Injury Association Impairment Scale Grade Research Articles

Clinical Characteristics and Outcomes of Patients with Traumatic Spinal Cord Injury at a Tertiary Care Center in the Philippines

Traumatic Spinal Cord Injury (TSCI) is a devastating condition which may result to lifelong complications that impact patient outcome and quality of life. Due to the increasing incidence of TSCI, it is important to comprehend the extent of this condition in terms of demographics, mechanism, and degree of disability to raise awareness and develop strategies in approaching care for these patients. There is lack of information regarding data on TSCI in Southeast Asia, especially in the Philippines. This study aims to describe the clinical characteristics and outcomes of patients with TSCI in a tertiary care hospital in the Philippines. This is a retrospective descriptive cohort study in individuals aged 18 years and above, who were admitted for TSCI in a Philippine tertiary care hospital between 2022 and 2023. Of 118 admitted patients, 100 patients were included in the study. The data were obtained from the review of patients' medical records. Demographics of TSCI, mechanism, presenting clinical characteristics, American Spinal Injury Association Impairment Scale (AIS) grade, radiographic findings, outcomes, and complications were analyzed. A total of 100 patients with TSCI were included in the study. The mean age of the patients is 43.4 ± 15.8 in years with males being predominant, 92%. The most common mechanism of injury was motor vehicular crash (MVC), 68%. followed by fall, 22%. Majority of patients were graded AIS C, 38% on admission. The most common level of injury is cervical, 70%. The usual complications recorded were sacral ulcer 28%, and Hospital Acquired Pneumonia (HAP), 20%. TSCI is common in young adult males with MVC as mechanism of injury. Majority of patients in the study had incomplete spinal cord injury (AIS C), with the cervical region as the most common level. The recorded mean length of hospital stay was 1-2 weeks. The most common co-occurring extra spinal injury was TBI. Upon discharge, majority developed sacral ulcer and HAP, with stable neurologic status. A multi-center prospective data collection with a larger population and inclusion of more variables are necessary to formulate a regression model and establish the factors that improve the outcomes of TSCI.

469 Recovery Rate of Motor Function During Rehabilitation After Traumatic Cervical Spinal Cord Injury Predicts Functional Status at Years 1 and 5 After Surgery: A Multicenter, Longitudinal Cohort Study

INTRODUCTION: Traumatic spinal cord injury (SCI) is a devastating condition. Early surgical decompression and rehabilitative efforts in cervical SCI patients has been shown to improve neurological outcomes. METHODS: A longitudinal, retrospective cohort study was conducted from the multicenter Spinal Cord Injury Model Systems (SCIMS) database on patients with motor Functional Independence Measure (FIM) scores at admission to and discharge from rehabilitation, year 1, and year 5. Patients who underwent surgical decompression with neurological levels of injury limited to the cervical region and those with American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades of A and B were included. The FIM score was utilized to calculate changes in motor FIM scores over each respective time period. Multivariate logistical regression was performed to identify longitudinal predictors associated with functional independence. RESULTS: A total of 351 patients met the inclusion criteria. The change in motor FIM score during the inpatient rehab period was a significant predictor of achieving FI at 1 and 5 years (year 1: aOR = 15.6, 95% CI 3.94-77.6, p < 0.0001; year 5: aOR = 28.0, 95% CI 6.13-173.6, p < 0.0001). For patients not achieving FI at year 1, the change in motor FIM score during inpatient rehab was a greater predictor of FI at year 5 (aOR = 64.7, 95% CI 5.15-1717.3, p = 0.0004). CONCLUSIONS: Inpatient rehabilitation efforts may lead to greater long-term functional status and carry emphasized importance for patients who do not attain functional independence by year 1.

