Understanding and modelling the economic impact of spinal cord injuries in the United Kingdom. Spinal Cord. 2019;57:778-788. [PMID: 31086273 PMCID: PMC6760568 DOI: 10.1038/s41393-019-0285-1]

Stakeholders and Contextual Factors in the Implementation of Assistive Robotic Arms for Persons With Tetraplegia: Deductive Content Analysis of Focus Group Interviews

BACKGROUND

Tetraplegia imposes significant challenges on affected individuals, caregivers, and health care systems. Assistive technologies (ATs) such as assistive robotic arms have been shown to improve the quality of life of persons with tetraplegia, fostering independence in daily activities and reducing caregiver burden. Despite potential benefits, the integration of AT innovations into daily life remains difficult. Implementation science offers a systematic approach to bridge this know-do gap.

OBJECTIVE

This study aimed to (1) identify and involve relevant stakeholders; (2) identify relevant contextual factors (barriers and facilitators); and (3) suggest a general outlook for the implementation of AT, specifically an assistive robotic arm, into the everyday private lives of individuals with tetraplegia in Switzerland.

METHODS

A qualitative design was used, involving 3 semistructured online focus group interviews with 8 stakeholder groups, including persons with tetraplegia as well as those who could provide perspectives on engineering or technology, legal matters, nursing or care, therapy, social counseling, social insurance, and political considerations. The interviews were analyzed using the Focus Group Illustration Mapping tool, and the data were aligned with the domains of the Consolidated Framework for Implementation Research.

RESULTS

3 focus group interviews comprising 22 participants were conducted, and data were mapped onto 21 constructs across the Consolidated Framework for Implementation Research domains. Identified barriers were customization to users' needs, safety concerns, and financing issues for the high AT costs. The collaboration with different stakeholders, including those who provided perspectives on political engagement, proved crucial. Identified facilitators included the enhancement of autonomy for persons with tetraplegia, improvement of quality of life, reduction of caregiver dependency, and addressing health care labor shortages. The implementation outlook involved the formation of an experienced team and the development of an implementation plan using hybrid type 1 and type 2 designs that incorporate both qualitative and quantitative implementation and innovation outcomes.

CONCLUSIONS

Robotic arms offer promising benefits in terms of improved participation for users, while high costs and regulatory complexities as to who will assume these costs limit their implementation. These findings highlight the complexities involved in implementing AT innovations and the importance of addressing contextual factors. A specific framework for the implementation of AT is needed to ensure the successful integration in Switzerland and other countries with comparable social and health insurance systems.

Predictors of Early Mortality After Traumatic Spinal Cord Injury in South Africa

Study DesignRetrospective cohort study.ObjectivesTo identify predictors for early mortality following traumatic spinal cord injury (TSCI), as recognition of factors associated with early mortality is essential for public resource allocation and optimized acute care.MethodsRetrospective Analysis of SCI patients admitted to the acute SCI ward from 2003 to 2022 was performed. Days elapsing from the date of injury to date of death established the survival time. Early mortality was defined as survival time ≤ 365 days. Multivariable logistic regression was used in modeling of early death following TSCI with age, gender, neurologic deficit, type of neurologic injury, ventilation status, and count of complications as covariates.ResultsSimple logistic regression indicated a significant association of early mortality with the number of complications (P < .0001), neurological deficit (P < .0001), complete neurological injury (P < .0001), ventilation status (P < .0001), and age group (P < .0003). After adjusting for other covariates, complete neurological injury (OR: 1.75, P < .0001), ventilation (OR: 2.80, P < .0001), and Age group (over 60 OR: 17.71, P < .0001) were significantly associated with early mortality. The multivariable model showed a good overall fit (Hosmer-Lemeshow P = .315; AUC 0.85).ConclusionsPredictors of early mortality after TSCI are high complete spinal cord injury, age, number of complications, and the need for ventilation. Identification of high-risk patients is crucial to rationalize and improve acute care to potentially reduce mortality rates.

'Time is of the essence': upper-body aerobic exercise to improve cardiovascular health during inpatient rehabilitation within the first year following spinal cord injury - protocol for a randomised clinical trial

INTRODUCTION

Individuals with spinal cord injury (SCI) face heightened cardiovascular disease (CVD) risks. While general exercise guidelines are promoted for SCI individuals, when and how to incorporate exercise during the subacute phase post-SCI remains unclear. Consequently, early aerobic exercise to reduce CVD risks is not standard practice in subacute SCI care, potentially missing an opportunity for optimal cardiovascular rehabilitation, especially given observed reductions in cardiac structure and function within the first year post-SCI. Addressing this gap could improve long-term cardiovascular health and health-related quality of life (HRQOL) for individuals with SCI. Early intervention might prevent worsening cardiovascular function and establish beneficial exercise habits. However, few studies have evaluated the effectiveness of early exercise interventions in this population. This study aims to provide insight into the impact of moderate-intensity arm-crank exercise training (ACET) on cardiometabolic, HRQOL, functional and fitness parameters in individuals with subacute (<12 months postinjury) SCI.

METHODS AND ANALYSIS

We will conduct a single-centre, two-group, single-blind randomised controlled trial with 42 participants who have sustained a cervical or thoracic SCI within the past year. The non-intervention group will receive hospital standard of care (control group) while the intervention group will receive hospital standard of care plus moderate-intensity ACET for 10 weeks in line with the SCI-specific exercise guidelines to improve cardiometabolic health. The primary outcome measure will be central arterial stiffness (carotid-to-femoral pulse wave velocity). Secondary outcomes include assessments of (1) blood biomarkers linked to CVD, (2) cardiac structure and function, (3) extracranial vasculature, (4) HRQOL, (5) cognitive function, (6) physical activity level, (7) cardiorespiratory fitness, (8) motor function and (9) feasibility outcomes. Assessments will occur at baseline (rehabilitation centre admission, -2 weeks), preintervention (0 weeks), postintervention (10 weeks) and follow-up (6 months after postintervention), for HRQOL outcomes only.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Wales Research Ethics Committee (HREC 22/WA/0329). Outcome data will be presented at international conferences, patient advocacy groups, health professional networks and community health events. Findings will be published in peer-reviewed journals and widely disseminated through strategic channels to reach researchers, healthcare providers, patients and the public.

TRIAL REGISTRATION NUMBER

ISRCTN99941302.

nTMS in spinal cord injury: Current evidence, challenges and a future direction

Spinal Cord Injury (SCI) has devastating consequences for patients and their families. Over the last few decades, a renewed interest in the utilization of non-invasive and cost-effective therapeutic technologies in the management of patients with SCI has emerged. This includes stimulation with navigated transcranial magnetic stimulation (nTMS) in order to improve the outcome for these patients alongside with existing clinical tools. nTMS has shown encouraging preliminary results in both clinical assessment and rehabilitation (motor and pain) of patients with SCI. However, different protocols - stimulation parameters, length of treatment and combination with other modalities - and patient selection criteria hampered definitive conclusions. So far, none of these have been adapted in regular clinical practice. In this article, we provide an overview on different assessment and therapeutic strategies using nTMS and review their effectiveness.

Recovr reality - Recover after injury or surgery to the brain and spinal cord with virtual Reality: ideal stage 2a clinical feasibility study

AIM

Neurorehabilitation is fundamental to improve outcomes for patients recovering from injury to the central nervous system. Access to neurorehabilitation is limited by resource shortages; the consequences of which are unfulfilled therapy needs, longer hospital stays and detrimental effects on quality of life. Virtual reality (VR) could be used to enhance neurorehabilitation in a self-directed, safe, virtual environment. The aim of this study is to investigate the feasibility of a VR rehabilitation programme in an acute neurosurgical inpatient environment to improve neurorehabilitation.

METHOD

A single-group, prospective, clinical feasibility study was conducted in a tertiary UK neurosurgical department. The study included patients aged 16 and over who had neurosurgical care following surgery or traumatic brain or spinal cord injury. Participants were offered a VR session at least once per day for the first 14 days post-surgery/injury or until discharge, whichever came first, with reasons for non-engagement collected. Primary outcomes were feasibility outcomes and secondary outcomes included rehabilitation engagement.

RESULTS

Of the thirty-nine eligible participants approached, thirty-two participants were recruited and received VR at least once. Intervention fidelity was deemed a success, as none of the VR equipment or applications failed. Median time between injury or surgery and first VR use was three days (IQR = 8.25). The Hopkins Rehabilitation Engagement scale and Simulation Sickness Questionnaires were deemed feasible instruments to measure outcomes.

CONCLUSIONS

We confirmed feasibility of using a VR rehabilitation tool for neurosurgical patients in this study. This now facilitates progression to a multi-centre, prospective, randomised, controlled, unblinded, parallel-group trial of VR-enhanced neurorehabilitation versus standard neurorehabilitation for improving recovery after neurotrauma or neurosurgery.

