Navigating the complexity of spinal cord injuries with retained foreign bodies and the diagnostic challenge of lead toxicity-a case reportaaa

INTRODUCTION

Retained shrapnel from gunshots is a common occurrence; however, retained shrapnel within the spinal canal is exceedingly uncommon. Guidelines for removal and treatment of these cases are a difficult topic, as surgical removal is not necessarily without consequence, and retention can lead to possible further injury or a secondary disease process of plumbism, which can be difficult to diagnose in this population.

CASE PRESENTATION

This case report provides a unique example of a young patient with retained shrapnel from a gunshot. This patient suffered an initial spinal cord injury due to a gunshot and secondarily presented with abdominal pain, fatigue, elevated blood lead levels, and was diagnosed with plumbism. This was addressed with operative removal of shrapnel and posterior instrumented spinal fusion, resulting in decreased lead levels and symptom resolution postoperatively.

DISCUSSION

Lead toxicity risk in patients with retained shrapnel, particularly in the spine, warrants vigilant monitoring. While management guidelines lack consensus, symptomatic lead toxicity may necessitate intervention. Residual neurological deficits complicate evaluation, emphasizing individualized management decisions.

Trend differences in cervical spinal cord injuries before and after the coronavirus disease 2019 pandemic

STUDY DESIGN

Cross-Sectional Study.

OBJECTIVES

To investigate the changes in the characteristics of cervical spinal cord injuries (CSCI) before and after the coronavirus disease 2019 (COVID-19) pandemic among patients transported to our hospital in Japan.

SETTING

Hospital with an emergency center in Chiba, Japan.

METHODS

Patients eligible for the study were those transported within 24 h of injury and diagnosed with cervical spinal cord injury between January 2018 and December 2021 at our hospital. Medical records were retrospectively examined to investigate the number and characteristics of patients with CSCI. The clinical variables of patients with CSCI were compared according to the time of admission as related to the COVID-19 pandemic: 2018-19 (before) or 2020-21 (after).

RESULTS

The total number of patients with CSCI from 2018 to 2021 was 108, with 57 before the COVID-19 pandemic and 51 after the COVID-19 pandemic. The number of severe cases with an injury severity score (ISS) of >16 decreased after COVID-19 (p < 0.05). Falls on level surfaces were the most common cause of injury both before and after COVID-19. Although the ranking of traffic accidents decreased after COVID-19, among those, the number of bicycle injuries tended to increase.

CONCLUSIONS

The number of serious cases with an ISS > 16 decreased, presumably because of the decline in high-energy trauma due to the background decrease in the number of traffic accidents.

Necroptosis pathway emerged as potential diagnosis markers in spinal cord injury

The present research focused on identifying necroptosis-related differentially expressed genes (NRDEGs) in spinal cord injury (SCI) to highlight potential therapeutic and prognostic target genes in clinical SCI. Three SCI-related datasets were downloaded, including GSE151371, GSE5296 and GSE47681. MSigDB and KEGG datasets were searched for necroptosis-related genes (NRGs). Differentially expressed genes (DEGs) and NRGs were intersected to obtain NRDEGs. The MCC algorithm was employed to select the first 10 genes as hub genes. A protein-protein interaction (PPI) network related to NRDEGs was developed utilizing STRING. Several databases were searched to predict interactions between hub genes and miRNAs, transcription factors, potential drugs, and small molecules. Immunoassays were performed to identify DEGs using CIBERSORTx. Additionally, qRT-PCR was carried out to verify NRDEGs in an animal model of SCI. Combined analysis of all datasets identified 15 co-expressed DEGs and NRGs. GO and KEGG pathway analyses highlighted DEGs mostly belonged to pathways associated with necroptosis and apoptosis. Hub gene expression analysis showed high accuracy in SCI diagnosis was associated with the expression of CHMP7 and FADD. A total of two hub genes, i.e. CHMP7, FADD, were considered potential targets for SCI therapy.

Neurological recovery rate and predictive factors of incomplete AIS grade C spinal cord injury in the older aged population

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C).

SETTINGS

Multi-institutions in Japan.

METHODS

We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis.

RESULTS

Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness).

CONCLUSIONS

Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL.

SPONSORSHIP

No funding was received for this study.

Guidelines for neuroprognostication in adults with traumatic spinal cord injury

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.

Influence of Blood Pressure on Acute Cervical Spinal Cord Injury Without Fracture and Dislocation: Results From a Retrospective Analysis

OBJECTIVE

The objective of this study was to investigate the influence of blood pressure on the severity and functional recovery of patients with acute cervical spinal cord injury (SCI) without fracture and dislocation.

METHODS

A retrospective case control study analyzed the data of 40 patients admitted to our orthopedics department (Beijing Tiantan Hospital, Capital Medical University) from January 2013 to February 2021. They were diagnosed as acute cervical SCI without fracture and dislocation. Gender, age, height, weight, history of hypertension, postinjury American Spinal Injury Association grade, postinjury modified Japanese Orthopaedic Association (mJOA) score, postoperative mJOA score, 1-year follow-up mJOA score, preoperative mean arterial pressure (MAP), intramedullary T2 hyperintensity, and hyponatremia were collected. The patients were divided into groups and subgroups based on their history of hypertension and preoperative MAP. The effects of history of hypertension and preoperative MAP on the incidence of T2 hyperintensity, hyponatremia, the improvement rate of the postoperative mJOA and 1-year follow-up mJOA scores were analyzed.

RESULTS

Patients with history of hypertension had a lower incidence of intramedullary T2 hyperintensity than patients without history of hypertension (P < 0.05). Patients with history of hypertension and patients with a higher preoperative MAP had better neurological recovery at 1 year of follow-up (P < 0.05).

CONCLUSIONS

Blood pressure has great influence on acute cervical SCI without fracture and dislocation. Maintaining a higher preoperative MAP is advantageous for better recovery after SCI. Attention should be paid to the dynamic management of blood pressure to avoid the adverse effects of hypotension after SCI.

Clinical Reasoning: A 24-Year-Old Woman With Penetrating Neck Injury From a Needlefish

Evaluating patients with a traumatic spinal cord injury can be complicated by other injuries. In this case, a 24-year-old woman injured by a needlefish presented with combined motor and sensory defects, cranial nerve deficits, and a blunt vascular injury. This case highlights the importance of neurologic and vascular localizations and an understanding of spinal cord injuries involving various ascending and descending tracts. Appreciation of these anatomical considerations through this case illustrates the diagnostic approach to neurologic evaluation. While we present a traumatic etiology for multiple neurologic syndromes, this case gives readers an opportunity to develop a comprehensive differential diagnosis and tailor investigations for other relevant etiologies. Readers walking through this stepwise process will ultimately arrive at several distinct but related diagnoses.

Intraoperative neurophysiological monitoring and spinal cord stimulator implantation

INTRODUCTION

Spinal cord injury (SCI) is one of the most dreaded complications after spinal cord stimulation (SCS) implantation surgery. As a result, intraoperative neurophysiological monitoring (IONM) has been proposed to avoid accidental damage to nervous structures under anesthesia and confirm positioning for optimal stimulation. Our study uses a large administrative claims database to determine the 30-day risk of SCI after SCS implantation.

METHODS

This retrospective cohort study used the IBM MarketScan Commercial and Medicare Supplemental Databases from 2016 to 2019. Adult patients undergoing SCS surgical procedures with at least 90 days of follow-up, IONM use, the type of sedation used during the procedure, and subsequent SCI were identified using administrative codes. In addition, logistic regression was used to examine the relationship between various risk factors and subsequent SCI.

RESULTS

A total of 9676 patients underwent SCS surgery (64.7% percutaneous implants) during the study period. Nine hundred and forty-four (9.75%) patients underwent SCS implantation with IONM. Conscious sedation, Monitored Anesthesia Care anesthesia, and general anesthesia were used in patients with 0.9%, 60.2%, and 28.6%, respectively. Eighty-one (0.8%) patients developed SCI within 30 days after SCS implant surgery. The SCI rate was higher in the group that underwent IONM (2% vs 0.7%, p value <0.001) during the implantation procedure, reflecting the underlying risk. After adjustment for other factors, the OR of SCI is 2.39 (95% CI: 1.33 to 4.14, p value=0.002) times higher for those with IONM than those without IONM.

CONCLUSIONS

Increased SCI risk among patients with IONM likely reflects higher baseline risk, and further research is needed for risk mitigation.

