Iatrogenic spinal cord injury: an observational study

Epidemiology of Spinal Cord Injury and Associated Mortality, Past and Present. Is There a Difference?

BACKGROUND

The demographics of the population with spinal cord injury (SCI) have been dynamic over time, especially as a result of aging. This study investigated the patterns of SCI admissions by age in the United States over the past decade.

METHODS

Data were evaluated (2010-2021), from the National Spinal Cord Injury Model Systems records. Patients were compared based on age (<70 and ≥70 years), analysis of mortality, neurologic level of injury, neurologic improvement, mortality by American Spinal Injury Association (ASIA) grade, and neurologic level of injury. Patients older than 70 years were defined as elderly.

RESULTS

The mean age of the 8137 patients reviewed was 42.6 years (range, 15-88 years). The mean admission rate per year was 678 (range, 378-758). For the elderly versus the younger cohort, the incidence of falls decreased by 5% versus 3.3%, vehicle accidents increased by 3% versus 14%, high tetraplegia increased by 14.7% versus 22.5%, and low tetraplegia decreased by 12% versus 5.7%. In the elderly, ASIA grades A, B, and C decreased significantly, whereas ASIA grade D increased by 23.8%. In the younger cohort, ASIA grade A and B injuries decreased, whereas grades C and D increased, all <5%. Overall, 32.1% of those with ASIA grade A and 68% with ASIA grade B injuries improved within 1-2 years after injury. In-hospital and 1-year mortality decreased by 14.5% and 35.4%, respectively, in the elderly.

CONCLUSIONS

The incidence of SCI increased. High cervical and incomplete injuries increased, whereas complete SCIs declined. In-hospital and 1-year mortality decreased. There was recovery in select cases of complete SCIs within 1 year.

Spinal cord infarction: A systematic review and meta-analysis of patient's characteristics, diagnosis accuracy, management, and outcome

Background

Acute spinal cord infarction (SCI) is a rare ischemic vascular lesion. It is difficult to diagnose during the acute phase because the clinical features can vary widely, and the diffusion-weighted imaging of spinal cord magnetic resonance imaging (MRI) often fails to detect any obvious abnormality. The first aim of this study was to describe the SCI patients' characteristics, evaluate the accuracy of its diagnosis tools and management, and then find the strength of the effect of spinal surgical decompression on the patient's outcome.

Methods

A PubMed keyword and Boolean search using ("spinal cord infarction" OR "spinal cord ischemia" AND diagnosis OR management OR outcome) returned 221,571 results by applying filters. We added 17,400 results from Google Scholar. Fourteen studies were included in the quantitative meta-analysis of mean differences.

Results

The Time to Nadir was <6 h (56.1%), 6-12 h (30.7%), 12-72 h (5.4%), and more than 72 h (7.8%). The higher proportion of Owl's eye findings in the MRI was reported at the cervical level (39.6%) and thoracic level (22.9%) P = 0.031. The T2DWI has a moderate accuracy (area under the curve = 0.835) in detecting the T2 hypersignal intensity (T2HSI) at the hyperacute time to NADIR (<6 h). The median modified Rankin Scale (mRS) at admission was 3 (2-3), and after a follow-up duration of 12 months (6-15.5), the median mRS was reported to be 1 (1-2). About 68.9% benefited from medical treatment and physiotherapy, whereas spinal surgical decompression was done in 22.8%. Seventy percent of the overall studies favor spinal surgical decompression, with the estimated average standardized mean difference between medical and surgical treatment being = 1.2083 (95% confidence interval: 1.0250-1.3917).

Conclusion

The T2DWI has moderate accuracy in detecting the T2HSI at the hyperacute time (NADIR <6 h). Even though surgical decompression favored good outcomes, medical treatment with physiotherapy was mostly used for the management of SCI.

Incidence and prevalence of traumatic spinal cord injury in Canada using health administrative data

INTRODUCTION

Incidence and prevalence data are needed for the planning, funding, delivery and evaluation of injury prevention and health care programs. The objective of this study was to estimate the Canadian traumatic spinal cord injury (TSCI) incidence, prevalence and trends over time using national-level health administrative data.

METHODS

ICD-10 CA codes were used to identify the cases for the hospital admission and discharge incidence rates of TSCI in Canada from 2005 to 2016. Provincial estimates were calculated using the location of the admitting facility. Age and sex-specific incidence rates were set to the 2015/2016 rates for the 2017 to 2019 estimates. Annual incidence rates were used as input for the prevalence model that applied annual survivorship rates derived from life expectancy data.

