The influence of time from injury to surgery on motor recovery and length of hospital stay in acute traumatic spinal cord injury: an observational Canadian cohort study

Traumatic spinal cord injury: a review of the current state of art and future directions - what do we know and where are we going?

Background

Traumatic spinal cord injury (SCI) remains a devastating condition, with limited functional recovery despite advancements in clinical management and understanding of its mechanisms. SCI pathophysiology involves primary mechanical trauma and secondary neuroimmune and structural changes, leading to neuronal death and chronic functional deficits.

Methods

Through a comprehensive literature review of articles published in the PubMed, MEDLINE, Embase, and Cochrane Reviews Library databases, this article provides an update on the current management of traumatic SCI with a focus on these emerging therapeutic strategies that hold potential for future advancements in the field.

Results

Current management strategies include pre-hospital care, acute clinical interventions, surgical decompression and spine destabilization, and neurorehabilitation. Despite these interventions, SCI patients often fail to fully restore lost functions. Emerging therapies focus on neuroprotection, neuroregeneration, and neuromodulation, leveraging advances in molecular biomarkers, imaging techniques, and cell-based treatments. Neuroprotective agents, including the sodium-glutamate antagonist riluzole, aim to keep cells alive through the secondary injury phase, while regenerative strategies utilize neurotrophic factors and stem cell transplantation or approaches to target inhibitor molecules such as NOGO or RGMa to regenerate new cells, axons, and neural circuits. Neuromodulation techniques, such as electrical and magnetic field stimulation, offer promising avenues for functional recovery. Combining these novel therapies with traditional neurorehabilitation holds potential for improved outcomes.

Conclusions

While significant strides have been made in understanding the mechanisms underlying SCI and in developing novel therapeutic approaches, the challenge and opportunity will be to tailor treatments to fit the heterogenous clinical presentation of patients with SCI and to better understand the heterogeneity in clinical trajectories.

Economic Optimization Through Adherence to Best Practice Guidelines: A Decision Analysis of Traumatic Spinal Cord Injury Care Pathways in Australia

Traumatic spinal cord injuries (TSCIs) have significant health, economic, and social effects on individuals, families, and society. In this economic analysis modeling study, we used record-linked administrative patient data from New South Wales, Australia, to construct a decision tree model to compare the economic cost of acute care for patients with TSCI under current clinical pathways with an optimal care (consensus guidelines-informed) modeled pathway. The optimal care pathway included direct transfer to a specialist SCI Unit (SCIU) or indirect transfer to SCIU within 24 h of injury, surgical intervention within 12 h of injury, and subsequent inpatient rehabilitation. Propensity score matching with inverse probability of treatment weighting (IPTW) was used to reduce potential confounding from baseline differences in patient characteristics. A generalized linear model regression with gamma distribution and log link, weighted with IPTW scores, was used for cost and length of stay (LoS) estimations to reduce any residual bias. Sensitivity analyses quantified the sensitivity of the findings to key model parameters. From the healthcare payer perspective, our economic analysis found acute TSCI care at an SCIU was more expensive, with delayed patient transfer pathways, surgery, and timing of surgery driving higher per-patient costs ($14,322 at specialist centers). Probabilistic sensitivity analysis (PSA) using 10,000 Monte Carlo iterations showed the modeled optimal pathway as the expensive option in the majority (86%) of stimulations. However, the modeled direct transfer care pathway demonstrated economic improvements compared to current care pathways, despite a higher upfront cost ($25,428 per patient), the modeled pathway reduced the episode LoS by 5 days (23 days vs. 28 days) on average, generating system-level savings of $20,628 per patient. In PSA, increasing the proportion of patients directly transferred to SCIU by 25%, the optimized pathway was preferred in 28.3% of the simulations. Furthermore, adopting this pathway lowered the incremental per patient cost to $17,157 while preserving a 5-day LoS benefit compared to current pathways (22 days vs. 27 days), which could generate potential savings of $3,471 per patient. Our findings show that guideline-based acute care management is initially resource-intensive but efficient in terms of patient LoS, with a higher proportion of direct transfers resulting in cost savings of $3,471 per patient, which represent system-level benefits from adopting the modeled pathway, rather than episode-level savings. Following consensus guidelines for acute care can provide an economically sustainable approach to resource-intensive patient needs while improving outcomes, as demonstrated in previous studies. In summary, while more intensive, adhering to clinical guidelines of direct transfer to SCIU demonstrates value for patients and health systems. Standardization to optimize time to surgery can achieve improved outcomes through earlier access to rehabilitation and substantial care efficiencies. These findings highlight the economic case for adherence to best practice care guidelines at the healthcare system level to inform future healthcare planning for patients with TSCI.

[Indications for surgical treatment of traumatic fractures of the thoracic spine and lumbar spine]

Fractures of the thoracic (Th) and lumbar (L) vertebrae are among the most frequent fracture entities in Germany and particularly affect the thoracolumbar junction (TLJ; Th11-L2). Based on expert recommendations and consensus meetings, the thoracolumbar AOSpine injury score was established for patients with healthy bone and the osteoporotic fracture (OF) score for geriatric patients with the respective classifications for treatment decisions. In both cohorts, the treatment decision is based on the fracture morphology, neurological status and patient-specific contextual factors. In terms of fracture morphology, surgical treatment is generally indicated for distraction and rotation/translation injuries. The treatment decision for compression fractures is more complex as additional factors must be taken into consideration. The decision in patients with healthy bone is primarily influenced by imaging morphological criteria (deformity and destruction) whereas in osteoporotic patients the decision is influenced by individual criteria, such as the general condition, the possibility of low pain mobilization and concomitant diseases. Overall, the treatment decision for fractures of the TLJ is not dogmatic as individual factors must be considered and high-quality studies are lacking.

Early Versus Delayed Surgery for Elderly Traumatic Cervical Spinal Injury: A Nationwide Multicenter Study in Japan

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

The effectiveness of early surgery for cervical spinal injury (CSI) has been demonstrated. However, whether early surgery improves outcomes in the elderly remains unclear. This study investigated whether early surgery for CSI in elderly affects complication rates and neurological outcomes.

METHODS

This retrospective multicenter study included 462 patients. We included patients with traumatic acute cervical spinal cord injury aged ≥65 years who were treated surgically, whereas patients with American Spinal Injury Association (ASIA) Impairment Scale E, those with unknown operative procedures, and those waiting for surgery for >1 month were excluded. The minimum follow-up period was 6 months. Sixty-five patients (early group, 14.1%) underwent surgical treatment within 24 hours, whereas the remaining 397 patients (85.9%) underwent surgery on a standby basis (delayed group). The propensity score-matched cohorts of 63 cases were compared.

RESULTS

Patients in the early group were significantly younger, had significantly more subaxial dislocations (and fractures), tetraplegia, significantly lower ASIA motor scores, and ambulatory abilities 6 months after injury. However, no significant differences in the rate of complications, ambulatory abilities, or ASIA Impairment Scale scores 6 months after injury were observed between the matched cohorts. At 6 months after injury, 61% of the patients in the early group (25% unsupported and 36% supported) and 53% of the patients in the delayed group (34% unsupported and 19% supported) were ambulatory.

CONCLUSIONS

Early surgery is possible for CSI in elderly patients as the matched cohort reveals no significant difference in complication rates and neurological or ambulatory recovery between the early and delayed surgery groups.

Pre-Hospital and Post-Hospital Quality of Care in Traumatic Spinal Column and Cord Injuries in Iran

STUDY DESIGN

A retrospective study.

OBJECTIVES

The quality of care (QoC) for spinal column/cord injury patients is a major health care concern. This study aimed to implement the QoC assessment tool (QoCAT) in the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to define the current state of pre- and post-hospital QoC of individuals with Traumatic Spinal Column and Spinal Cord Injuries (TSC/SCIs).

METHODS

The QoCAT, previously developed by our team to measure the QoC in patients with TSC/SCIs, was implemented in the NSCIR-IR. The pre-hospital QoC was evaluated through a retrospective analysis of NSCIR-IR registry data. Telephone interviews and follow-ups of patients with SCI evaluated the QoC in the post-hospital phase.