Concordance between needle electromyography and manual muscle test findings for muscles with motor grades 0 and 1

INTRODUCTION

When it is difficult to determine whether a muscle is grade 0 or 1, manual muscle test (MMT) accuracy can be further improved by using needle electromyography (EMG) as a supplementary and confirmatory examination tool.

OBJECTIVE

To evaluate concordance between needle EMG and MMT findings for key muscles with motor grades 0 and 1 on the International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI) examination, and to potentially improve the prognosis for grade 0 muscles with proven muscle activity based on needle EMG findings.

DESIGN

A retrospective analysis.

SETTING

Inpatient tertiary rehabilitation facility.

INTERVENTIONS

Not applicable.

PATIENTS

One hundred seven patients with spinal cord injury (SCI) admitted for rehabilitation (n = 1218 key muscles, grades 0 or 1).

MAIN OUTCOME MEASURES

Inter-rater reliability between MMTs and needle EMG was analyzed using Cohen's kappa coefficient (κ). A Mantel Haenszel linear-by-linear association chi-square test was used to determine whether the presence of motor unit action potentials (MUAPs) in muscles graded 0 on the initial MMT at admission was associated with MMT grades at discharge and readmission.

RESULTS

Moderate-to-substantial agreement between needle EMG and MMT findings was observed (κ = 0.671, p < .01). Concerning key upper and lower extremity muscles, moderate and substantial agreement was identified, respectively. The lowest agreement was noted for C6 muscles. During follow up, 68.8% of muscles with proven MUAPs showed improved motor grades.

CONCLUSIONS

At initial assessment, distinguishing between motor grades 0 and 1 is imperative because motor grade 1 muscles are more likely to have a better prognosis for improvement. Moderate-to-substantial agreement was observed between MMT and needle EMG findings. The MMT is a reliable method of muscle grading, yet needle EMG may be of value in certain clinical situations to evaluate for the presence of MUAPs when evaluating motor function.

Penile vibratory stimulation in men with spinal cord injury: an educational video demonstration

OBJECTIVES

To demonstrate the different techniques used to perform successful penile vibratory stimulation (PVS) to induce ejaculation in men with spinal cord injuries (SCIs).

DESIGN

A video demonstration of the PVS procedure performed in men with SCIs using the FertiCare 2.0 medical vibrator.

SETTING

Major University Medical Center.

PATIENTS

Men with SCIs.

INTERVENTION(S)

Spinal cord injury is the leading cause of anejaculation in young men. After SCIs, most of these men will need a method of assisted ejaculation to achieve biological fatherhood. In this study, a newly designed and tested vibrator (FertiCare 2.0) was used to induce ejaculation. The initial assessment of each patient included a standard history, physical examination, level of injury determination using the International Standards for Neurological Classification of Spinal Cord Injury as well as assessment of the hip flexor reflex and the bulbocavernosus reflex. Patients with a level of injury at or rostral to T6 were pretreated with 10-40 mg of sublingual nifedipine to manage autonomic dysreflexia. A single vibrator was applied to the dorsum, or frenulum, of the glans penis. Stimulation is delivered in 2-minute increments to a maximum of 10 minutes per visit. Application of two vibrators or abdominal electrical stimulation concurrently with PVS was used in select patients. Ejaculated semen was collected in a sterile cup and examined after liquefaction. Bladder preparation using sperm wash medium was performed in patients suspected of experiencing retrograde ejaculation.

MAIN OUTCOME MEASURE(S)

Successful ejaculation after performing the PVS procedure in men with SCIs.

RESULTS

Penile vibratory stimulation was successful in 86% of men whose level of injury was T10 or rostral. The total motile sperm count in antegrade ejaculates produced using PVS was >5 million (lower limit considered for intrauterine insemination) in 71% of ejaculates. No complications because of PVS were observed in 3,700 trials performed by our group and none in the patients presented in this video.

CONCLUSION(S)

Penile vibratory stimulation is a safe and effective method for the management of ejaculatory dysfunction in men with SCIs. Penile vibratory stimulation can be performed by the male partner after an initial evaluation by a specialized provider, and the ejaculate can be used to perform home insemination.

Identification of a reliable sacral-sparing examination to assess the ASIA impairment scale in patients with traumatic spinal cord injury

OBJECTIVES

We evaluated the time course of the American Spinal Cord Injury Association (ASIA) impairment scale (AIS) for up to three months in participants within 72 h after traumatic spinal cord injury (TSCI) with complete paralysis. We aimed to determine the most useful sacral-sparing examination (deep anal pressure [DAP], voluntary anal contraction [VAC], S4-5 light touch [LT], or pin prick [PP] sensation) in determining AIS grades.

DESIGN

Retrospective cohort study.

SETTING

Spinal Injuries Center, Fukuoka, Japan.

PARTICIPANTS

Among 668 TSCI participants registered in the Japan Single Center study for Spinal Cord Injury Database (JSSCI-DB) between January 2012 and May 2020, we extracted the data of 80 patients with AIS grade A within 72 h after injury and neurological level of injury (NLI) at T12 or higher.

INTERVENTIONS

None.

OUTCOME MEASURES

The sacral-sparing examination at the time of the change to incomplete paralysis was compared to the AIS determination using a standard algorithm and with each assessment including the VAC, DAP, S4-5LT, and S4-5PP examinations at the time of AIS functional change. Agreement among assessments was evaluated using weighted kappa coefficients. The relationship was evaluated using Spearman's rank correlation coefficients.

RESULTS

Fifteen participants (18.8%) improved to incomplete paralysis (AIS B to D) within three months after injury. The single assessment among the sacral-sparing examinations with the highest agreement and strongest correlation with AIS determination was the S4-5LT examination (k = 0.89, P < 0.01, r = 0.84, P < 0.01).

CONCLUSIONS

The S4-5LT examination is key in determining complete or incomplete paralysis due to its high discriminatory power.

Novel SERS Signal Amplification Strategy for Ultrasensitive and Specific Detection of Spinal Cord Injury-Related miRNA

The expression of microRNA (miRNA) changes in many diseases plays an important role in the diagnosis, treatment, and prognosis of diseases. Spinal cord injury (SCI) is a serious disease of the central nervous system, accompanied by inflammation, cell apoptosis, neuronal necrosis, axonal rupture, demyelination, and other pathological processes, resulting in impaired sensory and motor functions of patients. Studies have shown that miRNA expression has changed after SCI, and miRNAs participate in the pathophysiological process and treatment of SCI. Therefore, quantitative analysis and monitoring of the expression of miRNA were of great significance for the diagnosis and treatment of SCI. Through the SCI-related miRNA chord plot, we screened out miRNA-21-5p and miRNA-let-7a with a higher correlation. However, for traditional detection strategies, it is still a great challenge to achieve a fast, accurate, and sensitive detection of miRNA in complex biological environments. The most frequently used method for detecting miRNAs is polymerase chain reaction (PCR), but it has disadvantages such as being time-consuming and cumbersome. In this paper, a novel SERS sensor for the quantitative detection of miRNA-21-5p and miRNA-let-7a in serum and cerebrospinal fluid (CSF) was developed. The SERS probe eventually formed a sandwich-like structure of Fe3O4@hpDNA@miRNA@hpDNA@GNCs with target miRNAs, which had high specificity and stability. This SERS sensor achieved a wide range of detection from 1 fM to 1 nM and had a good linear relationship. The limits of detection (LOD) for miRNA-21-5p and miRNA-let-7a were 0.015 and 0.011 fM, respectively. This new strategy realized quantitative detection and long-term monitoring of miRNA-21-5p and miRNA-let-7a in vivo. It is expected to become a powerful biomolecule analysis tool and will provide ideas for the diagnosis and treatment of many diseases.

COVID-19 and spinal cord injury: clinical presentation, clinical course, and clinical outcomes of people hospitalised

STUDY DESIGN

Retrospective study OBJECTIVES: To describe the presenting symptoms/signs, clinical course and outcomes in hospitalised people with spinal cord injury (SCI) and symptomatic COVID-19 infections.

SETTING

One university hospital and two SCI centres in Switzerland.

METHODS

Descriptive analysis of symptoms/signs, clinical course and outcomes of people with SCI with symptomatic COVID-19 infections and need for hospitalisation.

