliorating neuroinflammation, reducing apoptosis, and inducing neuronal regrowth by facilitating a desirable microenvironment.

Early rehabilitation after spinal cord injury: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify the timings and types of early rehabilitation after spinal cord injury (SCI) that are documented in the literature, as well as identify possible research gaps in this field.

INTRODUCTION

Preclinical and clinical studies support the idea that early rehabilitation may be beneficial for patients with acute SCI. However, the timings and types of rehabilitation that should and could be used in the acute stage are still unclear. The first step towards such knowledge is to extensively review what is documented in the literature.

INCLUSION CRITERIA

This review will consider all papers focusing on early rehabilitation after SCI in adult humans or animals (<3 months' post-SCI for humans and other primates and <3 weeks' post-SCI for other animals). Interventions in the included papers must aim at sensorimotor or functional improvement and take place in a hospital or a rehabilitation center if they target human subjects. This review will include published and unpublished experimental and observational studies, research protocols, conference abstracts, systematic reviews, and guidelines.

METHODS

MEDLINE (PubMed), Scopus, Embase, PEDro, Web of Science Core Collection, CINAHL (EBSCOhost), Cochrane Database of Systematic Reviews, Cochrane CENTRAL, PROSPERO, ClinicalTrials.gov, and gray literature sources will be searched for eligible articles. No language or date limits will be applied. Two independent reviewers will perform study selection and data extraction, and the results will be presented according to the SCI type and severity.

REVIEW REGISTRATION

Open Science Framework https://osf.io/q45er.

Do all patients with functional motor-incomplete (AIS-D) traumatic spinal cord injury need specialized inpatient functional rehabilitation? A prospective observational cohort study proposing clinical criteria for home-based rehabilitation after acute care

CONTEXT/OBJECTIVE

Functional motor-incomplete AIS-D traumatic spinal cord injury (tSCI) represents an important growing population in neuro-traumatology. There is thus an important need for establishing strategies to optimize SCI rehabilitation resources. This study aims at proposing eligibility criteria to select individuals who could be discharged home (home-based rehabilitation) after acute care following an AIS-D tSCI and investigate its impact on the long-term functional status and quality of life (QOL), as compared to transfer to inpatient functional rehabilitation (IFR) resources.

DESIGN

An observational prospective cohort study.

SETTING

A single Level-1 specialized trauma center.

PARTICIPANTS

213 individuals sustaining an AIS-D tSCI.

INTERVENTIONS

Home-based rehabilitation based on clinical specific criteria to be assessed by the acute care team.

OUTCOME MEASURES

Functional status and QOL as assessed by the Spinal Cord Independence Measure version 3 and WHOQOL-BREF questionnaire one year following the injury, respectively.

RESULTS

A total 37.9% of individuals fulfilled proposed criteria for home-based rehabilitation after acute care. As expected, this group was significantly younger, experienced lesser comorbidities and acute complications, and showed higher motor and sensory function compared to the IFR group. Home-rehabilitation was associated with a higher long-term functional status, physical and psychological QOL, when accounting for relevant confounding factors after an acute AIS-D tSCI. There was no readmission due to failure of home-based rehabilitation.

CONCLUSION

Home-based rehabilitation in selected individuals sustaining an acute AIS-D tSCI is a safe and interesting strategy to optimize the long-term outcome in terms of functional recovery, physical and psychological QOL, as well as to optimize inpatient rehabilitation resources. The proposed eligibility criteria can be used by the acute care team to select the optimal discharge orientation in this important subpopulation.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hepatocyte Growth Factor Delivery to Injured Cervical Spinal Cord Using an Engineered Biomaterial Protects Respiratory Neural Circuitry and Preserves Functional Diaphragm Innervation

A major portion of spinal cord injury (SCI) cases occur in the cervical region, where essential components of the respiratory neural circuitry are located. Phrenic motor neurons (PhMNs) housed at cervical spinal cord level C3-C5 directly innervate the diaphragm, and SCI-induced damage to these cells severely impairs respiratory function. In this study, we tested a biomaterial-based approach aimed at preserving this critical phrenic motor circuitry after cervical SCI by locally delivering hepatocyte growth factor (HGF). HGF is a potent mitogen that promotes survival, proliferation, migration, repair, and regeneration of a number of different cell and tissue types in response to injury. We developed a hydrogel-based HGF delivery system that can be injected into the intrathecal space for local delivery of high levels of HGF without damaging the spinal cord. Implantation of HGF hydrogel after unilateral C5 contusion-type SCI in rats preserved diaphragm function, as assessed by in vivo recordings of both compound muscle action potentials and inspiratory electromyography amplitudes. HGF hydrogel also preserved PhMN innervation of the diaphragm, as assessed by both retrograde PhMN tracing and detailed neuromuscular junction morphological analysis. Furthermore, HGF hydrogel significantly decreased lesion size and degeneration of cervical motor neuron cell bodies, as well as reduced levels surrounding the injury site of scar-associated chondroitin sulfate proteoglycan molecules that limit axon growth capacity. Our findings demonstrate that local biomaterial-based delivery of HGF hydrogel to injured cervical spinal cord is an effective strategy for preserving respiratory circuitry and diaphragm function.

Initial Heart Rate Predicts Functional Independence in Patients With Spinal Cord Injury Requiring Surgery: A Registry-Based Study in a Mature Trauma System Over the Past 10 Years

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To determine the ability of early vital sign abnormalities to predict functional independence in patients with SCI that required surgery.

METHODS

A retrospective analysis of data extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients >18 years with a diagnosis of SCI who required urgent spine surgery in Pennsylvania from 1/1/2010-12/31/2020 and had complete records available.

RESULTS

A total of 644 patients met the inclusion criteria. The mean age was 47.1 ± 14.9 years old and the mean injury severity score (ISS) was 22.3 ± 12.7 with the SCI occurring in the cervical, thoracic, and lumbar spine in 61.8%, 19.6% and 18.0%, respectively. Multivariable logistic regression analyses for predictors of functional independence at discharge showed that higher HR at the scene (OR 1.016, 95% CI 1.006-1.027, P = .002) and lower ISS score (OR .894, 95% CI .870-.920, P < .001) were significant predictors of functional independence. Similarly, higher admission HR (OR 1.015, 95% CI 1.004-1.027, P = .008) and lower ISS score (OR .880, 95% CI 0.864-.914, P < .001) were significant predictors of functional independence. Peak Youden indices showed that patients with HR at scene >70 and admission HR ≥83 were more likely to achieve functional independence.

CONCLUSIONS

Early heart rate is a strong predictor of functional independence in patients with SCI. HR at scene >70 and admission HR ≥83 is associated with improved outcomes, suggesting lack of neurogenic shock.