Time to Surgery Following Complete Cervical Spinal Cord Injury: Evolution of Clinical Practice Patterns Over a Decade from 2010 to 2020 Across North American Trauma Centers

This study aims to quantify the change in time to surgery for treatment of complete traumatic cervical spinal cord injury (SCI) patients in American College of Surgeons accredited trauma centers across North America over the last decade (2010-2020). This multi-center retrospective observational cohort study used data from the Trauma Quality Improvement Program from 2010 to 2020. All surgically treated patients with complete traumatic cervical SCI were included. Primary outcome was time to spine surgery from treating hospital arrival in hours. Both descriptive statistics and a multi-variable Poisson regression model clustering standard of errors by each included trauma center were used to evaluate and quantify the annual change in time to surgical intervention. The study included 6855 complete traumatic cervical SCI patients managed across 484 trauma centers in North America. Median time to spine surgery was 14.6 h. A total of 4618 patients (67.3%) underwent surgical intervention within 24 h from hospital arrival. From 2010 to 2020, median time to surgery decreased by an average 0.6 h (±0.15) per year. A multi-variable adjusted model for time to surgery demonstrated a significant downward annual reduction of 5% in time to surgery between the years 2010 and 2020 (Incidence rate ratio = 0.95; 95% Confidence Interval: 0.93-0.96). This study provides compelling real-world based quantification of the change in time to surgical intervention following traumatic cervical SCI. A significant decreasing annual trend pertaining to surgical timing across trauma centers in North America over the past decade was demonstrated.

A Comprehensive Proteomic and Bioinformatic Analysis of Human Spinal Cord Injury Plasma Identifies Proteins Associated with the Complement Cascade and Liver Function as Potential Prognostic Indicators of Neurological Outcome

Spinal cord injury (SCI) is a major cause of disability, with complications postinjury often leading to lifelong health issues with the need for extensive treatment. Neurological outcome post-SCI can be variable and difficult to predict, particularly in incompletely injured patients. The identification of specific SCI biomarkers in blood may be able to improve prognostics in the field. This study has utilized proteomic and bioinformatic methodologies to investigate differentially expressed proteins in plasma samples across human SCI cohorts with the aim of identifying candidate prognostic biomarkers and biological pathway alterations that relate to neurological outcome. Blood samples were taken, following informed consent, from American Spinal Injury Association impairment scale (AIS) grade C "improvers" (those who experienced an AIS grade improvement) and "nonimprovers" (no AIS change) and AIS grade A and D at <2 weeks ("acute") and ∼3 months ("subacute") postinjury. The total protein concentration from each sample was extracted, with pooled samples being labeled and nonpooled samples treated with ProteoMiner™ beads. Samples were then analyzed using two 4-plex isobaric tag for relative and absolute quantification (iTRAQ) analyses and a label-free experiment for comparison before quantifying with mass spectrometry. Data are available via ProteomeXchange with identifiers PXD035025 and PXD035072 for the iTRAQ and label-free experiments, respectively. Proteomic datasets were analyzed using OpenMS (version 2.6.0). R (version 4.1.4) and, in particular, the R packages MSstats (version 4.0.1) and pathview (version 1.32.0) were used for downstream analysis. Proteins of interest identified from this analysis were further validated by enzyme-linked immunosorbent assay. The data demonstrated proteomic differences between the cohorts, with the results from the iTRAQ approach supporting those of the label-free analysis. A total of 79 and 87 differentially abundant proteins across AIS and longitudinal groups were identified from the iTRAQ and label-free analyses, respectively. Alpha-2-macroglobulin, retinol-binding protein 4 (RBP4), serum amyloid A1, peroxiredoxin 2 (PRX-2), apolipoprotein A1, and several immunoglobulins were identified as biologically relevant and differentially abundant, with potential as individual candidate prognostic biomarkers of neurological outcome. Bioinformatics analyses revealed that the majority of differentially abundant proteins were components of the complement cascade and most interacted directly with the liver. Many of the proteins of interest identified using proteomics were detected only in a single group and therefore have potential as binary (present or absent) biomarkers, RBP4 and PRX-2 in particular. Additional investigations into the chronology of these proteins and their levels in other tissues (cerebrospinal fluid in particular) are needed to better understand the underlying pathophysiology, including any potentially modifiable targets. Pathway analysis highlighted the complement cascade as being significant across groups of differential functional recovery.

Evaluation of transcriptomic changes after photobiomodulation in spinal cord injury

Spinal cord injury (SCI) is a significant cause of lifelong disability, with no available disease-modifying treatments to promote neuroprotection and axon regeneration after injury. Photobiomodulation (PBM) is a promising therapy which has proven effective at restoring lost function after SCI in pre-clinical models. However, the precise mechanism of action is yet to be determined. Here, we used an in-vivo model of SCI in adult rats that received daily PBM (660 nm, 24 mW/cm2, 1 min) and at three days post-injury, the injured spinal cord segment was harvested and subjected to whole transcriptome sequencing and subsequent pathway analysis (generally applicable gene-set enrichment (GAGE)). Pathway analysis demonstrated 1275 differentially expressed genes (DEGs) after PBM treatment, of which 397 were upregulated and 878 were downregulated. Key pathways were significantly enriched, including 8.6-fold enrichment of "neuron projection morphogenesis" (adjusted p = 8.10 × 10- 14), with upregulation of Notch3, Slit1/Robo2 and Sema3g pathways. Ribosomal and oxidative phosphorylation pathways and NADH dehydrogenase were downregulated, and there was upregulation of ATP-dependent activity, cAMP and calcium signalling pathways. Key genes in apoptotic pathways were downregulated, as were S100 and cyclo-oxygenase components. Together, our study supports the favourable effects of PBM in promoting neuroregeneration and suppressing apoptosis after neurological injury. Further findings from pathway analysis suggest that downregulation of metabolism-associated pathways is a mechanism by which acute post-injury mitochondrial dysfunction may be averted by PBM therapy.

Improving the rehabilitation of individuals admitted to England's National Spinal Injuries Centre with traumatic brain injury

STUDY DESIGN

Mixed methods service improvement project. Retrospective analysis of clinical documentation and qualitative focus group with clinicians.

OBJECTIVES

Although traumatic brain injury (TBI) and spinal cord injury (SCI) often co-occur, many barriers have been found to identifying TBI in SCI rehabilitation and adapting treatment accordingly. This study aimed to compare the number of individuals with a TBI detected at England's National Spinal Injuries Centre to figures found in previous research and understand the barriers to adapting SCI rehabilitation in the presence of TBI.

SETTING

England's National Spinal Injuries Centre at Stoke Mandeville Hospital.

METHODS

This mixed methods study assessed the documentation at each stage of 88 patients' treatment where a TBI could be detected and used to inform rehabilitation, and subsequently, a focus group was conducted with staff to explore the barriers to detecting TBI and adapting SCI rehabilitation.

RESULTS

Results suggested that data related to TBI were inconsistently recorded, the number of individuals recorded as having a TBI at the centre was lower than a recent study, and several barriers were interpreted from the focus group.

CONCLUSIONS

TBI in SCI populations may be an invisible unmet need. Several barriers may exist which prevent clinicians from detecting TBI in this population and adapting rehabilitation accordingly. Findings have implications for rehabilitation for individuals with TBI and SCI admitted to the service.

EEG Oscillations as Neuroplastic Markers of Neural Compensation in Spinal Cord Injury Rehabilitation: The Role of Slow-Frequency Bands

BACKGROUND

Spinal cord injury (SCI) affects approximately 250,000 to 500,000 individuals annually. Current therapeutic interventions predominantly focus on mitigating the impact of physical and neurological impairments, with limited functional recovery observed in many patients. Electroencephalogram (EEG) oscillations have been investigated in this context of rehabilitation to identify effective markers for optimizing rehabilitation treatments.

METHODS

We performed an exploratory cross-sectional study assessing the baseline EEG resting state of 86 participants with SCI as part of the Deficit of Inhibitory as a Marker of Neuroplasticity in Rehabilitation Cohort Study (DEFINE).

RESULTS

Our multivariate models demonstrated a positive correlation between frontal delta asymmetry and depression symptoms, while the frontal alpha asymmetry band and anxiety symptoms were negatively correlated. Theta oscillations were negatively associated with motor-evoked potential (MEP), whereas alpha oscillations were positively associated with MEP in all regions of interest and with CPM response as a negative correlation. Based on the potential role of lower-frequency oscillations in exerting a salutogenic compensatory effect, detrimental clinical and neurophysiological markers, such as depression and lower ME, likely induce slow oscillatory rhythms. Alpha oscillations may indicate a more salutogenic state, often associated with various cognitive functions, such as attention and memory processing.