RESULTS

In the pre-hospital phase, cervical collars and immobilization were implemented in 46.4% and 48.5% of the cases, respectively. Transport time from the scene to the hospital was documented as <1 hour and <8 hours in 33.4% and 93.9% of the patients, respectively. Post-hospital indicators in patients with SCI revealed a first-year mortality rate of 12.5% (20/160), a high incidence of secondary complications, reduced access to electrical wheelchairs (4.2%) and modified cars (7.7%), and low employment rate (21.4%).

CONCLUSION

These findings revealed a significant delay in transport time to the first care facilities, low use of immobilization equipment indicating low pre-hospital QoC. Further, the high incidence of secondary complications, low employment rate, and low access to electrical wheelchairs and modified cars indicate lower post-hospital QoC in patients with SCI. These findings imply the need for further planning to improve the QoC for patients with TSC/SCIs.

A novel online calculator based on inflammation-related endotypes and clinical features to predict postoperative pulmonary infection in patients with cervical spinal cord injury

BACKGROUND

Postoperative pulmonary infection (POI) of patients with cervical spinal cord injury (CSCI) is highly heterogeneous, while the potential endotypes and related risk factors remain unclear.

METHODS

A retrospective collection of 290 CSCI patients was conducted from January 2010 to July 2024 using 1:1 propensity score matching to compare POI (n = 145) and non-POI (n = 145) groups. We generated laboratory examination data from admission patients and identified endotypes using unsupervised consensus clustering and machine learning. CSCI patients were randomly assigned to the training set (n = 203) and internal validation set (n = 87). A separate cohort comprising 245 CSCI patients were used for external validation. Independent predictors for POI were identified using univariate and multivariate logistic regression. A nomogram and an online calculator were developed and validated, both internally and externally.

RESULTS

Two inflammation-related endotypes were identified: high inflammation endotype (endotype C1) and low inflammation endotype (endotype C2). Eight predictors for POI were identified (including age, operation duration, number of surgical segments, time between injury and surgery, preoperative steroid pulse, American Spinal Injury Association (ASIA) grade, smoking history, and inflammation-related endotype). A nomogram integrating the risk factors showed excellent discrimination in the training set (AUC, 0.976; 95% CI 0.956-0.996), internal validation set (AUC, 0.993; 95% CI 0.981-1.000), and external validation set (AUC, 0.799; 95%CI 0.744-0.854). Calibration curves demonstrated excellent fit, and decision curves highlighted its favorable clinical value. An online calculator (https://tjspine.shinyapps.io/dynnomapp/) was constructed to improve the convenience and efficiency of our prediction model.

CONCLUSIONS

We identified inflammation-related endotype and constructed a web-based calculator for predicting POI in patients with CSCI, exhibiting excellent clinical utility.

Alternate Level of Care Patients in Canada: a Scoping Review

Background

There has been increasing concern over the growing number of Alternate Level of Care (ALC) patients in Canada who must wait in hospitals for more appropriate settings to meet their needs. ALC patients may have to stay in hospitals for days or months due to a lack of available long-term care capacity, home care services, or other discharge routes.

Method

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) method to review 35 papers on the topic of ALC patients and delayed discharge in Canada from different perspectives, including (1) the shared characteristics of ALC patients in Canada; and (2) their impact on the Canadian health-care system, medical staff, and family members. Furthermore, from the reviewed works, (3) we also investigate the factors that impact the length of the hospital stays.

Results

We highlighted how the ALC problem is increasing healthcare costs, disrupting services, increasing waiting times, and compromising access to valuable resources. We found evidence suggesting that this far-reaching crisis affects the patients, their families, and the medical personnel. We discovered several logistical issues (such as access to long-term care) affecting the patient's hospital length of stay.

Conclusions

Our research contributes to understanding this intricate problem, and helps policymakers take steps to tackle this challenge to ensure timely and appropriate care for all patients.

How do early perioperative changes in AIS grade correlate with long-term neurological recovery? A retrospective cohort study

Context/Objective: Providing accurate counseling on neurological recovery is crucial after traumatic spinal cord injury (TSCI). The early neurological changes that occur in the subacute phase of the injury (i.e. within 14 days of early decompressive surgery) have never been documented. The objective of this study was to assess peri-operative neurological improvements after acute TSCI and determine their relationship with long-term neurological outcomes, measured 6-12 months following the injury.Methods: A retrospective cohort study of 142 adult TSCI patients was conducted. Early peri-operative improvement was defined as improvement of at least 1 AIS grade between the pre-operative and follow-up (6-12 months post-TSCI) assessment. neurological improvement of at least 1 AIS grade.Results: Out of the 142 patients, 18 achieved a peri-operative improvement of at least 1 AIS grade. Presenting a pre-operative AIS grade B and having shorter surgical delays were the main factors associated with stronger odds of achieving this outcome. Out of the 140 patients who still had potential for improvement at the time of the post-operative assessment, 44 achieved late neurological recovery (improvement of at least 1 AIS grade between the post-operative assessment and follow-up). Patients who presented a perioperative improvement seemed more likely to achieve later neurological improvement as well, although this was not statistically significant.Conclusion: Our results suggest that it is important to assess early perioperative neurological changes within 14 days of surgery because it can provide beneficial insight on long-term neurological outcomes for some patients. In addition, earlier surgery may promote early neurological recovery.

An Update on Spinal Cord Injury and Current Management

» Spinal cord injury is associated with increased lifelong cost and decreased life expectancy.» Current treatment guidelines have been limited to studies of small effect sizes and limited availability of randomized control trials.» Recovery is best correlated with the initial American Spinal Injury Association impairment scale grade with A and B less likely to recover regarding ambulation as compared with C and D grades.» Surgical intervention within less than 24 hours, especially in the cervical spine, has been associated with some motor improvement.» The use of mean arterial pressure goals and steroids to maintain perfusion and decrease secondary injury requires further study to elucidate clearer evidence-based results.

Thoracolumbar spinal cord injury: management, techniques, timing

Acute traumatic spinal cord injury (tSCI) is a complex and heterogeneous injury, where the level of injury, injury severity, duration and degree of spinal cord compression, and blood pressure management seem to influence neurologic outcome. Although data in the literature seem to be inconsistent regarding the effectiveness of surgical decompression and spinal fixation in patients with thoracic and thoracolumbar tSCI, some single-center studies suggest that early surgical decompression may lead to a superior neurologic outcome, especially in patients with incomplete tSCI, suggesting surgical decompression to be performed as soon as possible. However, high energy injuries, especially to the upper thoracic levels, may be too severe to be influenced by surgical decompression, which may represent a critical second hit for the polytraumatized patient. Therefore, the surgeon first needs to critically evaluate the potential for neurologic recovery in each patient before determining the ideal timing of surgery. Circulatory stabilization must be achieved before surgical intervention, and minimally invasive procedures should be preferred. Invasive blood pressure monitoring should be started on admission, and maintenance of a MAP between 85 and 90 mmHg is recommended for a duration of 5-7 days, with special attention to the prevention of hypoxia, fever, acidosis and deep venous thrombosis. The role of a 24-hour infusion of high-dose MPSS is still controversial, but it may be offered at the discretion of the treating surgeon to adult patients within 8 h of acute tSCI as a treatment option, especially in the case of very early decompression or incomplete tSCI.

Influential factors on stem cell therapy success in canine model of spinal cord Injury: A systematic review and meta-analysis

Spinal cord injury (SCI) is a serious medical condition. The search for an effective cure remains a persistent challenge. Current treatments, unfortunately, are unable to sufficiently improve neurological function, often leading to lifelong disability. This systematic review and meta-analysis evaluated the effectiveness of stem cell therapy for SCI using canine models. It also explored the optimal protocol for implementing stem cell therapy. A comprehensive search of studies was conducted from 2000 to October 2022. This study focused on five outcomes: motor function score, histopathology, IHC, western blot, and SEP. The results demonstrated a significant improvement in locomotion post-SCI in dogs treated with stem cell therapy. The therapy also led to an average increase of 3.15 points in the Olby score of the treated dogs compared to the control group. These findings highlights stem cell therapy's potential as a promising SCI treatment. The meta-analysis suggests that using bone marrow stem cells, undergoing neural differentiation in vitro, applying a surgical implantation or intrathecal route of administration, associating matrigel in combination with stem cells, and a waiting period of two weeks before starting treatment can enhance SCI treatment effectiveness.