Cervical fracture dislocation without neurological abnormality: Rare case reports

INTRODUCTION AND IMPORTANCE

Traumatic lower cervical dislocation with spinal cord injury (SCI) can cause long-lasting dysfunction in many organ systems resulting in significant financial burden and functional disability. The patient may come with complete or incomplete neurological deficit. However, there is also possibility of no neurological deficit.

CASE PRESENTATION

This case reports presented two cases of a 68-year-old man and a 54-year-old man that came to the emergency department after a traffic accident and fell from a height. Surprisingly there was no neurological deficit found on both patients. The patient underwent emergency open reduction and posterior stabilization. Several months later, the neurological function was still excellent, and the pain was absent.

CLINICAL DISCUSSION

Traumatic cervical dislocation without neurological deficit is rare. Enlargement of the spinal canal is significant when the vertebral body and the shattered posterior arch separate, which may play a protective role on the spinal cord. The neurological deficit did not happen in the first case due to a widening spinal canal. Still, in the second case, the patient's neurological condition remained excellent despite no disruption on the posterior arch after cervical dislocation.

CONCLUSION

Neurological deficit may not occur in the cervical dislocation with disruption of the posterior arch due to the widening of the spinal canal. This injury should be treated properly to prevent other morbidities and even mortality. The posterior technique for stabilization gives various benefits, such as the safety and familiarity of the procedure and the high success rate.

Delayed Diagnosis of Spinal Cord Injury in a Patient With Intellectual Disability: A Case Report

Spinal cord injury (SCI) can cause neurogenic shock accompanied by bradycardia and hypotension. If no preceding traumatic episodes are apparent and the neurological examination is complicated by the patient's intellectual disability, SCI is likely to be overlooked. A 63-year-old man with intellectual disability presented to our hospital. The patient had fallen on the floor; however, no apparent head or neck trauma was observed. The patient returned home after confirming the absence of intracranial hematoma on computed tomography. However, the patient was re-admitted because of hypotension and bradycardia, and sick sinus syndrome was suspected. As the manifestations were motor weakness in the extremities and urinary retention, screening spinal magnetic resonance imaging revealed cervical cord injury and spondylosis. Cervical SCI related to a fall was suspected. Cervical decompression surgery and rehabilitation therapy contributed to the improved patient status. Herein, we report a case of intellectual disability in which SCI was initially overlooked. No severe preceding traumatic episode or intellectual disability of the patient could have led to overlooking SCI in our case. Clinicians should be cautious about this rare condition.

Care needs of adults with spinal trauma in the prehospital and hospital setting from the perspective of patient care team: A qualitative research

BACKGROUND

Appropriate care of patients with definite spinal cord injury or at risk of it in the prehospital and hospital stages requires comprehensive planning in the health system. It is also the requirement of any successful program to explain the needs from the perspective of its stakeholders. Thus, this study aimed to discover the care needs of adults with spinal trauma in prehospital and hospital settings from the perspective of the patient care team.

MATERIALS AND METHODS

This qualitative study was conducted with the participation of urban and rural prehospital emergency personnel and emergency departments of educational and therapeutic hospitals affiliated to Isfahan, Tehran, Shiraz, Kermanshah, Ahvaz, and Yasuj Universities of Medical Sciences, through conducting 36 in-depth semi-structured interviews from September to December 2021. Using purposive sampling method, the participants were selected considering the maximum variation. The data saturation was reached after conducting interviews and group discussions with 36 subjects. Data were analyzed using conventional content analysis approach. Lundman and Graneheim approach were used for the study rigour. Data were simultaneously analyzed using MAXQDA software version 10.

RESULT

During the data analysis, two themes of prehospital care with two main categories (emergency care and management of secondary complications of spinal trauma) and hospital care with two main categories (emergency care and management of secondary complications of spinal trauma) emerged.

CONCLUSION

Emergency care and management of secondary complications of spinal cord injury in the prehospital and hospital stages can affect treatment results, improve quality of life, and reduce mortality rate, secondary injuries, and healthcare costs. Thus, identification of the care needs of the adults with spinal trauma from the perspective of the patient care team can help the authorities to plan appropriate interventions.

Role of Rehabilitation in Spine Tumors

ABSTRACT

Primary and metastatic spine tumors can lead to devastating complications, but timely and careful management of these patients can improve outcomes. A multidisciplinary and structured approach is the most effective way to evaluate patients with spine disease and mitigate the risk of complications. The neurologic, oncologic, mechanical and systemic disease framework gives comprehensive guidance to providers regarding appropriate management. Physiatrists play a critical role in these patients' initial evaluation and continued management throughout cancer treatment. Patients with spinal cord involvement have extensive needs, requiring an individualized management approach. Even though patients with nontraumatic spinal cord injury benefit from rehabilitation efforts and have improved outcomes, they are not routinely admitted to inpatient rehabilitation units or referred to outpatient cancer rehabilitation. Ongoing efforts are needed to promote rehabilitation medicine involvement in improving functional outcomes and quality of life for patients with spine involvement.

A Perspective on Hormonal Contraception Usage in Central Nervous System Injury

Naturally occurring life stages in women are associated with changes in the milieu of endogenous ovarian hormones. Women of childbearing age may be exposed to exogenous ovarian hormone(s) because of their use of varying combinations of estrogen and progesterone hormones-containing oral contraceptives (OC; also known as "the pill"). If women have central nervous system (CNS) injury such as spinal cord injury (SCI) and traumatic brain injury (TBI) during their childbearing age, they are likely to retain their reproductive capabilities and may use OC. Many deleterious side effects of long-term OC use have been reported, such as aberrant blood clotting and endothelial dysfunction that consequently increase the risk of myocardial infarction, venous thromboembolism, and ischemic brain injury. Although controversial, studies have suggested that OC use is associated with neuropsychiatric ramifications, including uncontrollable mood swings and poorer cognitive performance. Our understanding about how the combination of endogenous hormones and OC-conferred exogenous hormones affect outcomes after CNS injuries remains limited. Therefore, understanding the impact of OC use on CNS injury outcomes needs further investigation to reveal underlying mechanisms, promote reporting in clinical or epidemiological studies, and raise awareness of possible compounded consequences. The goal of the current review is to discuss the impacts of CNS injury on endogenous ovarian hormones and vice-versa, as well as the putative consequences of exogenous ovarian hormones (OC) on the CNS to identify potential gaps in our knowledge to consider for future laboratory, epidemiological, and clinical studies.

Digital psychosocial interventions for individuals with spinal cord injury: a scoping review

Objective

To provide an overview of the digital mental health care landscape for individuals with spinal cord injury (SCI).