Outcome and complications of operatively treated subaxial cervical spine injuries: A population-based retrospective cohort study

ObjectiveThe aim was to study the outcome and complications of operative treatment for subaxial cervical spine injuries with respect to injury morphology and surgical strategy. MethodsA population-based cohort of 271 consecutive patients treated at Kuopio University Hospital from 2003 to 2018 was retrospectively reviewed. ResultsThe mean age was 52.4 (range 12–90) years and 78.6% were male. The AOSpine morphological classification was C in 56.5%, B in 24.7% and A in 17.0% of cases. The surgical approach was anterior in 70.8%, posterior in 20.3% and combined in 8.9% of patients. Fixation alignment was maintained in 96.9% of patients. Instrumentation failures were observed only in patients operated anteriorly but no statistical difference was found between the surgical approaches. The American Spinal Injury Association Impairment Scale (AIS) grade improved in 22.1% of patients. Patients with preoperative AIS grade C had significant potential for neurological improvement (OR 10.44; 95% CI 1.77–61.56; p = 0.010). Postoperative, mostly mild, complications manifested in 22.5% of patients. The posterior approach was associated with fewer postoperative complications (OR 0.18; 95% CI 0.06–0.51; p = 0.001). Preoperative AIS grade A was a significant predisposing factor for complications (OR = 4.90; 95% CI = 1.49–16.10; p = 0.009). The perioperative (90-day) mortality rate was 3.3%. The mean follow-up period was 64.7 ± 25.9 (radiological)/136.7 ± 174.8 (clinical) days. ConclusionsOperative treatment is safe and effective but the surgical approach should be patient- and injury-specific. The prognosis for neurological recovery from spinal cord injury is superior in patients with partially preserved motor function.

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

Retrospective cohort study. 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). Multi-institutions in Japan. 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. 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). 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. No funding was received for this study.

Effects of early mobilization within 48 hours of injury in patients with incomplete cervical spinal cord injury

Objective To investigate the effects of early mobilization within 48 h of injury on motor function and walking ability in patients with incomplete cervical spinal cord injury (SCI). Design A retrospective observational study. Setting Intensive care unit or high care unit of a university hospital emergency center. Participants Of 224 patients with SCI having American Spinal Injury Association impairment scale grades C and D, 158 consecutive patients hospitalized for at least 3 weeks after injury were included. Interventions Patients were categorized into two groups: an early mobilization group in which patients were mobilized within 48 h of injury and a delayed mobilization group in which they were mobilized after 48 h of injury. Outcome measures The upper extremity motor score (UEMS), lower extremity motor score (LEMS), and Walking Index for Spinal Cord Injury II (WISCI II) were compared using propensity score matching analysis. Results Of the 158 patients who met the eligibility criteria, 32 were matched between the groups. There was a significant difference in the change in LEMS from the initial assessment to the assessment 2 weeks postoperatively in the early mobilization group (median 9 points vs. 3 points, p < 0.05). There were no significant differences in UEMS or WISCI II. Conclusion Early mobilization within 48 h may improve lower extremity motor function in patients with acute incomplete cervical SCI.

Prognostic value of the systemic inflammatory index (SII) and systemic inflammatory response index (SIRI) in patients with traumatic spinal cord injury.

The overwhelming inflammatory response plays a critical role in the secondary injury cascade of traumatic spinal cord injury (tSCI). The systemic immune inflammatory index (SII) and systemic inflammatory response index (SIRI) are two novel inflammatory biomarkers. The SII was calculated based on lymphocyte, neutrophil, and platelet counts, while the SIRI was calculated based on lymphocyte, neutrophil, and monocyte counts. Their prognostic value in patients with tSCI remains unclear. Patients with tSCI admitted within 24h of trauma were retrospectively and consecutively enrolled. Peripheral blood samples were collected on admission. The primary outcome was American Spinal Injury Association Impairment Scale (AIS) grade conversion at discharge. Multivariable logistic regression analysis was performed to determine the relationship between SII and SIRI and AIS grade conversion. We performed receiver operating characteristic curve (ROC) analysis to assess the discriminative ability of SII, and SIRI in predicting AIS grade conversion. Among 280 included patients, 77 (27.5%) had improved AIS grade conversion at discharge. After adjustment for confounders, SII was independently associated with AIS grade conversion (per SD, odds ratio [OR], 0.68; 95% confidence interval [CI] 0.47-0.98, p = 0.040), while the association between SIRI and AIS grade conversion was insignificant (per 1 SD, OR, 0.77; 95% CI 0.55-1.08, p = 0.130). The ROC analysis revealed that the SII had the best predictive value for AIS grade conversion (area under curve: 0.608, 95% CI 0.536-0.678). Increased SII was independently associated with a decreased likelihood of improved AIS grade conversion.