[Translated article] Efficacy of early versus delayed spinal cord decompression in neurological recovery after traumatic spinal cord injury: Systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To compare early (<24h) versus late (>24h) spinal cord decompression on neurological recovery in patients with acute spinal cord injury.

METHODS

A systematic review was performed according to the PRISMA protocol to identify studies published up to December 2022. Prospective cohort studies and controlled trials comparing early versus delayed decompression on neurological recovery were included. Variables included number of patients, level of injury, treatment time, ASIA grade, neurological recovery, use of corticosteroids, and complications. For the meta-analysis, the "forest plot" graph was developed. The risk of bias of the included studies was assessed using the ROBINS-I22 and Rob223 tools.

RESULTS

Six of the seven studies selected for our review were included in the meta-analysis, with a total of 1188 patients (592 patients in the early decompression group and 596 in the delayed decompression group), the mean follow-up was 8 months, in 5 studies used methylprednisolone, the most reported complications were thromboembolic cardiopulmonary events. Five studies showed significant differences in favour of early decompression (risk difference 0.10, 95% confidence interval 0.07-0.14, heterogeneity 46%). The benefit was greatest in cervical and incomplete injuries.

CONCLUSION

There is scientific evidence to recommend early decompression in the first 24h after traumatic spinal cord injury, as it improves final neurological recovery, and it should be recommended whenever the patient and hospital conditions allow it to be safely done.

Microbubble Contrast-Enhanced Transcutaneous Ultrasound Enables Real-Time Spinal Cord Perfusion Monitoring Following Posterior Cervical Decompression

BACKGROUND

Ultrasound imaging is inexpensive, portable, and widely available. The development of a real-time transcutaneous spinal cord perfusion monitoring system would allow more precise targeting of mean arterial pressure goals following acute spinal cord injury (SCI). There has been no prior demonstration of successful real-time cord perfusion monitoring in humans.

METHODS

Four adult patients who had undergone posterior cervical decompression and instrumentation at a single center were enrolled into this prospective feasibility study. All participants had undergone cervical laminectomies spanning ≥2 contiguous levels ≥2 months prior to inclusion with no history of SCI. The first 2 underwent transcutaneous ultrasound without contrast and the second 2 underwent contrast-enhanced ultrasound (CEUS) with intravenously injected microbubble contrast.

RESULTS

Using noncontrast ultrasound with or without Doppler (n = 2), the dura, spinal cord, and vertebral bodies were apparent however ultrasonography was insufficient to discern intramedullary perfusion or clear white-gray matter differentiation. With application of microbubble contrast (n = 2), it was possible to quantify differential spinal cord perfusion within and between cross-sectional regions of the cord. Further, it was possible to quantify spinal cord hemodynamic perfusion using CEUS by measuring peak signal intensity and the time to peak signal intensity after microbubble contrast injection. Time-intensity curves were generated and area under the curves were calculated as a marker of tissue perfusion.

CONCLUSIONS

CEUS is a viable platform for monitoring real-time cord perfusion in patients who have undergone prior cervical laminectomies. Further development has the potential to change clinical management acute SCI by tailoring treatments to measured tissue perfusion parameters.

Efficacy of early versus delayed spinal cord decompression in neurological recovery after traumatic spinal cord injury: Systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To compare early (<24h) versus late (>24h) spinal cord decompression on neurological recovery in patients with acute spinal cord injury.

METHODS

A systematic review was performed according to the PRISMA protocol to identify studies published up to December 2022. Prospective cohort studies and controlled trials comparing early versus delayed decompression on neurological recovery were included. Variables included number of patients, level of injury, treatment time, ASIA grade, neurological recovery, use of corticosteroids, and complications. For the meta-analysis, the «forest plot» graph was developed. The risk of bias of the included studies was assessed using the ROBINS-I22 and Rob223 tools.

RESULTS

Six of the seven studies selected for our review were included in the meta-analysis, with a total of 1188 patients (592 patients in the early decompression group and 596 in the delayed decompression group), the mean follow-up was 8 months, in 5 studies used methylprednisolone, the most reported complications were thromboembolic cardiopulmonary events. Five studies showed significant differences in favor of early decompression (risk difference 0.10, 95% confidence interval 0.07-0.14, heterogeneity 46%). The benefit was greatest in cervical and incomplete injuries.

CONCLUSION

There is scientific evidence to recommend early decompression in the first 24h after traumatic spinal cord injury, as it improves final neurological recovery, and it should be recommended whenever the patient and hospital conditions allow it to be safely done.

Tracing the evolving dynamics and research hotspots of spinal cord injury and surgical decompression from 1975 to 2024: a bibliometric analysis

Background

Exploration of the benefits and timing of surgical decompression in spinal cord injury (SCI) has been a research hotspot. However, despite the higher volume and increasing emphasis on quality there remains no bibliometric view on SCI and surgical decompression. In this study, we aimed to perform bibliometric analysis to reveal the core countries, affiliations, journals, authors, and developmental trends in SCI and surgical decompression across the past 50 years.

Methods

Articles and reviews were retrieved from web of science core collection between 1975 and 2024. The bibliometrix package in R was used for data analysis and visualizing.

Results

A total of 8,688 documents were investigated, indicating an ascending trend in annual publications. The USA and China played as the leaders in scientific productivity. The University of Toronto led in institutional productions. Core authors, such as Michael G. Fehlings, showed high productivity, and occasional authors showed widespread interests. Core journals like Spine and Spinal Cord served as beacons in this field. The interaction of core authors and international collaboration accentuated the cross-disciplinary feature of the field. Prominent documents emphasized the clinical significance of early decompression in 24 h post SCI.

Conclusion

Based on comprehensive bibliometric analysis and literature review, we identified the hotspots and future directions of this field: (1) further investigation into the molecular and cellular mechanisms to provide pre-clinical evidence for biological effects of early surgical decompression in SCI animal models; (2) further evaluation and validation of the optimal time window of surgical decompression based on large cohort, considering the inherent heterogeneity of subpopulations in complicated immune responses post SCI; (3) further exploration on the benefits of early decompression on the neurological, functional, and clinical outcomes in acute SCI; (4) evaluation of the optimal surgical methods and related outcomes; (5) applications of artificial intelligence-based technologies in spinal surgical decompression.

Advances and Challenges in Spinal Cord Injury Treatments

Spinal cord injury (SCI) is a debilitating condition that is associated with long-term physical and functional disability. Our understanding of the pathogenesis of SCI has evolved significantly over the past three decades. In parallel, significant advances have been made in optimizing the management of patients with SCI. Early surgical decompression, adequate bony decompression and expansile duraplasty are surgical strategies that may improve neurological and functional outcomes in patients with SCI. Furthermore, advances in the non-surgical management of SCI have been made, including optimization of hemodynamic management in the critical care setting. Several promising therapies have also been investigated in pre-clinical studies, with some being translated into clinical trials. Given the recent interest in advancing precision medicine, several investigations have been performed to delineate the role of imaging, cerebral spinal fluid (CSF) and serum biomarkers in predicting outcomes and curating individualized treatment plans for SCI patients. Finally, technological advancements in biomechanics and bioengineering have also found a role in SCI management in the form of neuromodulation and brain-computer interfaces.

Management of traumatic spinal cord injury: A current concepts review of contemporary and future treatment

Spinal Cord Injury (SCI) is a condition leading to inflammation, edema, and dysfunction of the spinal cord, most commonly due to trauma, tumor, infection, or vascular disturbance. Symptoms include sensory and motor loss starting at the level of injury; the extent of damage depends on injury severity as detailed in the ASIA score. In the acute setting, maintaining mean arterial pressure (MAP) higher than 85 mmHg for up to 7 days following injury is preferred; although caution must be exercised when using vasopressors such as phenylephrine due to serious side effects such as pulmonary edema and death. Decompression surgery (DS) may theoretically relieve edema and reduce intraspinal pressure, although timing of surgery remains a matter of debate. Methylprednisolone (MP) is currently used due to its ability to reduce inflammation but more recent studies question its clinical benefits, especially with inconsistency in recommending it nationally and internationally. The choice of MP is further complicated by conflicting evidence for optimal timing to initiate treatment, and by the reported observation that higher doses are correlated with increased risk of complications. Thyrotropin-releasing hormone may be beneficial in less severe injuries. Finally, this review discusses many options currently being researched and have shown promising pre-clinical results.