Methods

PubMed, PsycInfo, and PSYNDEX were searched for articles meeting the following criteria: (1) article written in English or German; (2) digital psychosocial intervention; (3) SCI only; (4) treatment of individuals with SCI and not their relatives or caregivers. Records were screened by title and abstract and records meeting the inclusion criteria were obtained for full text screening. The references of identified articles were screened to find further relevant articles. The literature search was updated before submission. Risk of Bias was assessed by using the Cochrane risk-of-bias tool for randomized trials (RoB 2) and a narrative synthesis was conducted.

Results

Ten randomized-controlled trials (RCT) and ten non-randomized-controlled trials were identified and compared in this review, evaluating twelve internet- and mobile-based interventions, five smartphone apps, and three virtual reality applications. The interventions were primarily used as stand-alone aftercare programs. While some were not based on any theory, cognitive behavioral therapy mostly served as the theoretical basis for the online interventions. The extent of human support also varied greatly between the studies. The number of intervention modules ranged between 2 and 72. There were also major differences in outcome variables and effects. A meta-analytical evaluation of the data was not conducted due to heterogeneity of studies.

Conclusion

Digital applications to promote the psychosocial health of individuals with SCI are an emerging field of research with many treatment approaches still to come. First high quality RCT studies report promising results. Unfortunately, not all studies are of high quality or the interventions have been insufficiently adapted to the needs of people with SCI. Therefore, more research is needed to further develop applications, and to generalize and test the effects found in the long term.

Musculoskeletal morbidity in adults with spinal cord injuries: A nationwide cohort study

BACKGROUND

An increase in the demand for quality of life following spinal cord injuries (SCIs) is associated with an increase in musculoskeletal (MSK) pain, highlighting the need for preventive measure research.

OBJECTIVE

This study aimed to evaluate the incidence and hazards of MSK morbidities among Korean adults with SCIs, as well as the influence of SCI location on MSK morbidities.

METHODS

Patient populations were selected from Korean National Health Insurance Service data (n = 276). The control group included individuals without SCIs (n = 10,000). We compared the incidences and determined the unadjusted and adjusted hazard ratios (HRs) of common MSK morbidities (osteoarthritis, connective tissue disorders, sarcopenia, myalgia, neuralgia, rheumatoid arthritis, myositis, and musculoskeletal infections) based on the location of injury (cervical, thoracic, or lumbar).

RESULTS

Adults with SCIs had a higher incidence of MSK morbidity (48.45% vs. 36.6%) and a lower survival probability than those without SCIs. The incidence of MSK morbidity and survival probabilities were not significantly different for cervical cord injuries, whereas both measures were significantly different for thoracic and lumbar injuries.

CONCLUSION

SCI increases the risk of MSK morbidity. Lumbar SCI is associated with a higher incidence and risk of MSK morbidity than are cervical or thoracic SCIs.

Adverse Effect of Neurogenic, Infective, and Inflammatory Fever on Acutely Injured Human Spinal Cord

This study aims to determine the effect of neurogenic, inflammatory, and infective fevers on acutely injured human spinal cord. In 86 patients with acute, severe traumatic spinal cord injuries (TSCIs; American Spinal Injury Association Impairment Scale (AIS), grades A-C) we monitored (starting within 72 h of injury, for up to 1 week) axillary temperature as well as injury site cord pressure, microdialysis (MD), and oxygen. High fever (temperature ≥38°C) was classified as neurogenic, infective, or inflammatory. The effect of these three fever types on injury-site physiology, metabolism, and inflammation was studied by analyzing 2864 h of intraspinal pressure (ISP), 1887 h of MD, and 840 h of tissue oxygen data. High fever occurred in 76.7% of the patients. The data show that temperature was higher in neurogenic than non-neurogenic fever. Neurogenic fever only occurred with injuries rostral to vertebral level T4. Compared with normothermia, fever was associated with reduced tissue glucose (all fevers), increased tissue lactate to pyruvate ratio (all fevers), reduced tissue oxygen (neurogenic + infective fevers), and elevated levels of pro-inflammatory cytokines/chemokines (infective fever). Spinal cord metabolic derangement preceded the onset of infective but not neurogenic or inflammatory fever. By considering five clinical characteristics (level of injury, axillary temperature, leukocyte count, C-reactive protein [CRP], and serum procalcitonin [PCT]), it was possible to confidently distinguish neurogenic from non-neurogenic high fever in 59.3% of cases. We conclude that neurogenic, infective, and inflammatory fevers occur commonly after acute, severe TSCI and are detrimental to the injured spinal cord with infective fever being the most injurious. Further studies are required to determine whether treating fever improves outcome. Accurately diagnosing neurogenic fever, as described, may reduce unnecessary septic screens and overuse of antibiotics in these patients.

Massive body-brain disconnection consequent to spinal cord injuries drives profound changes in higher-order cognitive and emotional functions: A PRISMA scoping review

Spinal cord injury (SCI) leads to a massive disconnection between the brain and the body parts below the lesion level representing a unique opportunity to explore how the body influences a person's mental life. We performed a systematic scoping review of 59 studies on higher-order cognitive and emotional changes after SCI. The results suggest that fluid abilities (e.g. attention, executive functions) and emotional regulation (e.g. emotional reactivity and discrimination) are impaired in people with SCI, with progressive deterioration over time. Although not systematically explored, the factors that are directly (e.g. the severity and level of the lesion) and indirectly associated (e.g. blood pressure, sleeping disorders, medication) with the damage may play a role in these deficits. The inconsistency which was found in the results may derive from the various methods used and the heterogeneity of samples (i.e. the lesion completeness, the time interval since lesion onset). Future studies which are specifically controlled for methods, clinical and socio-cultural dimensions are needed to better understand the role of the body in cognition.

Clinical Practice Guideline Development for Autonomic Dysreflexia in Spinal Cord Injury

Background

Autonomic Dysreflexia (AD) is a crucial emergency complication of cervical and upper thoracic spinal cord injury (SCI). Although there are several treatment options for AD, unfortunately, there is no consensus on the treatment of AD.This study aimed to present Clinical Practice Guidelines (CPG) development for AD in SCI in different conditions.

Methods

The project was carried out by an executive team of general practitioners and neurosurgeons. A national multidisciplinary panel of experts performed the decision-making step, which consisted of deciding on the final list of recommendations and articulating novel recommendations regarding the infrastructure and fundamental elements necessary for managing patients suffering from AD. Four appraisers evaluated the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tools.

Results

A total of 575 articles were found after searching different databases. After the primary screening, title, abstract, and full-text screening were performed, which yielded 9 records. Five were excluded after the AGREE II evaluation. The source guidelines' recommendations were tabulated as possible scenarios for 15 patient/population, intervention, comparison, and outcomes clinical questions. Based on the expert panel's opinion, all the recommendations were adaptable. Finally, the suggestions were transformed into a protocol for managing patients suffering from autonomic dysreflexia.

