Prevention Of Spinal Cord Injury Research Articles

A Clinical Practice Guideline on the Timing of Surgical Decompression and Hemodynamic Management of Acute Spinal Cord Injury and the Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury: Introduction, Rationale, and Scope.

Protocol for the development of clinical practice guidelines following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Acute SCI or intraoperative SCI (ISCI) can have devastating physical and psychological consequences for patients and their families. The treatment of SCI has dramatically evolved over the last century as a result of preclinical and clinical research that has addressed important knowledge gaps, including injury mechanisms, disease pathophysiology, medical management, and the role of surgery. In an acute setting, clinicians are faced with critical decisions on how to optimize neurological recovery in patients with SCI that include the role and timing of surgical decompression and the best strategies for hemodynamic management. The lack of consensus surrounding these treatments has prevented standardization of care across centers and has created uncertainty with respect to how to best manage patients with SCI. ISCI is a feared complication that can occur in the best of hands. Unfortunately, there are no systematic reviews or clinical practice guidelines to assist spine surgeons in the assessment and management of ISCI in adult patients undergoing spinal surgery. Given these limitations, it is the objective of this initiative to develop evidence-based recommendations that will inform the management of both SCI and ISCI. This protocol describes the rationale for developing clinical practice guidelines on (i) the timing of surgical decompression in acute SCI; (ii) the hemodynamic management of acute SCI; and (iii) the prevention, identification, and management of ISCI in patients undergoing surgery for spine-related pathology. Systematic reviews were conducted according to PRISMA standards in order to summarize the current body of evidence and inform the guideline development process. The guideline development process followed the approach proposed by the GRADE working group. Separate multidisciplinary, international groups were created to perform the systematic reviews and formulate the guidelines. All potential conflicts of interest were vetted in advance. The sponsors exerted no influence over the editorial process or the development of the guidelines. This process resulted in both systematic reviews and clinical practice guidelines/care pathways related to the role and timing of surgery in acute SCI; the optimal hemodynamic management of acute SCI; and the prevention, diagnosis and management of ISCI. The ultimate goal of this clinical practice guideline initiative was to develop evidence-based recommendations for important areas of controversy in SCI and ISCI in hopes of improving neurological outcomes, reducing morbidity, and standardizing care across settings. Throughout this process, critical knowledge gaps and future directions were also defined.

Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury in the Setting of Spine Surgery: A Proposed Care Pathway.

This study is a mixed methods approach. Intraoperative spinal cord injury (ISCI) is a challenging complication in spine surgery. Intra-operative neuromonitoring (IONM) has been developed to detect changes in neural function. We report on the first multidisciplinary, international effort through AO Spine and the Praxis Spinal Cord Institute to develop a comprehensive guideline and care pathway for the prevention, diagnosis, and management of ISCI. Three literature reviews were registered on PROSPERO (CRD 42022298841) and performed according to PRISMA guidelines: (1) Definitions, frequency, and risk factors for ISCI, (2) Meta-analysis of the accuracy of IONM for diagnosis of ISCI, (3) Reported management approaches for ISCI and related events. The results were presented in a consensus session to decide the definition of IONM and recommendation of its use in high-risk cases. Based on a literature review of management strategies for ISCI, an intra-operative checklist and overall care pathway was developed by the study team. An operational definition and high-risk patient categories for ISCI were established. The reported incidence of deficits was documented to be higher in intramedullary tumour spine surgery. Multimodality IONM has a high sensitivity and specificity. A guideline recommendation of IONM to be employed for high-risk spine cases was made. The different sections of the intraoperative checklist include surgery, anaesthetic and neurophysiology. The care pathway includes steps (1) initial clinical assessment, (2) pre-operative planning, (3) surgical/anaesthetic planning, (4) intra-operative management, and (5) post-operative management. This is the first evidence based comprehensive guideline and care pathway for ISCI using the GRADE methodology. This will facilitate a reduction in the incidence of ISCI and improved outcomes from this complication. We welcome the wide implementation and validation of these guidelines and care pathways in prospective, multicentre studies.

