Severe Cervical Spinal Cord Injury Research Articles

Abstract 18832: Early Leadless Pacemaker Implantation in a Case of Severe Cervical Spinal Cord Injury

Introduction: Bradycardia is a frequent cause of morbidity and mortality in spinal cord injury (SCI) patients and optimal timing of permanent pacemaker implant is unclear. Case Summary: A 67-year-old female with no cardiac history was admitted for fall of uncertain etiology complicated by severe cervical SCI and neurogenic shock. Despite emergent surgical decompression, the injury resulted in quadriplegia. Post-operatively, bradycardic arrest occurred requiring resuscitation and dependence on dopamine infusion. Rhythm strip from showed p-p slowing followed by high grade atrioventricular block with multiple blocked p waves. A decision was made for early intervention with implantation of a Micra leadless pacemaker (LPM) (Medtronic, Minneapolis, MN) for both hemodynamically significant bradycardia and backup to prevent bradycardic arrest. A LPM was successfully implanted without complication on hospital day 8. The pacemaker was set to VVI 60. Post operatively, the patient required intermittent pacing and tolerated dopamine weaning. Discussion: Bradycardia in SCI patients, especially those with high cervical and complete SCI, occurs due to unopposed parasympathetic activity, resulting in baseline sinus bradycardia. Even more concerning is the risk for sudden and unpredictable sinus arrest and/or AV block, which is a leading cause of mortality in the first year after SCI. While initial management of bradyarrhythmia in SCI patients may respond to pharmacologic intervention, temporary and/or permanent pacing may be indicated. Acute SCI patients may not be ideal candidates for traditional pacemakers since ICU and infectious complications are common in this cohort, but LPMs have extremely low risk of implant site and infectious complications and can be utilized earlier in the hospital course. Our case showcases this strategy of early leadless pacemaker implantation. Further study is needed to better evaluate the safety and efficacy of this strategy.

Changes in respiratory structure and function after traumatic cervical spinal cord injury: observations from spinal cord and brain.

Respiratory difficulties and mortality following severe cervical spinal cord injury (CSCI) result primarily from malfunctions of respiratory pathways and the paralyzed diaphragm. Nonetheless, individuals with CSCI can experience partial recovery of respiratory function through respiratory neuroplasticity. For decades, researchers have revealed the potential mechanism of respiratory nerve plasticity after CSCI, and have made progress in tissue healing and functional recovery. While most existing studies on respiratory plasticity after spinal cord injuries have focused on the cervical spinal cord, there is a paucity of research on respiratory-related brain structures following such injuries. Given the interconnectedness of the spinal cord and the brain, traumatic changes to the former can also impact the latter. Consequently, are there other potential therapeutic targets to consider? This review introduces the anatomy and physiology of typical respiratory centers, explores alterations in respiratory function following spinal cord injuries, and delves into the structural foundations of modified respiratory function in patients with CSCI. Additionally, we propose that magnetic resonance neuroimaging holds promise in the study of respiratory function post-CSCI. By studying respiratory plasticity in the brain and spinal cord after CSCI, we hope to guide future clinical work.

Spinal Cord Epidural Stimulation Improves Lower Spine Sitting Posture Following Severe Cervical Spinal Cord Injury.

Cervical spinal cord injury (SCI) leads to impaired trunk motor control, negatively impacting the performance of activities of daily living in the affected individuals. Improved trunk control with better sitting posture has been previously observed due to neuromuscular electrical stimulation and transcutaneous spinal stimulation, while improved postural stability has been observed with spinal cord epidural stimulation (scES). Hence, we studied how trunk-specific scES impacts sitting independence and posture. Fourteen individuals with chronic, severe cervical SCI with an implanted neurostimulator performed a 5-min tall-sit task without and with trunk-specific scES. Spine posture was assessed by placing markers on five spine levels and evaluating vertical spine inclination angles. Duration of trunk manual assistance was used to assess independence along with the number of independence changes and average independence score across those changes. With scES, the sacrum-L1 inclination and number of independence changes tended to decrease by 1.64 ± 3.16° (p = 0.07; Cohen's d = 0.53) and 9.86 ± 16.8 (p = 0.047; Cohen's d = 0.59), respectively. Additionally, for the participants who had poor sitting independence without scES, level of independence tended to increase by 12.91% [0%, 31.52%] (p = 0.38; Cohen's d = 0.96) when scES was present. Hence, trunk-specific scES promoted improvements in lower spine posture and lower levels of trunk assistance.

