Management Of Spinal Cord Injury Research Articles

Guidelines for the Management of Degenerative Cervical Myelopathy and Spinal Cord Injury: An Introduction to a Focus Issue.

Study Design:Introduction to a guidelines project.Objectives:The objective of this focus issue is to present guidelines that outline how to best manage patients with degenerative cervical myelopathy (DCM) and spinal cord injury (SCI). Topics addressed in this focus issue include: 1) management strategies for patients with mild, moderate and severe DCM; and 2a) timing of surgical decompression; b) the use of methylprednisolone sodium succinate; c) the type and timing of anticoagulation strategies; d) the role of magnetic resonance imaging in clinical decision making and outcome prediction; and e) the type and timing of rehabilitation in patients with SCI.Methods:Systematic reviews were conducted to address key clinical questions and to synthesize the current body of evidence. A multidisciplinary guideline development group used the results of these reviews, along with their clinical expertise, to develop clinical practice guidelines, in a process that adhered to methodology proposed by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group.Results:The multidisciplinary guideline development group combined the systematic review findings with their clinical expertise and opinions to formulate recommendations on how to manage patients with DCM and SCI.Conclusions:These guidelines will serve as tools to assist clinicians in their decision making by offering a perspective that combines the available evidence, expertise from a variety of clinicians, and patient values.

A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope.

Acute spinal cord injury (SCI) is a traumatic event that results in disturbances to normal sensory, motor, or autonomic function and ultimately affects a patient’s physical, psychological, and social well-being. The management of patients with SCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding available management strategies for the treatment of SCI, including the use of corticosteroids such as methylprednisolone sodium succinate, the optimal timing of surgical intervention, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and among the various disciplines that encounter patients with SCI. The objective of this guideline is to form evidence-based recommendations for these areas of controversy and outline how to best manage patients with SCI. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.

Translational Advances in the Management of Acute Spinal Cord Injury

Translational Advances in the Management of Acute Spinal Cord Injury

Spinal Cord Injury-What Are the Controversies?

Traumatic spinal cord injuries have a tremendous impact on individuals, families, and society as a whole. Substantial heterogeneity in the patient population, their presentation and underlying pathophysiology has sparked debates along the care spectrum from initial assessment to definitive treatment. This article reviews spinal cord injury (SCI) management followed by a discussion of the salient controversies in the field. Current care practices modeled on the American Association of Neurological Surgeons/Congress of Neurological Surgeons joint section guidelines are highlighted including key recommendations regarding immobilization, avoidance of hypotension, early International Standards for Neurological Classification of SCI examination and intensive care unit treatment. From a diagnostic perspective, the evolving roles of CT, MRI, and leading-edge microstructural MRI techniques are discussed with descriptions of the relevant clinical literature for each. Controversies in management relevant to clinicians including the timing of surgical decompression, methylprednisolone administration, blood pressure augmentation, intraoperative electrophysiological monitoring, and the role of surgery in central cord syndrome and pediatric SCI are also covered in detail. Finally, the article concludes with a reflection on clinical trial design tailored to the heterogeneous population of individuals with SCI.

Assessment and management of acute spinal cord injury: From point of injury to rehabilitation

Context: Spinal cord injury (SCI) is a devastating condition that can lead to significant neurological impairment and reduced quality of life. Despite advancements in our understanding of the pathophysiology and secondary injury mechanisms involved in SCI, there are currently very few effective treatments for this condition. The field, however, is rapidly changing as new treatments are developed and key discoveries are made. Methods: In this review, we outline the pathophysiology, management, and long-term rehabilitation of individuals with traumatic SCI. We also provide an in-depth overview of emerging therapies along the spectrum of the translational pipeline. Evidence synthesis: The concept of “time is spine” refers to the concept which emphasizes the importance of early transfer to specialized centers, early decompressive surgery, and early delivery of other treatments (e.g. blood pressure augmentation, methylprednisolone) to affect long-term outcomes. Another important evolution in management has been the recognition and prevention of the chronic complications of SCI including respiratory compromise, bladder dysfunction, Charcot joints, and pressure sores through directed interventions along with early integration of physical rehabilitation and mobilization. There have also been significant advances in neuroprotective and neuroregenerative strategies for SCI, many of which are actively in clinical trial including riluzole, Cethrin, stem cell transplantation, and the use of functional electrical stimulation. Conclusion: Pharmacologic treatments, cell-based therapies, and other technology-driven interventions will likely play a combinatorial role in the evolving management of SCI as the field continues to evolve.