RESULTS

For 2019, it was estimated that there were 1,199 cases (32.0 per million) of TSCI admitted to hospitals, with 123 (10% of admissions) in-hospital deaths and 1,076 people with TSCI (28.7 per million) were discharged in Canada. The estimated number of people living with TSCI was 30,239 (804/million); 15,533 (52%) with paraplegia and 14,706 (48%) with tetraplegia. Trends included an increase in the number of people injured each year from 874 to 1,199 incident cases (37%), an older average age at injury rising from 46.6 years to 54.3 years and a larger proportion over the age of 65 changing from 22 to 38%, during the 15-year time frame.

CONCLUSION

This study provides a standard method for calculating the incidence and prevalence of TSCI in Canada using national-level health administrative data. The estimates are conservative based on the limitations of the data but represent a large Canadian sample over 15 years, which highlight national trends. An increasing number of TSCI cases among the elderly population due to falls reported in this study can inform health care planning, prevention strategies, and future research.

A Study of Critical Events That Lead to Spinal Cord Injury and the Importance of Rapid Reversal of Surgical Steps in Improving Neurological Outcomes: A Porcine Model

STUDY DESIGN

Porcine model.

OBJECTIVE

To quantify critical vascular and mechanical events that occur before and during an evolving spinal cord injury.

SUMMARY OF BACKGROUND DATA

Spinal cord injuries are one of the most devastating complications in spine surgery. Intraoperative neuromonitoring changes can occur as a secondary event of spinal cord compression and decrease in spinal cord blood flow (SCBF). Laser Doppler flowmetry has been well validated for measuring blood flow.

METHODS

Seventeen pigs were studied, 14 of which completed the experiment. Multilevel, midthoracic laminectomies were performed. Laser Doppler flowmetry electrodes were placed on the dura to measure SCBF. Spinal cord injury was induced by incremental balloon inflation in the epidural space. The animals were separated into two groups. After motor-evoked potential (MEP) loss, group A underwent medical interventions and then balloon decompression approximately 20 minutes later. Group B underwent immediate balloon decompression followed by medical interventions. After interventions, wake-up test was performed and computed tomography scan measured thoracic spinal canal volume.

RESULTS

Median SCBF changes were seen 15.8 (5.4-25.1) minutes before MEP loss. However, the 20% threshold interval was often reached before. At the 20% threshold, median pressure was 7 psi, balloon volume was 0.5 cm, and 50% of the spinal canal was compromised. In group A, no pigs moved and all had pathology indicating ischemia. In group B, 9 of 10 were found to be moving their hind legs with 7 indicating ischemia.

CONCLUSION

Compression spinal cord injury is the end of a cascade involving increasing intracanal pressure, decreasing canal volume, and hypoperfusion. Rapid relief of compression leads to MEP return. SCBF monitoring can detect ischemia preinjury, giving surgeons an opportunity for early intervention.

LEVEL OF EVIDENCE

4.

Multimodal intraoperative monitoring during reduction of spine burst fracture and dislocation prevents neurologic injury

This study aims to evaluate the application of multimodal intraoperative monitoring (MIOM) in surgical treatment for spine burst fracture and dislocation (SBFD) patients.Eleven patients who underwent posterior reduction and instrumentation (PRI) for SBFD from June 2014 to July 2016 were included into the study. The function of the spinal cord was monitored by MIOM. The muscle strength of the lower extremities and American Spinal Injury Association (ASIA) scores were, respectively, evaluated (before surgery, and at 1, 3, 6, and 12 months after surgery). Furthermore, the extent of reduction was also assessed.Muscle strength recovery, ASIA score changes, and the extent of reduction were correlated with MIOM results. Among the 11 patients who received surgery under MIOM, 8 patients with negative MIOM results during the operation did not demonstrate neurological deterioration postoperatively and exhibited improvements in ASIA scores during follow-ups. However, among the 3 patients who encountered MIOM events (case 4, 7, and 8), 2 patients avoided nerve lesion and 1 patient suffered from neurologic deterioration postoperatively.The application of MIOM technology during PRI surgery may detect spinal cord impairment at the early stage, and operative schemes can be modified before permanent nerve compromise is triggered by surgical manipulation.

Rapid fluorescence imaging of spinal cord following epidural administration of a nerve-highlighting fluorophore

Iatrogenic spinal cord injury (SCI) is the most devastating complication of spine surgery, which usually results in permanent and serious disabilities of patients. Improvement of the visualization and discrimination of the spinal cord is critical for accuracy and safety during surgery; however, to date, there is no suitable technology to fulfill this clinical need. Here, we first show an efficient and rapid fluorescence imaging of the spinal cord in rabbit by epidural administration of a nerve-highlighting fluorophore, i.e. (E, E)-1,4-bis(p-aminostryl)-2-methoxy benzene (BMB). The BMB is firstly encapsulated into polymeric micelles to form a BMB-micelle (BMB-m) formulation with well-dispersion in normal saline solution. After epidural administration of BMB-m, BMB is transported by the flow of cerebrospinal fluid (CSF) and binds to the peripheral region of the white matter thus facilitating rapid staining of the spinal cord. Furthermore, this BMB imaging technology also holds great potential for visually monitoring the integrity of the spinal cord in real time and promptly identifying acute SCI during spine surgery.