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).

Multi-Site Spinal Cord Transcutaneous Stimulation Facilitates Upper Limb Sensory and Motor Recovery in Severe Cervical Spinal Cord Injury: A Case Study.

Individuals with cervical spinal cord injury (SCI) rank regaining arm and hand function as their top rehabilitation priority post-injury. Cervical spinal cord transcutaneous stimulation (scTS) combined with activity-based recovery training (ABRT) is known to effectively facilitate upper extremity sensorimotor recovery in individuals with residual arm and hand function post SCI. However, scTS effectiveness in facilitating upper extremity recovery in individuals with severe SCI with minimal to no sensory and motor preservation below injury level remains largely unknown. We herein introduced a multimodal neuro-rehabilitative approach involving scTS targeting systematically identified various spinal segments combined with ABRT. We hypothesized that multi-site scTS combined with ABRT will effectively neuromodulate the spinal networks, resulting in improved integration of ascending and descending neural information required for sensory and motor recovery in individuals with severe cervical SCI. To test the hypothesis, a 53-year-old male (C2, AIS A, 8 years post-injury) received 60 ABRT sessions combined with continuous multi-site scTS. Post-training assessments revealed improved activation of previously paralyzed upper extremity muscles and sensory improvements over the dorsal and volar aspects of the hand. Most likely, altered spinal cord excitability and improved muscle activation and sensations resulted in observed sensorimotor recovery. However, despite promising neurophysiological evidence pertaining to motor re-activation, we did not observe visually appreciable functional recovery on obtained upper extremity motor assessments.

Early expansive single sided laminoplasty decompression treatment severe traumatic cervical spinal cord injury.

BackgroundSevere traumatic cervical spinal cord injury (tcSCI) is a disastrous event for patients and families. Maximizing spinal cord function recovery has become the primary therapeutic goal. This study investigated the effect of early extensive posterior decompression on spinal cord function improvement after severe tcSCI.MethodsA retrospective review of 83 consecutive patients who underwent extensive open-door laminoplasty decompression within 24 h after severe tcSCI (American Spinal Injury Association (ASIA) impairment scale (AIS) grade A to C) between 2009 and 2017 at our institution was performed. The patient clinical and demographic data were collected. Neurological functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) score system, ASIA motor score (AMS) and AIS grade.ResultsAmong the 83 patients initially included, the baseline AIS grade was A in 12, B in 28, and C in 43. Twenty-three patients (27.7%) had a high cervical injury. Cervical spinal stenosis (CSS) was identified in 37 patients (44.6%). The mean intramedullary lesion length was 59.6 ± 20.4 mm preoperatively and 34.2 ± 13.3 mm postoperatively (p < 0.0001). At the final follow-up visit, an improvement of at least one and two AIS grades was found in 75 (90.4%) and 41 (49.4%) patients, respectively. 24 (64.9%) patients with an improvement of least two AIS grades had CSS. The mean AMS and JOA score were significantly improved at discharge and the final follow-up visit compared with on admission (p < 0.0001).ConclusionsOur results suggest that early expansive laminoplasty decompression may improve neurological outcomes after severe tcSCI, especially in patients with CSS. Larger and prospective controlled studies are needed to validate these findings.