Conclusion

This guideline presented the treatment and pharmacotherapy of autonomic dysreflexia. However, the treatment is being updated. We suggest more educational multimedia for health care professionals, primarily in the emergency department.

Health literacy of people with spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically review the evidence on health literacy (HL) of people diagnosed with spinal cord injury (SCI).

METHODS

PubMed, Cochrane Library, Web of Science and Embase databases were used to identify studies published from 1974 to 2021. Two reviewers independently carried out the study selection process and assessed the methodological quality of the studies. The risk of bias in the studies was classified according to the Joanna Briggs Institute (JBI).

RESULTS

In total, 1398 studies were identified from the initial search, and 11 were selected for reading thoroughly. After screening, five studies were included. All had a cross-sectional design, and most scientific production was from the United States. In the studies, people with SCI received assistance in rehabilitation services. The results were heterogeneous compared to the HL: reasonable HL; suitable HL; Inadequate HL. Better HL was identified in individuals from the white population compared to the black population with SCI.

CONCLUSION

Studies on HL in the SCI population are limited. Guidance and personalized education provided in rehabilitation programs seem to have an influence on HL levels in this population. More research is needed to broaden the understanding of HL in the rehabilitation process of people diagnosed with SCI.

Risk constellation of hospital acquired pressure injuries in patients with a spinal cord injury/ disorder - focus on time since spinal cord injury/ disorder and patients' age

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The aim of this study was to evaluate how time since spinal cord injury/disorder (SCI/D) and patients' age influence risk constellation for hospital acquired pressure injuries (HAPI) in patients with a SCI/D.

SETTING

Acute care and rehabilitation clinic specialized in SCI/D.

METHODS

We collected patients' characteristics and 85 risk factors for HAPI development in adults with SCI/D with at least one HAPI during their inpatient stay between August 2018 and December 2019. We analyzed patients' characteristics and HAPI risk factors using descriptive statistics according to time since SCI/D ( < 1 year, 1-15 years, > 15 years) and patients' age (18-35 years, 35-65 years, > 65 years).

RESULTS

We identified 182 HAPI in 96 patients. Comparing patients with SCI/D < 1 year with the other groups, autonomic dysreflexia (p < 0.001), abnormal body temperature (p = 0.001), hypertensive episode (p = 0.005), and pneumonia (p < 0.001) occurred more frequently; mean hemoglobin (p < 0.001), albumin (p = 0.002) and vitamin D levels (p = 0.013) were significantly lower, and patients with time since SCI/D < 1 year scored fewer points (10-12) on the Braden Scale (p < 0.001). Comparing groups per patients' age, only the SCIPUS score was higher in patients > 65 years compared to the other two groups (p = 0.002).

CONCLUSIONS

Different risk factor constellation seem to be underlying HAPI development with more differences in patients time since SCI/D than patients' age. Awareness of these differences in risk factor constellation depending on time since SCI/D in these patients might lead to different HAPI prevention strategies.

SPONSORSHIP

The study team didn't receive any additional sponsorship.

Is procalcitonin a reliable indicator of sepsis in spinal cord injury patients: an observational cohort study

STUDY DESIGN

Prospective observational cohort study.

OBJECTIVE

To understand if serum procalcitonin (PCT) is a reliable indicator of sepsis in spinal cord injury (SCI) patients for better prognosis and earlier diagnosis when compared with other common biomarkers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), blood culture and body temperature.

METHODS

From March 2021 to August 2022, data were collected for SCI patients who developed septicaemia. In addition to neurology and admission, the following blood samples were collected on day one of infection: PCT, CRP and WBC. Linear regression analysis was performed to determine the relationship between PCT, CRP and WBC.

RESULTS

A total of 27 SCI patients had an infection during their stay in the regional centre; however, only 10 developed septicaemias. 100% of SCI individuals with sepsis had elevated PCT levels, whilst 60% had elevated CRP and 30% had elevated WBC levels. There was a strong positive correlation between PCT and CRP (R2 = 0.673, CI = 95%, 5.5-22.8, p < 0.05) and a weaker positive correlation between PCT and WBC (R2 = 0.110, CI = 95%, 4.2-10.9, p < 0.05).

CONCLUSION

In SCI individuals, there was a correlation between serum PCT levels and septicaemia. Alongside this, PCT appeared to be more consistent throughout the study population when compared with CRP and WBC. However, this was a preliminary study and further research is required on a larger scale.

Predictors of hospital-acquired pressure injuries in patients with complete spinal cord injury: a retrospective case-control study

BACKGROUND

Despite current best practices, pressure injuries (PI) remain a devastating and prevalent hospital-acquired complication for patients with acute traumatic spinal cord injuries (SCIs). This study examined associations between risk factors for PI development in patients with complete SCI, such as norepinephrine dose and duration, and other demographic factors or lesion characteristics.

METHODS

This case-control study included adults with acute complete SCIs ASIA-A, who were admitted to a level-one trauma center between 2014-18. A retrospective review was implement using data on patient and injury characteristics, including age, gender, level of SCI (cervical vs. thoracic), Injury Severity Score (ISS), length of stay (LOS) and mortality; presence/absence of PI during their acute hospital stay; and treatment factors such as spinal surgery, mean arterial pressure (MAP) targets, and vasopressor treatment. Multivariable logistic regression evaluated associations with PI.

RESULTS

Eighty-two out of 103 eligible patients had complete data, and 30 (37%) developed PIs. Patient and injury characteristics, including age (Mean: 50.6; SD:21.3), location of SCI (48 cervical, 59%) and ISS (Mean 33.1; SD:11.8), did not differ between PI and non-PI groups. Logistic regression analysis revealed that male gender (OR:34.1; CI₉₅:2.3-506.5, p = 0.010) and increased LOS (log-transformed; OR:20.5, CI₉₅:2.8-149.9, p = 0.003) were associated with increased risk of PI. Having an order for a MAP > 80mmg (OR:0.05; CI₉₅:0.01-0.30, p = 0.001) was associated with a reduced risk of PI. There were no significant associations between PI and duration of norepinephrine treatment.

CONCLUSIONS

Norepinephrine treatment parameters were not associated with development of PI, suggesting that MAP targets should be a focus for future investigations for SCI management. Increasing LOS should highlight the need for high-risk PI prevention and vigilance.

A scoping review of medication self-management intervention tools to support persons with traumatic spinal cord injury

BACKGROUND

Persons with traumatic spinal cord injury (SCI) use multiple medications (polypharmacy) to manage the high number of secondary complications and concurrent conditions. Despite the prevalence of polypharmacy and challenges associated with managing medications, there are few tools to support medication self-management for persons with SCI.