[Characterization of injuries among elite football players during a sports season in Burkina Faso: the 2019-2020 sports season]

Introduction

injuries are a major undesirable event in sportsmen's career and prevention depends on their characteristics. The aim of this study was to determine the characteristics of injuries suffered by elite footballers in Burkina Faso during the 2019-2020 sports season.

Methods

we conducted a cross-sectional study among 160 players who were administered a questionnaire. Proportion and χ2 tests were used to calculate frequencies and determine associated factors, respectively.

Results

a total of 157 injuries were recorded in 143 players (89.4%). Muscle injuries (45.85%) and sprains (30.6%) were common. The majority of injuries (52%) were of medium severity. The thigh (30%), ankle (26.5%) and knee (18%) were the most affected areas. The frequency of injuries was higher after physical contact than without physical contact with another player (69.5% versus 30.5; p = 0.009), during matches than during training (82% versus 28%; p = 0.003) and during the return leg than the first leg of the championship (58.5% versus 41.5%; p = 0.02).

Conclusion

the frequency of injuries suffered by footballers during the 2019-2020 season was high. These injuries were mostly muscular and tendinous, and the lower limbs were mostly affected. They were associated with physical contact, matches and the return phase of the championship. To be effective, preventive measures should take these characteristics into account.

Optimizing Dual Antiplatelet Therapy in the Perioperative Period for Spine Surgery After Recent Percutaneous Coronary Intervention: A Comprehensive Review, Synthesis, and Catalyst for Protocol Formulation

The increased incidence of spine surgery within the past decade has highlighted the importance of robust perioperative management to improve patient outcomes overall. Coronary artery disease is a common medical comorbidity present in the population of individuals who receive surgery for spinal pathology that is often treated with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Discontinuation of DAPT before surgical intervention is typically indicated; however, contradictory evidence exists in the literature regarding the timing of DAPT use and discontinuation in the perioperative period. We review the most recent cardiac and spine literature on the intricacies of percutaneous coronary intervention and its associated risks in the postoperative period. We further propose protocols for DAPT use after both elective and urgent spine surgery to optimize perioperative care.

An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery

STUDY DESIGN

Clinical practice guideline development.

OBJECTIVES

Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI).

METHODS

A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence.

CONCLUSIONS

It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

Timing of Decompressive Surgery in Patients With Acute Spinal Cord Injury: Systematic Review Update

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Surgical decompression is a cornerstone in the management of patients with traumatic spinal cord injury (SCI); however, the influence of the timing of surgery on neurological recovery after acute SCI remains controversial. This systematic review aims to summarize current evidence on the effectiveness, safety, and cost-effectiveness of early (≤24 hours) or late (>24 hours) surgery in patients with acute traumatic SCI for all levels of the spine. Furthermore, this systematic review aims to evaluate the evidence with respect to the impact of ultra-early surgery (earlier than 24 hours from injury) on these outcomes.

METHODS

A systematic search of the literature was performed using the MEDLINE database (PubMed), Cochrane database, and EMBASE. Two reviewers independently screened the citations from the search to determine whether an article satisfied predefined inclusion and exclusion criteria. For all key questions, we focused on primary studies with the least potential for bias and those that controlled for baseline neurological status and specified time from injury to surgery. Risk of bias of each article was assessed using standardized tools based on study design. Finally, the overall strength of evidence for the primary outcomes was assessed using the GRADE approach. Data were synthesized both qualitatively and quantitively using meta-analyses.

RESULTS

Twenty-one studies met inclusion and exclusion criteria and formed the evidence base for this review update. Seventeen studies compared outcomes between patients treated with early (≤24 hours from injury) compared to late (>24 hours) surgical decompression. An additional 4 studies evaluated even earlier time frames: <4, <5, <8 or <12 hours. Based on moderate evidence, patients were 2 times more likely to recover by ≥ 2 grades on the ASIA Impairment Score (AIS) at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, moderate evidence suggested that patients receiving early decompression had an additional 4.50 (95% CI 1.70 to 7.29) point improvement on the ASIA motor score. With respect to administrative outcomes, there was low evidence that early decompression may decrease acute hospital length of stay. In terms of safety, there was moderate evidence that suggested the rate of major complications does not differ between patients undergoing early compared to late surgery. Furthermore, there was no difference in rates of mortality, surgical device-related complications, sepsis/systemic infection or neurological deterioration based on timing of surgery. Firm conclusions were not possible with respect to the impact of ultra-early surgery on neurological, functional or safety outcomes given the poor-quality studies, imprecision and the overlap in the time frames examined.

CONCLUSIONS

This review provides an evidence base to support the update on clinical practice guidelines related to the timing of surgical decompression in acute SCI. Overall, the strength of evidence was moderate that early surgery (≤24 hours from injury) compared to late (>24 hours) results in clinically meaningful improvements in neurological recovery. Further studies are required to delineate the role of ultra-early surgery in patients with acute SCI.

Understanding exosomes: Part 2-Emerging leaders in regenerative medicine

Exosomes are the smallest subset of extracellular signaling vesicles secreted by most cells with the ability to communicate with other tissues and cell types over long distances. Their use in regenerative medicine has gained tremendous momentum recently due to their ability to be utilized as therapeutic options for a wide array of diseases/conditions. Over 5000 publications are currently being published yearly on this topic, and this number is only expected to dramatically increase as novel therapeutic strategies continue to be developed. Today exosomes have been applied in numerous contexts including neurodegenerative disorders (Alzheimer's disease, central nervous system, depression, multiple sclerosis, Parkinson's disease, post-traumatic stress disorders, traumatic brain injury, peripheral nerve injury), damaged organs (heart, kidney, liver, stroke, myocardial infarctions, myocardial infarctions, ovaries), degenerative processes (atherosclerosis, diabetes, hematology disorders, musculoskeletal degeneration, osteoradionecrosis, respiratory disease), infectious diseases (COVID-19, hepatitis), regenerative procedures (antiaging, bone regeneration, cartilage/joint regeneration, osteoarthritis, cutaneous wounds, dental regeneration, dermatology/skin regeneration, erectile dysfunction, hair regrowth, intervertebral disc repair, spinal cord injury, vascular regeneration), and cancer therapy (breast, colorectal, gastric cancer and osteosarcomas), immune function (allergy, autoimmune disorders, immune regulation, inflammatory diseases, lupus, rheumatoid arthritis). This scoping review is a first of its kind aimed at summarizing the extensive regenerative potential of exosomes over a broad range of diseases and disorders.

An Insight into the Prospects and Drawbacks of Stem Cell Therapy for Spinal Cord Injuries: Ongoing Trials and Future Directions

Spinal cord injury (SCI) is a devastating neurological disorder that has a substantial detrimental impact on a person's quality of life. The estimated global incidence of SCI is 40 to 80 cases per million people and around 90% of cases are traumatic. Various etiologies can be recognized for SCI, and post-traumatic SCI represents the most common of these. Patients worldwide with SCI suffer from a persistent loss of motor and sensory function, which affects every aspect of their personal and social lives. Given the lack of effective treatments, many efforts have been made to seek a cure for this condition. In recent years, thanks to their ability to regenerate tissue and repair lost or damaged cells, much attention has been directed toward the use of stem cells (embryonic, induced pluripotent, mesenchymal, hematopoietic), aimed at restoring the functional integrity of the damaged spinal cord and improving a functional recovery including sensory and motor function. In this paper, we offer an overview of the benefits and drawbacks of stem cell therapy for SCI based on clinical evidence. This report also addresses the characteristics of various stem cell treatments, as well as the field's likely future. Each cell type targets specific pathological characteristics associated with SCI and demonstrates therapeutic effects via cell replacement, nutritional support, scaffolds, and immunomodulation pathways. SCI accompanied by complex pathological processes cannot be resolved by single treatment measures. Stem cells are associated with the adjustment of the expression of neurotrophic factors that help to achieve better nutrition to damaged tissue. Single-cell treatments have been shown in some studies to provide very minor benefits for SCI in multiple preclinical studies and a growing number of clinical trials. However, SCI damage is complex, and many studies are increasingly recognizing a combination approach such as physical therapy, electrical stimulation, or medication therapy to treatment.