Fourteen-year change in activities of daily living of a quadriplegic, ventilator-managed patient injured by high cervical spinal cord injury during infancy: a case report

BackgroundRehabilitation of patients with high cervical spinal cord injury (CSCI) to improve activities of daily living (ADL) is challenging due to severe paralysis. In addition, pediatric patients with CSCI are rare, and literature describing ADL changes as the patient grows are limited. In this case report, we present the long-term change in ADL over time in a girl with severe high CSCI from an injury during infancy.Case presentationA 2 years and 6 months old girl, who was injured in a traffic accident, was diagnosed with C3 CSCI, resulting in complete quadriplegia and respiratory paralysis below C3. Thus, she was managed with a ventilator. Rehabilitation for quadriplegia, respiratory dysfunction, and autonomic neuropathy was started on the fifth day after the injury while she was in the intensive care unit. Six months after the injury, the patient was transferred to a hospital. Thereafter, she was discharged with nursing and care guidance provided to her family and environmental changes at home. Afterwards, she continued to acquire skills through writing training using a mouse stick, computer operation training, and electric wheelchair operation training, which enabled her to improve her ADL despite her severe disability. In terms of education, she was able to go through a regular elementary school, a regular junior high school, and then to a senior high school of a support school.ConclusionsWe believe that training that utilizes current technology and changes in the environment that are appropriate for daily life are important for improving the ADL of children with severe CSCI.

Long-Term Effects of Neural Precursor Cell Transplantation on Secondary Injury Processes and Functional Recovery after Severe Cervical Contusion-Compression Spinal Cord Injury.

Cervical spinal cord injury (SCI) remains a devastating event without adequate treatment options despite decades of research. In this context, the usefulness of common preclinical SCI models has been criticized. We, therefore, aimed to use a clinically relevant animal model of severe cervical SCI to assess the long-term effects of neural precursor cell (NPC) transplantation on secondary injury processes and functional recovery. To this end, we performed a clip contusion-compression injury at the C6 level in 40 female Wistar rats and a sham surgery in 10 female Wistar rats. NPCs, isolated from the subventricular zone of green fluorescent protein (GFP) expressing transgenic rat embryos, were transplanted ten days after the injury. Functional recovery was assessed weekly, and FluoroGold (FG) retrograde fiber-labeling, as well as manganese-enhanced magnetic resonance imaging (MEMRI), were performed prior to the sacrifice of the animals eight weeks after SCI. After cryosectioning of the spinal cords, immunofluorescence staining was conducted. Results were compared between the treatment groups (NPC, Vehicle, Sham) and statistically analyzed (p < 0.05 was considered significant). Despite the severity of the injury, leading to substantial morbidity and mortality during the experiment, long-term survival of the engrafted NPCs with a predominant differentiation into oligodendrocytes could be observed after eight weeks. While myelination of the injured spinal cord was not significantly improved, NPC treated animals showed a significant increase of intact perilesional motor neurons and preserved spinal tracts compared to untreated Vehicle animals. These findings were associated with enhanced preservation of intact spinal cord tissue. However, reactive astrogliosis and inflammation where not significantly reduced by the NPC-treatment. While differences in the Basso–Beattie–Bresnahan (BBB) score and the Gridwalk test remained insignificant, animals in the NPC group performed significantly better in the more objective CatWalk XT gait analysis, suggesting some beneficial effects of the engrafted NPCs on the functional recovery after severe cervical SCI.

