Traumatic Cervical Spinal Cord Research Articles

Electrostimulation as a method of correction of respiratory disorders in patients with cervical spinal cord injury: A review

BACKGROUND:Patients with cervical spinal cord injury have the highest risk of developing respiratory dysfunction and associated complications such as pneumonia, atelectasis, and respiratory failure. Respiratory dysfunction is the leading cause of comorbid, somatic, and infectious pathology, and mortality following traumatic cervical spinal cord injuries. Mechanical ventilation of the lungs is the standard treatment for such patients; however, it is associated with atrophy and diaphragm dysfunction.
 AIM:To analyze literature data on the use of electrical stimulation techniques of the spinal cord, nerves, and muscles for the correction of respiratory disorders in patients with cervical spinal cord trauma.
 MATERIALS AND METHODS:This study presented the results of the search and analysis of peer-reviewed articles that examined the effects of various electrical stimulation techniques on respiratory function in patients with cervical spinal cord injury. ScienceDirect, Google Scholar, and PubMed were searched from 2000 to 2022.
 RESULTS:Currently, new treatment options are available for patients with tetraplegia, with reduced ventilatory function. Many studies have shown the positive effect of electrostimulation techniques on ventilatory function such as reduced time spent on mechanical ventilation and reduced incidence of infections and other lung complications.
 CONCLUSIONS:Electrical stimulation promotes neuromuscular plasticity and results in improved spontaneous activation of the diaphragm and respiratory muscles. Electrostimulation inacomprehensive rehabilitation program of patients with traumatic spinal cord injuries at the cervical level is currently employed to promote weaning from mechanical ventilation and prevent accompanying complications such as respiratory failure, pneumonia, and atelectasis. In addition to invasive electrical stimulation of the diaphragmatic nerve and/or spinal cord, existing less invasive electrostimulation techniques require further investigation in patients with spinal cord injury and respiratory dysfunction.

Neurological Outcome of Early versus Late Surgery Following Cervical Spinal Cord Injury

Background There are numerous retrospective studies and a few prospective studies to determine the neurologic outcome after early versus late surgical treatment for cervical spinal cord injury.
 Objective To compare the neurological outcome between early (within 72 hours after injury) and delayed (≥ 72 hours after injury) surgery in patients with cervical spinal injury.
 Method This is a retrospective analysis of the neurological outcome of early versus late surgery following cervical spinal cord trauma. Patients meeting appropriate inclusion criteria were divided into an early or a late surgical treatment group. The neurologic outcomes and other complications were recorded up to six months of follow-up.
 Result Overall, there was a significant difference in neurological status at presentation and at follow-up (p < 0.001). However, there was no statistically significant difference between the early versus late surgery groups (p-value 0.261) in terms of neurological outcome. Complications were found to be higher among those undergoing posterior surgical approach (OR = 23.75; 95% CI 2.65, 212.98) than those with anterior or combined approach (p=0.005). However, multivariate analysis of these variables failed to show any statistically significant difference between the two groups.
 Conclusion The timing of surgery does not alter the neurological outcomes and the development of complications significantly. The American Spinal Cord Injury Association (ASIA) status at the time of presentation is found to be the single most important factor correlating with the neurological outcome.

Is Blood Loss Greater in Elderly Patients under Antiplatelet or Anticoagulant Medication for Cervical Spine Injury Surgery? A Japanese Multicenter Survey.