A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery.

Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.

Prehospital Emergency Interventions for Idiopathic Spinal Cord Injury Prevention

Introduction: Despite the critical role of prehospital management, variations persist in global practices. Recent literature indicates that about 35% of emergency medical services (EMS) providers adhere to established guidelines for spinal immobilization in certain regions. This systematic review aimed to contribute to the ongoing dialogue surrounding the prehospital management of SCIs, ultimately improving outcomes for individuals affected by these traumatic injuries. Methods: A comprehensive literature review was conducted through a systematic search of electronic databases, employing refined search terms and Boolean operators to focus on prehospital management of spinal cord injuries from the inception of each database to July 2023. Inclusion criteria involved original research articles, systematic reviews, and meta-analyses, with a screening process led by two independent reviewers and subsequent data extraction to inform evidence synthesis, accounting for study limitations and bias assessments. Results: This systematic review summarizes findings from eight clinical interventional studies on preventing idiopathic spinal cord injury (SCI) during prehospital emergency aid for traumatized patients. The studies encompassed diverse populations and interventions, revealing variable effectiveness in reducing idiopathic SCI incidence. Notably, specialized protocols for pediatric spinal immobilization and modifications for geriatric patients demonstrated promising effectiveness, emphasizing the importance of age-specific considerations in prehospital care for SCI prevention. Conclusions: The systematic review findings underscore the nuanced nature of prehospital interventions for idiopathic spinal cord injury prevention, emphasizing the importance of age-specific considerations and cautioning against a one-size-fits-all approach, while also highlighting the need for ongoing research to refine protocols and improve patient outcomes given the lack of definitive evidence in favor of early versus delayed immobilization.

ScRNA analysis and ferroptosis-related ceRNA regulatory network investigation in microglia cells at different time points after spinal cord injury

Spinal cord injuries (SCI) are usually caused by mechanical trauma that leads to serious physical and psychological damage to the patient as well as a huge economic burden to the whole society. The prevention, treatment, and rehabilitation of spinal cord injuries have become a major issue for the medical community today due to the enormous social and economic expenditure induced via spinal cord injuries. Therefore, in-depth research into SCI is necessary. Microglia have been shown to be the key player in the immune inflammatory response after spinal cord injury, but the mechanisms of immune regulation at different time points after spinal cord injury remain unclear. To investigate the inflammatory biomarkers associated with microglia at different time points after SCI, we downloaded single-cell RNA sequencing data from mouse spinal cords 3- and 14-days after the injury and identified subpopulations associated with microglia. Further functional enrichment analysis also confirmed that microglia are associated with immune system regulation at different time points and that both can modulate cytokine production. As ferroptosis is a newly identified non-apoptotic programmed cell death, microglia establish a bridge between ferroptosis and CNS inflammation and may play an important role in spinal cord injury. We then screened for genes differentially expressed in microglia during 3- and 14-days after spinal cord injury and associated with iron death, named Stmn1 and Fgfbr1, respectively, and verified that these pivotal genes are closely related to the immune cells. Finally, we also screened for drug fractions associated with these pivotal genes. Our results predict key genes in the immune inflammatory process associated with microglia at different time points after spinal cord injury at the single-cell level and provide a molecular basis for better treatment of SCI.