Automated lever task with minimum antigravity movement for rats with cervical spinal cord injury

BackgroundAlthough there is currently no cure for paralysis due to spinal cord injury (SCI), the highest treatment priority is restoring arm and hand function for people with cervical SCI. Preclinical animal models provide an opportunity to test innovative treatments, but severe cervical injury models require significant time and effort to assess responses to novel interventions. Moreover, there is no behavioral task that can assess forelimb movement in rats with severe cervical SCI unable to perform antigravity movements. New methodWe developed a novel lever pressing task for rats with severe cervical SCI. We employed an automated adaptive algorithm to train animals using open-source software and commercially available hardware. We found that using the adaptive training required only 13.3 ± 2.5 training days to achieve behavioral proficiency. The lever press task could quantify immediate and long-term improvements in severely impaired forelimb function effectively. This behavior platform has potential to facilitate rehabilitative training and assess effects of therapeutic modalities following SCI. Comparison with existing methodsThere is no existing assessment aiming to quantify forelimb extension movement in rodents without function against gravity. We found that the new lever press task in the antigravity position could assess the severity of cervical SCI as well as the compensatory movement in the proximal forelimb less affected by the injury. ConclusionsThis study demonstrates that the new behavioral task is capable of tracking the functional changes with various therapies in rats with severe forelimb impairments in a cost- and time-efficient manner.

Subclinical Hypoventilation in Dogs Undergoing Ventral Slot Decompressive Surgery for Cervical Myelopathy Due to Intervertebral Disc Herniation.

The objective of this prospective cohort study was to document the occurrence of post-operative hypoventilation in dogs undergoing decompressive ventral slot or hemilaminectomy for the treatment of intervertebral disc herniation (IVDH). Twenty dogs undergoing ventral slot surgery and 20 dogs undergoing hemilaminectomy surgery for the treatment of IVDH that presented to XX between 2017 and 2020 were enrolled. Dogs were anesthetized using a standard protocol. Blood gas samples were taken at up to 11 time points beginning during anesthetic recovery and continuing for a maximum of 72 h post-operatively. Dogs with cervical lesions that were non-ambulatory before surgery had more evidence of subclinical hypoventilation in the immediate peri-extubation period than dogs with less severe injuries or those undergoing hemilaminectomy surgery. We found no difference in the ventilation status in dogs undergoing cervical or thoracolumbar decompressive surgery for IVDH from 8 to 72 h post-operatively. Other markers of acid-base status indicated that subclinical hypoventilation within the peri-extubation period was transient and self-limiting. There was a moderate positive correlation between sedation scores and estimated PaCO2. These data suggest that dogs with severe cervical spinal cord injuries may be at risk for subclinical hypoventilation in the immediate peri-extubation period. Increased sedation may be correlated with decreased ventilatory status in dogs recovering from decompressive vertebral column surgery.

Socioeconomic and Functional Outcomes after Severe Traumatic Cervical Spinal Cord Injuries: A Comparison of Surgical and Nonsurgical Patients

Socioeconomic and Functional Outcomes after Severe Traumatic Cervical Spinal Cord Injuries: A Comparison of Surgical and Nonsurgical Patients

Survival among patients with severe high cervical spine injuries \u2013 a TraumaRegister DGU\xae database study

BackgroundTrauma is a significant cause of death and impairment. The Abbreviated Injury Scale (AIS) differentiates the severity of trauma and is the basis for different trauma scores and prediction models. While the majority of patients do not survive injuries which are coded with an AIS 6, there are several patients with a severe high cervical spinal cord injury that could be discharged from hospital despite the prognosis of trauma scores. We estimate that the trauma scores and prediction models miscalculate these injuries. For this reason, we evaluated these findings in a larger control group.MethodsIn a retrospective, multi-centre study, we used the data recorded in the TraumaRegister DGU® (TR-DGU) to select patients with a severe cervical spinal cord injury and an AIS of 3 to 6 between 2002 to 2015. We compared the estimated mortality rate according to the Revised Injury Severity Classification II (RISC II) score against the actual mortality rate for this group.ResultsSix hundred and twelve patients (0.6%) sustained a severe cervical spinal cord injury with an AIS of 6. The mean age was 57.8 ± 21.8 years and 441 (72.3%) were male. 580 (98.6%) suffered a blunt trauma, 301 patients were injured in a car accident and 29 through attempted suicide. Out of the 612 patients, 391 (63.9%) died from their injury and 170 during the first 24 h. The group had a predicted mortality rate of 81.4%, but we observed an actual mortality rate of 63.9%.ConclusionsAn AIS of 6 with a complete cord syndrome above C3 as documented in the TR-DGU is survivable if patients get to the hospital alive, at which point they show a survival rate of more than 35%. Compared to the mortality prognosis based on the RISC II score, they survived much more often than expected.