OBJECTIVE

The purpose of this scoping review was to identify and summarize what is reported in the literature on medication self-management interventions for adults with traumatic SCI.

METHODS

Electronic databases and grey literature were searched for articles that included an adult population with a traumatic SCI and an intervention targeting medication management. The intervention was required to incorporate a component of self-management. Articles were double screened and data were extracted and synthesized using descriptive approaches.

RESULTS

Three studies were included in this review, all of which were quantitative. A mobile app and two education-based interventions to address self-management of SCI, medication management, and pain management, respectively, were included. Only one of the interventions was co-developed with patients, caregivers, and clinicians. There was minimal overlap in the outcomes measured across the studies, but learning outcomes (e.g., perceived knowledge and confidence), behavioural outcomes (e.g., management strategies, data entry), and clinical outcomes (e.g., number of medications, pain scores, functional outcomes) were evaluated. Results of the interventions varied, but some positive outcomes were noted.

CONCLUSIONS

There is an opportunity to better support medication self-management for persons with SCI by co-designing an intervention with end-users that comprehensively addresses self-management. This will aid in understanding why interventions work, for whom, in what setting, and under what circumstances.

Molecular Aspects of Hypoxic Stress Effects in Chronic Ethanol Exposure of Neuronal Cells

Experimental models of a clinical, pathophysiological context are used to understand molecular mechanisms and develop novel therapies. Previous studies revealed better outcomes for spinal cord injury chronic ethanol-consuming patients. This study evaluated cellular and molecular changes in a model mimicking spinal cord injury (hypoxic stress induced by treatment with deferoxamine or cobalt chloride) in chronic ethanol-consuming patients (ethanol-exposed neural cultures (SK-N-SH)) in order to explain the clinical paradigm of better outcomes for spinal cord injury chronic ethanol-consuming patients. The results show that long-term ethanol exposure has a cytotoxic effect, inducing apoptosis. At 24 h after the induction of hypoxic stress (by deferoxamine or cobalt chloride treatments), reduced ROS in long-term ethanol-exposed SK-N-SH cells was observed, which might be due to an adaptation to stressful conditions. In addition, the HIF-1α protein level was increased after hypoxic treatment of long-term ethanol-exposed cells, inducing fluctuations in its target metabolic enzymes proportionally with treatment intensity. The wound healing assay demonstrated that the cells recovered after stress conditions, showing that the ethanol-exposed cells that passed the acute step had the same proliferation profile as the cells unexposed to ethanol. Deferoxamine-treated cells displayed higher proliferative activity than the control cells in the proliferation-migration assay, emphasizing the neuroprotective effect. Cells have overcome the critical point of the alcohol-induced traumatic impact and adapted to ethanol (a chronic phenomenon), sustaining the regeneration process. However, further experiments are needed to ensure recovery efficiency is more effective in chronic ethanol exposure.

The Efficiency of Neurospheres Derived from Human Wharton's Jelly Mesenchymal Stem Cells for Spinal Cord Injury Regeneration in Rats

Spinal cord injury (SCI) causes inflammation and neuronal degeneration, resulting in functional movement loss. Since the availability of SCI treatments is still limited, stem cell therapy is an alternative clinical treatment for SCI and neurodegenerative disorders. Human umbilical cord Wharton's jelly-derived mesenchymal stem cells (hWJ-MSCs) are an excellent option for cell therapy. This study aimed to induce hWJ-MSCs into neural stem/progenitor cells in sphere formation (neurospheres) by using neurogenesis-enhancing small molecules (P7C3 and Isx9) and transplant to recover an SCI in a rat model. Inducted neurospheres were characterized by immunocytochemistry (ICC) and gene expression analysis. The best condition group was selected for transplantation. The results showed that the neurospheres induced by 10 µM Isx9 for 7 days produced neural stem/progenitor cell markers such as Nestin and β-tubulin 3 through the Wnt3A signaling pathway regulation markers (β-catenin and NeuroD1 gene expression). The neurospheres from the 7-day Isx9 group were selected to be transplanted into 9-day-old SCI rats. Eight weeks after transplantation, rats transplanted with the neurospheres could move normally, as shown by behavioral tests. MSCs and neurosphere cells were detected in the injured spinal cord tissue and produced neurotransmitter activity. Neurosphere-transplanted rats showed the lowest cavity size of the SCI tissue resulting from the injury recovery mechanism. In conclusion, hWJ-MSCs could differentiate into neurospheres using 10 µM Isx9 media through the Wnt3A signaling pathway. The locomotion and tissue recovery of the SCI rats with neurosphere transplantation were better than those without transplantation.

The efficacy of gait rehabilitations for the treatment of incomplete spinal cord injury: a systematic review and network meta-analysis

BACKGROUND

Recent pieces of evidence about the efficacy of gait rehabilitation for incomplete spinal cord injury remain unclear. We aimed to estimate the treatment effect and find the best gait rehabilitation to regain velocity, distance, and Walking Index Spinal Cord Injury (WISCI) among incomplete spinal cord injury patients.

METHOD

PubMed and Scopus databases were searched from inception to October 2022. Randomized controlled trials (RCTs) were included in comparison with any of the following: conventional physical therapy, treadmill, functional electrical stimulation and robotic-assisted gait training, and reported at least one outcome. Two reviewers independently selected the studies and extracted the data. Meta-analysis was performed using random-effects or fixed-effect model according to the heterogeneity. Network meta-analysis (NMA) was indirectly compared with all interventions and reported as pooled unstandardized mean difference (USMD) and 95% confidence interval (CI). Surface under the cumulative ranking curve (SUCRA) was calculated to identify the best intervention.

RESULTS

We included 17 RCTs (709 participants) with the mean age of 43.9 years. Acute-phase robotic-assisted gait training significantly improved the velocity (USMD 0.1 m/s, 95% CI 0.05, 0.14), distance (USMD 64.75 m, 95% CI 27.24, 102.27), and WISCI (USMD 3.28, 95% CI 0.12, 6.45) compared to conventional physical therapy. In NMA, functional electrical stimulation had the highest probability of being the best intervention for velocity (66.6%, SUCRA 82.1) and distance (39.7%, SUCRA 67.4), followed by treadmill, functional electrical stimulation plus treadmill, robotic-assisted gait training, and conventional physical therapy, respectively.

CONCLUSION

Functional electrical stimulation seems to be the best treatment to improve walking velocity and distance for incomplete spinal cord injury patients. However, a large-scale RCT is required to study the adverse events of these interventions.

TRIAL REGISTRATION

PROSPERO number CRD42019145797.

Incidence and pattern of traumatic spine injury in a single level I trauma center of southern Iran

PURPOSE

Spine injury is one of the leading causes of death and mortality worldwide. The objective of this study was to determine the incidence, pattern and outcome of trauma patients with spine injury referred to the largest trauma center in southern Iran during the last three years.