Exploring factors associated with heart rate variability in newly injured traumatic cervical spinal cord injury patients

Background: Assessment of heart rate variability (HRV) in traumatic cervical spinal cord injury (SCI) patients is widely reported, but few studies have examined the HRV in the newly injured. Further, there is paucity of data relating HRV to factors that might have a bearing on the extent of variability in them. Aim and Objectives: The current study explored the factors associated with the HRV of newly injured cervical SCI American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A/B patients. Materials and Methods: A secondary analysis of HRV data acquired from 24 newly injured tetraplegic patients in a previously published study compared the HRV between AIS grade A and B patients, and across cervical levels of lesion. In addition, the correlation of HRV indices with duration since injury and the patients’ age was examined. Results: The ratio of low to high frequency power was significantly lower in AIS B compared to AIS A patients, and significantly negatively correlated with duration since injury. Conclusion: The ratio of modulations of cardiac sympatho-vagal supply was lower in AIS B patients and reduced with increasing duration since injury. AIS grade and duration since injury need to be considered when interpreting the HRV data of newly injured tetraplegic patients.

Patient Perceptions and Clinical Assessments of Cardiometabolic Disease After Subacute Spinal Cord Injury

ObjectivesTo investigate the effectiveness of health care team communication regarding cardiometabolic disease (CMD) risk factors with patients with subacute spinal cord injury (SCI). DesignMulti-site prospective cross-sectional study. SettingFive National Institute on Disability, Independent Living, and Rehabilitation Research Model SCI Rehabilitation Centers. ParticipantsNinety-six patients with subacute SCI, aged 18-70 years, with SCI (neurologic levels of injury C2-L2, American Spinal Injury Association Impairment Scale grades A-D), and enrolled within 2 months of initial rehabilitation discharge (N=96). InterventionsNone. Main Outcome Measure(s)Objective risk factors of CMD (body mass index, fasting glucose, insulin, high-density lipoprotein cholesterol, triglyceride levels, and resting blood pressure). Patient reported recall of these present risk factors being shared with them by their health care team. Medications prescribed to patients to address these present risk factors were checked against guideline- assessed risk factors. ResultsObjective evidence of 197 CMD risk factors was identified, with patients recalling less than 12% of these (P<.0001) being shared with them by their health care team. Thirty-one individuals (32%) met criteria for a diagnosis of CMD, with only 1 of these patients (3.2%) recalling that this was shared by their health care team (P<.0001). Pharmacologic management was prescribed to address these risk factors only 7.2% of the time. ConclusionsDespite high prevalence of CMD risk factors after acute SCI, patients routinely do not recall being told of their present risk factors. Multifaceted education and professionals’ engagement efforts are needed to optimize treatment for these individuals.

Comparative evaluation of multi-fold rib and structural iliac bone grafts in single-segment thoracic and thoracolumbar spinal tuberculosis: clinical and radiological outcomes