The evolution of national care pathways in spinal cord injury management

Spinal cord injury service delivery in the UK has improved over the years. The modern concept of Spinal Cord Injury care commenced after the Second World War. Patients started to live longer after the improvement in the medical and nursing care which was delivered in Spinal Cord Injury Centres across the country. In the last five years, spinal cord injury care has seen major advances. The Spinal Cord Injury Strategy Board was established in 2010 which led to the development of the Spinal Injury Pathway, the Spinal Injury National database and the creation of the clinical reference group for Spinal Cord Injury. This led to improvement in the care of evidence-based management.

Active physiological conservative management in traumatic spinal cord injuries – an evidence-based approach

The management of the traumatic spinal cord injury remains controversial. Guttmann demonstrated that with simultaneous attention to all medical and non-medical effects of the spinal cord injury, a significant number of patients recovered motor and sensory functions to ambulate and the majority were pain-free following conservative management. Active physiological conservative management of the spinal injury requires simultaneous scrupulous care of the injured spine together with; the multisystem neurogenic effects of the spinal cord injury on the respiratory, cardiovascular, urinary, gastrointestinal, dermatological, sexual and reproductive functions; the management of the associated psychological effects of paralysis from the early hours or days of injury as well as; the physical rehabilitation and modification of the environment. To date, there is no evidence to suggest that the surgical decompression and/or stabilisation of the neurologically impaired spinal cord injury patient is advantageous. This article considers the debates and evidence of surgical management including the effects of timing of the surgical decompression. Also addressed are the factors influencing decisions on management, prognostic indicators of recovery and natural history of complete and incomplete cord injuries. Traumatic biomechanical instability of the spine, physiological instability of the spinal cord, traumatic spinal canal encroachment and traumatic cord compression are also discussed. Early mobilisation, indications for surgery at the RJAH and economic considerations of spinal cord injuries are presented. The ultimate goals of the active physiological conservative management are to ensure maximum neurological recovery and independence, a pain-free and flexible spine, safe and convenient functioning of the various systems of the body with minimal inconvenience to patients and the prevention of complications.

3D Poly(Lactic-co-glycolic acid) Scaffolds for Treating Spinal Cord Injury.

In this paper, poly(lactic-co-glycolic acid) (PLGA) was used to fabricate spinal cord scaffolds using low temperature deposition manufacturing (LDM) technology. The PLGA scaffolds were characterized as having good porosity, hydrophilicity and considerable biodegradability. The effects of the PLGA scaffolds on cell proliferation and cytotoxicity were evaluated by culturing Schwann cells (SCs) on the surfaces of the scaffolds. The results showed that the SCs spread and proliferated well on the PLGA scaffolds. Histological assessment including Glia fibrillary acidic protein (GFAP) staining, Nissl staining, Luxol fast blue (LFB) staining and Bielschowsky silver staining showed that the spinal cord recoveries considerably improved with the PLGA scaffolds, indicating that the PLGA scaffolds exhibited potential for applications in the management of spinal cord injuries.

Pulmonary outcomes following specialized respiratory management for acute cervical spinal cord injury: a retrospective analysis