RESULTS

Twenty-two people with SCI were included, 15 (68%) were male, median age 64.5 years (interquartile range, IQR, 52-73 years). Nine (41%) had tetraplegia, and eight (36%) were classified with motor-complete lesions. Frequent clinical symptoms were fever (59%), coughing (54%), fatigue (50%), and dyspnoea (27%). Most frequent complications were bacterial pulmonary superinfection (18%), and acute respiratory distress syndrome (18%). Fifteen persons (68%) needed oxygen therapy during the course of hospitalisation, and 7 (32%) people were ventilated. Median length of stay (LOS) was 23 days (IQR 15-35), varying by age for people under 60 years with a median LOS of 9 days (IQR 8-27), and for those older than 60 years with a median of 34 days (IQR 17-39), respectively. In total, 3 persons (14%) died during hospitalisation, all older with paraplegia.

CONCLUSIONS

Typical symptoms like fever and coughing were not present in all people. People with tetraplegia did not demonstrate worse outcomes, on the contrary, they had shorter LOS, no difference in ventilation needs, and no higher mortality compared to people with paraplegia. Older people showed longer LOS. This study recommends close supervision of the SCI population to detect early signs and symptoms of COVID-19 infection.

Intraoperative Monitoring of Scoliosis Surgery in Young Patients

SUMMARY

Intraoperative neurophysiologic monitoring has added substantially to the safety of spinal deformity surgery correction since its introduction over four decades ago. Monitoring routinely includes both somatosensory evoked potentials and motor evoked potentials. Either modality alone will detect almost all instances of spinal cord injury during deformity correction. The combined use of the two modalities provides complementary information, can permit more rapidly identification of problems, and enhances safety though parallel redundancy should one modality fail. Both techniques are well established and continue to be refined. Although there is room for provider preference, proper monitoring requires attention to technical detail, understanding of the underlying physiology, and familiarity with effects of commonly used anesthetic agents.

The revised zone of partial preservation (ZPP) in the 2019 International Standards for Neurological Classification of Spinal Cord Injury: ZPP applicability in incomplete injuries

STUDY DESIGN

Consensus process.

OBJECTIVES

To provide a reference for the Zone(s) of Partial Preservation (ZPP) in the 2019 International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and analyze the initial impact of applicability of the revised ZPPs. Revisions include the use of ZPPs in selected incomplete injuries (in addition to prior use in sensorimotor complete injuries). Specifically, the revised motor ZPPs are applicable bilaterally in injuries with absent voluntary anal contraction (VAC) and the revised sensory ZPP for a given side is applicable if deep anal pressure (DAP), light touch and pin prick sensation in S4-5 are absent on that side.

SETTING

Committee with 16 ISNCSCI experts and datasets from the European Multicenter Study about Spinal Cord Injury (EMSCI).

METHODS

Occurrence frequencies of applicable ZPPs were determined in an EMSCI cohort consisting of two ISNCSCI examinations from 665 individuals with traumatic SCI.

RESULTS

Motor ZPPs were derived in 35.2% of all datasets of incomplete injuries, while sensory ZPPs are much less frequent (1.0%). Motor ZPPs are applicable in all American Spinal Injury Association Impairment Scale (AIS) B datasets (mean ZPP length: 0.9 ± 1.0 segments), in 55.4% of all AIS C datasets (ZPP length: 11.8 ± 8.2 segments) and in 9.9% of the AIS D datasets (ZPP length: 15.4 ± 7.9 segments).

CONCLUSIONS

The revised ZPP allows for determining motor ZPPs in approximately 1/3 of all incomplete injuries. The broadened applicability enables the use of ZPPs beyond complete injuries for complementary description of residual functions in more individuals.

SPONSORSHIP

N/A.

Quantifying unsupported sitting posture impairments in humans with cervical spinal cord injury using a head-mounted IMU sensor

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To evaluate unsupported sitting posture impairments and identify postural regulatory strategies in cervical spinal cord injury (cSCI) participants via a head-mounted IMU sensor.

SETTING

A research lab in the United States of America.

METHODS

cSCI participants and controls maintained postural stability during unsupported sitting with eyes either open or closed. The head-mounted IMU sensor recorded accelerometer data to calculate cumulative sway motion. The postural regulatory strategy was analyzed by assessing the normalized power spectral density (PSD) in four frequency bands: 0-0.1 Hz (visual regulation), 0.1-0.5 Hz (vestibular regulation), 0.5-1 Hz (cerebellar regulation), and >1 Hz (proprioception and muscle control).

RESULTS

Significant increases in postural sway were observed in cSCI participants compared to controls during unsupported sitting. For cSCI participants, normalized PSD significantly increased in the low-frequency bands (0-0.1 Hz and 0.1-0.5 Hz) but decreased in the high-frequency band (>1 Hz) compared to controls.

CONCLUSIONS

cSCI participants were more reliant on visual and vestibular systems for sitting balance, while depending less on proprioception and muscle control compared to controls. These findings suggest that the altered postural regulatory strategy is ineffective in maintaining postural stability during unsupported sitting, emphasizing the importance of proprioception and muscle control for seated postural stability in cSCI participants.

Traumatic Spinal Cord Injury

OBJECTIVE

This article provides a review of the initial clinical and radiologic evaluation and treatment of patients with traumatic spinal cord injuries. It specifically highlights essential knowledge for neurologists who encounter patients with these complex injuries.

LATEST DEVELOPMENTS

There has been improvement in the care of patients with traumatic spinal cord injuries, particularly in the prehospital evaluation, approach for immediate immobilization, standardized spinal clearance, efficient triage, and transportation of appropriate patients to traumatic spinal cord injury specialized centers. Advancements in spinal instrumentation have improved the surgical management of spinal fractures and the ability to manage patients with spinal mechanical instability. The clinical evidence favors performing early surgical decompression and spine stabilization within 24 hours of traumatic spinal cord injuries, regardless of the severity or location of the injury. There is no evidence that supports the use of neuroprotective treatments to improve outcomes in patients with traumatic spinal cord injuries. The administration of high-dose methylprednisolone, which is associated with significant systemic adverse effects, is strongly discouraged. Early and delayed mortality rates continue to be high in patients with traumatic spinal cord injuries, and survivors often confront substantial long-term physical and functional impairments. Whereas the exploration of neuroregenerative approaches, such as stem cell transplantation, is underway, these methods remain largely investigational. Further research is still necessary to advance the functional recovery of patients with traumatic spinal cord injuries.

ESSENTIAL POINTS

Traumatic spinal cord injury is a complex and devastating condition that leads to long-term neurologic deficits with profound physical, social, and vocational implications, resulting in a diminished quality of life, particularly for severely affected patients. The initial management of traumatic spinal cord injuries demands comprehensive interdisciplinary care to address the potentially catastrophic multisystem effects. Ongoing endeavors are focused on optimizing and customizing initial management approaches and developing effective therapies for neuroprotection and neuroregeneration to enhance long-term functional recovery.

Hypoxic Ischemic Encephalopathy with Cervical Spinal Cord Injury: A Diagnostic Dilemma

Perinatal spinal cord injury is a relatively uncommon, but a frequently misdiagnosed disorder. Improvements in obstetric care have certainly led to a decrease in the incidence of birth related spinal cord trauma but unfortunately the incidence of hypoxic-ischemic encephalopathy is still very high. The exact incidence of spinal cord trauma is difficult to determine because the spinal cord is not routinely examined in far and few neonatal autopsies done in India. Here, authors present a neonate who received treatment for birth asphyxia and then had extubation failure which made the clock tick towards cervical cord injury. This baby had a hemorrhagic contusion of cervical spinal cord.

The Predictive Abilities of Machine Learning Algorithms in Patients with Thoracolumbar Spinal Cord Injuries

OBJECTIVES

The goal of this study is to implement machine learning (ML) algorithms to predict mortality, non-home discharge, prolonged length of stay (LOS), prolonged length of intensive care unit stay (ICU-LOS), and major complications in patients diagnosed with thoracolumbar spinal cord injury, while creating a publicly accessible online tool.

METHODS

The American College of Surgeons Trauma Quality Program database was used to identify patients with thoracolumbar spinal cord injury. Feature selection was performed with the Least Absolute Shrinkage and Selection Operator algorithm. Five ML algorithms, including TabPFN, TabNet, XGBoost, LightGBM, and Random Forest, were used along with the Optuna optimization library for hyperparameter tuning.

RESULTS

A total of 147,819 patients were included in the analysis. For each outcome, we determined the best model for deployment in our web application based on the area under the receiver operating characteristic (AUROC) values. The top performing algorithms were as follows: LightGBM for mortality with an AUROC of 0.885, TabPFN for non-home discharge with an AUROC of 0.801, LightGBM for prolonged LOS with an AUROC of 0.673, Random Forest for prolonged ICU-LOS with an AUROC of 0.664, and LightGBM for major complications with an AUROC of 0.73.