CONCLUSIONS

These results show an attempt by the CNS to reorganize and restore function despite the disruption caused by SCI. Indeed, this finding also challenges the notion that low-frequency EEG rhythms are associated with cortical lesions. These results may contribute to the development of rehabilitation strategies and potentially improve the clinical outcomes of patients with SCI.

The role of payment sources in the continuation of rehabilitation therapy in tertiary hospitals for patients with traumatic spinal cord injury: a study in Southwest China

Medical security support for rehabilitation therapy in China is different from that in other countries. We investigated whether the discharge plan to continue rehabilitation therapy in tertiary hospitals for patients after traumatic spinal cord injury (TSCI) was influenced by payment sources or other conditions. This was a cross-sectional, observational study. Information was collected on the general condition, caregiver, types of payment sources for continued rehabilitation, American Spinal Injury Association Impairment Scale (AIS) scores, and discharge plans. In total, 135 patients with TSCI (107 male, mean age 41.00 ± 13.73 years, mean spinal cord injury duration 238.43 ± 345.54 days) were enrolled. Medical insurance (43%) and out-of-pocket payments (27.4%) were the primary payment sources. Although most patients were beyond the acute phase, 40% continued rehabilitation therapy at other tertiary hospitals. The caregiver, payment sources, injury level, AIS level, and complete urinary tract infection (UTI) were different due to discharge plans (p > .05). Patients seemingly consider a higher AIS level and co-UTI as the requirement for tertiary hospital therapy. In non-medical insurance payment source patients, the discharge plan also differed due to the AIS level and co-UTI (p > .05). However, in medical insurance patients, the discharge plan differed only in terms of TSCI duration (p > .05). The restricted duration of medical coverage restricted the continuation of rehabilitation therapy and influenced the discharge plan of most patients with TSCI.

A Systematic Review of the Impact of Spinal Cord Injury on Costs and Health-Related Quality of Life

OBJECTIVE

To systematically review the health-related quality of life (HRQoL) burden and costs of spinal cord injury (SCI) on health services, patients and wider society.

METHODS

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was conducted in March 2021 through Scopus, PubMed and Embase databases. Inclusion criteria were quantitative studies on SCI reporting healthcare costs, social costs and/or HRQoL measured with the Euroqol EQ-5D or Short-Form 36. Risk of bias was assessed using the QualSyst tool. Descriptive analyses, random-effects direct meta-analysis and random-effects meta-regression were conducted.

RESULTS

A total of 67 studies were eligible for inclusion. SCI individuals tend to report higher HRQoL in mental than physical dimensions of the Short-Form 36. Neurological level of SCI negatively affects HRQoL. Cross-sectional studies find employment is associated with better HRQoL, but the effect is not observed in longitudinal studies. The estimated lifetime expenditure per individual with SCI ranged from US$0.7 million to US$2.5 million, with greater costs associated with earlier age at injury, neurological level, United States of America healthcare setting and the inclusion of non-healthcare items in the study.

CONCLUSIONS

SCI is associated with low HRQoL on mobility and physical dimensions. Mental health scores tend to be greater than physical scores, and most dimensions of HRQoL appear to improve over time, at least over the first year. SCI is associated with high costs which vary by country.

CLINICAL TRIALS REGISTRATION

This review was registered in PROSPERO (registration number: CRD42021235801).

Implantable and transcutaneous photobiomodulation promote neuroregeneration and recovery of lost function after spinal cord injury

Spinal cord injury (SCI) is a cause of profound and irreversible damage, with no effective therapy to promote functional recovery. Photobiomodulation (PBM) may provide a viable therapeutic approach using red or near-infrared light to promote recovery after SCI by mitigating neuroinflammation and preventing neuronal apoptosis. Our current study aimed to optimize PBM dose regimens and develop and validate the efficacy of an invasive PBM delivery paradigm for SCI. Dose optimization studies were performed using a serum withdrawal model of injury in cultures of primary adult rat dorsal root ganglion neurons (DRGN). Implantable and transcutaneous PBM delivery protocols were developed and validated using cadaveric modeling. The efficacy of PBM in promoting recovery after SCI in vivo was studied in a dorsal column crush injury model of SCI in adult rats. Optimal neuroprotection in vitro was achieved between 4 and 22 mW/cm2. 11 mW/cm2 for 1 min per day (0.66 J/cm2) increased cell viability by 45% over 5 days (p <0.0001), increasing neurite outgrowth by 25% (p <0.01). A method for invasive application of PBM was developed using a diffusion-tipped optogenetics fiber optic. Delivery methods for PBM were developed and validated for both invasive (iPBM) and noninvasive (transcutaneous) (tcPBM) application. iPBM and tcPBM (24 mW/cm2 at spinal cord, 1 min per day (1.44 J/cm2) up to 7 days) increased activation of regeneration-associated protein at 3 days after SCI, increasing GAP43+ axons in DRGN from 18.0% (control) to 41.4% ± 10.5 (iPBM) and 45.8% ± 3.4 (tcPBM) (p <0.05). This corresponded to significant improvements at 6 weeks post-injury in functional locomotor and sensory function recovery (p <0.01), axonal regeneration (p <0.01), and reduced lesion size (p <0.01). Our results demonstrated that PBM achieved a significant therapeutic benefit after SCI, either using iPBM or tcPBM application and can potentially be developed for clinical use in SCI patients.

Enhancing Spinal Cord Injury Care: Using Wearable Technologies for Physical Activity, Sleep, and Cardiovascular Health

Wearable devices have the potential to advance health care by enabling real-time monitoring of biobehavioral data and facilitating the management of an individual's health conditions. Individuals living with spinal cord injury (SCI) have impaired motor function, which results in deconditioning and worsening cardiovascular health outcomes. Wearable devices may promote physical activity and allow the monitoring of secondary complications associated with SCI, potentially improving motor function, sleep, and cardiovascular health. However, several challenges remain to optimize the application of wearable technologies within this population. One is striking a balance between research-grade and consumer-grade devices in terms of cost, accessibility, and validity. Additionally, limited literature supports the validity and use of wearable technology in monitoring cardio-autonomic and sleep outcomes for individuals with SCI. Future directions include conducting performance evaluations of wearable devices to precisely capture the additional variation in movement and physiological parameters seen in those with SCI. Moreover, efforts to make the devices small, lightweight, and inexpensive for consumer ease of use may affect those with severe motor impairments. Overcoming these challenges holds the potential for wearable devices to help individuals living with SCI receive timely feedback to manage their health conditions and help clinicians gather comprehensive patient health information to aid in diagnosis and treatment.

Exoskeleton Training for Spinal Cord Injury Neuropathic Pain (ExSCIP): Protocol for a Phase 2 Feasibility Randomised Trial

Background

Following Spinal Cord Injury (SCI), 53% of people develop neuropathic pain (NP). NP can be more debilitating than other consequences of SCI, and a persistent health issue. Pharmacotherapies are commonly recommended for NP management in SCI, although severe pain often remains refractory to these treatments in many sufferers. Furthermore, poor medication adherence exists, stemming from unacceptable side-effects and fear of dependency.Sensorimotor stimulation using active walking with robotic assistance has not been well studied in NP after SCI, despite convincing locomotor-based pre-clinical studies, identifying prevention and reversal of NP.Our primary aim is to assess the impact of exoskeleton-based walking on NP intensity and interference after SCI and examine feasibility outcomes for progression to a definitive trial.

Methods

This is a phase 2 single-blinded, randomised feasibility study. It will test the feasibility and acceptability of exoskeleton-based walking 3 times per week for 12 weeks (intervention), as a mechanistic-based intervention for NP after SCI. The comparator will be an equally dosed, blended relaxation programme devoid of motor imagery prompts. 40 participants with moderate-to-severe NP post SCI will be recruited and randomised to intervention and comparator groups.The primary outcomes are feasibility outcomes for progression to definitive trial which include recruitment and retention rates, adverse events and acceptability of the intervention.Secondary outcomes explore changes in NP intensity and interference as measured by the International Spinal Cord Injury Pain Basic Data Set 3.0 (ISCIPBDS) at baseline, post-intervention (week 13) and at 6-month follow-up.

Conclusions

There is a need to explore non-pharmacological management of NP after SCI. The findings of this feasibility trial will inform the development of a future multicentre, international RCT.

Trial Registration

NCT06463418, 08/07/2024, https://clinicaltrials.gov/study/NCT06463418.