Comparison of Landmark-Guided Versus Fluoroscopy-Guided Cerebrospinal Fluid Drain-Related Complications After Aortic Repairs

Cerebrospinal fluid drains (CSFDs) are efficacious in preventing spinal cord injury after thoracic or thoracoabdominal aortic repair with extensive coverage. Increasingly, fluoroscopy is used to guide placement instead of the traditional landmark-based approach, but it is unknown which approach is associated with fewer complications. A retrospective cohort study. In the operating room. Patients having undergone thoracic or thoracoabdominal aortic repair with a CSFD over a 7-year period at a single center. No intervention. Groups were reviewed and statistically compared with respect to baseline characteristics, ease of CSFD placement, and major and minor complications directly related to placement. A total of 150 CSFDs were placed with landmark guidance as opposed to 95 with fluoroscopy guidance. Compared to the landmark group, patients with fluoroscopy-guided CSFDs were older (p < 0.008), had lower American Society of Anesthesiologists physical status scores (p=0.008), required fewer CSFD placement attempts (p=0.011), had the CSFD in place for longer duration (p < 0.001), and had a similar incidence of CSFD-related complications (p > 0.999). Composites of both major (4.5% of cases) and minor CSFD-related complications (6.1% of cases), the primary outcomes of the study, occurred with similar incidences between the 2 groups (p > 0.999 for both comparisons) after adjusting potential confounders. In patients undergoing thoracic or thoracoabdominal aortic repairs, there were no significant differences in the risk of major and minor CSFD-related complications between fluoroscopic guidance and the landmark approach. Although the authors' institution is a high-volume center for this type of procedure, the study was limited by a small sample size. Hence, regardless of the technique used for the placement of CSFD, the risks related to the placement should be balanced carefully against the potential benefits resulting from spinal cord injury prevention. Fluoroscopy-aided insertion of CSFD requires fewer attempts and, hence, may be better tolerated by patients.

Quercetin prevents the ferroptosis of OPCs by inhibiting the Id2/transferrin pathway

Spinal cord injury (SCI) is a destructive neurological disorder that causes impaired mobility, sensory, and autonomic dysfunctions. The loss of oligodendrocyte progenitor cells (OPCs), which can differentiate into mature oligodendrocytes and re-myelinate damaged axons, is related to poorer recovery for SCI patients. However, inhibiting OPCs loss has always been a difficult problem to overcome. In this study, we demonstrated the anti-ferroptosis effects of quercetin as a mechanism in erastin-induced OPC ferroptosis. Quercetin ameliorated erastin-induced ferroptosis in OPCs, as indicated by decreased iron concentration, reactive oxygen species (ROS) production, and increased content of glutathione (GSH) as well as more normal mitochondria morphology. Compared with erastin-induced OPCs, the myelin basic protein (MBP)-positive myelin and NF200-positive axonal was remarkably increased in quercetin-treated OPCs. Furthermore, quercetin ameliorated the erastin-induced ferroptosis as well as the myelin and axon loss of OPCs by downregulating transferrin. Transfected OPCs with transferrin overexpression plasmids significantly abrogated the protective role of quercetin in OPC ferroptosis. Using ChIP-qPCR, a direct interaction of transferrin with its upstream gene Id2 was found. The overexpression of Id2 reversed the effect of quercetin on OPC ferroptosis. In vivo study found that quercetin greatly decreased the area of injury, and enhanced the BBB score after SCI. Furthermore, in the SCI model, quercetin significantly downregulated Id2 and transferrin expression, while significantly up-regulated GPX4 and PTGS2 expression. In conclusion, quercetin prevents the ferroptosis of OPCs by inhibiting the Id2/transferrin pathway. These findings highlight quercetin as an anti-ferroptosis agent for the treatment or prevention of spinal cord injury.

Exploring the mechanism of Buyang Huanwu Decoction in the treatment of spinal cord injury based on network pharmacology and molecular docking.