ObjectiveTo compare clinical and radiological outcomes of multi-fold rib and structural iliac bone grafts, the primary autologous graft techniques in anterolateral-only surgery for single-segment thoracic and thoracolumbar spinal tuberculosis.MethodsThis retrospective study included 99 patients treated from January 2014 to March 2022, categorized into 64 with multi-fold rib grafts (group A) and 35 with structural iliac bone grafts (group B). Outcomes assessed included hospital stay, operation time, intraoperative blood loss, postoperative drainage, complications, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the Visual Analog Scale (VAS) for pain, the Oswestry Disability Index (ODI), bone fusion time, and the American Spinal Injury Association (ASIA) impairment scale grade. Segmental kyphotic angle and intervertebral height were measured radiologically before surgery and follow-up.ResultsThe mean follow-up was 63.50 ± 26.05 months for group A and 64.97 ± 26.43 months for group B (P > 0.05). All patients had achieved a clinical cure. Group A had a shorter operation time (P = 0.004). Within one week post-surgery, group B reported higher VAS scores (P < 0.0001). Neurological performance and quality of life significantly improved in both groups. No significant differences were observed in segmental kyphotic angle and intervertebral height between the groups pre- and postoperatively (P > 0.05). However, group A showed a greater segmental kyphotic angle at the final follow-up, while group B had better maintenance of kyphotic angle correction and intervertebral height (P < 0.05). Bone fusion was achieved in all patients without differences in fusion time (P > 0.05).ConclusionsMulti-fold rib grafts resulted in shorter operation times and less postoperative pain, while structural iliac bone grafts provided better long-term maintenance of spinal alignment and stability, suggesting their use in cases where long-term outcomes are critical.

Lower Extremity Somatosensory Evoked Potentials Predict Functional Outcomes in Complete Traumatic Cervical Spinal Cord Injury

Traumatic cervical spinal cord injury (tCSCI) is often a debilitating injury, making early prognosis important for medical and surgical planning. Currently, the best early predictors of prognosis are the physical examination, imaging studies, and patient demographics. Despite these factors, patient outcomes continue to vary significantly. The purpose of this study was to evaluate the prognostic value of somatosensory evoked potentials (SSEPs) with functional outcomes in tCSCI patients. A retrospective study was conducted on prospectively collected data from two academic institutions. Patients 18 years and older who had tCSCI and underwent posterior cervical decompression and stabilization with intraoperative neuromonitoring were reviewed. The outcomes of interest were the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and ASIA motor score at follow-up. Outcomes measures were assessed via student t-tests, chi-squared tests, and multivariable regression analysis. A total of 79 patients were included. In complete injuries, detectable lower extremity SSEPs were associated with higher ASIA motor scores at follow-up (p=0.002), greater increases in ASIA motor scores at follow-up (p=0.009), and a greater likelihood of clinically important improvement in ASIA motor score (p=0.024). Incomplete, AIS grade C injuries has higher rates of grade conversion (p=0.019) and clinically important improvement in ASIA motor score (p=0.010), compared to AIS grade A or B injuries. The detection of lower extremity SSEP signals during initial surgical treatment of tCSCI is associated with greater improvement in ASIA motor scores postoperatively. The association is most applicable to patients with complete injury.

Predicting the Progression of Spasticity in the Early Phase of Spinal Cord Injury: A Prospective Cohort Study.

Spasticity-defined as involuntary movements caused by insult to upper motor neurons after spinal cord injury (SCI)-interferes with patients' activities of daily living. Spasticity is generally identified and managed in the chronic phase of SCI, but few reports have examined the onset of spasticity after injury. The purpose of this study is to elucidate serial changes in spasticity after SCI and clarify the timing of severe spasticity. We prospectively examined individuals with acute traumatic SCI admitted within two weeks after injury. Severity of spasticity was evaluated using the Modified Ashworth Scale (MAS) at 2, 4, 6, and 8 weeks, followed by 3, 4, 5, and 6 months after injury. After completing evaluation of the cohort, the patients were divided into two groups: a spasticity group with MAS scores ≥3 (marked increase in muscle tone through most of the range of motion (ROM)) in at least one joint movement within 6 months of injury and a control group with MAS scores ≤2 in all joint movements throughout the 6 months after injury. Neurological findings such as the American Spinal Injury Association (ASIA) Impairment Scale grades and ASIA motor scores were also assessed at all time points, and the correlations between the onset of spasticity, severity of spasticity, and neurological findings were analyzed. There were 175 patients with traumatic SCI who were assessed consecutively for 6 months after injury. The MAS scores of the group significantly increased over time until 4 months after injury. The spasticity group had significantly higher MAS scores compared with the control group as early as 2 weeks post-injury. We found that the patients with earlier onset of spasticity had higher final MAS scores. No correlation was found between the ASIA Impairment Scale grade and the onset of spasticity. Our results reveal that the development of severe spasticity may be predictable from as early as 2 weeks after SCI, suggesting that early therapeutic intervention to mitigate problematic spasticity may enhance the benefits of post-injury rehabilitation.