CONCLUSIONS

ML models demonstrate good predictive ability for in-hospital mortality and non-home discharge, fair predictive ability for major complications and prolonged ICU-LOS, but poor predictive ability for prolonged LOS. We have developed a web application that allows these models to be accessed.

Prediction of early bladder outcomes after spinal cord injury: The HALT score

AIMS

Neurogenic bladder (NB) is a prevalent and debilitating consequence of spinal cord injury (SCI). Indeed, the accurate prognostication of early bladder outcomes is crucial for patient counseling, rehabilitation goal setting, and personalized intervention planning.

METHODS

A retrospective exploratory analysis was conducted on a cohort of consecutive SCI patients admitted to a rehabilitation facility in China from May 2016 to December 2022. Demographic, clinical, and electrophysiological data were collected within 40 days post-SCI, with bladder outcomes assessed at 3 months following SCI onset.

RESULTS

The present study enrolled 202 SCI patients with a mean age of 40.3 ± 12.3 years. At 3 months post-SCI, 79 participants exhibited complete bladder emptying. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analyses identified the H-reflex of the soleus muscle, the American Spinal Injury Association Lower Extremity Motor Score (ASIA-LEMS), and the time from lesion to rehabilitation facility (TLRF) as significant independent predictors for bladder emptying. A scoring system named HALT was developed, yielding a strong discriminatory performance with an area under the receiver operating characteristics curve (aROC) of 0.878 (95% CI: 0.823-0.933). A simplified model utilizing only the H-reflex exhibited excellent discriminatory ability with an aROC of 0.824 (95% CI: 0.766-0.881). Both models demonstrated good calibration via the Hosmer-Lemeshow test and favorable clinical net benefits through decision curve analysis (DCA). In comparison to ASIA-LEMS, both the HALT score and H-reflex showed superior predictive accuracy for bladder outcome. Notably, in individuals with incomplete injuries, the HALT score (aROC = 0.973, 95% CI: 0.940-1.000) and the H-reflex (aROC = 0.888, 95% CI: 0.807-0.970) displayed enhanced performance.

CONCLUSION

Two reliable models, the HALT score and the H-reflex, were developed to predict bladder outcomes as early as 3 months after SCI onset. Importantly, this study provides hitherto undocumented evidence regarding the predictive significance of the soleus H-reflex in relation to bladder outcomes in SCI patients.

Neutrophil-to-lymphocyte ratio at admission for early diagnosis, severity assessment, and prognosis of acute traumatic spinal cord injury

STUDY DESIGN

A retrospective study.

OBJECTIVE

This study examined the value of neutrophil-to-lymphocyte ratio at admission for early diagnosis, severity assessment, and prognosis of acute traumatic SCI.

SETTING

The First People's Hospital of Neijiang, China.

METHODS

This was a single-center, retrospective, cohort study of patients treated within 12 h of acute SCI between January 2018 and October 2022. Ninety-four SCI patients were selected as the Observation group, including 26 with complete injury (AIS grade A) and 68 with incomplete injury (AIS grade B-D), while 94 patients with simple spinal fracture were randomly selected as the Control group. Eighty-one observation group patients underwent surgical treatment, of which 33 had a higher AIS grade (Good prognosis subgroup) and 48 a lower or equal grade post-surgery (Poor prognosis subgroup). Univariate and multivariate analyses were performed to assess predictors of early diagnosis, severity, and 6-month outcome.

RESULTS

Initial white blood cell count, neutrophil count, monocyte count, and NLR were higher in the Observation group than the Control group, while lymphocyte count was lower in the Observation group. Multivariate logistic regression analysis identified NLR as an independent predictor of early diagnosis. Spinal canal encroachment ≥50%, neutrophil count, and NLR were higher in the complete injury subgroup, and spinal canal encroachment ≥50% was an independent predictor of complete injury, while NLR was not. The NLR was higher in the poor prognosis subgroup and was an independent risk factor.

CONCLUSIONS

Peripheral blood NLR is useful for early diagnosis of acute SCI and is predictive of clinical outcome.

Arabic version of the SF-Qualiveen: cross-cultural adaptation, translation, and validation of urinary disorder-specific instruments in patients with spinal cord injury

BACKGROUND

The Short-Form Qualiveen (SF-Qualiveen) questionnaire assesses the effect of bladder and urinary symptoms on patients' quality of life (QoL) with urological impairment caused by neurological diseases. There is no validated SF-Qualiveen questionnaire in Arabic, so this study aims to provide a translated and validated version of the SF-Qualiveen questionnaire among Arabic patients experiencing spinal cord injury (SCI).

METHODS

Psychometric features such as content and construct validity, test-retest reliability, and internal consistency were analyzed. Construct validity was evaluated by contrasting the SF-Qualiveen with the Neurogenic Bladder Symptom Score Short-Form (NBSS-SF) questionnaire. Internal consistency was measured using Cronbach's alpha, whereas the intraclass correlation coefficient (ICC) was employed to assess the test-retest reliability. Factorial validity was established by principal component analysis (PCA).

RESULTS

The internal consistency of the total SF-Qualiveen and the domains "Bother with limitations," "Fear," "Feeling," and "Frequency of limitations" showed good internal consistency (Cronbach's alpha of > 0.7). ICC was 0.90 for the total score, 0.83 for the bother with limitations, 0.80 for fears, 0.84 for feeling, and 0.81 for frequency of limitations. The correlation analysis revealed a positive association between the total scores on the NBSS-SF and the domains of the SF-Qualiveen, comprising bother with limitations (r = 0.53, p = 0.02), fears (r = 0.44, p = 0.03), feelings (r = 0.49, p = 0.04), and frequency of limitations (r = 0.46, p = 0.02). The best-fit four-factor model for confirming overall item communalities ranged from 0.552 to 0.814, which indicates moderate to high communalities, and confirms the homogeneity of the SF-Qualiveen using PCA.

CONCLUSIONS

The findings of this validation study revealed that the SF-Qualiveen is a reliable and valid instrument appropriate for Arabic-speaking patients with SCI in both research and clinical practices.

Determination of cut-off points in the Trunk control test for spinal cord injury to assess the ability to perform different activities of daily living

STUDY DESIGN

Observational, comparative, and transversal study.

OBJECTIVE

To identify the cut-off points in the Trunk Control Test (TCT) for individuals with Spinal Cord Injury (SCI) to determine the ability to perform independently the different activities of daily living (ADL) according to the Spinal Cord Independence Measure-III (SCIM-III).

SETTING

National Institute of Rehabilitation, Mexico City.

METHODS

Individuals with SCI of any neurologic level and severity according to ISNCSCI, in sub-acute and chronic phases were included. Receiver Operating Characteristic (ROC) curves were made to identify the cut-off points on the TCT that discriminate the individuals that can independently perform each of the ADL described in the SCIM-III.

RESULTS

A total of 604 participants were evaluated, 70.7% male; mean age of 34 (± 14) years; time since injury was 134 ± 360 days; predominating motor complete injury (50.1%). It was demonstrated through ROC curves, that there are different cut-off points in the TCT that are sensitive and specific to discriminate individuals that can independently perform the majority of the items of the SCIM-III of those who perform it with assistance. Domains that do not depend on an adequate trunk control (respiration and sphincter management) had poor areas under the curve, with low sensitivity and specificity.

CONCLUSIONS

The application of the TCT in individuals with SCI allows to discriminate between individuals who perform the different ADL independently of those who do not, at this subject institute. These results can guide the management of individuals with SCI, helping to establish short term goals.

Minimal clinically important difference (MCID) and minimal detectable change (MDC) of Spinal Cord Ability Ruler (SCAR)

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To find minimal clinically important difference (MCID) and minimal detectable change (MDC) of Spinal Cord Ability Ruler (SCAR) in Thai participants with spinal cord injury (SCI).

SETTING

Rehabilitation ward at Maharaj Nakorn Chiang Mai Hospital.

METHODS

Data of individuals with SCI who were not diagnosed with central cord syndrome and were admitted for the first time for rehabilitation were analyzed. Upper extremities motor score, self-care and mobility items of Spinal Cord Independence Measure version III were collected and used to calculate SCAR difference between data on date of admission and discharge. MCID and MDC were calculated by distribution-based method and categorized for each subgroup according to SCI characteristics.