Introduction In elderly patients with cervical spinal cord injury, comorbidities such as cardiovascular and cerebrovascular diseases are common, with frequent administration of antiplatelet/anticoagulant (APAC) drugs. Such patients may bleed easily or unexpectedly during surgery despite prior withdrawal of APAC medication. Few reports have examined the precise relationship between intraoperative blood loss and history of APAC use regarding surgery for cervical spine injury in the elderly. The present multicenter database survey aimed to answer the question of whether the use of APAC drugs affected the amount of intraoperative blood loss in elderly patients with cervical spinal cord trauma. Methods The case histories of 1512 patients with cervical spine injury at 33 institutes were retrospectively reviewed. After excluding cases without spinal surgery or known blood loss volume, 797 patients were enrolled. Blood volume loss was the outcome of interest. We calculated propensity scores using the inverse probability of treatment weighting (IPTW) method. As an alternative sensitivity analysis, linear mixed model analyses were conducted as well. Results Of the 776 patients (mean age: 75.1±6.4 years) eligible for IPTW calculation, 157 (20.2%) were taking APAC medications before the injury. After weighting, mean estimated blood loss was 204 mL for non-APAC patients and 215 mL for APAC patients. APAC use in elderly patients was not significantly associated with surgical blood loss according to the IPTW method with propensity scoring or linear mixed model analyses. Thus, it appeared possible to perform surgery expecting comparable blood loss in APAC and non-APAC cases. Conclusions This multicenter study revealed no significant increase in surgical blood loss in elderly patients with cervical trauma taking APAC drugs. Surgeons may be able to prioritize patient background, complications, and preexisting conditions over APAC use before injury when examining the surgical indications for cervical spine trauma in the elderly.

Combination of a Gellan Gum-Based Hydrogel With Cell Therapy for the Treatment of Cervical Spinal Cord Injury.

Cervical spinal cord trauma represents more than half of the spinal cord injury (SCI) cases worldwide. Respiratory compromise, as well as severe limb motor deficits, are among the main consequences of cervical lesions. In the present work, a Gellan Gum (GG)-based hydrogel modified with GRGDS peptide, together with adipose tissue-derived stem/stromal cells (ASCs) and olfactory ensheathing cells (OECs), was used as a therapeutic strategy after a C2 hemisection SCI in rats. Hydrogel or cells alone, and a group without treatment, were also tested. Four weeks after injury, compound muscle action potentials (CMAPs) were performed to assess functional phrenic motor neuron (PhMN) innervation of the diaphragm; no differences were observed amongst groups, confirming that the PhMN pool located between C3 and C5 was not affected by the C2 injury or by the treatments. In the same line, the vast majority of diaphragmatic neuromuscular junctions remained intact. Five weeks post-injury, inspiratory bursting of the affected ipsilateral hemidiaphragm was evaluated through EMG recordings of dorsal, medial and ventral subregions of the muscle. All treatments significantly increased EMG amplitude at the ventral portion in comparison to untreated animals, but only the combinatorial group presented increased EMG amplitude at the medial portion of the hemidiaphragm. No differences were observed in forelimb motor function, neither in markers for axonal regrowth (neuronal tracers), astrogliosis (GFAP) and inflammatory cells (CD68). Moreover, using Von Frey testing of mechanical allodynia, it was possible to find a significant effect of the group combining hydrogel and cells on hypersensitivity; rats with a SCI displayed an increased response of the contralateral forelimb to a normally innocuous mechanical stimulus, but after treatment with the combinatorial therapy this behavior was reverted almost to the levels of uninjured controls. These results suggest that our therapeutic approach may have beneficial effects on both diaphragmatic recovery and sensory function.

The characteristics of cervical spinal cord trauma at a North Tanzanian Referral Hospital: a retrospective hospital based study.

IntroductionSurviving a traumatic cervical Spinal Cord Injury (SCI) has an immense effect on an individual's physical function and independence. It also predisposes them to financial, social, psychological and several medical complications throughout their life. In high-income countries, improved multidisciplinary care has led to better long term outcomes, however in low-income countries, the burden of the condition and its associated mortality remain high. The aim of this study was to illustrate the sociodemographic and clinical characteristics of cervical level Traumatic Spinal Cord Injuries (TSCIs) at Kilimanjaro Christian Medical Centre (KCMC) in northern Tanzania.MethodsThis was a retrospective hospital-based study of 105 cervical TSCI cases admitted to KCMC from January 2012 to December 2016.ResultsWe included 105 patients in the study cohort, with a male preponderance of 86.7%, giving a male-to-female ratio of 6.5:1. The mean age at injury was 44.1 years. Overall, 65.7% were farmers and 69 patients were from within the Kilimanjaro region. Road Traffic Crashes (RTCs) accounted for 47.6% of the injuries, 17.9% had associated injuries, 38.1% sustained complete TSCIs and 45.7% developed secondary complications during the ward stay. The mortality rate before discharge from hospital care was 35.2%.ConclusionThe majority of patients were males from a low socioeconomic background and the most common cause of injury was RTCs. The secondary complication rates and mortality rates before discharge from hospital care are high.