The effects of acteoside on locomotor recovery after spinal cord injury - The role of autophagy and apoptosis signaling pathway

In the current study, we investigated the effects of acteoside as a phenylpropanoid glycoside on interaction with neurons to assesses locomotor recovery after spinal cord injury (SCI) in rats by focusing on evaluating the factors involved in autophagy, apoptosis, inflammation and oxidative stress processes. 49 Spargue-Dawley rats were prepared and divided into seven healthy and SCI groups receiving different concentrations of acteoside. After 28 days of disease induction and treatment with acteoside, a BBB score test was used to evaluate locomotor activity. Then, by preparing spinal cord cell homogenates, the expression levels of MAP1LC3A, MAP-2, glial fibrillary acidic protein (GFAP), Nrf2, Keap-1, Caspase 3 (Casp3), Bax, Bcl-2, TNF-a, IL-1B, reactive oxygen species (ROS), and malondialdehyde (MDA) were measured. Improvement of locomotor activity in SCI rats receiving acteoside was observed two weeks after the beginning of the experiment and continued until the fourth week. Both MAP1LC3A and MAP-2 were significantly up-regulated in SCI rats treated with acteoside compared to untreated SCI rats, and GFAP levels were significantly decreased in these animals. Pro-apoptotic proteins Bax and Casp3 and anti-apoptotic protein Bcl-2 were down-regulated and up-regulated, respectively, in SCI rats receiving acteoside. In addition, a significant downregulation of iNOS, TNF-α, and IL-1β and a decrease in contents of both ROS and MDA as well as increases in Nrf2 and Keap-1 were seen in rats receiving acteoside. Furthermore, acteoside strongly interacted with MAP1LC3A, TNF-α, and Casp3 targets with binding affinities of -8.3 kcal/mol, -8.3 kcal/mol, and -8.5 kcal/mol, respectively, determined by molecular docking studies. In general, it can be concluded that acteoside has protective effects in SCI and can be considered as an adjuvant therapy in the treatment of this disease. However, more studies, especially clinical studies, are needed in this field.

Smartphone accessibility: understanding the lived experience of users with cervical spinal cord injuries

PURPOSE

To explore accessibility challenges encountered by smartphone users with cervical spinal cord injuries (C1-C8). To investigate the suitability of current technology and make recommendations to help future technology meet user needs.

METHODS

The study uses a mixed-method approach combining an inductive thematic analysis of nine semi-structured interviews with a quantitative analysis of thirty-nine questionnaires.

RESULTS

The analysis generated four themes: 'the drive for independence and self-efficacy'; 'trying to make it work'; 'getting the right technology for me'; 'using the phone as and when I want to'. These themes highlighted how unresolved access issues and situational barriers limited independence and created unwanted privacy compromises for effective communication. There was a lack of information or support on available smartphone accessibility features and assistive technology (AT). Smartphone AT was regarded as overpriced, poorly designed and lacking the voices of people with disabilities.

CONCLUSIONS

The smartphone's potential to improve quality of life, participation, and well-being is limited by accessibility challenges hindering independent and private smartphone use. Future design work should focus on improving accessibility, investigating reasons for AT's poor quality and high cost, and removing barriers to end-user inclusion. To enhance user awareness of available technology, stakeholders should build and maintain an open platform to act as an information source for peer and professional support on assistive technology.

Genetic or Pharmacological Ablation of Acid-Sensing Ion Channel 1a (ASIC1a) Is Not Neuroprotective in a Mouse Model of Spinal Cord Injury

Acid-sensing ion channel 1a (ASIC1a) is a proton-activated channel that is expressed ubiquitously throughout the central nervous system and in various types of immune cells. Its role in spinal cord injury (SCI) is controversial; inhibition of ASIC1a has been reported to improve SCI pathology in vivo, but conversely, gene ablation increased kainite-mediated excitotoxic cell death in vitro. Here, we re-examined the role of ASIC1a in a mouse model of SCI. First, we observed functional outcomes up to 42 days post-operation (DPO) in SCI mice with a selective genetic ablation of ASIC1a. Mice lacking ASIC1a had significantly worsened locomotor ability and increased lesion size compared with mice possessing the ASIC1a gene. Next, we explored pharmacological antagonism of this ion channel by administering the potent ASIC1a inhibitor, Hi1a. Consistent with a role for ASIC1a to attenuate excitotoxicity, accelerated neuronal cell loss was found at the lesion site in SCI mice treated with Hi1a, but there were no differences in locomotor recovery. Moreover, ASIC1a inhibition did not cause significant alterations to neutrophil migration, microglial density, or blood-spinal cord barrier integrity.

BCI-controlled wheelchairs: end-users' perceptions, needs, and expectations, an interview-based study

PURPOSE

Brain-computer interface (BCI)-controlled wheelchairs have the potential to improve the independence of people with mobility impairments. The low uptake of BCI devices has been linked to a lack of knowledge among researchers of the needs of end-users that should influence BCI development.

MATERIALS AND METHODS

This study used semi-structured interviews to learn about the perceptions, needs, and expectations of spinal cord injury (SCI) patients with regards to a BCI-controlled wheelchair. Topics discussed in the interview include: paradigms, shared control, safety, robustness, channel selection, hardware, and experimental design. The interviews were recorded and then transcribed. Analysis was carried out using coding based on grounded theory principles.

RESULTS

The majority of participants had a positive view of BCI-controlled wheelchair technology and were willing to use the technology. Core issues were raised regarding safety, cost and aesthetics. Interview discussions were linked to state-of-the-art BCI technology. The results challenge the current reliance of researchers on the motor-imagery paradigm by suggesting end-users expect highly intuitive paradigms. There also needs to be a stronger focus on obstacle avoidance and safety features in BCI wheelchairs. Finally, the development of control approaches that can be personalized for individual users may be instrumental for widespread adoption of these devices.

CONCLUSIONS

This study, based on interviews with SCI patients, indicates that BCI-controlled wheelchairs are a promising assistive technology that would be well received by end-users. Recommendations for a more person-centered design of BCI controlled wheelchairs are made and clear avenues for future research are identified.

Cervical spine immobilisation following blunt trauma in pre-hospital and emergency care: A systematic review

OBJECTIVES

To assess whether different cervical spine immobilisation strategies (full immobilisation, movement minimisation or no immobilisation), impact neurological and/or other outcomes for patients with suspected cervical spinal injury in the pre-hospital and emergency department setting.

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library and two research registers were searched until September 2023.

ELIGIBILITY CRITERIA

All comparative studies (prospective or retrospective) that examined the potential benefits and/or harms of immobilisation practices during pre-hospital and emergency care of patients with a potential cervical spine injury (pre-imaging) following blunt trauma.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected and extracted data. Risk of bias was appraised using the Cochrane ROBINS-I tool for non-randomised studies. Data were synthesised without meta-analysis.

RESULTS

Six observational studies met the inclusion criteria. The methodological quality was variable, with most studies having serious or critical risk of bias. The effect of cervical spine immobilisation practices such as full immobilisation or movement minimisation during pre-hospital and emergency care did not show clear evidence of benefit for the prevention of neurological deterioration, spinal injuries and death compared with no immobilisation. However, increased pain, discomfort and anatomical complications were associated with collar application during immobilisation.

CONCLUSIONS

Despite the limited evidence, weak designs and limited generalisability, the available data suggest that pre-hospital cervical spine immobilisation (full immobilisation or movement minimisation) was of uncertain value due to the lack of demonstrable benefit and may lead to potential complications and adverse outcomes. High-quality randomised comparative studies are required to address this important question.

TRIAL REGISTRATION

PROSPERO REGISTRATION Fiona Lecky, Abdullah Pandor, Munira Essat, Anthea Sutton, Carl Marincowitz, Gordon Fuller, Stuart Reid, Jason Smith. A systematic review of cervical spine immobilisation following blunt trauma in pre-hospital and emergency care. PROSPERO 2022 CRD42022349600 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022349600.

Safety of tranexamic acid in surgically treated isolated spine trauma

BACKGROUND

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma.

AIM

To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively.

METHODS

This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom.

RESULTS

We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA.

CONCLUSION

Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.

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

Objective

The aim was to study the outcome and complications of operative treatment for subaxial cervical spine injuries with respect to injury morphology and surgical strategy.

Methods

A population-based cohort of 271 consecutive patients treated at Kuopio University Hospital from 2003 to 2018 was retrospectively reviewed.

Results

The mean age was 52.4 (range 12-90) years and 78.6% were male. The AOSpine morphological classification was C in 56.5%, B in 24.7% and A in 17.0% of cases. The surgical approach was anterior in 70.8%, posterior in 20.3% and combined in 8.9% of patients. Fixation alignment was maintained in 96.9% of patients. Instrumentation failures were observed only in patients operated anteriorly but no statistical difference was found between the surgical approaches. The American Spinal Injury Association Impairment Scale (AIS) grade improved in 22.1% of patients. Patients with preoperative AIS grade C had significant potential for neurological improvement (OR 10.44; 95% CI 1.77-61.56; p = 0.010). Postoperative, mostly mild, complications manifested in 22.5% of patients. The posterior approach was associated with fewer postoperative complications (OR 0.18; 95% CI 0.06-0.51; p = 0.001). Preoperative AIS grade A was a significant predisposing factor for complications (OR = 4.90; 95% CI = 1.49-16.10; p = 0.009). The perioperative (90-day) mortality rate was 3.3%. The mean follow-up period was 64.7 ± 25.9 (radiological)/136.7 ± 174.8 (clinical) days.