RESULTS

From data of 311 individuals, MCID of SCAR is approximately 4 for individual with tetraplegia AIS A, B, C; and individual with AIS D at any level, and 2 for individual with paraplegia AIS A, B, C. MDC of SCAR should be 1 for individual with tetraplegia AIS A, B, C; and individual with AIS D at any level and 0.5 for individual with paraplegia AIS A, B, C.

CONCLUSION

This study provides MCID and MDC of SCAR in each subgroup. These values could be used as a benchmark for clinicians and researchers to determine whether participant has significant improvement or not after receiving an intervention.

A future blood test for acute traumatic spinal cord injury

Acute spinal cord injury (SCI) requires prompt diagnosis and intervention to minimize the risk of permanent neurologic deficit. Presently, SCI diagnosis and interventional planning rely on magnetic resonance imaging (MRI), which is not always available or feasible for severely injured patients. Detection of disease-specific biomarkers in biofluids via liquid biopsy may provide a more accessible and objective means of evaluating patients with suspected SCI. Cell-free DNA, which has been used for diagnosing and monitoring oncologic disease, may detect damage to spinal cord neurons via tissue-specific methylation patterns. Other types of biomarkers, including proteins and RNA species, have also been found to reflect neuronal injury and may be included as part of a multi-analyte assay to improve liquid biopsy performance. The feasibility of implementing liquid biopsy into current practices of SCI management is supported by the relative ease of blood sample collection as well as recent advancements in droplet digital polymerase chain reaction technology. In this review, we detail the current landscape of biofluid biomarkers for acute SCI and propose a framework for the incorporation of a putative blood test into the clinical management of SCI.

Precision medicine for traumatic cervical spinal cord injuries: accessible and interpretable machine learning models to predict individualized in-hospital outcomes

BACKGROUND CONTEXT

A traumatic spinal cord injury (SCI) can cause temporary or permanent motor and sensory impairment, leading to serious short and long-term consequences that can result in significant morbidity and mortality. The cervical spine is the most commonly affected area, accounting for about 60% of all traumatic SCI cases.

PURPOSE

This study aims to employ machine learning (ML) algorithms to predict various outcomes, such as in-hospital mortality, nonhome discharges, extended length of stay (LOS), extended length of intensive care unit stay (ICU-LOS), and major complications in patients diagnosed with cervical SCI (cSCI).

STUDY DESIGN

Our study was a retrospective machine learning classification study aiming to predict the outcomes of interest, which were binary categorical variables, in patients diagnosed with cSCI.

PATIENT SAMPLE

The data for this study were obtained from the American College of Surgeons (ACS) Trauma Quality Program (TQP) database, which was queried to identify patients who suffered from cSCI between 2019 and 2021.

OUTCOME MEASURES

The outcomes of interest of our study were in-hospital mortality, nonhome discharges, prolonged LOS, prolonged ICU-LOS, and major complications. The study evaluated the models' performance using both graphical and numerical methods. The receiver operating characteristic (ROC) and precision-recall curves (PRC) were used to assess model performance graphically. Numerical evaluation metrics included AUROC, balanced accuracy, weighted area under PRC (AUPRC), weighted precision, and weighted recall.

METHODS

The study employed data from the American College of Surgeons (ACS) Trauma Quality Program (TQP) database to identify patients with cSCI. Four ML algorithms, namely XGBoost, LightGBM, CatBoost, and Random Forest, were utilized to develop predictive models. The most effective models were then incorporated into a publicly available web application designed to forecast the outcomes of interest.

RESULTS

There were 71,661 patients included in the analysis for the outcome mortality, 67,331 for the outcome nonhome discharges, 76,782 for the outcome prolonged LOS, 26,615 for the outcome prolonged ICU-LOS, and 72,132 for the outcome major complications. The algorithms exhibited an AUROC value range of 0.78 to 0.839 for in-hospital mortality, 0.806 to 0.815 for nonhome discharges, 0.679 to 0.742 for prolonged LOS, 0.666 to 0.682 for prolonged ICU-LOS, and 0.637 to 0.704 for major complications. An open access web application was developed as part of the study, which can generate predictions for individual patients based on their characteristics.

CONCLUSIONS

Our study suggests that ML models can be valuable in assessing risk for patients with cervical cSCI and may have considerable potential for predicting outcomes during hospitalization. ML models demonstrated good predictive ability for in-hospital mortality and nonhome discharges, fair predictive ability for prolonged LOS, but poor predictive ability for prolonged ICU-LOS and major complications. Along with these promising results, the development of a user-friendly web application that facilitates the integration of these models into clinical practice is a significant contribution of this study. The product of this study may have significant implications in clinical settings to personalize care, anticipate outcomes, facilitate shared decision making and informed consent processes for cSCI patients.

Test-retest reliability of short- and long-term heart rate variability in individuals with spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To investigate test-retest reliability of heart rate variability (HRV) metrics in SCI without restriction of activity over long (24-h) and shorter durations (5-min, 10-min, 1-h, 3-h and 6-h).

SETTINGS

University hospital in Khon Kaen, Thailand.

METHODS

Forty-five participants (11 with tetraplegia and 34 with paraplegia) underwent two 24-h recordings of RR-intervals to derive time and frequency HRV metrics. Relative reliability was assessed by intraclass correlation coefficient (ICC) and absolute reliability by coefficient of variation (CV) and Bland-Altman limits of agreement (LoA).

RESULTS

For 5- and 10-min durations, eight of eleven HRV metrics had moderate to excellent reliability (ICC 0.40-0.76); the remaining three were poor (ICC < 0.4). HRV values from 1-h and 3-h durations showed moderate to excellent reliability (ICC of 0.46-0.81), except for 1-h reliability of ULF and TP (ICC of 0.06 and 0.30, respectively). Relative reliability was excellent (ICC of 0.77-0.92) for 6-h and 24-h durations in all HRV metrics. Absolute reliability improved as recording duration increased (lower CVs and narrower LoAs). Participants with high AD risk (SCI level at or above T6) showed lower test-retest reliability of HF and LF values than participants with low AD risk.

CONCLUSION

Relative reliability of HRV was excellent for 6-h and 24-h. The best absolute reliability values were for 24-h duration. Time-domain outcomes were more reliable than frequency domain outcomes. Participants with high risk of AD, particularly those with tetraplegia, showed lower reliability, especially for HF and LF.

Construct validity of the international standards to document remaining autonomic function after spinal cord injury (ISAFSCI) (1st edition)

STUDY DESIGN

Observational study.

OBJECTIVES

To assess the construct validity of the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) (2012 1st Edition).

SETTING

Two Canadian spinal cord injury (SCI) centers.

METHODS

Data were collected between 2011-2014. Assessments included the ISAFSCI, standardized measures of autonomic function and a clinical examination. Construct validity of ISAFSCI was assessed by testing a priori hypotheses on expected ISAFSCI responses to standard measures (convergent hypotheses) and clinical variables (clinical hypotheses).

RESULTS

Forty-nine participants with an average age of 45 ± 12 years were included, of which 42 (85.7%) were males, 37 (77.6%) had a neurological level of injury at or above T6, and 23 (46.9%) were assessed as having motor and sensory complete SCI. For the six General Autonomic Function component hypotheses, two hypotheses (1 clinical, 1 convergent) related to autonomic control of blood pressure and one clinical hypothesis for temperature regulation were statistically significant. In terms of the Lower Urinary Tract, Bowel and Sexual Function component of the ISAFSCI, all the hypotheses (5 convergent, 3 clinical) were statistically significant except for the hypotheses on female sexual items (2 convergent, 2 clinical), likely due to small sample size.

CONCLUSION

The construct validity of ISAFSCI (2012 1st Edition) for the General Autonomic Function component was considered to be weak while it was much stronger for the Lower Urinary Tract, Bowel and Sexual Function component based on a priori hypotheses. These results can inform future psychometric studies of the ISAFSCI (2021 2nd Edition).

Impact of routine urine cultures on antibiotic usage in those undergoing a routine annual spinal cord injury evaluation

OBJECTIVE

The Veterans Health Administration (VHA), the largest single provider of spinal cord injury and disorder (SCI/D) care in the United States, currently mandates that every patient receives a screening urine culture during the annual evaluation, a yearly comprehensive history and physical examination. This testing has shown in a small subset of patients to overidentify asymptomatic bacteriuria that is then inappropriately treated with antibiotics. The objective of the current analysis was to assess the association of the annual evaluation on urine testing and antibiotic treatment in a national sample of Veterans with SCI/D.

DESIGN/METHOD

A retrospective cohort study using national VHA electronic health record data of Veterans with SCI/D seen between October 1, 2017-September 30, 2019 for their annual evaluation.