Study design:Retrospective analysis.Objectives:To identify multivariate interactions of respiratory function that are sensitive to spinal cord injury level and pharmacological treatment to promote strategies that increase successful liberation from mechanical ventilation.Setting:United States regional spinal cord injury (SCI) treatment center.Methods:Retrospective chart review of patients consecutively admitted to Santa Clara Valley Medical Center between May 2013 and December 2014 for ventilator weaning with C1–C5 American Spinal Injury Association Impairment Scale (AIS) A or B SCI, <3 months from injury and who had a tracheostomy in place. A nonlinear, categorical principal component analysis (NL-PCA) was performed to test the multivariate interaction of respiratory outcomes from patients (N=36) being weaned off ventilator support after acute SCI with (N=15) or without (N=21) theophylline treatment.Results:In total, 36 patients met inclusion criteria (2 C1, 5 C2, 11 C3, 14 C4 and 4 C5). The NL-PCA returned three independent components that accounted for 95% of the variance in the data set. Multivariate general linear models hypothesis tests revealed a significant syndromic interaction between theophylline treatment and SCI level (Wilks' Lambda, P=0.028, F (12,64)=2.116, η2=0.256, 1−β=0.838), with post hoc testing demonstrating a significant interaction on PC1, explained by a positive correlation between improved forced vital capacity and time it took to reach 16 h of ventilator-free breathing. Thirty-three patients (92%) achieved 16 h of ventilator-free breathing (VFB) and 30 patients (83%) achieved 24 h of VFB.Conclusions:We suspect that some portion of the high success rate of ventilator weaning may be attributable to theophylline use in higher cervical SCI, in addition to our aggressive regimen of high volume ventilation, medication optimization and pulmonary toilet (positive pressure treatments and mechanical insufflation–exsufflation).

Massive open online courses for educating physiotherapists about spinal cord injuries: a descriptive study.

This was a descriptive study with the primary objective of describing two Massive Open Online Courses (MOOCs) about the physiotherapy management of spinal cord injuries. We sought to determine the number of participants who registered and then completed the MOOCs, and changes in participants' knowledge. The secondary objective was to determine whether the MOOCs increased usage of www.elearnSCI.org. The setting for this study was global and online. Two 5-week MOOCs were run in 2014 and 2016 about physiotherapy management of spinal cord injuries. The MOOCs were based on the physiotherapy module of www.elearnSCI.org. The data were collected on the number of participants who completed the MOOCs. Participants' knowledge was assessed prior to the commencement of the MOOC and upon completion of the MOOC. In addition, Google analytics were used to determine whether the MOOCs increased usage of www.elearnSCI.org over the two 5-week periods in which the MOOCs were run. In total, 3500 and 10 000 physiotherapists and physiotherapy students registered for the MOOC in 2014 and 2016, respectively. Participants' knowledge increased by a median (interquartile) of 15% (5 to 25% for 2014; 0 to 25% for 2016). Lessons from www.elearnSCI.org that formed part of the MOOC were accessed a median (interquartile range) of 8626 (6150 to 10 773) and 17 631 (15 262 to 22 929) times per day during the 2014 and 2016 MOOCs, respectively. MOOCs provide a relatively inexpensive way of providing education about the physiotherapy management of spinal cord injuries, but it is yet to be determined whether they improve clinical skills.

Development of an &lt;i&gt;in&lt;/i&gt; situ polymeric hydrogel implant of methylprednisolone for spinal injuries

Purpose: To prepare and characterize in situ gel-forming implants of methylprednisolone for the treatment of spinal cord injuries.Methods: In situ hydrogels of methylprednisolone were prepared by dispersing polylactide glycolic acid (PLGA) polymer and methylprednisolone in N-methyl-pyrrolidone solvent, and subsequent membrane sterilization. Hydrogels were prepared using varying concentrations of PLGA polymer. The physicochemical properties of hydrogels, including visual appearance, clarity, pH, viscosity, drug content, and in vitro drug release, were characterized. In vivo studies were performed to examine antiinflammatory activity (paw edema test) and in vivo motor function activity in a rat spinal injury model after injecting the hydrogels into rats.Results: The physicochemical properties of the gels were satisfactory. F1, F2, F3, and F4 formulations showed 99.67, 95.29, 88.89 and 88.20 % drug release, respectively, at the end of 7 days. In vivo antiinflammatory activity was highest for F1 (62.85 %). Motor function activity scores (arbitrary scale) for the F1, F2, F3 and F4 formulations were 4.82 ± 0.12, 4.70 ± 0.12, 4.68 ± 0.02, and 4.60 ± 0.05, respectively, and were higher (p &lt; 0.05) for F1, F2 and F3) than for the standard (methylprednisolone, 30 mg/kg body weight, iv; activity score, 4.59 ± 0.20).Conclusions: The in situ hydrogels of methylprednisolone developed may be useful for the effective management of spinal cord injuries in patients. However, further investigations are required to ascertain their suitability for clinical use.Keywords: Methylprednisolone, In situ hydrogel, Spinal injury, Motor activity, Implant

Preclinical Efficacy Failure of Human CNS-Derived Stem Cells for Use in the Pathway Study ofCervical Spinal Cord Injury.