METHODS

This is a cross-sectional study conducted between 2018 and 2021 in the largest trauma center in the southern Iran. The data collection form included the age, sex, injury location (cervical, thoracic, and lumbar), canuse of injury (traffic accidents, falls, and assaults), length of hospital stay, injured segment of spine injury, severity of injury, and outcome. Statistical analyzes were performed using SPSS software version 24.

RESULTS

Totally 776 cases of spine injury were identified. The spine injury rate was 17.0%, and the mortality rate was 15.5%. Cervical spine injury (20.4%) more often occulted in motorcycle accident, and thoracic spine injury (20.1%) occulted in falls. The highest and lowest rates of spine injurys were related to lumbar spine injury (30.2%) and cervical spine injury (21.5%), respectively. There was a statistically significant relationship between the mechanism of injury and the location of spine injury (p ≤ 0.001). And patients with lumbar spine injury had the highest mortality rate (16.7%). Injury severity score (OR= 1.041, p ≤ 0.001) and length of stay (OR = 1.018, p ≤ 0.001) were strong predictors of mortality in trauma patients with spine injury.

CONCLUSION

The results of the study showed that the incidence of traumatic spine injury rate was approximately 17.0% in southern of Iran. Road traffic injury and falls are the common mechanism of injury to spine. It is important to improve the safety of roads, passages, and work environment, and increase the quality of cars. Also, paying attention to the pattern of spine injury may assist to prevent the missing diagnosis of SCI in multiple trauma patients.

The Application of Biomaterials in Spinal Cord Injury

The spinal cord and the brain form the central nervous system (CNS), which is the most important part of the body. However, spinal cord injury (SCI) caused by external forces is one of the most difficult types of neurological injury to treat, resulting in reduced or even absent motor, sensory and autonomic functions. It leads to the reduction or even disappearance of motor, sensory and self-organizing nerve functions. Currently, its incidence is increasing each year worldwide. Therefore, the development of treatments for SCI is urgently needed in the clinic. To date, surgery, drug therapy, stem cell transplantation, regenerative medicine, and rehabilitation therapy have been developed for the treatment of SCI. Among them, regenerative biomaterials that use tissue engineering and bioscaffolds to transport cells or drugs to the injured site are considered the most promising option. In this review, we briefly introduce SCI and its molecular mechanism and summarize the application of biomaterials in the repair and regeneration of tissue in various models of SCI. However, there is still limited evidence about the treatment of SCI with biomaterials in the clinic. Finally, this review will provide inspiration and direction for the future study and application of biomaterials in the treatment of SCI.

A New Nonlinear Autoregressive Exogenous (NARX)-based Intra-spinal Stimulation Approach to Decode Brain Electrical Activity for Restoration of Leg Movement in Spinally-injured Rabbits

Introduction

This study aimed at investigating the stimulation by intra-spinal signals decoded from electrocorticography (ECoG) assessments to restore the movements of the leg in an animal model of spinal cord injury (SCI).

Methods

The present work is comprised of three steps. First, ECoG signals and the associated leg joint changes (hip, knee, and ankle) in sedated healthy rabbits were recorded in different trials. Second, an appropriate set of intra-spinal electric stimuli was discovered to restore natural leg movements, using the three leg joint movements under a fuzzy-controlled strategy in spinally-injured rabbits under anesthesia. Third, a nonlinear autoregressive exogenous (NARX) neural network model was developed to produce appropriate intra-spinal stimulation developed from decoded ECoG information. The model was able to correlate the ECoG signal data to the intra-spinal stimulation data and finally, induced desired leg movements. In this study, leg movements were also developed from offline ECoG signals (deciphered from rabbits that were not injured) as well as online ECoG data (extracted from the same rabbit after SCI induction).

Results

Based on our data, the correlation coefficient was 0.74±0.15 and the normalized root means square error of the brain-spine interface was 0.22±0.10.

Conclusion

Overall, we found that using NARX, appropriate information from ECoG recordings can be extracted and used for the generation of proper intra-spinal electric stimulations for restoration of natural leg movements lost due to SCI.

Does Wait Time During Acute Care for Transfer to Rehabilitation Admission Impact the Outcomes After a Traumatic Spinal Cord Injury?: A Retrospective Cohort Study

BACKGROUND

The objective of this study was to determine the impact of wait time in acute care for inpatient functional rehabilitation admission on the inpatient functional rehabilitation length of stay and functional outcome after a traumatic spinal cord injury.

METHODS

A retrospective cohort including 277 patients admitted to a single level 1 spinal cord injury acute care center was completed. Partial correlations were used between wait time (in days) for transfer to inpatient functional rehabilitation, the inpatient functional rehabilitation length of stay, and the Spinal Cord Independence Measure total score in the chronic period, adjusting for confounding variables. Stratified analyses were carried out based on the age group and severity of the injury.

RESULTS

Patients had to wait a mean of 7.3 ± 6.4 days (median = 6 days, interquartile range = 2-10 days, max = 29 days) for inpatient functional rehabilitation admission after rehabilitation readiness, which was not associated with the outcomes when adjusted ( P > 0.05). However, individuals 65 yrs or older with a motor-complete injury showed a lower functional status when exposed to wait time for transfer ( r = -0.87, P = 0.02).

CONCLUSIONS

Wait time up to 29 days may have no impact on the inpatient functional rehabilitation length of stay nor functional outcome after traumatic spinal cord injury. However, additional resources and/or prioritization should be considered for vulnerable subgroups.

Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

BACKGROUND

Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI.

METHODS

We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics.

RESULTS

We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001).

CONCLUSIONS

Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.

Exoskeleton use in acute rehabilitation post spinal cord injury: A qualitative study exploring patients' experiences

CONTEXT/OBJECTIVE

Spinal cord injury (SCI) is intensely life altering, affecting multiple body systems and functions, including the ability to walk. Exoskeleton assisted walking (EAW) is a rehabilitation tool that aims to support locomotor training, yet little is known about the patient experience. The purpose of this qualitative study, part of a prospective observational case series, was to increase our understanding of SCI patient experience using a robotic exoskeleton in this acute post-injury period.

DESIGN

A qualitative descriptive approach was implemented in this study, with the aim to explore and understand participants' experience with EAW training.

PARTICIPANTS/SETTING

Nine of the 11 participants enrolled in the observational study agreed to participate in an interview. All participants had suffered a SCI, and had received their trauma care and inpatient rehabilitation at a tertiary center in Calgary, Alberta, Canada.