Results of Early Versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: A Single Center Prospective Study

Abstract Objective This study was done with the aim to compare the clinical outcome and patient's quality of life between early (within 24 hours post-injury) versus delayed (after 24 hours to 7 days) surgically treated patients of acute cervical spinal cord injury. The current study was based on the hypothesis that early surgical decompression and fixations in acute cervical spinal cord trauma are safe and are associated with improved outcome as compared with delayed surgical decompression. Methods A total of 54 patients were recruited and divided into early decompression surgery group A (operated within 24 hours of trauma; n = 25) and late/delayed decompression surgery group B (operated between 24 hours and 7 days of trauma; n = 29). The patients in both groups were followed up, and comparative differences noted in the neurological outcome, quality of life, and bony fusion. Results The early surgery group had lesser postoperative complications. In group A, 54.17% patients had 1 American Spinal Injury Association Impairment Scale (AIS) grade improvement, while 29.17% experienced > 2 AIS grade improvement (p = 0.015). In group B, the neurological improvement was 50 and 21.43%, respectively (p = 0.003). There was a significant improvement in the postoperative quality of life scores in early surgery group. Conclusion Early surgery in patients with acute cervical spinal cord injury should be considered strongly in view of the lesser complications, better neurological recovery, and reduced mortality.

Early versus delayed decompression in acute subaxial cervical spinal cord injury: A prospective outcome study at a Level I trauma center from India.

Aims:This study was done with the aim to compare the clinical outcome and patients’ quality of life between early versus delayed surgically treated patients of acute subaxial cervical spinal cord injury. The current study was based on the hypothesis that early surgical decompression and fixations in acute subaxial cervical spinal cord trauma is safe and is associated with improved outcome as compared to delayed surgical decompression.Materials and Methods:A total of 69 patients were recruited and divided into early decompression surgery Group A (operated within 48 h of trauma; n = 23) and late/delayed decompression surgery Group B (operated between 48 h and 7 days of trauma; n = 46). The patients in both groups were followed up, and comparative differences noted in the neurological outcome, quality of life, and bony fusion.Results:The early surgery group spent lesser days in the intensive care unit and hospital (Group A 28.6 vs. Group B 35 days) had lesser postoperative complications (Group A 43% vs. Group B 61%) and a reduced mortality (Group A 30% vs. Group B 45%). In Group A, 38% patients had 1 American Spinal Injury Association (ASIA) grade improvement while 31% experienced >2 ASIA grade improvement. In Group B, the neurological improvement was 27% and 32%, respectively (P = 0.7). There was a significant improvement in the postoperative quality of life scores in both groups.Conclusion:Early surgery in patients with acute subaxial cervical spine injury should be considered strongly in view of the lesser complications, early discharge, and reduced mortality.

Advanced Imaging Techniques in Cervical Spinal Cord Trauma

paper recently published in WORLD NEUROSURGERY contains a very important article by Vedantam et al. that A expands on the use of fractional anisotropy (FA) and diffusion tensor imaging (DTI) in spinal cord injury (SCI). Acute SCI is a condition that carries potentially grave consequences for the patient, the health care system, and society in general. Successful treatment of acute SCI begins with rapid identification and characterization of the injury, and initiation of treatment. Although diagnosis by physical examination remains of the utmost importance, imaging has become a critical and ubiquitous component of assessing patients with acute SCI. Often in the acute trauma setting, computed tomography is the initial imaging of choice due to its low cost, detailed evaluation of bony anatomy, and rapid image acquisition. With a negative computed tomography scan and high clinical suspicion, physicians often rely on magnetic resonance imaging for further delineation of a possible spinal injury. However, recent literature suggests that T2-weighted imaging alone has a low sensitivity for identification of acute myelopathy (2, 5). Furthermore, high signal intensity on T2-weighted images appears in late clinical stages of compression. DTI images of the spinal cord white matter tracts reveal well-organized pathways traveling in different directions, with those oriented in the craniocaudal direction having a higher apparent diffusion coefficient compared with those extending primarily in a transverse direction (12).