RESULTS

There were 9447 Veterans with SCI/D who received an annual evaluation; 5088 (54%) had a urine culture obtained. 2910 cultures (57%) were positive; E. coli was the most common organism obtained (12.9% of total urine cultures). Of the patients with positive urine cultures, 386 were prescribed antibiotics within the 7 days after that encounter (13%); of the patients with negative cultures (n = 2178), 121 (6%) were prescribed antibiotics; thus, a positive urine culture was a significant driver of antibiotic use (p < 0.001).

CONCLUSION

The urine cultures ordered at the annual exam are often followed by antibiotics; this practice may be an important target for antibiotic stewardship programs in SCI.

Serum glucose/potassium ratio as a clinical risk factor for predicting the severity and prognosis of acute traumatic spinal cord injury

OBJECTIVE

Acute traumatic Spinal cord injury (TSCI) is a devastating event that causes severe sensory and motor impairments as well as autonomic dysfunction in patients, yet relevant clinical biomarkers have not been established. This study aimed to determine the significance of the serum glucose/potassium ratio (GPR) in evaluating TSCI severity and predicting prognosis.

METHODS

An analysis of 520 clinical records of acute TSCI patients from January 2012 to June 2022 was conducted. The relationships between serum GPR and The American Spinal Injury Association Impairment Scale (AIS) grade 6-month post-trauma prognosis and the admission AIS grade were analyzed. To evaluate the discriminatory ability, a receiver operating characteristic curve (ROC) analysis was used. All methods were performed in accordance with the relevant guidelines and regulations.

RESULTS

Based on the initial assessment of AIS grade, 256 (49.2%) patients were categorized into the severe TSCI group (AIS A-B), and there was a significant correlation between the severe TSCI group and serum GPR (p < 0.001). Serum GPR was reduced in an AIS grade-dependent manner (R = - 0.540, p < 0.001). Of the 520 patients, 262 (50.4%) patients were classified as having a poor prognosis according to the AIS grade at discharge. Serum GPR was also reduced in an AIS grade at discharge-dependent manner (R = - 0.599, p < 0.001), and was significantly higher in the poor prognosis group compared to the good prognosis group (p < 0.001). Poor prognosis was significantly associated with sex (p = 0.009), severity of TSCI (p < 0.001), location of TSCI (p < 0.001), surgical decompression (p < 0.018), body temperature (p < 0.001), heart rate (p < 0.001), systolic arterial pressure (SAP) (p < 0.001), diastolic arterial pressure (DAP) (p < 0.001), serum GPR (p < 0.001), serum glucose (p < 0.001), serum potassium (p < 0.001), and white blood cell count (p = 0.003). Multivariate logistic regression analysis showed a significant correlation between poor prognosis and serum GPR (p = 0.023). The ROC analysis showed the area under the curve of serum GPR to be a poor predictor of prognosis in TSCI patients at 0.842 (95% confidence interval, 0.808-0.875).

CONCLUSION

There was a significant relationship between serum GPR and admission injury severity and the 6-month prognosis of acute TSCI patients. Serum GPR serves as a readily available clinical risk factor for predicting the severity and 6-month prognosis of acute traumatic spinal cord injury, which holds potential clinical significance for patients with TSCI.

A Fast-Track Respiratory Protocol for High Cervical Spine Injury: A Case Report

BACKGROUND

Cervical spinal cord injury can greatly affect pulmonary function, resulting in complications, including respiratory failure with prolonged mechanical ventilation, ultimately leading to increased mortality and high health care costs. Weaning from mechanical ventilation is particularly challenging in patients with complete high spinal cord injury.

CASE PRESENTATION

We present the case of a 42-year-old man who suffered a complete cervical 5-6 spinal cord injury following a rollover motor vehicle crash and subsequently developed postoperative pneumonia and severe hypoxemic respiratory failure. He received a novel approach to fast-track respiratory care, including early and aggressive secretion clearance management, moderate pressure level of airway pressure release ventilation, timely transition to spontaneous mode, early tracheostomy and humane care, and high-flow oxygenation via tracheotomy after weaning off the ventilator. As a result, the patient experienced significant improvement in pulmonary function and was successfully liberated from the ventilator within a 2-week period.

CONCLUSION

This case highlights the potential effectiveness of fast-track respiratory care in promoting lung function restoration and expediting liberation from mechanical ventilation in patients with severe hypoxemic respiratory failure following a complete cervical spinal cord injury. However, further research is warranted to validate these findings and expand our understanding in this area.

A new balance assessment tool for quantifying balance impairment in patients with motor incomplete spinal cord injury: Pilot study

OBJECTIVE

This study aimed to quantitatively and objectively evaluate the balance impairment in patients with motor incomplete spinal cord injury (SCI) using a new evaluation tool for balance and to assess its role in comprehensive balance assessment.

DESIGN

Retrospective pilot study.

SETTING

Rehabilitation hospital.

PARTICIPANTS

14 patients with motor incomplete spinal cord injury.

INTERVENTIONS

None.

OUTCOME MEASURES

We retrospectively compared and analyzed the results of 14 patients with motor incomplete SCI who underwent various balance assessments, including the FRA510S test, using correlation.

RESULTS

The agreement between the FRA510S and existing balance assessment was confirmed through Bland-Altman plots; moreover, high degree of agreement was observed in Berg Balance Scale in the eye closed state and in Five Times Sit-to-Stand Test in the eye open state.

CONCLUSIONS

It was confirmed that the FRA510S equipment provides quantitative values for balance function. Balance assessment using the FRA510S, along with neurological, electrophysiological, and clinical tests, may provide comprehensive additional information related to falls and gait rehabilitation in patients with SCI.

Risk factors of AIS C incomplete cervical spinal cord injury for poor prognosis-The significance of anorectal evaluation

BACKGROUND

Although the prognosis of incomplete cervical spinal cord injury (SCI) diagnosed as American Spinal Injury Association Impairment Scale grade C (AIS C) is generally favorable, some patients remain non-ambulatory. The present study explored the clinical factors associated with the non-ambulatory state of AIS C patients.

METHODS

This study was a single-center retrospective observational study. Seventy-three participants with AIS C on admission were enrolled and divided into two groups according to ambulatory ability after one year. Prognostic factors of SCI were compared in ambulatory (A-group) and non-ambulatory participants (NA-group). Univariable and multivariable logistic regression analyses were performed on demographic information, medical history, mechanism of injury, presence of fracture, ASIA motor scores (MS) of the extremities, neurological findings, including an anorectal examination on admission, and imaging findings.

RESULTS

Forty-one patients were included in the A-group and 32 in the NA-group. Univariable analysis revealed that the following factors were related to poor outcomes (p < 0.05): older age, history of cerebrovascular disorder, impairment/absence of S4-5 sensory score, deep anal pressure (DAP) (-), voluntary anal contraction (VAC) (-), anorectal tone (-), anal wink reflex (-), and low MS of the upper and lower extremities. In the multivariable analysis using age, presence or absence of sacral abnormality, and history of cerebrovascular disorders (adjusted for these three factors), older age and presence of sacral abnormality on admission were independent risk factors for a non-ambulatory state at the 1-year follow-up.

CONCLUSIONS

Incomplete AIS C SCI individuals with older age and/or impairment of anorectal examination could remain non-ambulatory at 1-year follow-up.

Central cord syndrome definitions, variations and limitations

Central cord syndrome (CCS) is the most common, yet most controversial, among the different spinal cord injury (SCI) incomplete syndromes. Since its original description in 1954, many variations have been described while maintaining the core characteristic of disproportionate weakness in the upper extremities compared to the lower extremities. Several definitions have been proposed in an attempt to quantify this difference, including a widely accepted criterion of ≥10 motor points in favor of the lower extremities. Nevertheless, recent reports have recommended revisiting the terminology and criteria of CCS as existing definitions do not capture the entire essence of the syndrome. Due to methodological differences, the full extent of CCS is not known, and a large variation in prevalence has been described. This review classifies the different definitions of CCS and describes some inherent limitations, highlighting the need for universal quantifiable criteria.

Performance of the Dutch clinical prediction rule for the ambulation outcome after spinal cord injury in a middle-income country clinical setting: an external validation study in the Thai retrospective cohort

OBJECTIVE

To perform external geographic and domain validation of the clinical prediction rule (CPR) of the ambulation outcome of patients with traumatic spinal cord injury (SCI) originally developed by van Middendorp, et al. (2011) in Thais with traumatic and non-traumatic SCI.