RESULTS

The benefits to EAW use described by participants were primarily psychological and included the joy of eye level contact, excitement at being able to walk with assistance, improvement in mood, and hope for the future. Potential physiological benefits include increased strength, decreased spasticity and reduced pain. Challenges to EAW use include weakness and fatigue, and a fear of incontinence.

CONCLUSION

Qualitative research will continue to be an important component in future research on the use of EAW training as part of the rehabilitation process. Increasing understanding of the participants experience with this novel therapeutic modality and technology will be fundamental to improve its implementation in clinical practice.

Thermo-sensitive hydrogel combined with SHH expressed RMSCs for rat spinal cord regeneration

Purpose: Spinal cord injury (SCI) has a damaging impact on patients, amid being a worldwide problem with no effective treatment. Herein, we reported a method for functional therapy of SCI in rats, wherein we combined thermo-sensitive hydrogel with Sonic Hedgehog (SHH) expressed in rat bone-marrow derived mesenchymal stem cells (RMSCs).

Methods: Bone marrow-derived mesenchymal stem cells (BMSCs) were isolated from Sprague-Dawley (SD) female rats. The SHH was optimized and transferred into RMSCs via cationic liposomes, while thermo-sensitive hydrogel was reformed with hyaluronate (HA) and Pluronic F127. Then, a rat model with SCI was established accordingly by male SD rats and randomized into sham, model, RMSCs with hydrogel and SHH-RMSCs with hydrogel. The evaluation of SCI repair based on Basso, Beattie Bresnahanlocomotor rating scale (BBB scale) and inclined plate score. Immunofluorescence, immunohistochemistry and hematoxylin-eosin were utilized to explore the expression of protein (GFAP, GAP43, NF200 and MBP) and histopathology.

Results: It was demonstrated that transfection of SHH with cationic liposomes exhibited more effect in RMSCs than lipofectamine 2000. As shown in SEM, 3.5% HA-F127 demonstrated porous structure. In the MTT and dead/live assay, 3.5% HA-F127 showed good biocompatibility for RMSCs. Both RMSCs and SHH-RMSCs groups could significantly promote BBB and inclined plate scores (p < 0.01) compared with the model. Furthermore, the SHH-RMSC group was significantly improved than RMSC with the expression of related proteins, where NF200, MBP, and GAP43 were principally enhanced with the GFAP expression being virtually down-regulated.

Conclusion: All in all, the results suggested that transplantation of RMSCs with SHH could improve the function of SCI and promote nerve regeneration.

Should Non-Pharmacological and Non-Surgical Interventions be Used to Manage Neuropathic Pain in Adults With Spinal Cord Injury? - A Systematic Review

Spinal Cord Injury (SCI) results in a permanent or temporary alteration of the motor, sensory and/or autonomic functions, frequently leading to neuropathic pain. To deal with this comorbidity, several non-pharmacological and non-surgical (NP-NS) interventions have been developed. However, their efficacy is still uncertain. The aim of this study was to systematically synthetize the available evidence assessing the efficacy of NP-NS interventions for treating neuropathic pain in people with SCI. Thus, an electronic search was conducted in five databases (Pubmed, Scopus, Cochrane Central, Web of Science and EBSCO) and trials registry databases, in addition to a manual search strategy to retrieve additional records. The review included randomized controlled trials with adults with SCI, in any stage of the condition. Data on the efficacy of the interventions was narratively synthetized. Once the research was completed, of 4853 identified references, 24 were included with a total of 653 participants with SCI and neuropathic pain, mostly male and with paraplegia. These studies investigated the effect of 13 types of NP-NS interventions with different protocols and methodological limitations. Seven different assessment scales were analyzed, with neuropathic pain being the primary outcome in 21 studies. Such high heterogeneity impaired the conduction of meta-analysis for any of the interventions. Although promising results were found regarding analgesic effect of NP-NS on neuropathic pain in people with SCI, it is not yet possible to safely state that these interventions are in fact effective. Further studies with homogeneous protocols and methodological quality are still needed. PERSPECTIVE: This article presents a review of existing studies on the effectiveness of NP-NS interventions in neuropathic pain in SCI. This synthesis could potentially alert and motivate clinicians to develop studies on this topic, so that interventions can be objectively evaluated and recommendations for an evidence-based practice be created.

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

Effects of photobiomodulation in experimental spinal cord injury models: A systematic review

This systematic review investigated the repercussions of photobiomodulation using low-level laser therapy (LLLT) for the treatment of spinal cord injury (SCI) in experimental models. Studies were identified from relevant databases published between January 2009 and December 2021. Nineteen original articles were selected and 68.4% used light at an infrared wavelength. There was a considerable variation of the power used (from 25 to 200 mW), total application time (8-3000 s) and total energy (0.3-450 J). In 79% of the studies, irradiation was initiated immediately after or within 2 h of the SCI, and treatment time ranged continuously from 5 to 21 days. In conclusion, LLLT can be an auxiliary therapy in the treatment of SCI, playing a neuroprotective role, enabling functional recovery, increasing the concentration of nerve connections around the injury site and reducing pro-inflammatory cytokines. However, there is a need for standardization in the dosimetric parameters.

Soft robotics and functional electrical stimulation advances for restoring hand function in people with SCI: a narrative review, clinical guidelines and future directions

Background

Recovery of hand function is crucial for the independence of people with spinal cord injury (SCI). Wearable devices based on soft robotics (SR) or functional electrical stimulation (FES) have been employed to assist the recovery of hand function both during activities of daily living (ADLs) and during therapy. However, the implementation of these wearable devices has not been compiled in a review focusing on the functional outcomes they can activate/elicit/stimulate/potentiate. This narrative review aims at providing a guide both for engineers to help in the development of new technologies and for clinicians to serve as clinical guidelines based on the available technology in order to assist and/or recover hand function in people with SCI.

Methods

A literature search was performed in Scopus, Pubmed and IEEE Xplore for articles involving SR devices or FES systems designed for hand therapy or assistance, published since 2010. Only studies that reported functional outcomes from individuals with SCI were selected. The final collections of both groups (SR and FES) were analysed based on the technical aspects and reported functional outcomes.

Results

A total of 37 out of 1101 articles were selected, 12 regarding SR and 25 involving FES devices. Most studies were limited to research prototypes, designed either for assistance or therapy. From an engineering perspective, technological improvements for home-based use such as portability, donning/doffing and the time spent with calibration were identified. From the clinician point of view, the most suitable technical features (e.g., user intent detection) and assessment tools should be determined according to the particular patient condition. A wide range of functional assessment tests were adopted, moreover, most studies used non-standardized tests.

Conclusion

SR and FES wearable devices are promising technologies to support hand function recovery in subjects with SCI. Technical improvements in aspects such as the user intent detection, portability or calibration as well as consistent assessment of functional outcomes were the main identified limitations. These limitations seem to be be preventing the translation into clinical practice of these technological devices created in the laboratory.