Buyang Huanwu Decoction, a traditional Chinese medicine decoction, is widely used to treat spinal cord injury in China. However, the underlying mechanism of this decoction in treating spinal cord injury is unclear. This study used network pharmacology and molecular docking to examine the pharmacological mechanism of Buyang Huanwu Decoction in prevention and treatment of spinal cord injury. The active compounds and target genes of Buyang Huanwu Decoction were collected from the Traditional Chinese Medicine Systems Pharmacology and the SwissTargetPrediction Database. The network diagram of ”traditional Chinese medicine compound target“ was constructed by Cytoscape software. Genetic data of spinal cord injury were obtained by GeneCards database. According to the intersection of Buyang Huanwu Decoction’s targets and disease targets, the core targets were searched. The protein-protein interaction network were constructed using the STRING and BisoGenet platforms. Meanwhile, gene ontology enrichment and Kyoto encyclopedia of genes, and genome pathway were performed on the intersection targets by Metascape. Molecular docking technology was adopted to verify the combination of main components and core targets. A total of 109 active compounds and 5440 prediction targets were screened from 7 Chinese herbal medicines of Buyang Huanwu Decoction, with 98 active components and 49 related prediction targets being strongly linked to Spinal Cord Injury. By studying protein-protein interaction network, a total of 8 core proteins were identified, primarily interleukin-6, tumor protein P53, epidermal growth factor receptor, and others. Positive regulation of kinase activity regulation of reaction to inorganic chemicals are the basic biological processes. Buyang Huanwu Decoction cures Spinal Cord Injury primarily by moderating immunological inflammation, apoptosis, and oxidative stress, which involves the cancer pathway, the HIF-1 signaling pathway, the p53 signaling pathway, the MAPK signaling pathway, and so on. The results of molecular docking demonstrated that the primary components could attach to the target protein effectively. Finally, the mechanism of Buyang Huanwu Decoction in the treatment of spinal cord injury through multicomponent, multitarget, and multichannel was deeply explored. And it offers new ideas and directions for future research on the mechanism of the treatment of spinal cord injury.

Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know.

Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium–left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair.

Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review of current evidence.

SummaryAround 1 million people sustain a spinal cord injury each year, which can have significant psychosocial, physical and socio‐economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the airway management of patients with confirmed or suspected traumatic spinal cord injury to promote best clinical practice. All airway interventions are associated with some degree of movement of the cervical spine; in general, these are very small and whether these are clinically significant in terms of impingement of the spinal cord is unclear. Manual in‐line stabilisation does not effectively immobilise the cervical spine and increases the likelihood of difficult and failed tracheal intubation. There is no clear evidence of benefit of awake tracheal intubation techniques in terms of prevention of secondary spinal cord injury. Videolaryngoscopy appears to cause a similar degree of cervical spine displacement as flexible bronchoscope‐guided tracheal intubation and is an appropriate alternative approach. Direct laryngoscopy does cause a slightly greater degree of cervical spinal movement during tracheal intubation than videolaryngoscopy, but this does not appear to increase the risk of spinal cord compression. The risk of spinal cord injury during tracheal intubation appears to be minimal even in the presence of gross cervical spine instability. Depending on the clinical situation, practitioners should choose the tracheal intubation technique with which they are most proficient and that is most likely to minimise cervical spine movement.

Effects of fluids vs. vasopressors on spinal cord microperfusion in hemorrhagic shock induced ischemia/reperfusion