Guidelines for neuroprognostication in adults with traumatic spinal cord injury

BackgroundTraumatic 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.MethodsA 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.ResultsSix 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.ConclusionsThese 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.

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

ObjectiveAcute 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.MethodsAn 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.ResultsBased 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).ConclusionThere 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.

Expansive Spinal Cord Injury After Autologous Olfactory Mucosal Transplantation: Case Report and Systematic Review

To present strategies for managing tumor mass formation and their corresponding postoperative outcomes. We conducted a systematic literature review following the guidelines and protocol of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched the PubMed and EMBASE databases, screened titles and abstracts, and further evaluated full-text publications to select relevant studies. Additionally, a narrative review of other pertinent articles on PubMed was performed. Case reports, cohort studies, and clinical trials were included. Animal studies were excluded. Of 6 patients enrolled in this study, most had American Spinal Injury Association Impairment Scale grade A (66.7%) following intramedullary injury, and 1 patient had American Spinal Injury Association Impairment Scale grade D (16.65%). The discovery time of the intramedullary mass formation ranged from approximately 5 to 14 years. Surgical intervention was performed in most cases (66.7%), with improvement reported in 3 of the surgical cases (75%). The majority of cases (83.3%) involved cervical lesions, while only 1 case (16.7%) involved a thoracic lesion. Due to the scarcity of described cases, there is no specific treatment for this tumor. Although our patient remained stable after conservative treatment, other studies have shown improvement in symptoms after mass resection. It is essential that the management of this complication be researched further due to the variety of clinical characteristics presented.

Comparative Analysis of Cytokine Profiles in Cerebrospinal Fluid and Blood Serum in Patients with Acute and Subacute Spinal Cord Injury.

Cytokines are actively involved in the regulation of the inflammatory and immune responses and have crucial importance in the outcome of spinal cord injuries (SCIs). Examining more objective and representative indicators of the patient's condition is still required to reveal the fundamental patterns of the abovementioned posttraumatic processes, including the identification of changes in the expression of cytokines. We performed a dynamic (3, 7, and 14 days post-injury (dpi)) extended multiplex analysis of cytokine profiles in both CSF and blood serum of SCI patients with baseline American Spinal Injury Association Impairment Scale grades of A. The data obtained showed a large elevation of IL6 (>58 fold) in CSF and IFN-γ (>14 fold) in blood serum at 3 dpi with a downward trend as the post-traumatic period increases. The level of cytokine CCL26 was significantly elevated in both CSF and blood serum at 3 days post-SCI, while other cytokines did not show the same trend in the different biosamples. The dynamic changes in cytokine levels observed in our study can explore the relationships with the SCI region and injury severity, paving the way for a better understanding of the pathophysiology of SCI and potentially more targeted and personalized therapeutic interventions.

Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

ObjectiveThis study aims to determine the relationship between spinal cord perfusion pressure (SCPP) and breathing function in patients with acute cervical traumatic spinal cord injuries.MethodsWe included 8 participants without cervical TSCI plus 13 patients with cervical traumatic spinal cord injuries, American Spinal Injury Association Impairment Scale grades A–C. In the TSCI patients, we monitored intraspinal pressure from the injury site for up to a week and computed the SCPP as mean arterial pressure minus intraspinal pressure. Breathing function was quantified by diaphragmatic electromyography using an EDI (electrical activity of the diaphragm) nasogastric tube as well as by ultrasound of the diaphragm and the intercostal muscles performed when sitting at 20°–30°.ResultsWe analysed 106 ultrasound examinations (total 1370 images/videos) and 198 EDI recordings in the patients with cervical traumatic spinal cord injuries. During quiet breathing, low SCPP (< 60 mmHg) was associated with reduced EDI-peak (measure of inspiratory effort) and EDI-min (measure of the tonic activity of the diaphragm), which increased and then plateaued at SCPP 60–100 mmHg. During quiet and deep breathing, the diaphragmatic thickening fraction (force of diaphragmatic contraction) plotted versus SCPP had an inverted-U relationship, with a peak at SCPP 80–90 mmHg. Diaphragmatic excursion (up and down movement of the diaphragm) during quiet breathing did not correlate with SCPP, but diaphragmatic excursion during deep breathing plotted versus SCPP had an inverse-U relationship with a peak at SCPP 80–90 mmHg. The thickening fraction of the intercostal muscles plotted versus SCPP also had inverted-U relationship, with normal intercostal function at SCPP 80–100 mmHg, but failure of the upper and middle intercostals to contract during inspiration (i.e. abdominal breathing) at SCPP < 80 or > 100 mmHg.ConclusionsAfter acute, cervical traumatic spinal cord injuries, breathing function depends on the SCPP. SCPP 80–90 mmHg correlates with optimum diaphragmatic and intercostal muscle function. Our findings raise the possibility that intervention to maintain SCPP in this range may accelerate ventilator liberation which may reduce stay in the neuro-intensive care unit.

Reduction of cervicothoracic spondyloptosis in an ambulatory patient: when traction fails.

Cervical spondyloptosis is a rare complication of high-energy trauma which often results in significant patient morbidity and mortality. The authors present a case of spondyloptosis of C7 over T1 with minimal radicular symptoms and otherwise complete spinal cord sparing. This case highlights the surgical challenges faced with cervical spondyloptosis and the techniques used when traction fails. A 21-year-old man with no significant past medical history presented after a high-speed motor vehicle collision with cervicothoracic pain and mild hand grip weakness in addition to numbness of the fourth and fifth digits bilaterally (American Spinal Injury Association Impairment Scale Grade D). Computed tomography imaging revealed spondyloptosis of C7 over T1, a fracture of the C2 vertebral body, and a burst fracture of C3. To relieve spinal cord compression and restore sagittal realignment, closed reduction was attempted, however this resulted in perching of the bilateral C7-T1 facets, leading to an open posterior approach. The patient underwent C7 laminectomy, bilateral C7-T1 facetectomy, and manual reduction using a Mayfield skull clamp followed by C2-T3 fixation. Postoperatively, pain was diminished, sensory disturbances were resolved and the patient was otherwise neurologically stable. There is a role for closed traction for reduction of cervical spondyloptosis, however, its role is debated especially when the patient is predominately neurologically intact. In this setting, the spine surgeon may be required to change traction and operative strategies in order to minimize potentially harmful manipulation while restoring sagittal realignment and stabilizing the spine for preservation of neurological function.

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

BackgroundCervical 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.MethodsThis 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).DiscussionWe 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 registrationIRAS: 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).

Incidence and Risk Factors for Pneumonia in the Chronic Phase of Cervical Spinal Cord Injury with Complete Motor Paralysis.

Pneumonia is one of the leading causes of acute- and chronic-phase mortality in patients with cervical spinal cord injury (CSCI) with quadriplegia. The risk factors for chronic-phase pneumonia recurrence in CSCI are still unknown. This study aimed to investigate the incidence of pneumonia in the chronic phase after injury and to identify its risk factors. This retrospective clinical observational study included patients with CSCI with American Spinal Injury Association Impairment Scale grades of A or B admitted to our center within 72 h of CSCI injury who started treatment and were available for follow-up for at least 90 days. The patients were assessed for incidences of pneumonia and its associations with clinical characteristics, including risk factors at the time of injury. Patients in whom pneumonia developed within 30 days postadmission and those after 30 days of hospitalization were comparatively examined using univariate and multivariate analyses. Pneumonia occurred in 36% of the 69 enrolled patients throughout the study period and in 20% of all patients after 30 days of hospitalization. Multivariate analysis of risk factors for pneumonia showed that atelectasis (adjusted OR [aOR], 95% confidence interval [CI]: 4.9, 1.2-20.0), enteral feeding (aOR [95% CI]: 13.3 [3.0-58.9]), mechanical ventilation (aOR [95% CI]: 4.0 [1.0-15.0]), and tracheotomy (aOR [95% CI]: 14.6 [2.3-94.6]) within 30 days of admission were significantly associated with the occurrence of pneumonia even after 30 days of hospitalization. The risk factors for developing pneumonia in the chronic phase were atelectasis, enteral feeding, mechanical ventilation, and tracheotomy within 30 days of hospitalization. This study suggests that treatment of atelectasis, long-term respiratory muscle rehabilitation, and training to improve swallowing function are essential to prevent the recurrence of pneumonia after 30 days of hospitalization.