Improved neurological function in a patient with complete spinal cord injury through bone marrow mesenchymal stem cells implantation: a case report

Aim: Spinal cord injury (SCI) can cause severe disability. Several clinical trials of stem-cell based therapies are ongoing. We describe our experience of bone marrow mesenchymal stem cell (BMSC) therapy in a patient with complete SCI in the chronic stage. Case report: A 25-year-old man with complete SCI at T6 level presented with paraplegia for 5 years. We transplanted autologous BMSCs intramedullary. After 12 months follow-up, his Barthel index score was noticeably improved from severe to moderate dependency, and the sensation level improved from T7 to S5, but no improvement of motor function. Conclusion: Autologous BMSCs are potentially safe for patients with complete SCI in the chronic stage and may improve neurological function and quality of life.

Ultra-early (≤8 hours) surgery for thoracolumbar spinal cord injuries: A systematic review and meta-analysis

Background

The impact of the timing of surgery on neurological recovery in thoracolumbar spinal cord injuries (tSCI) is still a subject of discussion. Accumulating evidence is supporting early decompression (<24 hours) following tSCI. However, the potential advantages of earlier decompression remain uncertain. This systematic review and meta-analysis summarize and analyze the current evidence on the effectiveness of ultra-early decompression surgery on clinical outcomes following tSCI.

Methods

A search was conducted in the electronic databases Medline, Embase, Scopus, and Web of Science from their inception until May 2022 for human studies. Groups were stratified into ultra-early (surgery within 8 hours of injury) vs control group operated >8 hours of injury. The authors included the study data from their institutional case series of thoracolumbar spinal cord injury from 2015 to 2018. An arm-based meta-analysis was performed on all studies using the R Studio. For studies that qualified, a contrast-based meta-analysis was also performed with a standardized mean difference (SMD). Outcomes were reported as effect size, treatment effect, and effect difference, all with 95% confidence intervals (CI).

Results

Of the 133 patients, 74.4% patients were male. 76 (57.1%) underwent decompression ≤8 hours, while 57 (42.9%) underwent decompression >8 hours from injury. Quantitative analysis using the SMD model showed a significant difference in mean AIS improvement in the ultra-early group (Effect size 1.15 [0.62-1.67], p<.0001). On arm-based meta-analysis, a statistically significant treatment effect was found for the ultra-early arm (1.25 [0.91-1.67]), while > 8-hour arm did not show significance (0.30 [-0.08-0.71]). There was a statistically significant effect difference between the two arms (0.96 [0.49-1.48]).

Conclusions

This study observed a significant improvement in the mean AIS score in patients undergoing decompression within 8 hours of tSCI. Given the scant literature regarding ultra-early decompression of tSCI, this study solidifies the need to further explore the role of early interventions for tSCIs to improve patient outcomes.

A critical appraisal of clinical practice guidelines on surgical treatments for spinal cord injury

BACKGROUND CONTEXT

Spinal cord injury (SCI) is a global health problem with a heavy economic burden. Surgery is considered as the cornerstone of SCI treatment. Although various organizations have formulated different guidelines on surgical treatment for SCI, the methodological quality of these guidelines has still not been critically appraised.

PURPOSE

We aim to systematically review and appraise the current guidelines on surgical treatments of SCI and summarize the related recommendations with the quality evaluation of supporting evidence.

STUDY DESIGN

Systematic review.

METHODS

Medline, Cochrane library, Web of Science, Embase, Google Scholar, and online guideline databases were searched from January 2000 to January 2022. The most updated and recent guidelines containing evidence-based or consensus-based recommendations and established by authoritative associations were included. The Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument containing 6 domains (eg, applicability) was used to appraise the included guidelines. An evidence-grading scale (ie, level of evidence, LOE) was utilized to evaluate the quality of supporting evidence. The supporting evidence was categorized as A (the best quality), B, C, and D (the worst quality).

RESULTS

Ten guidelines from 2008 to 2020 were included, however, all of them acquired the lowest scores in the domain of applicability among all the six domains. Fourteen recommendations (eight evidence-based recommendations and six consensus-based recommendations) were totally involved. The SCI types of the population and timing of surgery were studied. Regarding the SCI types of the population, eight guidelines (8/10, 80%), two guidelines (2/10, 20%), and three guidelines (3/10, 30%) recommended surgical treatment for patients with SCI without further clarification of characteristics, incomplete SCI, and traumatic central cord syndrome (TCCS), respectively. Besides, one guideline (1/10, 10%) recommended against surgery for patients with SCI without radiographic abnormality. Regarding the timing of surgery, there were eight guidelines (8/10, 80%), two guidelines (2/10, 20%), and two guidelines (2/10, 20%) with recommendations for patients with SCI without further clarification of characteristics, incomplete SCI, and TCCS, respectively. For patients with SCI without further clarification of characteristics, all eight guidelines (8/8, 100%) recommended for early surgery and five guidelines (5/8, 62.5%) recommended for the specific timing, which ranged from within 8 hours to within 48 hours. For patients with incomplete SCI, two guidelines (2/2, 100%) recommended for early surgery, without specific time thresholds. For patients with TCCS, one guideline (1/2, 50%) recommended for surgery within 24 hours, and another guideline (1/2, 50%) simply recommended for early surgery. The LOE was B in eight recommendations, C in three recommendations, and D in three recommendations.

CONCLUSIONS

We remind the reader that even the highest quality guidelines often have significant flaws (eg, poor applicability), and some of the conclusions are based on consensus recommendations which is certainly less than ideal. With these caveats, we found most included guidelines (8/10, 80%) recommended early surgical treatment for patients after SCI, which was consistent between evidence-based recommendations and consensus-based recommendations. Regarding the specific timing of surgery, the recommended time threshold did vary, but it was usually within 8 to 48 hours, where the LOE was B to D.

Costs, length of stay and inpatient complications of early surgical decompression after spinal cord injury in a geriatric cohort

Debate regarding timing of surgical decompression after spinal cord injury continues. Recent evidence indicates that early decompression improves neurological outcomes. However, little investigation has been performed regarding how it affects one's hospitalization in a geriatric cohort. 8,999 cases of traumatic SCI who underwent surgical decompression (2002-2011, age 65 + years) within the Nationwide Inpatient Sample were included in univariate and multivariate analyses. Univariate analysis shows that early decompression is more cost effective ($88,564.00 vs $107,849.00, p < 0.0005) and is associated with shorter length of stay (LOS) (8.00 ± 16.15 vs 12.00 ± 15.93 days, p < 0.0005) when compared to late decompression. In multivariate analysis, early decompression continued to be associated with a shorter LOS, though cost was no longer statistically different. Early decompression had less odds of surgical site infection, vasopressor use, decubitus ulcers, but higher odds of cardiac complications, acute renal failure, transfusions and hardware complications. Spinal level of SCI did not affect timing of surgery. Vertebral column fracture did not influence cost or length of stay. In summary, the complex mix of results regarding inpatient complications highlight the innumerable variables and complex decision making that involves surgical treatment of SCI, especially within a susceptible geriatric cohort. However, shorter LOS and lower costs associated with early decompression continue to support its uniform implementation after traumatic SCI.