ObjectiveSpinal cord injury induced by ischemia/reperfusion is a devastating complication of aortic repair. Despite developments for prevention and treatment of spinal cord injury, incidence is still considerably high majorly impacting patient outcome. Microcirculation is paramount for tissue perfusion and oxygen supply and often dissociated from macrohemodynamic parameters used to guide resuscitation. Effects of fluids vs. vasopressors in the setting of hemodynamic resuscitation on spinal cord microperfusion are unknown. Aim of this study was to compare the effects of vasopressor and fluid resuscitation on spinal cord microperfusion in a translational acute pig model of hemorrhagic shock induced ischemia/reperfusion injury. MethodsWe designed this study as prospective randomized explorative large animal study. We induced hemorrhagic shock in 20 pigs as a model of global ischemia/reperfusion injury. We randomized animals to receive either fluid or vasopressor resuscitation. We measured spinal cord microperfusion using fluorescent microspheres as well as laser-Doppler probes. We monitored and analyzed macrohemodynamic parameters and cerebrospinal fluid pressure. ResultsSpinal cord microperfusion decreased following hemorrhagic shock induced ischemia/reperfusion injury. Both fluids and vasopressors sufficiently restored spinal cord microperfusion. There were no important changes between groups (percentage changes compared to baseline: fluids 14.0 (0.31–27.6) vs. vasopressors 24.3 (8.12–40.4), p = .340). However, cerebrospinal fluid pressure was higher in animals receiving fluid resuscitation (percentage changes compared to baseline: fluids 27.7 (12.6–42.8) vs. vasopressors −5.56 ((−19.8)–8.72), p = .003). Microcirculatory resuscitation was in line with improvements of macrohemodynamic parameters. ConclusionsBoth, fluids and vasopressors, equally restored spinal cord microperfusion in a porcine acute model of hemorrhagic shock induced ischemia/reperfusion injury. However, significant differences in cerebrospinal fluid pressure following resuscitation were present. Future studies should evaluate these effects in perfusion disruption induced ischemia/reperfusion conditions of microcirculatory deterioration.

Evaluating the incidence of spinal cord injury after spinal cord stimulator implant: an updated retrospective review

IntroductionWhile spinal cord stimulator implant is an increasingly safe procedure, one of the most feared complications is spinal cord injury. Still, literature regarding its incidence remains highly variable. This retrospective...

Ultrafast ultrasound localization microscopy method for spinal cord mircovasculature imaging

Function of spinal cord is crucial to nerve conduction pathway. Traumatic spinal cord injury often results in a vasculature disruption after primary insult and further leads to abnormal responses of the intact vessels in neighboring tissue during secondary injury. Therefore, the vasculature and blood supply play significant roles in evaluating the spinal cord function . Ultrasound localization microscopy (ULM) overcomes the shortcomings of extensively used angiography, such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA), in terms of limited resolution, radiation and poor-portability, which meets the needs of comprehensive intraoperative examination and prognosis tracking. In this study, an L22-14vX probe with a transmission frequency of 15.625 MHz is utilized, yielding an imaging wavelength of 100 μm. The ULM is conducted based on ultrafast ultrasound technology with multiple tilted plane-wave illuminations. Robust principal component analysis (RPCA) based spatial-temporal clutter filtering method is used for separating the microbubble signals from tissue signals and high frequency noise. Through microbubble localization, trajectory tracking and mapping, subwavelength super-resolution ultrasound imaging is finally achieved. The whole process of microbubble localization and vessel reconstruction are monitored through measuring the time dependent microbubble detections and saturation. Saturation curve corresponds to the time dependent total area covered by microbubble detections on the image. Quantification analysis is carried out for evaluating the imaging results including resolution measurements based on the Fourier ring correlation (FRC) and full-width at half-maximum (FWHM). The &lt;i&gt;i&lt;/i&gt;&lt;i&gt;n-vivo&lt;/i&gt; experimental results show that ULM can be used to obtain super-resolution vasculature imaging in rat spinal cord. The velocity distributed from 1 mm/s to 50 mm/s can be detected. Within the same vessel, the velocity of a point is inversely correlated with the distance from the point to the center of the vessel. The velocity in the center of the vessel is larger than that at the wall of the vessel. The larger vessels support higher flow in the center of the vessel. The FWHM results indicate that ultrafast Doppler displays vessels in diameters between 135 μm and 270 μm while ULM displays them in diameters between 28 μm and 35 μm. The FRC-based resolution evaluation shows that the ULM achieves a super resolution of 16 μm, much less than the imaging wavelength of 100 μm. Yet, long acquisition time is required to detect microbubbles in the smallest vessels, leading to long reconstruction of the microvasculature, which is still a problem worth studying . Compromise between saturation and acquisition time needs considering. Generally speaking, microbubbles are more likely to flow in large vessels, leading to relatively short reconstruction time of large vessels. When saturation curve almost converges, the imaging improvement with new vessels is not so significant that the detail sacrifice of some small microvessels can reduce acquisition time (i.e. most of microvasculature can still be gained when the saturation curve does not converge). Besides, the increase of microbubble concentration and advanced track identification and extraction may also accelerate the saturation rate of convergence with acquisition time decreasing. In conclusion, ULM can be used to obtain a super-resolution imaging of spinal cord microvasculature, giving a 10-fold improvement in resolution in comparison with ultrafast Doppler imaging. Relevant results can facilitate the super-resolution ULM imaging of spinal cord which may promote the function diagnosis, treatment intervention, disability prevention, and prognosis recovery of spinal cord injury.