Is early surgical intervention effective for traumatic severe cervical spinal cord injury? A retrospective study secondary publication

Although early surgery is known to be effective for the treatment of traumatic cervical spinal cord injury (CSCI), whether it is equally effective in severe CSCI cases remains undetermined. This study aimed to determine whether surgery within 24 h improves the neurological prognosis and reduces the complications associated with surgery for traumatic severe CSCI. The data of 42 patients with traumatic severe CSCI with American Spinal Injury Association Impairment Scale (AIS) grades A–B who underwent surgery between December 2007 and May 2018 were retrospectively reviewed. The participants were classified into early surgery (&lt;24 h) and late surgery (&gt;24 h) groups. Using the inverse probability of treatment weighting with propensity score adjustment for confounding factors, the AIS grades before and 1 month following surgical treatment, which were considered the primary outcomes, were compared. The secondary outcomes were the intensive care unit length of stay (ICU-LOS) and occurrence of respiratory complications and cardiac arrest. In the early surgery group (n = 32, 76%), the average time to surgery was 10.25 h (4–23 h). The inverse probability of treatment weighting analysis indicated significant differences in the neurological improvement according to the AIS grade at 1 month following surgery (odds ratio [OR]: 17.1, 95% confidence interval [Cl]: 1.9–156.7, p = 0.012), the ICU-LOS &gt;7 days (OR: 0.14, 95% Cl: 0.02–0.90, p = 0.04), and the occurrence of respiratory complications (OR: 0.08, 95% Cl: 0.01–0.73, p = 0.03) and cardiac arrest (OR: 0.13, 95% Cl: 0.02–0.85, p = 0.03). Early surgery (within 24 h) for traumatic severe CSCI may improve the neurological prognosis and prevent a long ICU-LOS and postoperative complications.

Early Surgical Intervention (&lt;12h) for Severe Traumatic Cervical Spinal Cord Injury Reduces Postoperative Complications

Early Surgical Intervention (&lt;12h) for Severe Traumatic Cervical Spinal Cord Injury Reduces Postoperative Complications

모바일 게임 기반의 호흡 운동이 중증 경수 손상 장애인의 호흡 근력과 기침 능력에 미치는 영향: A Preliminary Case Stu

모바일 게임 기반의 호흡 운동이 중증 경수 손상 장애인의 호흡 근력과 기침 능력에 미치는 영향: A Preliminary Case Stu

Influence of early extensive posterior decompression on hyponatremia and cardiopulmonary dysfunction after severe traumatic cervical spinal cord injury: A clinical observational study.

Retrospective single institution observational study.The aim of the present study was to analyze the influence of early extensive posterior decompression on complications in patients with severe traumatic cervical spinal cord injury (tcSCI).Cervical SCI is associated with a high prevalence of hyponatremia and cardiopulmonary dysfunction. However, very few studies have focused on this exploration to reduce the incidence of SCI early complications.We reviewed the medical records of consecutive patients undergoing extensive posterior decompression within 24 h for severe tcSCI (American Spinal Injury Association Impairment Scale [AIS] A to C) admitted between January 2009 and January 2018. The data collected retrospectively included age, gender, mechanism, and level of SCI, AIS grade, fracture or dislocation, electrolyte, and cardiopulmonary complications.Of the 97 enrolled patients, the baseline AIS grade was AIS A in 14, AIS B in 31, and AIS C in 52. Improvement of at least two AIS grades was found in 26 (26.8%), and improvement of at least one grade was found in 80.4% of patients at discharge. Twenty-nine (29.9%) patients had mild hyponatremia, 8 (8.2%) had moderate hyponatremia, and 3 (3.1%) had severe hyponatremia during hospitalization. The incidences of hyponatremia, hypotension, and tracheotomy were 41.2%, 13.4%, and 6.2%, respectively. The mean forced vital capacity (FVC) on admission and at discharge was 1.34 ± 0.46 L and 2.21 ± 0.41 L (P < .0001), respectively. Five patients developed pneumonia.Our results suggest that early expansive posterior decompression significantly reduces the incidence of hyponatremia, hypotension, and tracheotomy by promoting recovery of spinal cord function after severe tcSCI.