The impact of time from injury to surgery on the risk of neuropathic pain after traumatic spinal cord injury

Traumatic spinal cord injury (SCI) is a devastating neurological disorder often accompanied by neuropathic pain (NeP), significantly affecting patients' quality of life. This retrospective study aimed to investigate the impact of the time from injury to surgery on the development of NeP following traumatic SCI. Medical records of patients with traumatic SCI who underwent surgical intervention between January 2017 and January 2021 at two specialized centers were reviewed. Variables associated with NeP including demographics, injury profiles, medical history, surgical details, and pain assessments were investigated. Independent risk factors related to NeP were identified using multivariate logistic regression analysis. A total of 320 patients met the inclusion criteria, with 245 (76.6%) being male and a mean age of 56.5 ± 13.2 years. NeP was identified in 48.4% of patients (155 of 320). The multivariate analysis identifies age at injury, Injury Severity Score, and the neurological level of injury as independent risk factors for the development of NeP in both AIS A and AIS B, C, and D subgroups. Additionally, a significant association between the time from injury to surgery and NeP was observed in AIS B, C, and D patients, while no such association was found in AIS A patients. This study highlights the benefits of early and ultra-early surgical intervention in preventing NeP in patients with incomplete traumatic SCI (AIS B, C, and D), underscoring the importance of optimizing surgical timing to improve patient outcomes. Prospective studies are warranted to establish evidence-based surgical guidelines for managing traumatic SCI and preventing NeP effectively.

A Review of Strategies Associated with Surgical Decompression in Traumatic Spinal Cord Injury

Traumatic spinal cord injury (TSCI) is frequent. Timely diagnosis and treatment have reduced the mortality, but the long-term recovery of neurologic functions remains ominous. After TSCI, tissue bleeding, edema, and adhesions lead to an increase in the intraspinal pressure, further causing the pathophysiologic processes of ischemia and hypoxia and eventually accelerating the cascade of secondary spinal cord injury. Timely surgery with appropriate decompression strategies can reduce that secondary injury. However, disagreement about the safety and effectiveness of decompression surgery and the timing of surgery still exists. The level and severity of spinal cord injury do have an impact on the timing of surgery; therefore, TSCI subpopulations may benefit from early surgery. Early surgery perhaps has little effect on recovery from complete TSCI but might be of benefit in patients with incomplete injury. Early decompression should be considered in patients with incomplete cervical TSCI. Patient age should not be used as an exclusion criterion for early surgery. The best time point for early surgery is although influenced by the shortest duration to thoroughly examine the patient's condition and stabilize the patient's state. After the patient's condition is fully evaluated, we can perform the surgical modality of emergency myelotomy and decompression. Therefore, a number of conditions should be considered, such as standardized decompression methods, indications and operation timing to ensure the effectiveness and safety of early surgical intervention, and promotion of the functional recovery of residual nerve tissue.

[Surgical management of acute traumatic spinal cord injury : Stability vs. functionality]

BACKGROUND

Traumatic spinal cord injuries represent a devastating condition in the lives of those affected, with physical, emotional, and economic burdens for the patients themselves, their social environment, and society as a whole.

OBJECTIVE

Surgical approach and techniques in traumatic spinal cord injuries.

RESULTS

Traumatic spinal cord injuries should be surgically treated as soon as possible, but at least within 24 h of injury. If accompanying dural injuries occur, suturing or applying a patch is the primary method of choice. Early surgical decompression is essential, particularly in cervical spinal cord injuries. Stabilization in terms of instrumentation or fusion is inevitable and should be carried out over short segments to maintain the functionality of the cervical spine. Long-distance dorsal instrumentation with prior reduction in thoracolumbar spinal cord injuries provides high stability and preserved functionality in patients. Injuries to the thoracolumbar junction often require a two-stage anterior treatment.

CONCLUSION

Early surgical decompression, reduction, and stabilization of traumatic spinal cord injuries within 24 h are recommended. While short-segment stabilization is recommended in the cervical spine in addition to decompression, instrumentation should be over long segments in the thoracolumbar spine to provide the necessary stability while maintaining functionality.

Quality of life of patients with traumatic spinal cord injuries: a cross-sectional study at a tertiary hospital in Uganda

Background

The study aimed to assess the perceived quality of life of patients with traumatic spinal cord injuries.

Methodology

This was a cross sectional study conducted in the Spine Unit of a tertiary hospital in Uganda. The study population comprised of patients with spinal cord injuries. Data were collected using the WHO Quality of Life Brief questionnaire and Functional Independence Measure tool.

Results

103 patients participated in the study, most were male (73.8%), and had a mean age of 37.7 years. Most participants were married (57.3%), unemployed (72.8%) and had no steady source of income (62.1%). Road traffic accidents accounted for most injuries (59.2%). The mean duration since injury was 20.5 months. Most participants (58.3%) had incomplete spinal cord injuries and 84.5% had complications. The perceived overall quality of life was poor in 87.4% of patients. Being employed (p= 0.02), the presence of complications (p= 0.03), and injury severity (p= 0.003) significantly affected quality of life. Functional independent measure scores were significantly better in individuals less severe injuries and those with lumbar level of injury with mean scores of 113.1±8.9 and 99.9±15.3 respectively.

Conclusion

The overall self-reported quality of life among patients with traumatic spinal cord injury was generally poor.

Sex-related Differences in Epidemiology, Treatment, and Economic Burden of Traumatic Spinal Cord Injury in China (2013-2018)

STUDY DESIGN

Retrospective epidemiological study.

OBJECTIVE

To describe differences based on biological sex in the epidemiology and treatment of the economic burden of traumatic spinal cord injury (TSCI) in China (2013-2018).

SUMMARY OF BACKGROUND DATA

Although there have been many regional single-center studies on TSCI in China, there are few reports involving multicenter data, especially those that report on discrepancies related to biological sex.

MATERIALS AND METHODS

This study is a nationally representative hospital-based retrospective study. The treatment data of TSCI patients in 30 hospitals in 11 provinces/cities from January 2013 to December 2018 were analyzed. Sociodemographic characteristics, accident and related injury characteristics, treatment methods, and hospital costs were obtained. Regression models were used to evaluate differences in the outcomes of interest based on biological sex and other factors.

RESULTS

There were 13,465 individuals with TSCI, with a mean age of 50.0 years, and females (52.2) older than males (49.3). Overall, the average ratio of males to females was 3.1:1, ranging from 3.0:1 in 2013 to 2.8:1 in 2018. The overall proportion of patients with TSCI increased from 2013 to 2018 [annual percentage change (APC)=6.8%, 95% CI, 3.3-10.4] ( P < 0.05). The percent increase in females (APC=8.2%, 95% CI, 5.6-10.8) was greater than that of males (APC=6.3%, 95% CI, 2.1-10.6). Overall, high-level falls mainly affected males (30.8%), and low-level falls mainly occurred in females (36.6%). Females demonstrated a higher frequency of thoracolumbar trauma and less severe neurological impairment.

CONCLUSIONS

This study suggests that although the main population of TSCI is male, the average ratio of males to females is decreasing. The frequency of TSCI may be increasing faster in females than in males. Therefore, it is necessary to develop sex-specific public prevention measures. In addition, more medical resources should be devoted to improving the ability of hospitals to perform early surgery.

Early surgical intervention for acute spinal cord injury: time is spine

Acute traumatic spinal cord injury (tSCI) is a devastating occurrence that significantly contributes to global morbidity and mortality. Surgical decompression with stabilization is the most effective way to minimize the damaging sequelae that follow acute tSCI. In recent years, strong evidence has emerged that supports the rationale that early surgical intervention, within 24 h following the initial injury, is associated with a better prognosis and functional outcomes. In this review, we have summarized the evidence and elaborated on the nuances of this concept. Additionally, we have reviewed further concepts that stem from "time is spine," including earlier cutoffs less than 24 h and the challenging entity of central cord syndrome, as well as the emerging concept of adequate surgical decompression. Lastly, we identify barriers to early surgical care for acute tSCI, a key aspect of spine care that needs to be globally addressed via research and policy on an urgent basis.

Updates in the Early Management of Acute Spinal Cord Injury

Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future.

Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care

Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.