Artery of Adamkiewicz and the clinical repercussion of its lesion in thoracoabdominal surgeries: a systematic review

The knowledge of the spinal cord irrigation is important for the therapeutic planning of aortic pathologies; however, its vasculature is complex due to the caliber of its arteries that pass through a three-dimensional network with great anatomical variability. Its clinical importance is evidenced during the preoperative procedure of thoracic and thoracoabdominal aortic surgeries, because its identification is essential for the prevention of spinal cord injuries. This study consists of a literature review, in which searches were conducted in the databases - Bireme, Science Direct, Pubmed and Lilacs. Articles published between 1999 and 2020, written in English, Portuguese or Spanish, were selected. The search was conducted using the descriptors Anatomy, Spinal Cord Irrigation and Spinal Cord Ischemia. The Adamkiewicz artery is the main artery responsible for the arterial supply to the lower part of the spinal cord. Thus, paraplegia is a complication of this type of surgical approach resulting from ischemic suffering of the spinal cord during the process. Therefore, further study on these factors should be encouraged, because the preservation of this vessel is relevant given the search for protection of the spinal cord and the maintenance of its functions in this type of procedure.

Surgical Metastasectomy in the Spine: A Review Article.

The use of surgical metastasectomy (SM) has increased across cancer types in recent decades despite the increasing efficacy of modern systemic treatment modalities. Symptomatic spinal metastases severely compromise patients' performance status. However, as spinal SM is a complex surgery with potentially significant complications, it is not considered the treatment of choice. We reviewed the articles on SM in several primary cancers with different types of metastatic lesions and extracted the data from relevant articles to provide a comprehensive review including the surgical techniques, indications, reported outcomes, and future prospects of SM in spinal metastases. Total en bloc spondylectomy (TES) is a method of spinal SM associated with a lower risk of tumor recurrence and complications. Intralesional transpedicular osteotomy using a fine threadwire saw allows prevention of spinal cord and nerve root injuries. Spinal SM is considered suitable for patients with controlled primary disease having no evidence of disseminated extraspinal metastases, a completely resectable solitary lesion in the spine, and adequate cardiopulmonary reserve to tolerate the surgery. Metastatic lesions from kidney and thyroid cancers have been reported as the best candidates for spinal SM. Although data about spinal SM are limited, the reported outcomes are favorable with acceptable local recurrence rates in long-term follow-up. In patients with isolated resectable spinal metastases, complete SM including TES is a useful option as it can improve function and survival. However, appropriate patient selection and surgical feasibility remain the most important aspects of management. Surgical metastasectomy for spinal metastases may be a potentially curative treatment option with a low risk of local recurrence and lead to prolonged long-term survival if appropriate patients are selected and if the surgery is carried out by experienced surgeons in high-volume centers.