The usage of tractography of the spinal cord as a predictor of neurological disorders regression in patients with severe cervical spine and spinal cord injury

Мета: провести первинну оцінку прогностичних можливостей трактографії у пацієнтів з ускладненою хребетно-спинномозковою травмою шийного відділу хребта на субаксіальному рівні. Матеріали і методи. Клінічну групу утворили 5 пацієнтів, які перебували на стаціонарному лікуванні у відділенні патології спинного мозку та хребта Інституту нейрохірургії ім. акад. А.П. Ромоданова НАМН України в період з квітня до липня 2019 р. із травматичним ушкодженням шийного відділу хребта та спинного мозку тяжкого ступеня. В післяопераційний період на 5-ту–7-му добу пацієнтам проведено магнітно-резонансну томографію в режимах Т1W, Т2W, FLAIR, STIR, T2W FFE, CSF flow і дифузійно-тензорного зображення. Оцінювали динаміку регресу неврологічних порушень за International Standards for Neurological Classification of Spinal Cord Injury. Ступінь травматичного стенозу хребтового каналу визначали за допомогою спіральної комп’ютерної томографії до і після хірургічної корекції. З огляду на малу клінічну групу статистичну обробку отриманих цифрових показників не проводили. Основним завданням було виявлення загальних закономірностей для визначення напрямів подальших деталізованих досліджень. Результати. Набряк спинного мозку на рівні ушкодження, що відповідало ступеню неврологічних розладів, спостерігали в усіх пацієнтів. Наявність геморагічного компонента виявлено у 3 пацієнтів (по 1 випадку посттравматичного стенозу хребтового каналу >50 %, <50 % та <25 %). Набряк паренхіми спинного мозку супроводжувався компресією лікворних просторів різного ступеня – від субтотальної до тотальної, при цьому наявність або відсутність геморагічного компонента не впливала на інтенсивність ліквородінамічних порушень у пацієнтів. Оцінка результатів дифузійно-тензорного зображення виявила помірну обернено пропорційну залежність між фракційною анізотропією та середньою дифузійною здатністю. У 2 пацієнтів зареєстровано регрес неврологічних розладів. Відновлення сенсомоторних функцій не корелювало зі ступенем компресії хребтового каналу та характером змін паренхіми спинного мозку, але відзначено у пацієнтів з максимальними значеннями фракційної анізотропії та низькими величинами середньої дифузійної здатності. Висновки. Трактографія є інформативним предиктором регресу неврологічних розладів у пацієнтів, які перенесли хребетно-спинномозкову травму. Необхідно провести додаткові дослідження для виявлення оптимальних термінів її проведення та встановлення діагностично значущих значень показників анізотропної дифузії.