Conclusions

Operative treatment is safe and effective but the surgical approach should be patient- and injury-specific. The prognosis for neurological recovery from spinal cord injury is superior in patients with partially preserved motor function.

Predicting inpatient rehabilitation length of stay for adults with traumatic spinal cord injury

INTRODUCTION

Most post-injury traumatic spinal cord injury (TSCI) care occurs in the inpatient rehabilitation setting. The inpatient rehabilitation length of stay (R-LOS) has been shown to be a significant predictor of motor function restoration in persons with TSCI. Due to the complexity, and heterogeneity of individuals with TSCI, the R-LOS is challenging to predict at admission.

PURPOSE

To identify the main predictors of R-LOS and derive an equation to estimate R-LOS in persons with TSCI.

METHODS

This is a retrospective analysis of data from adults with TSCI from The Rick Hansen Spinal Cord Injury Registry in Alberta, Canada, who received rehabilitation care between May 10, 2005, and January 28, 2020. Multiple linear regression analysis was used to determine significant relationships between R-LOS and measures of participant demographics, length of stay, impairment and injury classification, and comorbidities.

RESULTS

The analysis included 736 adults with TSCI from an eligible cohort of 1365. The median R-LOS was 65 days (IQR 39-99 days), ranging from 1 to 469 days. Multivariate linear regression analysis identified two significant predictors of R-LOS, total FIM score and the injury classification. This model was used to derive a R-LOS prediction equation, which explained 34% of the variance in R-LOS.

CONCLUSION

We developed a simple equation to predict R-LOS based on the level of impairment and total FIM scores in persons with TSCI. These data have implications for health system planning, improvement, and innovation, and provide insights to support further research into the predictors of R-LOS, identification of higher-risk individuals.

Evolving trends in the surgical, anaesthetic, and intensive care management of acute spinal cord injuries in the UK

PURPOSE

We surveyed the treatment of acute spinal cord injuries in the UK and compared current practices with 10 years ago.

METHODS

A questionnaire survey was conducted amongst neurosurgeons, neuroanaesthetists, and neurointensivists that manage patients with acute spinal cord injuries. The survey gave two scenarios (complete and incomplete cervical spinal cord injuries). We obtained opinions on the speed of transfer, timing and aim of surgery, choice of anaesthetic, intraoperative monitoring, targets for physiological parameters, and drug treatments.

RESULTS

We received responses from 78.6% of UK units that manage acute spinal cord injuries (33 neurosurgeons, 56 neuroanaesthetists/neurointensivists). Most neurosurgeons operate within 12 h for incomplete (82%) and complete (64%) injuries. There is a significant shift from 10 years ago, when only 61% (incomplete) and 30% (complete) of neurosurgeons operated within 12 h. The preferred anaesthetic technique in 2022 is total intravenous anaesthesia (TIVA), used by 69% of neuroanaesthetists. Significantly more intraoperative monitoring is now used at least sometimes, including bispectral index (91%), non-invasive cardiac output (62%), and neurophysiology (73-77%). Methylprednisolone is no longer used by surgeons. Achieving at least 80 mmHg mean arterial blood pressure is recommended by 70% neurosurgeons, 62% neuroanaesthetists, and 75% neurointensivists.

CONCLUSIONS

Between 2012 and 2022, there was a paradigm shift in managing acute spinal cord injuries in the UK with earlier surgery and more intraoperative monitoring. Variability in practice persists due to lack of high-quality evidence and consensus guidelines.

The choice for colostomy following spinal cord injury: A grounded theory study

AIM

Explore experiences and choices related to bowel management following spinal cord injury.

BACKGROUND

In one UK spinal centre, more are choosing a colostomy soon after injury in contravention of professional guidelines. Reasons for this were unknown.

METHODS

Grounded theory study using semi-structured interviews with 12 individuals living with spinal cord injury.

RESULTS

All 'Experienced Loss' related to bowel function. Those who chose colostomy later 'Progressed into Suffering'. Colostomy transformed lives and was likened to 'Being Alive Again'. 'Failures of Care' contributed to experiences and decision-making.

CONCLUSION

Possessing information and choice emerge as key in transforming lives following spinal cord injury. They allow individuals to make choices from a lifeworld perspective, which may differ from those professionals assume. Present neurogenic bowel management guidelines fail to account for the wider lifeworlds of those they are designed for.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

An imperative emerges to make information and choice available and involve patients in the reconstruction of guidelines.

IMPACT

Unique knowledge emerges about patient experiences and motivations, and points to a patient-led revolution in how bowel management following spinal cord injury is understood and managed. The imperative for adequate access to information and choice is demonstrated.

REPORTING METHOD

EQUATOR Standards for Reporting Qualitative Research (SRQR) were adhered to.

PATIENT OR PUBLIC CONTRIBUTION

The methodology facilitated discussion of areas important to patients and made them co-constructors of theory.

Are Clinical Prediction Rules Used in Spinal Cord Injury Care? A Survey of Practice

Background

Accurate outcome prediction is desirable post spinal cord injury (SCI), reducing uncertainty for patients and supporting personalized treatments. Numerous attempts have been made to create clinical prediction rules that identify patients who are likely to recover function. It is unknown to what extent these rules are routinely used in clinical practice.

Objectives

To better understand knowledge of, and attitudes toward, clinical prediction rules amongst SCI clinicians in the United Kingdom.

Methods

An online survey was distributed via mailing lists of clinical special interest groups and relevant National Health Service Trusts. Respondents answered questions about their knowledge of existing clinical prediction rules and their general attitudes to using them. They also provided information about their level of experience with SCI patients.

Results

One hundred SCI clinicians completed the survey. The majority (71%) were unaware of clinical prediction rules for SCI; only 8% reported using them in clinical practice. Less experienced clinicians were less likely to be aware. Lack of familiarity with prediction rules was reported as being a barrier to their use. The importance of clinical expertise when making prognostic decisions was emphasized. All respondents reported interest in using clinical prediction rules in the future.

Conclusion

The results show widespread lack of awareness of clinical prediction rules amongst SCI clinicians in the United Kingdom. However, clinicians were positive about the potential for clinical prediction rules to support decision-making. More focus should be directed toward refining current rules and improving dissemination within the SCI community.

Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence

Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.

The impact of COVID-19 and associated lockdowns on traumatic spinal cord injury incidence: a population based study

STUDY DESIGN

Natural experiment OBJECTIVES: To determine whether COVID-19 restrictions were associated with changes in the incidence of traumatic spinal cord injury (TSCI) in Scotland.

SETTING

The Queen Elizabeth National Spinal Injuries Unit (QENSIU), the sole provider of treatment for TSCI in Scotland.

METHODS

Time series analysis of all admissions for TSCI between 1st January 2015 and 31st August 2022.

RESULTS

Over the 8-year study period, 745 patients were admitted to the QENSIU with a TSCI. Interrupted time series analysis showed that level 3 and 4 COVID-19 lockdown restrictions (the most severe levels) were associated with lower incidence of TSCI (RR 0.63, CI% CI 0.47, 0.82, p < 0.001). The associations were stronger in people aged over 45 (additive interaction p = 0.001), males (additive interaction p = 0.01) and non-tetraplegia (additive interaction p = 0.002). The incidence of TSCI due to deliberate self-harm was higher (0.41 versus 0.23 per month) during restrictions.

CONCLUSIONS

Overall, TSCI incidence reduced in Scotland when lockdowns were implemented, presumably due to lower engagement in risky activities. The increase in TSCI due to deliberate self-harm may reflect increased mental health problems and social isolation and should be anticipated and targeted in future pandemics. The change in incidence during the COVID-19 pandemic may have an economic impact and see a temporary reduction in the burden on health and social care. The results of this study will be useful for resource planning in future pandemics.

Histopathological and immunohistochemical investigation of the effect of Shilajit in rats with experimental spinal cord injury

BACKGROUND

This experimental study was designed to investigate the histopathological and immunohistochemical effects of Shilajit in rats with experimentally induced spinal cord injury (SCI).