Soluble Nogo-Receptor-Fc decoy (AXER-204) in patients with chronic cervical spinal cord injury in the USA: a first-in-human and randomised clinical trial

Spinal cord injury (SCI) causes neural disconnection and persistent neurological deficits, so axon sprouting and plasticity might promote recovery. Soluble Nogo-Receptor-Fc decoy (AXER-204) blocks inhibitors of axon growth and promotes recovery of motor function after SCI in animals. This first-in-human and randomised trial sought to determine primarily the safety and pharmacokinetics of AXER-204 in individuals with chronic SCI, and secondarily its effect on recovery. We conducted a two-part study in adults (aged 18-65 years) with chronic (>1 year) cervical traumatic SCI at six rehabilitation centres in the USA. In part 1, AXER-204 was delivered open label as single intrathecal doses of 3 mg, 30 mg, 90 mg, or 200 mg, with primary outcomes of safety and pharmacokinetics. Part 2 was a randomised, parallel, double-blind comparison of six intrathecal doses of 200 mg AXER-204 over 104 days versus placebo. Participants were randomly allocated (1:1) by investigators using a central electronic system, stratified in blocks of four by American Spinal Injury Association Impairment Scale grade and receipt of AXER-204 in part 1. All investigators and patients were masked to treatment allocation until at least day 169. The part 2 primary objectives were safety and pharmacokinetics, with a key secondary objective to assess change in International Standards for Neurological Classification of SCI (ISNCSCI) Upper Extremity Motor Score (UEMS) at day 169 for all enrolled participants. This trial is registered with ClinicalTrials.gov, NCT03989440, and is completed. We treated 24 participants in part 1 (six per dose; 18 men, six women), and 27 participants in part 2 (13 placebo, 14 AXER-204; 23 men, four women), between June 20, 2019, and June 21, 2022. There were no deaths and no discontinuations from the study due to an adverse event in part 1 and 2. In part 2, treatment-related adverse events were of similar incidence in AXER-204 and placebo groups (ten [71%] vs nine [69%]). Headache was the most common treatment-related adverse event (five [21%] in part 1, 11 [41%] in part 2). In part 1, AXER-204 reached mean maximal CSF concentration 1 day after dosing with 200 mg of 412 000 ng/mL (SD 129 000), exceeding those concentrations that were efficacious in animal studies. In part 2, mean changes from baseline to day 169 in ISNCSCI UEMS were 1·5 (SD 3·3) for AXER-204 and 0·9 (2·3) for placebo (mean difference 0·54, 95% CI -1·48 to 2·55; p=0·59). This study delivers the first, to our knowledge, clinical trial of a rationally designed pharmacological treatment intended to promote neural repair in chronic SCI. AXER-204 appeared safe and reached target CSF concentrations; exploratory biomarker results were consistent with target engagement and synaptic stabilisation. Post-hoc subgroup analyses suggest that future trials could investigate efficacy in patients with moderately severe SCI without prior AXER-204 exposure. Wings for Life Foundation, National Institute of Neurological Disorders and Stroke, National Center for Advancing Translational Sciences, National Institute on Drug Abuse, and ReNetX Bio.