Survival in 222 Patients With Severe CSCI: An 8-Year Epidemiologic Survey in Western China

ObjectiveTo assess the survival and the predictors of mortality in patients with severe cervical spinal cord injuries (CSCI). DesignRetrospective study. ParticipantsFrom January 1, 2010, to May 31, 2018, patients who suffered from severe CSCIs in Western China were enrolled in this study (N=222). InterventionsNot applicable. Main Outcome MeasuresSurvival rates and mortality risk factors. Measures were calculated by the product-limit method (Kaplan-Meier) and the Cox model. ResultsThe overall 1-year, 3-year, 5-year, and 8-year postoperative mortalities were 24.4%, 30.6%, 33.3%, 36.2%, and 39.0%, respectively. Most deaths occurred within 36 months after the injury. According to the Cox proportional hazards model, the significant predictors of survival were as follows: (1) age; (2) neurologic level; (3) treatment options (surgical or conservative); (4) ventilator support (P<.05). The 8-year mortality for older patients (>50y) was 50.2%, which was significantly higher than that for younger patients (32.4%, <50y). The risk of death was 2.053 times higher in higher levels of injury (C1-C4) than in lower levels of injury (C5-C8) (P<.05). Compared with conservative treatment, patients who received surgical treatment (either anterior or posterior decompression) had a lower risk of death (P<.05). No significant difference was detected in the risk of death between early surgery (<3d) and mid-term surgery (3-7d) (P>.05). However, patients who received late-term surgery (>7d) had a higher mortality risk (P<.05). The overall 8-year mortality risk of patients who needed ventilator support was much higher than those who did not need ventilator support (P<.05). ConclusionsAge, neurologic level, ventilator dependence, treatment options, and timing to surgery were main risk factors for mortality in patients with severe CSCIs. Better understanding of the predictors for survival could possibly contribute to the improvement of survival rates.

Traumatic Spinal Cord Injury.

This article provides an update on the acute and subacute management and prognostication of patients with traumatic spinal cord injury. Immobilization of the spine and spine clearance should be individualized depending on the ability to perform a reliable neurologic examination, the presence of neck pain, and the imaging findings. Early surgery (within 24 hours) to achieve definitive cord decompression and spine stabilization may be beneficial. Ensuring adequate oxygenation and perfusion and avoiding secondary systemic complications remain the goals of the critical care of these patients. No neuroprotective treatment has been shown to improve outcomes. In fact, the use of high-dose methylprednisolone is now generally discouraged because of its major systemic adverse effects. Survivors of severe cervical traumatic spinal cord injury typically sustain substantial long-term functional impairment. Advances in our understanding of neuroregenerative strategies, especially stem cell transplantation, can offer the future hope of functional improvement to the many patients currently living with the consequences of traumatic spinal cord injury. Yet, at present, these therapies remain strictly investigational. The treatment of traumatic spinal cord injury remains supportive, and prognosis is still poor for patients who are severely affected. While much remains to be learned about how to optimize the acute management of these patients, future efforts would be most useful if focused on injury prevention and the development of effective neuroregenerative therapies.

The use of classification tree analysis to assess the influence of surgical timing on neurological recovery following severe cervical traumatic spinal cord injury.

Post hoc analysis of prospectively collected data. Assess the influence of surgical timing on neurological recovery using classification tree analysis in patients sustaining cervical traumatic spinal cord injury. Hôpital du Sacré-Coeur de Montreal METHODS: 42 patients sustaining cervical SCI were followed for at least 6 months post injury. Neurological status was assessed from the American Spinal Injury Association impairment scale (AIS) and neurological level of injury (NLI) at admission and at follow-up. Age, surgical timing, AIS grade at admission and energy of injury were the four input parameters. Neurological recovery was quantified by the occurrence of improvement by at least one AIS grade, at least 2 AIS grades and at least 2 NLI. Proportion of patients that improved at least one ASIA grade was higher in the group that received early surgery (75 vs. 41 %). The proportion of patients that improved two AIS grades was also higher in the group that received early surgery (67 vs. 38 %). Finally, 30 % of the patients that received early decompression improved two NLI as compared with 0% in the other group. Early surgery was also associated with a non-statistically significant improvement in functional recovery. Neurological recovery of patients sustaining cervical traumatic spinal cord injury can be improved by early decompression surgery performed within 19 h post trauma. U.S. Army Medical Research and Material Command, Rick Hansen Institute.