SummaryWe previously showed the efficacy of multiple research cell lines (RCLs) of human CNS neural stem cells (HuCNS-SCs) in mouse and rat models of thoracic spinal cord injury (SCI), supporting a thoracic SCI clinical trial. Experts recommend in vivo preclinical testing of the intended clinical cell lot/line (CCL) in models with validity for the planned clinical target. We therefore tested the efficacy of two HuCNS-SC lines in cervical SCI: one RCL, and one CCL intended for use in the Pathway Study of cervical SCI in man. We assessed locomotor recovery and sensory function, as well as engraftment, migration, and fate. No evidence of efficacy of the CCL was observed; some data suggested a negative impact of the CCL on outcomes. These data raise questions about the development and validation of potency/comparability assays for clinical testing of cell products, and lack of US Food and Drug Administration requirements for in vivo testing of intended clinical cell lines.

What prompts nurses to seek help from wound care consultants in spinal cord injury management?

Objective: This study aimed to identify clinical scenarios that might prompt nurses to seek advice from a spinal cord injury wound care nurse consultant for pressure injury management. In addition, some attributes of nurses were examined for associations with intention to seek the help of a consultant. Design: Exploratory quantitative survey. Setting: Queensland, Australia. Subjects: Fifty currently practising hospital and community based nurses. Main outcome measure(s): Two part online survey - part one presented hypothetical clinical case scenarios, in which respondents indicated their likelihood of seeking help; and, part two examined participant attributes and work experience. Results: Each scenario presented was rated as either of little importance or utmost importance by at least one respondent. Participants identified consultant personality and proximity as more influential on help seeking than timeliness, common sense or knowledge. Conclusion: The study did not identify a pattern of association between the presence of certain clinical factors and intention to seek help from a spinal cord injury consultant nurse for pressure injury management. What is important and influential for one person may be of less importance for others. Consultants must market their value to nurses in order that they are front of mind during the help seeking process. Further studies are required to examine the decision making process associated with help seeking.

Update on Medical Management of Acute Spinal Cord Injuries

Schroeder, Gregory D. MD; Wilson, Jefferson R. MD, PhD; Hollern, Douglas A. MD; Hartjen, Eric BS; Olsson, Erik C. MD; Vaccaro, Alexander R. MD, PhD, MBA Author Information

Update on Medical Management of Acute Spinal Cord Injuries

Update on Medical Management of Acute Spinal Cord Injuries

Surgical Management of Civilian Gunshot-Induced Spinal Cord Injury: Is It Overutilized?

Retrospective chart review. Assess appropriate utilization of surgery for civilian gunshot-induced spinal cord injuries (CGSWSCI) according to literature standards in a large cohort. CGSWSCI are mechanically stable injuries that rarely require surgery. Nonetheless, we continue to see high numbers of these patients undergo surgical treatment. This study compares indications for surgeries performed in a large cohort of CGSWSCI patients to established indications for surgical management of such injuries. The rate of over-utilization of surgical management was calculated. Four hundred eighty-nine CGSWSCI patients transferred for rehabilitation to our institution between 2000 and 2014 were identified. Retrospective chart review was performed to identify patients who underwent initial surgical treatment, the specific surgeries performed, and indications given. We assessed appropriateness of surgery according to literature standards. Patients treated surgically were followed to assess for complications and the need for additional intervention and compared to nonsurgical patients. Secondarily, visual analog scale pain scores (0-10) and patient perceived improvement were compared between surgical and nonsurgical patients after telephone survey of both groups. Of 489 patients, 91 (18%) underwent initial surgery. Of 91 surgeries, 69 (75%) were not indicated by literature standards. Five of 91 (5.5%) of initially operated patients required a secondary surgery compared with two of 398 (0.5%) of the nonoperative group (P = 0.003). Over-utilization rate of the entire cohort was 14.1%. No difference was seen for pain scores or patient perceived improvement between operative and nonoperative patients. We report a high overutilization rate (14%) of surgery for CGSWSCI in our cohort. Surgical management was associated with higher infection and secondary surgery rates compared to nonsurgical management. Surgery done without a clear, demonstrable benefit poses unnecessary risk to patients and accumulates unwarranted healthcare costs. 3.