Comparative evaluation of posterior percutaneous endoscopy cervical discectomy using a 3.7\u2009mm endoscope and a 6.9\u2009mm endoscope for cervical disc herniation: a retrospective comparative cohort study

BackgroundPosterior percutaneous endoscopy cervical discectomy (p-PECD) is an effective strategy for the treatment of cervical diseases, with a working cannula ranging from 3.7 mm to 6.9 mm in diameter. However, to date, no studies have been performed to compare the clinical outcomes of the use of endoscopes with different diameters in cervical disc herniation (CDH) patients. The purpose of this study was to compare the clinical outcomes of patients with unilateral CDH treated with p-PECD using a 3.7 mm endoscope and a 6.9 mm endoscope.MethodsFrom January 2016 to June 2018, a total of 28 consecutive patients with single-level CDH who received p-PECD using either the 3.7 mm or the 6.9 mm endoscope were enrolled. The clinical results, including the surgical duration, hospitalization, visual analog scale (VAS) score and modified MacNab criteria, were evaluated. Cervical fluoroscopy, CT, and MRI were also performed during follow-up.ResultsTthere was a significant difference in regard to the average identification time of the “V” point (18.608 ± 3.7607 min vs. 11.256 ± 2.7161 min, p < 0.001) and the mean removal time of the overlying tissue (16.650 ± 4.1730 min vs. 12.712 ± 3.3079 min, p < 0.05) for the use of the 3.7 mm endoscope and the 6.9 mm endoscope, respectively. The postoperative VAS and MacNab scores of the two endoscopes were significantly improved compared with those the preoperative scores (p < 0.05).ConclusionThe application of both the 3.7 mm endoscope and 6.9 mm endoscope represent an effective method for the treatment of CDH in selected patients, and no significant difference can be observed in the clinical outcomes of the endoscopes. The 6.9 mm endoscope shows superiority to the 3.7 mm endoscope in terms of the efficiency of “V” point identification, the removal of overlying soft tissue and the prevention of spinal cord injury. However, the 6.9 mm endoscope may be inferior to the 3.7 mm endoscope in regards to anterior foraminal decompression due to its large diameter; this result needs to be further evaluated with the support of a large number of randomized controlled trials.

Savings of loss-of-life expectancy and lifetime medical costs from prevention of spinal cord injuries: analysis of nationwide data followed for 17 years

BackgroundThe objectives of this research were to determine the savings of loss-of-life expectancy (LE) and lifetime medical costs (LMC) from prevention of spinal cord injuries (SCI) in Taiwan.MethodsFrom the claims...

Designing a Guideline for Emergency Medical Communication Center Staff to Help Road Traffic Crash Patients: A Delphi Study

Background: Injuries and deaths from RTC are critical health problems of societies and one of the main causes of death especially among the young. Objective: This study aimed to design and compile a guideline for emergency medical communication centers (EMCC) staff to provide direct assistance offered by road traffic crash (RTC) bystanders. Methods: Based on prior literature, the RTC bystanders' initial draft guideline contained 20 domains and 28 items. As a validation step, the draft guideline was reviewed by content experts (one emergency medicine and two disaster specialists) and modified based on their recommendations. The subsequent draft guideline was then reviewed in three Delphi rounds by 67 participants, including health professionals in emergencies and disasters, emergency medicine, nurses, emergency medical experts, and EMCC staff. The accepted agreement coefficient was set at ≥70%. As the final step, an expert consensus meeting was held to review the guideline. Results: The participants agreed on 56 items regarding 20 domains, including scene safety, hand precautions, and personal protection, alertness assessment, respiration, cardiopulmonary resuscitation (CPR), bleeding control, recovery position, splinting, rapid evacuation, scene management, patient transfer, triage, spinal cord injury prevention and immobilization, injured transportation, psychological support, hypothermia prevention, water and food, amputated limb protection, and support of deceased people. Two items in relation to airway opening maneuvers were added to the guideline during the expert consensus meeting. Conclusion: Compared to other RTC bystander guidelines for EMCC staff, more comprehensive guidelines can be served as a basis for directing RTC bystanders to provide assistance. Important areas of hand care and personal protection, breathing, airway, splinting, scene management, mental and psychological support, and support of deceased people were included in this guideline. EMCC staff can provide guidance to be performed by RTC bystanders. RTC bystanders can play important roles at crash scenes, including preventing secondary injury, supporting scene management, and providing first aid for the injured people. This guideline can be used to help direct appropriate care and behavior by RTC bystanders.