METHODS

The rats were divided into three groups: Control group: The group in which spinal cord damage was created but no drug was administered. Low-dose group: This is the group in which intraperitoneal Shilajit is given at a dose of 150 mg/kg at the 1st h, 1st day, 2nd day, and 3rd day after spinal cord damage was induced. High-dose group: This is the group in which intraperitoneal Shilajit is given at a dose of 250 mg/kg at the 1st h, 1st day, 2nd day, and 3rd day after spinal cord damage was induced. Thin sections taken from the spinal cord after euthanasia were sent for histopathological and immunohistochemical examination.

RESULTS

Histopathological examination of the high-dose group showed lower amounts of morphological findings compared to the low-dose group and control group. While a significant CD68 immune reaction was observed in the control group of rats with spinal injury, the positive immune reaction was found to be significantly decreased in the Shilajit-applied groups.

CONCLUSION

It is thought that the use of Shilajit in SCI will reduce the effects of secondary damage in SCI and that its administra-tion to such patients will have positive effects on the results.

EPIDEMIOLOGY OF POST-TRAUMATIC SPINAL CORD INJURY IN A TERTIARY HOSPITAL

Objective

to outline the profile of risk groups for spinal cord injury (SCI) at the Hospital de Clinicas de Campinas by an epidemiological survey of 41 patients with SCI.

Methods

Data from patients with SCI were collected and analyzed: demographic data, level of neurological injury, visual analogue scale (VAS), and the current American Spinal Injury Association (ASIA) impairment scale (AIS), using questionnaires, medical records, and imaging tests. Fisher's exact test was used to assess the relationship between categorical variables, Spearman's correlation coefficient was used for numerical variables, and the Mann-Whitney and Kruskal-Wallis tests were used to analyze the relationship between categorical and numerical variables, with significance level of 5%.

Results

There was a prevalence of 82.9% of men, a mean age of 26.5 years, and traffic accidents as the cause of SCI in 56.1% of cases.

Conclusion

Results suggest the importance of SCI prevention campaigns directed at this population. Level of Evidence II, Retrospective Study.

Cell therapies for spinal cord injury: a review of the clinical trials and cell-type therapeutic potential

Spinal cord injury (SCI) is an as yet untreatable neuropathology that causes severe dysfunction and disability. Cell-based therapies hold neuroregenerative and neuroprotective potential, but, although being studied in SCI patients for more than two decades, long-term efficacy and safety remain unproven, and which cell types result in higher neurological and functional recovery remains under debate. In a comprehensive scoping review of 142 reports and registries of SCI cell-based clinical trials, we addressed the current therapeutical trends and critically analysed the strengths and limitations of the studies. Schwann cells, olfactory ensheathing cells (OECs), macrophages and various types of stem cells have been tested, as well as combinations of these and other cells. A comparative analysis between the reported outcomes of each cell type was performed, according to gold-standard efficacy outcome measures like the ASIA impairment scale, motor and sensory scores. Most of the trials were in the early phases of clinical development (phase I/II), involved patients with complete chronic injuries of traumatic aetiology and did not display a randomized comparative control arm. Bone marrow stem cells and OECs were the most commonly tested cells, while open surgery and injection were the main methods of delivering cells into the spinal cord or submeningeal spaces. Transplantation of support cells, such as OECs and Schwann cells, resulted in the highest ASIA Impairment Scale (AIS) grade conversion rates (improvements in ∼40% of transplanted patients), which surpassed the spontaneous improvement rate expected for complete chronic SCI patients within 1 year post-injury (5-20%). Some stem cells, such as peripheral blood-isolated and neural stem cells, offer potential for improving patient recovery. Complementary treatments, particularly post-transplantation rehabilitation regimes, may contribute highly to neurological and functional recovery. However, unbiased comparisons between the tested therapies are difficult to draw, given the great heterogeneity of the design and outcome measures used in the SCI cell-based clinical trials and how these are reported. It is therefore crucial to standardize these trials when aiming for higher value clinical evidence-based conclusions.

A dynamic nomogram for predicting the probability of irreversible neurological dysfunction after cervical spinal cord injury: research based on clinical features and MRI data

BACKGROUND

Irreversible neurological dysfunction (IND) is an adverse event after cervical spinal cord injury (CSCI). However, there is still a shortage of objective criteria for the early prediction of neurological function. We aimed to screen independent predictors of IND and use these findings to construct a nomogram that could predict the development of neurological function in CSCI patients.

METHODS

Patients with CSCI attending the Affiliated Hospital of Southwest Medical University between January 2014 and March 2021 were included in this study. We divided the patients into two groups: reversible neurological dysfunction (RND) and IND. The independent predictors of IND in CSCI patients were screened using the regularization technique to construct a nomogram, which was finally converted into an online calculator. Concordance index (C-index), calibration curves analysis and decision curve analysis (DCA) evaluated the model's discrimination, calibration, and clinical applicability. We tested the nomogram in an external validation cohort and performed internal validation using the bootstrap method.

RESULTS

We enrolled 193 individuals with CSCI in this study, including IND (n = 75) and RND (n = 118). Six features, including age, American spinal injury association Impairment Scale (AIS) grade, signal of spinal cord (SC), maximum canal compromise (MCC), intramedullary lesion length (IMLL), and specialized institution-based rehabilitation (SIBR), were included in the model. The C-index of 0.882 from the training set and its externally validated value of 0.827 demonstrated the model's prediction accuracy. Meanwhile, the model has satisfactory actual consistency and clinical applicability, verified in the calibration curve and DCA.

CONCLUSION

We constructed a prediction model based on six clinical and MRI features that can be used to assess the probability of developing IND in patients with CSCI.

The predictive value of cortical activity during motor imagery for subacute spinal cord injury-induced neuropathic pain

OBJECTIVE

The aim of this study is to explore whether cortical activation and its lateralization during motor imagery (MI) in subacute spinal cord injury (SCI) are indicative of existing or upcoming central neuropathic pain (CNP).

METHODS

Multichannel electroencephalogram was recorded during MI of both hands in four groups of participants: able-bodied (N = 10), SCI and CNP (N = 11), SCI who developed CNP within 6 months of EEG recording (N = 10), and SCI who remained CNP-free (N = 10). Source activations and its lateralization were derived in four frequency bands in 20 regions spanning sensorimotor cortex and pain matrix.

RESULTS

Statistically significant differences in lateralization were found in the theta band in premotor cortex (upcoming vs existing CNP, p = 0.036), in the alpha band at the insula (healthy vs upcoming CNP, p = 0.012), and in the higher beta band at the somatosensory association cortex (no CNP vs upcoming CNP, p = 0.042). People with upcoming CNP had stronger activation compared to those with no CNP in the higher beta band for MI of both hands.

CONCLUSIONS

Activation intensity and lateralization during MI in pain-related areas might hold a predictive value for CNP.

SIGNIFICANCE

The study increases understanding of the mechanisms underlying transition from asymptomatic to symptomatic early CNP in SCI.

The neuroprotective effects of estrogen and estrogenic compounds in spinal cord injury

Spinal cord injury (SCI) occurs when the spinal cord is damaged from either a traumatic event or disease. SCI is characterised by multiple injury phases that affect the transmission of sensory and motor signals and lead to temporary or long-term functional deficits. There are few treatments for SCI. Estrogens and estrogenic compounds, however, may effectively mitigate the effects of SCI and therefore represent viable treatment options. This review systematically examines the pre-clinical literature on estrogen and estrogenic compound neuroprotection after SCI. Several estrogens were examined by the included studies: estrogen, estradiol benzoate, Premarin, isopsoralen, genistein, and selective estrogen receptor modulators. Across these pharmacotherapies, we find significant evidence that estrogens indeed offer protection against myriad pathophysiological effects of SCI and lead to improvements in functional outcomes, including locomotion. A STRING functional network analysis of proteins modulated by estrogen after SCI demonstrated that estrogen simultaneously upregulates known neuroprotective pathways, such as HIF-1, and downregulates pro-inflammatory pathways, including IL-17. These findings highlight the strong therapeutic potential of estrogen and estrogenic compounds after SCI.

Advantages and Limitations in the Evaluation of the Neurological and Functional Deficit in Patients with Spinal Cord Injuries

(1) Background: Vertebro-medullary trauma (VMT) causes osteo-articular injuries in a varied anatomical lesion associated with multiple clinical manifestations and therapeutic indications. The neurological evaluation of patients who have suffered a spinal cord injury (SCI) is costly in testing the motor and sensory function. To standardize the assessment, several scales are used that measure the neurological deficit in order to guide subsequent treatment according to complete or incomplete SCI. The aim of this study is to identify and present the relevant tools for assessing SCI. (2) Methods: Relevant SCI studies were used for a fact-finding investigation from a rational and critical perspective of this field of research. The relationship between clinical tools and those with a psychosocial component was assessed based on studies reported in the literature. (3) Results: SCI severity scales have been proposed throughout to be able to estimate the functional prognosis of victims of these traumatic events. These tools can be divided into scales for assessing the neurological deficit due to trauma, and functional scales that assess the ability to perform daily activities, self-care, etc. (4) Conclusions: The closest scale to the need for standardization and the most accurate assessment of neurological deficits secondary to SCI is ASIA/IMSOP.

Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: an international multi-professional Delphi consensus

PURPOSE

International multi-professional expert consensus was sought to develop best practice recommendations for clinical management of patients following cervical spinal cord injury with oropharyngeal dysphagia and associated complications. Additionally, risk factors for dysphagia were identified to support the development of a screening tool.

MATERIALS AND METHODS

A two-round Delphi study was undertaken with a 27-member panel of expert professionals in cervical spinal cord injury and complex dysphagia. They rated 85 statements across seven topic areas in round one, using a five-point Likert scale with a consensus set at 70%. Statements not achieving consensus were revised for the second round. Comparative group and individual feedback were provided at the end of each round.

RESULTS

Consensus was achieved for 50 (59%) statements in round one and a further 12 (48%) statements in round two. Recommendations for best practice were agreed for management of swallowing, respiratory function, communication, nutrition and oral care. Twelve risk factors for dysphagia were identified for components of a screening tool.

CONCLUSIONS

Best practice recommendations support wider clinical management to prevent complications and direct specialist care. Screening for risk factors allows early dysphagia identification with the potential to improve clinical outcomes. Further evaluation of the impact of these recommendations is needed.Implications for RehabilitationDysphagia is an added complication following cervical spinal cord injury (cSCI) affecting morbidity, mortality and quality of life.Early identification of dysphagia risk allows focused interventions that reduce associated nutritional and respiratory impairments.Best practice recommendations based on expert consensus provide a baseline of appropriate interventions, in the absence of empirical evidence.A multi-professional approach to rehabilitation encourages a consistent and coordinated approach to care across acute and rehabilitation settings.

Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

BACKGROUND

Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI.

METHODS

We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics.

RESULTS

We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001).

CONCLUSIONS

Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.

A systematic review identifying outcome measures used in evaluating adults sustaining cervical spine fractures

OBJECTIVE

To assess the outcome measures used in studies investigating cervical spine fractures in adults, with or without associated spinal cord injury, to inform development of a core outcome set.

METHODS

Medline, Embase and Scopus were searched for relevant studies until May 28, 2022, without a historic limit on study date. Study characteristics, population characteristics and outcomes reported were extracted and analyzed.

RESULTS

Our literature search identified 536 studies that met criteria for inclusion, involving 393,266 patients. Most studies were single center (87.3%), retrospective studies (88.9%) and involved a median of 40 patients (range 6-167,278). Treatments assessed included: surgery (55.2%), conservative (6.2%), halo immobilization (4.9%), or a mixture (33.2%). Median study duration was 84 months (range 3-564 months); the timing of clinical and/or radiological follow-up assessment after injury was reported in 56.7%. There was significant heterogeneity in outcomes used, with 79 different reported outcomes measures. Differences in use were identified between smaller/larger, retro-/prospective and single/multicenter cohorts. Over time, the use of radiological outcomes has declined with greater emphasis on patient-reported outcome measures (PROMs). Studies of conservative management were more likely to detail PROMs and mortality, whereas surgical studies reported Frankel/ASIA grade, radiological fusion, complication rates, duration of hospital stay and re-operation rates more frequently. In studies assessing the elderly population (> 65 years), use of PROMs, mortality, hospital stay and discharge destination were more common, whereas fusion was reported less often. Response rates for outcome assessments were lower in studies assessing elderly patients, and studies using PROMs.

CONCLUSIONS

We have classified the various outcome measures used for patients with cervical spine fractures based on the COMET outcome taxonomy. We also described the contexts in which different outcomes are more commonly employed to help guide decision-making when designing future research endeavors.

Is Graphene Shortening the Path toward Spinal Cord Regeneration?

Along with the development of the next generation of biomedical platforms, the inclusion of graphene-based materials (GBMs) into therapeutics for spinal cord injury (SCI) has potential to nourish topmost neuroprotective and neuroregenerative strategies for enhancing neural structural and physiological recovery. In the context of SCI, contemplated as one of the most convoluted challenges of modern medicine, this review first provides an overview of its characteristics and pathophysiological features. Then, the most relevant ongoing clinical trials targeting SCI, including pharmaceutical, robotics/neuromodulation, and scaffolding approaches, are introduced and discussed in sequence with the most important insights brought by GBMs into each particular topic. The current role of these nanomaterials on restoring the spinal cord microenvironment after injury is critically contextualized, while proposing future concepts and desirable outputs for graphene-based technologies aiming to reach clinical significance for SCI.

Burden in caregivers of spinal cord injury patients: a systematic review and meta-analysis

BACKGROUND

Caregivers of individuals with spinal cord injury encounter high levels of physical, psychosocial, and financial burden by providing lifelong assistance. In the present study, we aimed to assess the overall burden score of caregivers in spinal cord injury by pooling different standard scores together as a review.

METHOD

Search on databases of PubMed/Medline, Web of Science and Scopus was conducted using PRISMA guidelines. Studies that assessed the burden of care using the caregiver burden inventories of CBI (caregiver burden inventory), CBS (caregiver burden scale), CG (caregiver), CSI (Caregiver Strain Index), and short- and long-form Zarit questionnaires were included in our study. The results were analyzed using the meta-analysis method and a random effect pooled estimator. All analyses were performed using STATA SE software version 14.

RESULT

A total of 23 articles out of 399 retrieved studies were added to this review study. The overall score of caregiver burden in individuals with SCI was calculated 48.68 (95% CI 42.574-54.788). The I2 heterogeneity was 11.7%, suggesting a low level of heterogeneity among the included studies. There was no systematic difference between various questionnaires added to meta-analysis (P = 0.526). In addition, the caregiver burden did not differ in less and highly developed countries (P = 0.405).

CONCLUSION

Since SCI places a considerable burden on caregivers, scoring the burden of care can help policymakers plan for essential interventions and allocate more facilities for these patients and their caregivers.

Development of an IoT Electrostimulator with Closed-Loop Control

The most used approach in the motor rehabilitation of spinal cord injury is functional electrical stimulation. However, current devices do not provide real-time feedback, work in the closed-loop, and became remotely operable. In this scenario, this paper presents the development of an open access 4-channel IoT electrostimulator device with an inertial sensor. The electrostimulator circuit was designed with four modules: Boost Converter, H-bridge, Inertial Measurement Unit, and Processing Module. The firmware was implemented in the processing module to manage the modules to perform closed-loop stimulation (using PID controller). To perform the proof of concept of the device, a closed loop test was performed to control the ankle joint, performing the movements of dorsiflexion, plantar flexion, inversion, and eversion. The designed hardware allowed one to freely change the boost converter voltage and modulate the signal with 200 μs of pulse duration and 50 Hz of period in a safe and stable way. Furthermore, the controller was able to move the ankle joint in all desired directions following the reference values and respecting the imposed constraints. In general, the developed hardware was able to safely control a closed-loop joint.

Nogo-A Is a Potential Prognostic Marker for Spinal Cord Injury

Objective

Spinal cord injury (SCI) has become prevalent worldwide in recent years, and its prognosis is poor and the pathological mechanism has not been fully elucidated. Nogo-A is one of the isoforms of the neurite outgrowth inhibitory protein reticulon 4. The purpose of this study was to determine whether Nogo-A could be used as a marker for predicting the prognosis of SCI.

Methods

We screened eligible SCI patients and controls based on inclusion and exclusion criteria. We also collected baseline clinical information and peripheral venous blood of the enrolled population. Participants' baseline serum Nogo-A levels were measured by enzyme-linked immunosorbent assay (ELISA). The American Spinal Injury Association (ASIA) scale was used to evaluate the prognosis of SCI patients after 3 months.

Results

Baseline clinical information (age; gender; smoking; drinking; SBP, systolic blood pressure; DBP, diastolic blood pressure; fasting blood glucose; WBC, white blood cells; CRP, C-reactive protein) of SCI patients and controls were not statistically significant academic differences (p > 0.05). The baseline serum Nogo-A levels of SCI patients and controls were 192.7 ± 13.9 ng/ml and 263.1 ± 22.4 ng/ml, respectively, and there was a statistically significant difference between the two groups (p < 0.05). We divided SCI patients into 4 groups according to their baseline serum Nogo-A quartile levels and analyzed their relationship with ASIA scores. The trend test results showed that with the increase of Nogo-A level, the ASIA sensation score and ASIA motor score were significantly decreased (p < 0.001). Multivariate regression analysis showed that serum Nogo-A levels remained a potential cause affecting the prognosis of SCI after adjusting for confounding factors in multiple models.