STUDY DESIGN

Retrospective cohort study.

SETTING

A tertiary rehabilitation facility in Chiang Mai, Thailand.

METHODS

A validation data set, including predictive (age and four neurological variables) and outcome (ambulation status) parameters was retrospectively collected from medical records of patients with traumatic and non-traumatic SCI admitted between December 2007 and December 2019. The performance of the original model was evaluated in both discrimination and calibration aspects, using an area under the receiver-operating characteristic curve (auROC) and calibration curves, respectively.

RESULTS

Three hundred and thirty-three patients with SCI were included in the validation set. The prevalence of ambulators was 59% (197 of 333 participants). An auROC of 0.93 (95% CI 0.90-0.96) indicated excellent discrimination whereas the calibration curve demonstrated underestimation, especially in patients with AIS grade D. Performance of the CPR was decreased but acceptable in patients with non-traumatic SCI.

CONCLUSIONS

Our external validation study demonstrated excellent discrimination but slightly underestimated calibration of the CPR of ambulation outcome after SCI. Regardless of the geographic and etiologic background of the population, the Dutch CPR could be applied to predict the ambulation outcome in patients with SCI.

[Initial Medical Care for Spinal Injury]

Neurosurgeons who treat head traumas often encounter cervical spinal injuries. They should be aware of the neurological symptoms, the severity of the symptoms, and the imaging features of cervical injuries. When surgery is required, fixation is often performed.

Machine learning for the prediction of postoperative nosocomial pulmonary infection in patients with spinal cord injury

PURPOSE

The purpose of this study was to establish the best prediction model for postoperative nosocomial pulmonary infection through machine learning (ML) and assist physicians to make accurate diagnosis and treatment decisions.

METHODS

Patients with spinal cord injury (SCI) who admitted to a general hospital between July 2014 and April 2022 were included in this study. The data were segmented according to the ratio of seven to three, 70% were randomly selected to train the model, and the other 30% were used for testing. We used LASSO regression to screen the variables, and the selected variables were used in the construction of six different ML models. Shapley additive explanations and permutation importance were used to explain the output of the ML models. Finally, sensitivity, specificity, accuracy and area under receiver operating characteristic curve (AUC) were used as the evaluation index of the model.

RESULTS

A total of 870 patients were enrolled in this study, of whom 98 (11.26%) developed pulmonary infection. Seven variables were used for ML model construction and multivariate logistic regression analysis. Among these variables, age, ASIA scale and tracheotomy were found to be the independent risk factors for postoperative nosocomial pulmonary infection in SCI patients. Meanwhile, the prediction model based on RF algorithm performed best in the training and test sets. (AUC = 0.721, accuracy = 0.664, sensitivity = 0.694, specificity = 0.656).

CONCLUSION

Age, ASIA scale and tracheotomy were the independent risk factors of postoperative nosocomial pulmonary infection in SCI. The prediction model based on RF algorithm had the best performance.

[Rehabilitation after Spinal Cord Injury : Current trends and principles]

Traumatic and non traumatic spinal cord injury are rare and an orphan disease in comparison to common diseases. Those affected represent a very special patient population in the treatment even at the site of the accident and in emergency medicine and require a high level of professional expertise. The rehabilitation with the complexity of a spinal cord injury can only succeed with a multiprofessional team that is less focused on the often similar diagnoses according to the International Classification of Diseases (ICD) but on functional disorders and associated activity impairments. Only then the best possible integration and participation/inclusion in sociocultural and professional life can be achieved. In addition to the importance of classical physiotherapy and occupational therapy, this article highlights important but often missing team players, such as neurourology and electrical stimulation. In addition, the problems of frequent and some less recognized complications, such as autonomic dysfunction and the benefits of airway management are highlighted. For a comprehensive overview of rehabilitation in spinal cord injury, reference textbooks and guidelines are recommended that are cited in the text.

Construct Validity of the Gait Deviation Index for People With Incomplete Spinal Cord Injury (GDI-SCI)

BACKGROUND

The Gait Deviation Index for Spinal Cord Injury (SCI-GDI) was recently proposed as a dimensionless multivariate kinematic measure based on 21 gait features derived from 3-dimensional kinematic data which quantifies gait impairment of adult population with incomplete spinal cord injury (iSCI) relative to the normative gait of a healthy group. Nevertheless, no validity studies of the SCI-GDI have been published to date.

OBJECTIVE

To assess the construct validity of the SCI-GDI in adult population following iSCI. Methods. SCI-GDI data were obtained from a sample of 50 healthy volunteers and 35 adults with iSCI. iSCI group was also assessed with the following measures: 10-Meter Walk Test (10MWT) at both self-selected (SS) and maximum speeds, Timed Up and Go Test (TUGT), SS and maximum levels of the Walking Index for Spinal Cord Injury (WISCI) II, mobility items of the Spinal Cord Independence Measure III (SCIM IIIIOMob), Lower Extremity Motor Score (LEMS), and Modified Ashworth Scale (MAS). Spearman's correlation coefficient was used to investigate the relationship with the SCI-GDI.

RESULTS

SCI-GDI shows strong correlation with the 10MWT (r ≥ -.716) and good correlation with LEMS (r = .638), TUGT (r = -.582), SS WISCI II levels (r = .521), and SCIM IIIIOMob (r = .501). No significant correlations were found with maximum WISCI II levels and MAS (P > .006).

CONCLUSIONS

Construct validity of the SCI-GDI was demonstrated with the 10MWT, TUGT, LEMS, SCIM IIIIOMob, and SS WISCI II levels for independently walking adults with iSCI. Future work will include assessing the psychometric characteristics with a more heterogeneous sample, also considering the pediatric population.

Interrater reliability of the Standing and Walking Assessment Tool for spinal cord injury

STUDY DESIGN

Psychometric study.

OBJECTIVES

The Standing and Walking Assessment Tool (SWAT) is a standardized approach to the evaluation of standing and walking capacity following traumatic spinal cord injury (tSCI) in Canada. The SWAT classifies individuals with a tSCI into 12 stages of standing and walking capacity that are paired with well-established outcome measures, such as the Berg Balance Scale and 10-m Walk Test. Prior research has demonstrated the validity and responsiveness of the SWAT stages; however, the reliability remains unknown. The objective of this study was to evaluate the interrater reliability of the SWAT stages.

SETTING

Inpatient units of two Canadian rehabilitation hospitals.

METHODS

Adults with sub-acute tSCI were recruited. SWAT stage was evaluated for each participant by two physical therapists separately. The two therapists aimed to complete the evaluations within one day of each other. To evaluate interrater reliability, the percentage agreement between the SWAT stages rated by the two physical therapists was calculated, along with a linear weighted kappa statistic with a 95% CI.

RESULTS

Forty-five individuals with sub-acute tSCI (36 males, 9 females, mean (SD) age of 54.8 (17.9) years) participated. The percentage agreement in SWAT stages between the two physical therapists was 75.6%. A kappa statistic of 0.93 with a 95% CI, 0.81-1.05 was obtained. In cases where therapists disagreed (18% of participants), therapists differed by 1-2 stages only.

CONCLUSIONS

The SWAT stages have high interrater reliability, providing further support for the use of the SWAT in rehabilitation practice in Canada.

Can the electrically stimulated manual muscle test differentiate upper from lower motor neuron injury in persons with acute SCI?

OBJECTIVE

To determine if the motor response on the stimulated manual muscle test (SMMT) in muscles with a grade 0 motor score on the manual muscle test (MMT) can differentiate lower motor neuron (LMN) from upper motor neuron (UMN) injury based on the presence of spontaneous activity (SA) with needle EMG.

DESIGN

Prospective Study.

PARTICIPANTS/METHODS

Twenty-one subjects with acute traumatic cervical SCI.

METHODS

An upper extremity International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) evaluation was completed on all subjects. A needle EMG and an electrically stimulated manual muscle test (SMMT) were completed on all key upper extremity muscles with a MMT motor score of zero.

RESULTS

The MMT, SMMT and Needle EMG were done on 77 muscles. The SMMT motor score was 0 on 10 muscles and >1 on 67 muscles. The needle EMG identified spontaneous activity (SA) in 55/77 muscles. Seventy percent (7/10) of the muscles with MMT and SMMT motor score of zero demonstrated SA on EMG. Seventy-two percent (48/67) of the muscles with MMT motor score = 0 and SMMT motor score ≥1 demonstrated SA on EMG.