Effects of ethanol and deferoxamine on rat primary glial cell cultures, in regard with ischemia induced by traumatic spinal cord injury

Although they have been regarded, in the past, as passive support cells, many experimental data have shown that glial cells play a critical role in the development and functioning of the nervous system. Despite the advances that have been made in understanding astrocytes' role in the nervous system's development and function, our knowledge of their interactions with other cells is still limited, albeit neurons are dependent on the trophic support provided by astrocytes release. Materials and Methods. The use of the McCarthy and de Vellis methods for isolating glial cells has been regarded as an essential tool for studying their function. This study aims to evaluate the effects of ethanol and deferoxamine on primary rat glial cell cultures and try to explain, as far as possible, the relevance of such effects for patients with chronic alcoholism and traumatic spinal cord injuries. Discussion. Because glial cells are very important in the functioning of the central nervous system and experiments cannot be performed on human primary nerve cell cultures, we performed an experiment on glial cells harvested from the newborn rat, analyzing the dynamics of IL-6 and TNF alpha on models of suffering in spinal cord injury (hypoxia and thermally stress). Conclusion. Inhibition of TNF alpha synthesis was more important at 7 days posttraumatic in cells with prolonged ethanolic exposure, even if protein levels of IL-6 were elevated (under similar experimental conditions). Thus, we can say that long-term exposure to ethanol of nerve cells can ensure a favorable evolution of medical recovery (by increasing TNF alpha), even if the inflammatory process remains active (shown by elevated IL-6 values). Keywords: ethyl alcohol, deferoxamine, primary glial cells cultures, traumatic Spinal Cord Injury

Early Stages Management of Traumatic Spinal Cord Injury in Latin America: A Scoping Review

OBJECTIVE

To understand the extent and type of evidence on diagnosis, clinical presentation, management, outcomes, and costs of traumatic spinal cord injury (TSCI) in the early stages in Latin America.

METHODS

The Joanna Briggs Institute methodology for scoping reviews was followed. Extracted data included study aim, country, methodology, population characteristics, and outcome measures.

RESULTS

Thirteen studies met the inclusion criteria. Studies were grouped into 5 categories: associated lesions and intensive care unit (ICU); treatment; complications; neurologic outcomes; length of hospital stay (LOS), costs, and mortality. Studies were from Brazil, Mexico, Argentina, Colombia, Chile, and one included several countries. A significant number of patients had associated injuries, little information was found about ICU management. A high variability existed in the surgical and conservative management rate. Some medical therapies were found to be used that could partially alleviate the neurologic symptoms. Most complications were preventable, not always directly related to the event, and could be associated with increased mortality. LOS could be related to complications and to the type of interventions required, which, in turn, could increase the in-hospital costs.

CONCLUSIONS

Information about the management of traumatic spinal cord injury in the early stages in Latin America is not exhaustive and high variability exists among the studies in all the examined sections. Nevertheless, many patients are polytraumatized, and little is known about ICU requirement. Treatment is heterogeneous and the complications are in many cases preventable conditions that can increase LOS, costs, and mortality.

Total Testosterone and Cortisol During Wheelchair Rugby Training in Athletes With Cervical Spinal Cord Injury

CONTEXT

Hormonal assessment in the sport context is important to monitor the physiological adaptations of athletes. However, Paralympic athletes, especially with cervical spinal cord injury (CSCI), may have different hormonal responses than nondisabled athletes. Therefore, the aim of this study was to evaluate the blood concentrations of total testosterone (TT) and cortisol (C) during acute (one training session) and chronic (1 and 2 month) training of athletes with CSCI in wheelchair rugby (WCR).

DESIGN

Longitudinal and observational study.

METHODS

Eight high-performance athletes with CSCI (31 [3.9] y; 75.6 [15.8] kg; 22.9 [4.2] kg/m2 body mass index; 6.2 [2] y of experience in sport) were evaluated at 3 different intervals (evaluations 1, 2, and 3 [E1, E2, and E3]) over 2 months of training. TT and C blood were evaluated before (pre) and after (post) the training sessions at each training moment, as well as the training load through the ratings of perceived exertion.

RESULTS

Athletes with CSCI had low TT concentrations. In acute training sessions, at E3, C decreases after the training session, unlike the TT/C ratio, which increased after the session. Regarding hormonal changes during chronic training at the end of the training period, unlike C, which increased. The training load (arbitrary units) decreased in E3 when compared with the other evaluation moments.

CONCLUSION

It was concluded that in chronic training, TT concentrations decreased, while C increased at the end of the 2 months of training. These results may indicate that training volume was high throughout training and that a reduction in training volume could benefit athletes. On the other hand, in the acute training session with reduced training load, a decrease in C was observed after the training session. This indicates that athletes may be well recovered in this training session. Therefore, we suggest acute and long-term hormonal assessment for athletes with CSCI as a strategy to monitor anabolic/catabolic hormonal status during WCR training.

Diaphragm Pacing in Spinal Cord Injury Can Significantly Decrease Mechanical Ventilation in Multicenter Prospective Evaluation

BACKGROUND

Cervical spinal cord injury (SCI) can lead to dependence on mechanical ventilation (MV) with significant morbidity and mortality. The diaphragm pacing system (DPS) was developed as an alternative to MV.

METHODS

We conducted a prospective single arm study of DPS in MV dependent patients with high SCI and intact phrenic nerves. Following device acclimation, pacing effectiveness to provide ventilation was evaluated. The primary endpoint was the number who could use DPS to breathe for four continuous hours without MV. Secondary endpoints included the number of patients that could use DPS 24 hours/day free of MV and the ability of DPS to maintain clinically acceptable tidal volume (Vt). In addition, we conducted a meta-analysis that included the prospective study along with data from four recently published studies to evaluate DPS hourly use.

RESULTS

Fifty-three patients were implanted in the prospective study. Most were male (77.4%) with a median time from injury to treatment of 28.3 (IQR 12.1, 83.3) months. Four- and 24-hour use occurred in 96.2% (95%CI - 87.0%, 99.5%) and 58.5% (95% CI - 44.1%, 74.9%), respectively. Four and 24-hour results in the meta-analysis cohort (n=196) exhibited similar results 92.2% (95% CI - 82.6%,96.7%) and 52.7% (95% CI - 36.2%,68.6%) using DPS for four and 24 hours, respectively. DPS use significantly exceeded the calculated basal tidal volume requirements by a mean of 48.4% (95% CI - 37.0, 59.9%; p<0.001).

CONCLUSIONS

This study demonstrates that in most ventilator-dependent patients, diaphragm pacing can effectively supplement or completely replace the need for MV and support basal metabolic requirements.