Conclusions

Serum Nogo-A levels were significantly elevated in SCI patients. Moreover, elevated Nogo-A levels often indicate poor prognosis and can be used as a marker to predict the prognosis of SCI.

Missed cervical spine injuries: aim for the top

PURPOSE

To determine the incidence of missed cervical spine injuries by radiology registrars in a major trauma centre and to identify any common blind spots.

MATERIALS AND METHODS

All patients with an acute traumatic injury who underwent a CT scan of the cervical spine in our unit, which serves a population of approximately 900,000, between September 2016 and December 2017 and whom had a separate radiology trainee report and final neuroradiology consultant report available were included in the study. We recorded the date and time of the scan, the registrar error and the registrar grade. An error was defined as follows: (1) a missed fracture; (2) a missed ligamentous injury; (3) overcall of a fracture (e.g. degenerative calcification or nutrient vessel). Groups were compared with the chi-square test.

RESULTS

Five hundred seventy-three CT scans of the cervical spine fitted the inclusion criteria and were analysed. There were a total of 149 injuries over eight levels in 96 patients. There were 12 registrar errors (2.1% discrepancy rate), of which 11 were missed acute injuries (9 fractures and 2 disco-ligamentous injuries). The grade of the registrar was not significant (p = 0.603). Seventy-three percent (8/11) missed injuries were disproportionately at the cranio-cervical junction, where only 11.6% of traumatic cervical spine injuries occur p < 0.0001. Forty-five percent of the missed injuries included occipital condyle fractures, which occurred in only 12/149 injuries (8%).

CONCLUSIONS

Radiology registrars safely report emergency CT scans of the cervical spine performed following trauma with a low discrepancy rate. Missed cervical spine injuries commonly occur at the cranio-cervical junction, which should become a standard review area.

Rehabilitation length of stay and functional improvement among patients with traumatic spinal cord injury

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Investigate the association between rehabilitation length of stay (LOS) and motor FIM® (mFIM) between rehabilitation admission and discharge among patients with traumatic spinal cord injury (SCI).

SETTING

Seventeen SCI Model Systems (SCIMS) centers in the United States.

METHODS

A total of 3386 patients with traumatic SCI enrolled in the SCIMS Database from 2011 to 2018. The main outcome measure was the mean change in mFIM (12 items) between rehabilitation admission and discharge by twelve neurological categories (C1-C4 American Spinal Injury Association impairment scale (AIS) A-B, AIS C, AIS D, and C5-C8 AIS A-B, AIS C, AIS D, and T1-T10 AIS A-B, AIS C, AIS D, and T11-S3 AIS A-B, C, D). Linear regression models were applied to estimate changes across rehabilitation LOS groups (shortest LOS, quarter2, quarter3, and longest LOS) after adjusting for covariables for each neurological category.

RESULTS

The mean age of study patients was 44.5 years. Patients were predominantly men (78.5%), non-Hispanic white (64.8%), and had private insurance (57.1%). The median LOS was 42 days across the entire sample. Longer LOS was associated with a higher mFIM score compared to the shortest LOS among patients with C1-C4 AIS D; C5-C8 AIS D; T1-T10 AIS A-B; and T11-S3 AIS A-B, C, and D after adjusting for demographics and clinical characteristics.

CONCLUSION

Among patients with C1-C4 AIS D; C5-C8 AIS D; T1-T10 AIS A-B; and T11-S3 AIS A-B, C, and D injuries, those with longer rehabilitation stays tended to have more motor function improvement.

Electroactive Scaffolds to Improve Neural Stem Cell Therapy for Spinal Cord Injury

Spinal cord injury (SCI) is a serious condition caused by damage to the spinal cord through trauma or disease, often with permanent debilitating effects. Globally, the prevalence of SCI is estimated between 40 to 80 cases per million people per year. Patients with SCI can experience devastating health and socioeconomic consequences from paralysis, which is a loss of motor, sensory and autonomic nerve function below the level of the injury that often accompanies SCI. SCI carries a high mortality and increased risk of premature death due to secondary complications. The health, social and economic consequences of SCI are significant, and therefore elucidation of the complex molecular processes that occur in SCI and development of novel effective treatments is critical. Despite advances in medicine for the SCI patient such as surgery and anaesthesiology, imaging, rehabilitation and drug discovery, there have been no definitive findings toward complete functional neurologic recovery. However, the advent of neural stem cell therapy and the engineering of functionalized biomaterials to facilitate cell transplantation and promote regeneration of damaged spinal cord tissue presents a potential avenue to advance SCI research. This review will explore this emerging field and identify new lines of research.

Establishing the Socio-Economic Impact of Degenerative Cervical Myelopathy Is Fundamental to Improving Outcomes [AO Spine RECODE-DCM Research Priority Number 8]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To contextualize AO Spine RECODE-DCM research priority number 5: What is the socio-economic impact of DCM? (The financial impact of living with DCM to the individual, their supporters, and society as a whole).

METHODS

In this review, we introduce the methodology of health-economic investigation, including potential techniques and approaches. We summarize the current health-economic evidence within DCM, so far focused on surgical treatment. We also cover the first national estimate, in partnership with Myelopathy.org from the United Kingdom, of the cost of DCM to society. We then demonstrate the significance of this question to advancing care and outcomes in the field.

RESULTS

DCM is a common and often disabling condition, with a significant lack of recognition. While evidence demonstrates the cost-effectives of surgery, even among higher income countries, health inequalities exist. Further the prevalent residual disability in myelopathy, despite treatment affects both the individual and society as a whole. A report from the United Kingdom provides the first cost-estimate to their society; an annual cost of ∼£681.6 million per year, but this is likely a significant underestimate.

CONCLUSION

A clear quantification of the impact of DCM is needed to raise the profile of a common and disabling condition. Current evidence suggests this is likely to be globally substantial.

Neuroinduction and neuroprotection co-enhanced spinal cord injury repair based on IL-4@ZIF-8-loaded hyaluronan-collagen hydrogels with nano-aligned and viscoelastic cues

Spontaneous recovery after spinal cord injury (SCI) is extremely limited since the severe inflammatory responses lead to secondary damage, and the diseased extracellular matrix (ECM) fails to provide inductive cues...

Risk Factors for Tracheostomy after Traumatic Cervical Spinal Cord Injury: A 10-Year Study of 456 Patients

Objectives

To explore the difference between tracheostomy and non‐tracheostomy and identify the risk factors associated with the need for tracheostomy after traumatic cervical spinal cord injury (TCSCI).

Methods

The demographic and injury characteristics of 456 TCSCI patients, treated in the Xinqiao Hospital from 2010 to 2019, were retrospective analyzed. Patients were divided into the tracheostomy group (n = 63) and the non‐tracheostomy group (n = 393). Variables included were age, gender,smoking history, mechanism of injury, concomitant injury, American Spinal Injury Association (ASIA) Impairment Scale, the neurological level of injury, Cervical Spine Injury Severity Score (CSISS), surgery, and length of stay in ICU and hospital. SPSS 25.0 (SPSS, Chicago, IL) was used for statistical analysis and ROC curve drawing. Chi‐square analysis was applied to find out the difference of variables between the tracheostomy and non‐tracheostomy groups. Univariate logistic regression analysis (ULRA) and multiple logistic regression analysis (MLRA) were used to identify risk factors for tracheostomy. The area under the ROC curve (AUC) was used to evaluate the performance of these risk factors.

Results

Of 456 patients who met the inclusion criteria, 63 (13.8%) underwent tracheostomy. There were differences in age (χ² = 6.615, P = 0.032), mechanism of injury (χ² = 9.87, P = 0.036), concomitant injury (χ² = 6.131, P = 0.013),ASIA Impairment Scale (χ² = 123.08, P < 0.01), the neurological level of injury (χ² = 34.74, P < 0.01), and CSISS (χ² = 19.612, P < 0.01) between the tracheostomy and non‐tracheostomy groups. Smoking history, CSISS ≥ 7, AIS A and, NLI ≥ C5 were identified as potential risk factors for tracheostomy by ULRA. Smoking history (OR = 2.960, 95% CI: 1.524–5.750, P = 0.001), CSISS ≥ 7 (OR = 4.599, 95% CI: 2.328–9.085, P = 0.000), AIS A (OR = 14.213, 95% CI: 6.720–30.060, P = 0.000) and NLI ≥ C5 (OR = 8.312, 95% CI: 1.935–35.711, P = 0.004) as risk factors for tracheostomy were determined by MLRA. The AUC for the risk factors of tracheostomy after TCSCI was 0.858 (95% CI: 0.810–0.907).

Conclusions

Smoking history, CSISS ≥ 7, AIS A and, NLI ≥ C5 were identified as risk factors needing of tracheostomy in patients with TCSCI. These risk factors may be important to assist the clinical decision of tracheostomy.