Traumatismo da medula espinhal em cães e gatos: estudo prospectivo de 57 casos

O traumatismo da medula espinhal é uma causa comum de disfunção neurológica em cães e gatos. Lesões nestas espécies ocorrem devido a vários tipos de acidentes, podendo ocasionar sequelas que prejudicam o paciente como animais de estimação ou lesões que comprometam a vida. O objetivo principal deste estudo foi a monitoração intensiva de animais com lesão medular atendidos entre 8/2009 e 11/2010 no Hospital Veterinário da Universidade Estadual de Londrina, estudando os fatores epidemiológicos e etiológicos, fatores de risco, segmentos medulares mais afetados, resultados dos tratamentos conservativo ou cirúrgico, relação entre o tempo de atendimento e a recuperação do animal, eficácia e efeitos colaterais do succinato sódico de metilprednisolona, complicações, sequelas e evolução do quadro. Durante este período foram acompanhados 57 animais (48 cães e nove gatos). Observou-se predominância de animais machos (68%) e domiciliados (79%). A principal causa de lesão foi o atropelamento (66%). O tempo entre o trauma e o atendimento foi menos de oito horas em 42% dos casos e mais de um dia em 51%. O segmento medular mais atingido foi o toracolombar (52%). Vinte animais foram submetidos à eutanásia após o atendimento inicial devido ao prognóstico reservado. O tratamento conservativo com repouso e/ou imobilização externa foi realizado em 29 animais e um bom resultado com esta modalidade foi obtida em 72,4% dos casos: houve recuperação funcional total em 17 (58,6%) animais e parcial em quatro (13,8%). Quatro animais não se recuperaram e quatro animais morreram. Oito pacientes foram submetidos ao tratamento cirúrgico, sendo que três animais recuperaram-se, um paciente não apresentou recuperação e quatro morreram ou foram submetidos a eutanásia devido a complicações no trans ou pós-operatório. O tratamento conservativo foi viável, principalmente em cães com lesão medular cervical.

P5.24 Peripheral nerve involvement in patients with traumatic complete cervical and thoracic spinal cord injuries

P5.24 Peripheral nerve involvement in patients with traumatic complete cervical and thoracic spinal cord injuries

Life threatening spinal shock and complete neurological recovery following minor spinal cord trauma in a patient with pre-existing cervical canal stenosis: Case report

Mild to moderate trauma to the spinal cord that is complicated by existing cervical canal stenosis or spondylosis can be a life threatening event. It is against this background that we present a 41 year old male with cervical spinal stenosis who developed marked quadriparesis and respiratory embarrassment following collision with a colleague. He was admitted to the intensive care unit, electively sedated, paralysed and ventilated for a period of 48 hours. During the initial 24 hours of admission, he received methylprednisolone as per the National Acute Spinal Cord Injury Studies (NASCIS) protocol. Forty five hours later he had regained full neurological and respiratory function, allowing extubation and subsequent discharge from the intensive care unit. While patients with cervical spinal cord trauma in a setting of cervical canal stenosis or spondylosis can deteriorate dramatically, early recognition of this condition and prompt management using methylprednisolone, cervical stabilisation and ventilatory support during the initial window of opportunity will enable them make a full recovery.

Stab Wound in the Neck with Injury to the Cervical Cord and Ipsilateral Vertebral Artery: Report of a Case

Stab wounds of the cervical spine with spinal cord and vertebral artery injuries are rare. We report here a case of penetrating cervical spinal cord trauma with ipsilateral vertebral artery injury and incomplete spinal injury. After appropriate surgical management, the patient has functional recovery. With the advent of radiologic imaging, early recognition can be readily made to identify the extent of damage. The choice of treatment is controversial. Adequate management may result in favorable outcome in patients with incomplete spinal injury. A high index of suspicion for this kind of rare injury is imperative in the management of traumatized patients.