Chapter 15 - Management of acute traumatic spinal cord injuries

Acute traumatic spinal cord injury (SCI) is a devastating disease process affecting tens of thousands of people across the USA each year. Despite the increase in primary prevention measures, such as educational programs, motor vehicle speed limits, automobile running lights, and safety technology that includes automobile passive restraint systems and airbags, SCIs continue to carry substantial permanent morbidity and mortality. Medical measures implemented following the initial injury are designed to limit secondary insult to the spinal cord and to stabilize the spinal column in an attempt to decrease devastating sequelae. This chapter is an overview of the contemporary management of an acute traumatic SCI patient from the time of injury through the stay in the intensive care unit. We discuss initial triage, immobilization, and transportation of the patient by emergency medical services personnel to a definitive treatment facility. Upon arrival at the emergency department, we review initial trauma protocols and the evidence-based recommendations for radiographic evaluation of the patient's vertebral column. Finally, we outline closed cervical spine reduction and various aggressive medical therapies aimed at improving neurologic outcome.

A novel nonpharmacological intervention - breathing-controlled electrical stimulation for neuropathic pain management after spinal cord injury - a preliminary study.

ObjectiveThe objective of this study was to examine the effectiveness of a novel nonpharmacological intervention – breathing-controlled electrical stimulation (BreEStim) – for neuropathic pain management in spinal cord injury (SCI) patients.Subjects and methodsThere were two experiments: 1) to compare the effectiveness between BreEStim and conventional electrical stimulation (EStim) in Experiment (Exp) 1 and 2) to examine the dose–response effect of BreEStim in Exp 2. In Exp 1, 13 SCI subjects (6 males and 7 females, history of SCI: 58.2 months, from 7 to 150 months, impairments ranging from C4 AIS B to L1 AIS B) received both BreEStim and EStim in a randomized order with at least 3 days apart. A total of 120 electrical stimuli to the median nerve transcutaneously were triggered by voluntary inhalation during BreEStim or were randomly delivered during EStim. In Exp 2, a subset of 7 subjects received BreEStim120 and 240 stimuli randomly on two different days with 7 days apart (BreEStim120 vs BreEStim240). The primary outcome variable was the visual analog scale (VAS) score.ResultsIn Exp 1, both BreEStim and EStim showed significant analgesic effects. Reduction in VAS score was significantly greater after BreEStim (2.6±0.3) than after EStim (0.8±0.3) (P<0.001). The duration of analgesic effect was significantly longer after BreEStim (14.2±6 hours) than after EStim (1.9±1 hours) (P=0.04). In Exp 2, BreEStim120 and BreEStim240 had similar degree and duration of analgesic effects.ConclusionThe findings from this preliminary study suggest that BreEStim is an effective alternative nonpharmacological treatment for chronic neuropathic pain in patients suffering from SCI.

Spinal cord injury: is monitoring from the injury site the future?

This paper challenges the current management of acute traumatic spinal cord injury based on our experience with monitoring from the injury site in the neurointensive care unit. We argue that the concept of bony decompression is inadequate. The concept of optimum spinal cord perfusion pressure, which differs between patients, is introduced. Such variability suggests individualized patient treatment. Failing to optimize spinal cord perfusion limits the entry of systemically administered drugs into the injured cord. We conclude that monitoring from the injury site helps optimize management and should be subjected to a trial to determine whether it improves outcome.

Acute Inpatient Rehabilitation Management of Spinal Cord Injury in Pediatric Neuromyelitis Optica

Acute Inpatient Rehabilitation Management of Spinal Cord Injury in Pediatric Neuromyelitis Optica