Real-Time Assessment of Spinal Cord Microperfusion in a Porcine Model of Ischemia/Reperfusion.

Spinal cord injury is a devastating complication of aortic repair. Despite developments for the prevention and treatment of spinal cord injury, its incidence is still considerably high and therefore, influences patient outcome. Microcirculation plays a key role in tissue perfusion and oxygen supply and is often dissociated from macrohemodynamics. Thus, direct evaluation of spinal cord microcirculation is essential for the development of microcirculation-targeted therapies and the evaluation of existing approaches in regard to spinal cord microcirculation. However, most of the methods do not provide real-time assessment of spinal cord microcirculation. The aim of this study is to describe a standardized protocol for real-time spinal cord microcirculatory evaluation using laser-Doppler needle probes directly inserted in the spinal cord. We used a porcine model of ischemia/reperfusion to induce deterioration of the spinal cord microcirculation. In addition, a fluorescent microsphere injection technique was used. Initially, animals were anesthetized and mechanically ventilated. Thereafter, laser-Doppler needle probe insertion was performed, followed by the placement of cerebrospinal fluid drainage. A median sternotomy was performed for exposure of the descending aorta to perform aortic cross-clamping. Ischemia/reperfusion was induced by supra-celiac aortic cross-clamping for a total of 48 min, followed by reperfusion and hemodynamic stabilization. Laser-Doppler Flux was performed in parallel with macrohemodynamic evaluation. In addition, automated cerebrospinal fluid drainage was used to maintain a stable cerebrospinal pressure. After completion of the protocol, animals were sacrificed, and the spinal cord was harvested for histopathological and microsphere analysis. The protocol reveals the feasibility of spinal cord microperfusion measurements using laser-Doppler probes and shows a marked decrease during ischemia as well as recovery after reperfusion. Results showed comparable behavior to fluorescent microsphere evaluation. In conclusion, this new protocol might provide a useful large animal model for future studies using real-time spinal cord microperfusion assessment in ischemia/reperfusion conditions.

Evaluation of spinal cord protective threshold of serum memantine, an NMDA receptor antagonist, in a rabbit model of paraplegia.

To evaluate the threshold of serum memantine for prevention of spinal cord injury (SCI) in a rabbit paraplegic model. Forty-two New Zealand white rabbits were divided into 7 groups. Preoperatively, oral memantine was given starting from 60mg OD for 7days in the initial group, then reducing the dose and/or duration to 60mg OD for 5days, 30mg OD for 5days, 30mg OD for 3days, 15mg OD for 3days, 30mg single dose, and 60mg single dose, in subsequent 6 groups. A paraplegic model was created by clamping both infrarenal aorta and inferior vena cava (IVC) for 45min. Motor evoked potentials (MEPs), modified Tarlov score (0-5), serum memantine concentration, and histopathology of the spinal cord were evaluated. Half of all rabbits (21/42) showed spinal protection. Receiver operating characteristic (ROC) curve analysis showed serum level of 4.5ng/ml as a cutoff value for spinal protection (sensitivity 86%, specificity 62%, area under the curve (AUC) 0.785, P = .002). Sixteen rabbits had serum level ≥ 4.5ng/ml (group A), with 26 rabbits having < 4.5ng/ml (group B). Further comparison was done between groups A and B. The mean modified Tarlov score at 6, 24, 48, and 72h was 4.5 ± 0.9 and 2.4 ± 1.6, in groups A and B, respectively (P < .001). The modified Tarlov score showed positive correlation with serum memantine level (Spearman's rho = 0.618, P = .01). Results of MEP and histopathology were significantly better for group A. We showed that memantine is protective against SCI at serum levels ≥ 4.5ng/ml in a rabbit model; thus, it can be a potential adjunct for spinal protection during thoracic/thoracoabdominal aortic surgeries.