Acute Care in Cervical Spinal Cord Trauma with Long-Term Benefit: A Review

Abstract Spinal cord injury involves three phases. In the first, trauma events deliver direct pressure to the cervical spine, which may compress, dislocate, or fracture the spine, and in turn compress, crush, or transect the spinal cord. In the process, local neurons are destroyed and sensory and motor pathways can be severed. In the second phase, acute tissue responses, bleeding, and inflammation rapidly and radically change the physical and chemical conditions at the wound site. Finally, days, weeks, and months after the initial trauma, chronic post-injury processes reform the wound site into a lasting scar that impedes regeneration of spinal cord pathways. A major goal of current spinal cord injury research should be rapid and lasting inhibition of acute and chronic tissue reactions in the spinal cord wound that lead to a growth-inhibiting environment and diverting these reactions toward conditions that favor regeneration of severed spinal pathways. Here, we consider experimental strategies that could form the basis for treatments that can be rapidly administered after trauma and provides lasting benefit to spinal cord regeneration and rehabilitation.

Reversible posterior leukoencephalopathy in a patient with autonomic dysreflexia: a case report

Case report. To report a case of reversible posterior leukoencephalopathy (RPL) in a patient with traumatic cervical spinal cord injury. Neurologic inpatient Unit, Lahey Clinic, Burlington, MA, USA. A 55-year-old woman with a residual spastic quadriparesis from a traumatic C5-C6 fracture developed, during an assisted cough maneuver, sudden severe headache followed by cortical blindness in the setting of high blood pressure. Magnetic resonance imaging (MRI) showed T2 hyperintensities in the subcortical white matter of both medial occipital lobes and left post-central gyrus. Elevation of the head of the bed during subsequent cough maneuvers with occasional use of sublingual nifedipine prevented further episodes of acute arterial hypertension and development of new symptoms. Repeat MRI of the head done one month later was normal. RPL can occur in the setting of autonomic dysreflexia in patients with traumatic cervical cord injury. The prompt recognition of this syndrome is of importance to prevent further morbidity and mortality in patients with spinal cord injury.

Traumatic cervical cord injury at C3-4 without radiographic abnormalities: correlation of magnetic resonance findings with clinical features and outcome.

Clinical features and outcomes of 43 patients at the Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama, were studied prospectively. These patients were not found to have radiographic abnormalities but magnetic resonance images showed acute cervical spinal cord trauma at the C3-4 disc level. Magnetic resonance images were analysed at presentation (immediately after the injury) and subsequent follow-up visits (at subacute and chronic stages, respectively) in an attempt to correlate imaging findings to clinical features and outcomes, respectively. The injury mechanism was usually a hyperextension of the cervical spine. The level of neurological involvement was assessed in 9 patients with complete tetraplegia: the motor level was C5 in 6 patients and C4 in 3, whereas the sensory level was C5 in 7 patients, C4 in one, and C3 in one. Respiratory dysfunction in patients with severe paralysis, or numb and clumsy hands in patients with incomplete paralysis were the characteristic clinical features of cervical spinal cord injury at these lesions. Three patterns of signal change on magnetic resonance images were observed in patients with spinal cord injury at C3-4. A low-intensity area on T2-weighted images in the acute stage indicated a poor prognosis, while a high-intensity area at 2 to 3 weeks after injury indicated some degree of permanent paralysis. The serial signal changes of magnetic resonance images and the clinical severity or outcome seemed to be well correlated.

Quantitative Assessment of Respiratory Function Following Contusion Injury of the Cervical Spinal Cord

In this study, we describe a new method for quantitative assessment of phrenic inspiratory motor activity in two models of cervical spinal cord contusion injury. Anesthetized rats received contusion injury either to the descending bulbospinal respiratory pathway on one side of the spinal cord alone (C2lateralized contusion) or to both the descending pathway, as well as the phrenic motoneuron pool bilaterally (C4/C5midline contusion). Following injury, respiratory-associated phrenic nerve motor activity was recorded under standardized and then asphyxic conditions. Phrenic nerve efferent activity was rectified, integrated, and quantitated by determining the mean area under the integrated neurograms. The mean integrated area of the four inspiratory bursts recorded just before turning off the ventilator (to induce asphyxia) was determined and divided by the integrated area under the single largest respiratory burst recorded during asphyxia. This latter value was taken as the maximal inspiratory motor response that the rat was capable of generating during respiratory stress. Thus, a percentage of the maximal inspiratory motor drive was established for breathing in control and injured rats under standardized conditions. The results indicate that noninjured rats use 52 ± 1.8% of maximal inspiratory motor drive under standardized conditions. In C2-contused rats, the results showed that while the percentage of maximal inspiratory motor drive on the noncontused side was similar to the control (55±4.1%), it was increased on the contused side (78±2.6%). In C4/5lesions, the results indicate that this percentage was increased on both sides (77±4.4%). The results show the feasibility for performing quantitative evaluation of respiratory dysfunction in an animal model of cervical contusion injury. These findings lend to further development of this model for investigations of neuroplasticity and/or therapeutic interventions directed at ameliorating respiratory compromise following cervical spinal cord trauma.