CONCLUSION

In our study, 70% of the muscles with a SMMT motor response of zero and 72% of the muscles with a SMMT motor response greater than or equal to one demonstrated SA on EMG. The use of the SMMT as a clinical measure to differentiate LMN from UMN integrity may be limited when applied.

Machine learning to develop a predictive model of pressure injury in persons with spinal cord injury

STUDY DESIGN

A 5-year longitudinal, retrospective, cohort study.

OBJECTIVES

Develop a prediction model based on electronic health record (EHR) data to identify veterans with spinal cord injury/diseases (SCI/D) at highest risk for new pressure injuries (PIs).

SETTING

Structured (coded) and text EHR data, for veterans with SCI/D treated in a VHA SCI/D Center between October 1, 2008, and September 30, 2013.

METHODS

A total of 4709 veterans were available for analysis after randomly selecting 175 to act as a validation (gold standard) sample. Machine learning models were created using ten-fold cross validation and three techniques: (1) two-step logistic regression; (2) regression model employing adaptive LASSO; (3) and gradient boosting. Models based on each method were compared using area under the receiver-operating curve (AUC) analysis.

RESULTS

The AUC value for the gradient boosting model was 0.62 (95% CI = 0.54-0.70), for the logistic regression model it was 0.67 (95% CI = 0.59-0.75), and for the adaptive LASSO model it was 0.72 (95% CI = 0.65-80). Based on these results, the adaptive LASSO model was chosen for interpretation. The strongest predictors of new PI cases were having fewer total days in the hospital in the year before the annual exam, higher vs. lower weight and most severe vs. less severe grade of injury based on the American Spinal Cord Injury Association (ASIA) Impairment Scale.

CONCLUSIONS

While the analyses resulted in a potentially useful predictive model, clinical implications were limited because modifiable risk factors were absent in the models.

Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial

BACKGROUND

Cervical traumatic spinal cord injury is a devastating condition. Current management (bony decompression) may be inadequate as after acute severe TSCI, the swollen spinal cord may become compressed against the surrounding tough membrane, the dura. DISCUS will test the hypothesis that, after acute, severe traumatic cervical spinal cord injury, the addition of dural decompression to bony decompression improves muscle strength in the limbs at 6 months, compared with bony decompression alone.

METHODS

This is a prospective, phase III, multicenter, randomized controlled superiority trial. We aim to recruit 222 adults with acute, severe, traumatic cervical spinal cord injury with an American Spinal Injury Association Impairment Scale grade A, B, or C who will be randomized 1:1 to undergo bony decompression alone or bony decompression with duroplasty. Patients and outcome assessors are blinded to study arm. The primary outcome is change in the motor score at 6 months vs. admission; secondary outcomes assess function (grasp, walking, urinary + anal sphincters), quality of life, complications, need for further surgery, and mortality, at 6 months and 12 months from randomization. A subgroup of at least 50 patients (25/arm) also has observational monitoring from the injury site using a pressure probe (intraspinal pressure, spinal cord perfusion pressure) and/or microdialysis catheter (cord metabolism: tissue glucose, lactate, pyruvate, lactate to pyruvate ratio, glutamate, glycerol; cord inflammation: tissue chemokines/cytokines). Patients are recruited from the UK and internationally, with UK recruitment supported by an integrated QuinteT recruitment intervention to optimize recruitment and informed consent processes. Estimated study duration is 72 months (6 months set-up, 48 months recruitment, 12 months to complete follow-up, 6 months data analysis and reporting results).

DISCUSSION

We anticipate that the addition of duroplasty to standard of care will improve muscle strength; this has benefits for patients and carers, as well as substantial gains for health services and society including economic implications. If the addition of duroplasty to standard treatment is beneficial, it is anticipated that duroplasty will become standard of care.

TRIAL REGISTRATION

IRAS: 292031 (England, Wales, Northern Ireland) - Registration date: 24 May 2021, 296518 (Scotland), ISRCTN: 25573423 (Registration date: 2 June 2021); ClinicalTrials.gov number : NCT04936620 (Registration date: 21 June 2021); NIHR CRN 48627 (Registration date: 24 May 2021).

Positive predictive value of a sepsis-screening protocol for patients with tetraplegia

OBJECTIVE

To determine the positive predictive value (PPV) of a sepsis-screening protocol in patients with cervical spinal cord injury (SCI).

DESIGN/METHOD

Retrospective review of all patients with cervical SCI who screened positive for two or more systemic inflammatory response syndrome (SIRS) criteria while hospitalized in acute care or inpatient rehabilitation units over a 3.5-year period. Sepsis was defined by the occurrence of (1) any culture order followed by an intravenous (IV) antibiotic within 72 hours or (2) an IV antimicrobial followed by a culture order within 24 hours.

RESULTS

A total of 134 patients screened positive for two or more SIRS criteria. Of these, 36 patients (26.9%) were diagnosed with sepsis. Factors associated with a true-positive SIRS screen on multivariable analysis included American Spinal Injury Association Impairment Scale (AIS) grade A-C (vs. D; p < .001). The PPV of the screen was 38% in patients with AIS A-C and 9% in patients with AIS D. Altered mental status (AMS) was strongly associated with a diagnosis of sepsis; 16 of 18 (88.9%) of those with AMS had sepsis (p < .001). Age, sex, and neurologic level of injury were not associated with true-positive screening. For patients with new SCI, the first true-positive screen occurred a median of 31 days post-injury. The most common SIRS criteria combinations in patients with true-positive screens were elevated heart rate and either abnormal white blood cell count (43% of true positives) or abnormal temperature (26% of true positives). Abnormally low body temperature (<36°C) contributed to false-positive screening for 10 of 38 (26%) AIS D patients who screened positive.

CONCLUSION

Sepsis screening using SIRS criteria in hospitalized patients with tetraplegia has a PPV of 26.9%; it is significantly higher in patients with AIS A-C versus D injuries. AMS, when combined with a positive SIRS screening, is strongly associated with sepsis.

Diagnosis and Management of Cardiovascular Risk in Individuals With Spinal Cord Injury: A Narrative Review

More than 16 000 Americans experience spinal cord injury (SCI), resulting in chronic disability and other secondary sequelae, each year. Improvements in acute medical management have increased life expectancy. Cardiovascular disease is a leading cause of death in this population, and seems to occur earlier in individuals with SCI compared with the general population. People with SCI experience a high burden of traditional cardiovascular disease risk factors, including dyslipidemia and diabetes, and demonstrate anatomic, metabolic, and physiologic changes alongside stark reductions in physical activity after injury. They also experience multiple, complex barriers to care relating to disability and, in many cases, compounding effects of intersecting racial and socioeconomic health inequities. Given this combination of risk factors, some investigators have proposed that people with SCI are at increased risk for cardiovascular disease, beyond that associated with traditional risk factors, and SCI could be considered a risk-enhancing factor, analogous to other risk-enhancing factors defined by the 2019 American Heart Association/American College of Cardiology Primary Prevention Guidelines. However, more research is needed in this population to clarify the role of traditional risk factors, novel risk factors, health care access, social determinants of health, and intersectionality of disability, race, and socioeconomic status. There is an urgent need for primary care physicians and cardiologists to have awareness of the importance of timely diagnosis and management of cardiac risk factors for people with SCI.

Spinal cord tethering and syringomyelia after trauma: impact of age and surgical outcome

Posttraumatic spinal cord tethering and syringomyelia frequently lead to progressive neurological loss. Although several studies demonstrated favourable outcome following spinal cord detethering with/without shunting, additional research is required as no clear consensus exists over the ideal treatment strategy and knowledge about prognostic demographic determinants is currently limited. In this investigation, we retrospectively investigated 67 patients (56 men, 11 women) who were surgically treated and followed for symptomatic spinal cord tethering and syringomyelia from 2012 to 2022 at our center. Age (B-coefficient 0.396) and severity of trauma to the spinal cord (B-coefficient - 0.462) have been identified as independent predictors for the rate of development of symptomatic spinal cord tethering and syringomyelia (p < 0.001). Following untethering surgery including expansion duraplasty with/without shunting, 65.9% of patients demonstrated an improvement of neurological loss (p < 0.001) whereas 50.0% of patients displayed amelioration of spasticity and/or neuropathic pain (p < 0.001). Conclusively, active screening for symptomatic spinal cord tethering and syringomyelia, particularly in younger patients with severe spinal trauma, is crucial as surgical untethering with/without shunting is able to achieve favourable clinical outcomes. This knowledge may enable clinicians to tailor treatment strategies in spinal cord injury patients suffering from progressive neurological loss towards a more optimal and personalized patient care.

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.