Risk factors in iatrogenic spinal cord injury

STUDY DESIGN

In the last years, there has been a change in the aetiology of spinal cord injury. There has been an increase in the number of elderly patients with spinal cord injuries caused by diseases or medical procedures.

OBJECTIVE

The aim of this study is to investigate the frequency of the occurrence of iatrogenic spinal cord injury in our unit. The secondary aim is to study what variables can be associated with a higher risk of iatrogenesis.

METHODS

A retrospective, descriptive, observational study of patients with acute spinal cord injury admitted from June 2009 to May 2014 was conducted. The information collected included the patient age, aetiology, neurological level and grade of injury when admitted and when discharged, cardiovascular risk factors, a previous history of depression and any prior treatment with anticoagulant or antiplatelet drugs. We applied a logistic regression. The grade of statistical significance was established as P<0.05.

RESULTS

In total, 265 patients were included. In 48 of the cases, the cause was iatrogenic (18.18%±4.6% IC). The most frequent level of injury was the thoracic level (48%). The main aetiology of spinal cord injury caused by iatrogenesis was surgery for degenerative spine disease, in patients under the age of 30 were treated with intrathecal chemotherapy.

CONCLUSIONS

Iatrogenic spinal cord injury is a frequent complication. A statistically significant association between a patient history of depression and iatrogenic spinal cord injury was found as well as with anticoagulant and antiplatelet drug use prior to iatrogenic spinal cord injury.

Epidemiology of persistent iatrogenic spinal cord injuries in Western Norway

OBJECTIVES

Iatrogenic spinal cord injuries (SCIs) caused by invasive procedures or surgical interventions have previously been reported as case studies. The primary objective of this study was to investigate and analyze the incidence, etiology, and prognosis of iatrogenic SCI in Western Norway.

METHODS

Medical records of all 183 patients admitted to the SCU between 01.01.2004 and 31.12.2013 were reviewed. Gender, age, diagnosis, iatrogenic medical procedure, symptoms and findings before and after injury, mechanism of injury, level of injury, and ASIA Impairment Scale (AIS) score prior iatrogenic SCI, at admittance and discharge were recorded, as were the length of the period prior to admittance and the length of stay.

RESULTS

Twenty-three (12.5%; 14 men, nine women) of 183 patients met the criteria for iatrogenic SCI. The annual incidence rate was estimated 2,3 per 1,000,000 (SD ±1.0). Mean age at iatrogenic SCI was 55.5 years (range 16-79 years). Intervention for cervical spinal stenosis was the leading cause of iatrogenic SCI, followed by operations on the aorta and spine. Iatrogenic SCIs was most frequently located on the thoracic level. The patients suffered from clinical incomplete injuries (AIS score C and D) both at admittance and discharge from the SCU. Most patients improved, but no patient recovered completely after SCI.

CONCLUSION

Although the annual incidence rate of iatrogenic SCI is low in Norway, individual consequences are serious. Increased awareness of the causes of SCI may decrease the risk of iatrogenic SCI.

International Spinal Cord Injury Data Sets for non-traumatic spinal cord injury

STUDY DESIGN

Multifaceted: extensive discussions at workshop and conference presentations, survey of experts and feedback.

OBJECTIVES

Present the background, purpose and development of the International Spinal Cord Injury (SCI) Data Sets for Non-Traumatic SCI (NTSCI), including a hierarchical classification of aetiology.

SETTING

International.

METHODS

Consultation via e-mail, presentations and discussions at ISCoS conferences (2006-2009), and workshop (1 September 2008). The consultation processes aimed to: (1) clarify aspects of the classification structure, (2) determine placement of certain aetiologies and identify important missing causes of NTSCI and (3) resolve coding issues and refine definitions. Every effort was made to consider feedback and suggestions from participants.

RESULTS

The International Data Sets for NTSCI includes basic and an extended versions. The extended data set includes a two-axis classification system for the causes of NTSCI. Axis 1 consists of a five-level, two-tier (congenital-genetic and acquired) hierarchy that allows for increasing detail to specify the aetiology. Axis 2 uses the International Statistical Classification of Diseases (ICD) and Related Health Problems for coding the initiating diseases(s) that may have triggered the events that resulted in the axis 1 diagnosis, where appropriate. Additional items cover the timeframe of onset of NTSCI symptoms and presence of iatrogenicity. Complete instructions for data collection, data sheet and training cases are available at the websites of ISCoS (http://www.iscos.org.uk) and ASIA (http://www.asia-spinalinjury.org).

CONCLUSIONS

The data sets should facilitate comparative research involving NTSCI participants, especially epidemiological studies and prevention projects. Further work is anticipated to refine the data sets, particularly regarding iatrogenicity.