Transient Increase of Parasympathetic Tone in Patients with Cervical Spinal Cord Trauma

Transient Increase of Parasympathetic Tone in Patients with Cervical Spinal Cord Trauma

Frequency of intra-abdominal injury in cases of blunt trauma to the cervical spinal cord.

Historically, early management of the blunt trauma victim with hemodynamic instability and cervical spinal cord injury has been hampered by the physician's inability to perform an accurate physical examination. Invasive and time-consuming diagnostic tests are often run to check for the presence of occult intra-abdominal injuries. For this reason, we decided to study these patients by reviewing a clinical registry to assess the frequency of intra-abdominal injuries in cases of cervical spinal cord trauma. We hypothesized that intra-abdominal injury would occur infrequently in cases of blunt trauma to the cervical spinal cord. In fact, data from the Maryland Institute for Emergency Medical Services Systems revealed that blunt trauma victims with cervical cord injury rarely (2.6%) sustained intra-abdominal wounds. Further analysis of this population revealed that specific mechanisms of trauma and the presence of hemodynamic instability and other major injuries were factors strongly associated with occult intra-abdominal injury. In light of these findings, we have outlined a protocol for management of these patients that is geared toward more rapid stabilization of the injured spinal column.

Forelimb motor performance following cervical spinal cord contusion injury in the rat

The purpose of this study was to examine the degree, persistence, and nature of forelimb behavioral deficits following cervical spinal cord contusion injury in the rat. Forelimb reaching and pellet retrieval, forehead adhesive sticker removal, and vibrissae-induced forelimb placing were examined for 16 weeks following a weight-drop injury (10.0 g-2.5 cm) at the C 4–C 5 spinal level. Nine of 13 rats studied were unable to perform the pellet retrieval task due to pronounced forelimb extension hypometria. However, these animals did carry out the forehead sticker removal and vibrissae-induced placing tasks. Therefore, the loss of reaching ability related to pellet retrieval was not due to generalized paralysis. This interpretation was further supported by evaluation of the rostrocaudal extent of relative motoneuron loss from 1-mm divisions through the lesion zone. The extent of motoneuron pathology ranged from 2 to 6 mm but was largely confined to the C 4–C 5 spinal segments. Morphometric assessments of axonal sparing revealed that pellet retrieval performance during the last month of observation was significantly correlated with fiber sparing in the dorsal columns and ventral white matter, whereas no significant correlation could be demonstrated with regard to dorsolateral white matter. While there were no conspicuous differences in qualitative assessments of damage to interneuron pools (i.e., laminae V to VII) between the nonreaching and retrieval-recovered rats, the possibility of combined white and gray matter pathology contributing to this deficit still exists. These initial findings thus demonstrate that the weight-drop contusion injury model can be adopted to studies of cervical spinal cord trauma in the rat. Such lesions yield permanent deficits in forelimb function lending to future studies of possible therapeutic interventions. Furthermore, performance deficits observed at 1 week postinjury in the placing and forehead sticker removal tasks can be predictive of any potential for long-range spontaneous recovery in pellet retrieval ability.

Diencephalic syndrome following cervical spinal cord trauma.

The authors discuss about five cases of diabetes insipidus observed in patients affected by traumatic cervical spine fractures and/or dislocations, without either evident lesions of the cerebral structures at CT scan examination, or important craniocerebral trauma. In all patients polyuria and hyperthermia arose some days after the traumatic accident and regressed spontaneously or after exogeneous vasopressin administration. Vasopressin urinary levels confirmed the presence of a true diabetes insipidus, the origin of which is in largely obscure. A central medullary vasopressin mediated pathway, demonstrated only in experimental animals, may be responsible for such a finding.