Interhospital Transfer Delays Care for Spinal Cord Injury Patients: A Report from the North American Clinical Trials Network for Spinal Cord Injury

Abstract The North America Clinical Trials Network (NACTN) for Spinal Cord Injury (SCI) is a consortium of tertiary medical centers that has maintained a prospective SCI registry since 2004, and it has espoused that early surgical intervention is associated with improved outcome. It has previously been shown that initial presentation to a lower acuity center and necessity of transfer to a higher acuity center reduce rates of early surgery. The NACTN database was evaluated to examine the association between interhospital transfer (IHT), early surgery, and outcome, taking into account distance traveled and site of origin for the patient. Data from a 15-year period of the NACTN SCI Registry were analyzed (years 2005-2019). Patients were stratified into transfers directly from the scene to a Level 1 trauma center (NACTN site) versus IHT from a Level 2 or 3 trauma facility. The main outcome was surgery within 24 hours of injury (yes/no), whereas secondary outcomes were length of stay, death, discharge disposition, and 6-month American Spinal Injury Association Impairment Scale (AIS) grade conversion. For the IHT patients, distance traveled for transfer was calculated by measuring the shortest distance between origin and NACTN hospital. Analysis was performed with Brown-Mood test and chi-square tests. Of 724 patients with transfer data, 295 (40%) underwent IHT and 429 (60%) were admitted directly from the scene of injury. Patients who underwent IHT were more likely to have a less severe SCI (AIS D; p = 0.002), have a central cord injury (p = 0.004), and have a fall as their mechanism of injury (p < 0.0001) than those directly admitted to an NACTN center. Of the 634 patients who had surgery, direct admission to an NACTN site was more likely to result in surgery within 24 hours compared with IHT patients (52% vs. 38%) (p < 0.0003). Median IHT distance was 28 miles (interquartile range [IQR] = 13-62 miles). There was no significant difference in death, length of stay, discharge to a rehab facility versus home, or 6-month AIS grade conversion rates between the two groups. Patients who underwent IHT to an NACTN site were less likely to have surgery within 24 hours of injury, compared with those directly admitted to the Level 1 trauma facility. Although there was no difference in mortality rates, length of stay, or 6-month AIS conversion between groups, patients with IHT were more likely be older with a less severe level of injury (AIS D). This study suggests there are barriers to timely recognition of SCI in the field, appropriate admission to a higher level of care after recognition, and challenges related to the management of individuals with less severe SCI.

One-stage tracheostomy during surgery reduced early pulmonary infection and mechanical ventilation length in complete CSCI patients

Objective

Complete cervical spinal cord injury (CSCI) is a devastating injury that usually requires surgical treatment. Tracheostomy is an important supportive therapy for these patients. To evaluate the effectiveness of early one-stage tracheostomy during surgery compared with necessary tracheostomy after surgery, and to identify clinical factors for one-stage tracheostomy during surgery in complete cervical spinal cord injury.

Design

Data from 41 patients with complete CSCI treated with surgery were retrospectively analyzed.

Participants and interventions

Ten patients (24.4%) underwent one-stage tracheostomy during surgery, thirteen (31.7%) underwent tracheostomy when necessary after surgery, and eighteen (43.9%) did not have a tracheostomy.

Main results

One-stage tracheostomy during surgery significantly reduced the development of pneumonia at 7 days after tracheostomy (p = 0.025), increased the PaO2 (p &lt; 0.05), and decreased the length of mechanical ventilation (p = 0.005), length of stay (LOS) in the intensive care unit (ICU) (p = 0.002), hospital LOS (p = 0.01) and hospitalization expenses compared with necessary tracheostomy after surgery (p = 0.037). A high neurological level of injury (NLI) (NLI C5 and above), a high PaCO2 in the blood gas analysis before tracheostomy, severe breathing difficulty, and excessive pulmonary secretions were the statistically significant factors for one-stage tracheostomy during surgery in the complete CSCI patients, but no independent clinical factor was found.

Conclusions

In conclusion, one-stage tracheostomy during surgery reduced the number of early pulmonary infections and the length of mechanical ventilation, ICU LOS, hospital LOS and hospitalization expenses, and one-stage tracheostomy should be considered when managing complete CSCI patients by surgical treatment.

Which treatment provides the best neurological outcomes in acute spinal cord injury?

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Predicting the Role of Preoperative Intramedullary Lesion Length and Early Decompressive Surgery in ASIA Impairment Scale Grade Improvement Following Subaxial Traumatic Cervical Spinal Cord Injury

BACKGROUND

 Traumatic cervical spinal cord injury (TCSCI) is a disabling condition with uncertain neurologic recovery. Clinical and preclinical studies have suggested early surgical decompression and other measures of neuroprotection improve neurologic outcome. We investigated the role of intramedullary lesion length (IMLL) on preoperative magnetic resonance imaging (MRI) and the effect of early cervical decompressive surgery on ASIA impairment scale (AIS) grade improvement following TCSCI.

METHODS

 In this retrospective study, we investigated 34 TCSCI patients who were admitted over a 12-year period, from January 1, 2008 to January 31, 2020. We studied the patient demographics, mode of injury, IMLL and timing of surgical decompression. The IMLL is defined as the total length of edema and contusion/hemorrhage within the cord. Short tau inversion recovery (STIR) sequences or T2-weighted MR imaging with fat saturation increases the clarity of edema and depicts abnormalities in the spinal cord. All patients included had confirmed adequate spinal cord decompression with cervical fixation and a follow-up of at least 6 months.

RESULTS

 Of the 34 patients, 16 patients were operated on within 24 hours (early surgery group) and 18 patients were operated on more than 24 hours after trauma (delayed surgery group). In the early surgery group, 13 (81.3%) patients had improvement of at least one AIS grade, whereas in the delayed surgery group, AIS grade improvement was seen in only in 8 (44.5%) patients (early vs. late surgery; odds ratio [OR] = 1.828; 95% confidence interval [CI]: 1.036-3.225). In multivariate regression analysis coefficients, the timing of surgery and intramedullary edema length on MRI were the most significant factors in improving the AIS grade following cervical SCI. Timing of surgery as a unique variance predicted AIS grade improvement significantly (p < 0.001). The mean IMLL was 41.47 mm (standard deviation [SD]: 18.35; range: 20-87 mm). IMLL was a predictor of AIS grade improvement on long-term outcome in bivariate analysis (p < 0.001). This study suggests that patients who had IMLL of less than 30 mm had a better chance of grade conversion irrespective of the timing of surgery. Patients with an IMLL of 31 to 60 mm had chances of better grade conversion after early surgery. A longer IMLL predicts lack of improvement (p < 0.05). If the IMLL is greater than 61 mm, the probability of nonconversion of AIS grade is higher, even if the patient is operated on within 24 hours of trauma.

CONCLUSION

 Surgical decompression within 24 hours of trauma and shorter preoperative IMLL are significantly associated with improved neurologic outcome, reflected by better AIS grade improvement at 6 months' follow-up. The IMLL on preoperative MRI can reliably predict outcome after 6 months. The present study suggests that patients have lesser chances of AIS grade improvement when the IMLL is ≥61 mm.

Clinical Trials Targeting Secondary Damage after Traumatic Spinal Cord Injury

Spinal cord injury (SCI) often causes loss of sensory and motor function resulting in a significant reduction in quality of life for patients. Currently, no therapies are available that can repair spinal cord tissue. After the primary SCI, an acute inflammatory response induces further tissue damage in a process known as secondary injury. Targeting secondary injury to prevent additional tissue damage during the acute and subacute phases of SCI represents a promising strategy to improve patient outcomes. Here, we review clinical trials of neuroprotective therapeutics expected to mitigate secondary injury, focusing primarily on those in the last decade. The strategies discussed are broadly categorized as acute-phase procedural/surgical interventions, systemically delivered pharmacological agents, and cell-based therapies. In addition, we summarize the potential for combinatorial therapies and considerations.

Early Decompression in Acute Spinal Cord Injury : Review and Update

Spinal cord injury (SCI) has a significant negative effect on the quality of life due to permanent neurologic damage and economic burden by continuous treatment and rehabilitation. However, determining the correct approach to ensure optimal clinical outcomes can be challenging and remains highly controversial. In particular, with the introduction of the concept of early decompression in brain pathology, the discussion of the timing of decompression in SCI has emerged. In addition to that, the concept of "time is spine" has been added recently, and the mortality and complications caused by SCI have been reduced by providing timely and professional treatment to patients. However, there are many difficulties in establishing international clinical guidelines for the timing of early decompression in SCI because policies for each country and medical institution differ according to the circumstances of medical infrastructure and economic conditions in the surgical treatment of SCI. Therefore, we aim to provide a current review of timing of early decompression in patient with SCI.

Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review

BACKGROUND

Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI.

OBJECTIVE

To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs).

METHODS

A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis.

RESULTS

After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review.

CONCLUSIONS

Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.

Impact of Mechanism of Injury on Long-term Neurological Outcomes of Cervical Sensorimotor Complete Acute Traumatic Spinal Cord Injury

OBJECTIVE

Mechanism of injury is a largely understudied descriptor of acute traumatic spinal cord injury (tSCI). This study sought to compare the impact of high-energy and low-energy mechanisms of injury in neurological outcomes of cervical sensorimotor complete tSCI.

METHODS

Patients with tSCI were identified in 4 prospective, multicenter clinical trials and registries. American Spinal Injury Association Impairment Scale (AIS) grade was assessed ≤ 72 hours postinjury and followed up between 12 to 52 weeks. Patients were included if they had a cervical and sensorimotor complete (AIS-A) injury at baseline. Study outcomes were change in AIS grade and lower extremity motor, upper extremity motor, and total motor scores. Propensity score matching between high-energy mechanisms of injury (HEMI; e.g. , motor vehicle collisions) and low-energy mechanisms of injury (LEMI; e.g. , falls) groups was performed. Adjusted groups were compared with paired t-tests and McNemar test.

RESULTS

Of 667 patients eligible for inclusion, 523 experienced HEMI (78.4%). HEMI patients were younger, had lower body mass index, more associated fractures or dislocations, and lower baseline lower extremity motor scores. After propensity score matching of these baseline variables, 118 pairs were matched. HEMI patients had a significantly worse motor recovery from baseline to follow-up based on their diminished change in upper extremity motor scores and total motor scores.

CONCLUSION

Cervical sensorimotor complete tSCIs from HEMI were associated with significantly lower motor recovery compared to LEMI patients. Our findings suggest that mechanism of injury should be considered in modelling prognosis and in understanding the heterogeneity of outcomes after acute tSCI.

Characteristics, Determinants, and Outcomes of Traumatic Vertebral and Spinal Injuries: A Retrospective Study in the Al-Qassim Region of Saudi Arabia

Background In Saudi Arabia, traumatic vertebral and spinal injuries (TVSIs) are well-recognized injuries with long-term morbidity and mortality. Al-Qassim is among the five regions in the kingdom with the highest number of TVSIs. Little is known about the characteristics of and outcomes for patients with a TVSI in the Al-Qassim region, and we aimed to explore these further. Methodology Electronic medical records of patients with a TVSI admitted to Buraidah Central Hospital between January 1, 2017, and December 31, 2019, were examined. Characteristics, outcomes, and length of stay (LOS) in the hospital acute care were reported for the patients, along with their scores (A through E) on the American Spinal Injury Association (ASIA) impairment scale at admission and at discharge. Results  The sample included 243 patients with a TVSI (median age 35 years). The majority of the participants were Saudi (70%), admitted due to road traffic accidents (67%), and had an ASIA score of E at admission (83%). The median (interquartile range [IQR]) LOS in acute care was 10.0 (4-18) days. Determinants of a prolonged hospital stay included being non-Saudi, having an ASIA score of A through D at admission, and having associated orthopedic injuries. An ASIA score of A through D at admission was the only significant determinant of having an ASIA score of A through D at discharge. Conclusions Road traffic accidents accounted for the majority of TVSIs in Al-Qassim. Not having a normal and preserved function at admission (i.e., ASIA score of A through D) was associated with a prolonged hospital stay.

Hyperbaric Oxygen Therapy-Induced Molecular and Pathway Changes in a Rat Model of Spinal Cord Injury: A Proteomic Analysis

Hyperbaric Oxygen Therapy (HBOT) has definitive therapeutic effects on spinal cord injury (SCI), but its mechanism of action is still unclear. Here, we've conducted a systemic proteomic analysis to identify differentially expressed proteins (DEPs) between SCI rats and HBOT + SCI rats. The function clustering analysis showed that the top enriched pathways of DEPs include oxygen transport activity, oxygen binding, and regulation of T cell proliferation. The results of functional and signal pathway analyses indicated that metabolic pathways, thermogenesis, LXR/RXR activation, acute phase response signaling, and the intrinsic prothrombin pathway in the SCI + HBOT group was higher than SCI group.

The Time Sequence of Gene Expression Changes after Spinal Cord Injury

Gene expression changes following spinal cord injury (SCI) are time-dependent, and an accurate understanding of these changes can be crucial in determining time-based treatment options in a clinical setting. We performed RNA sequencing of the contused spinal cord of rats at five different time points from the very acute to chronic stages (1 hour, 1 day, 1 week, 1 month, and 3 months) following SCI. We identified differentially expressed genes (DEGs) and Gene Ontology (GO) terms at each time point, and 14,257 genes were commonly expressed at all time points. The biological process of the inflammatory response was increased at 1 hour and 1 day, and the cellular component of the integral component of the synaptic membrane was increased at 1 day. DEGs associated with cell activation and the innate immune response were highly enriched at 1 week and 1 month, respectively. A total of 2841 DEGs were differentially expressed at any of the five time points, and 18 genes (17 upregulated and 1 downregulated) showed common expression differences at all time points. We found that interleukin signaling, neutrophil degranulation, eukaryotic translation, collagen degradation, LGI–ADAM interactions, GABA receptor, and L1CAM-ankyrin interactions were prominent after SCI depending on the time post injury. We also performed gene–drug network analysis and found several potential antagonists and agonists which can be used to treat SCI. We expect to discover effective treatments in the clinical field through further studies revealing the efficacy and safety of potential drugs.

Established and Emerging Therapies in Acute Spinal Cord Injury

Acute spinal cord injury (SCI) is devastating for patients and their caretakers and has an annual incidence of 20–50 per million people. Following initial assessment with appropriate physical examination and imaging, patients who are deemed surgical candidates should undergo decompression with stabilization. Earlier intervention can improve neurological recovery in the post-operative period while allowing earlier mobilization. Optimized medical management is paramount to improve outcomes. Emerging strategies for managing SCI in the acute period stem from an evolving understanding of the pathophysiology of the injury. General areas of focus include ischemia prevention, reduction of secondary injury due to inflammation, modulation of the cytotoxic and immune response, and promotion of cellular regeneration. In this article, we review established, emerging, and novel experimental therapies. Continued translational research on these methods will improve the feasibility of bench-to-bedside innovations in treating patients with acute SCI.

Machine Learning-based Prediction of Prolonged Intensive Care Unit Stay for Critical Patients with Spinal Cord Injury

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The objective of the study was to develop machine-learning (ML) classifiers for predicting prolonged intensive care unit (ICU)-stay and prolonged hospital-stay for critical patients with spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

Critical patients with SCI in ICU need more attention. SCI patients with prolonged stay in ICU usually occupy vast medical resources and hinder the rehabilitation deployment.

METHODS

A total of 1599 critical patients with SCI were included in the study and labeled with prolonged stay or normal stay. All data were extracted from the eICU Collaborative Research Database and the Medical Information Mart for Intensive Care III-IV Database. The extracted data were randomly divided into training, validation and testing (6:2:2) subdatasets. A total of 91 initial ML classifiers were developed, and the top three initial classifiers with the best performance were further stacked into an ensemble classifier with logistic regressor. The area under the curve (AUC) was the main indicator to assess the prediction performance of all classifiers. The primary predicting outcome was prolonged ICU-stay, while the secondary predicting outcome was prolonged hospital-stay.

RESULTS

In predicting prolonged ICU-stay, the AUC of the ensemble classifier was 0.864 ± 0.021 in the three-time five-fold cross-validation and 0.802 in the independent testing. In predicting prolonged hospital-stay, the AUC of the ensemble classifier was 0.815 ± 0.037 in the three-time five-fold cross-validation and 0.799 in the independent testing. Decision curve analysis showed the merits of the ensemble classifiers, as the curves of the top three initial classifiers varied a lot in either predicting prolonged ICU-stay or discriminating prolonged hospital-stay.

CONCLUSION

The ensemble classifiers successfully predict the prolonged ICU-stay and the prolonged hospital-stay, which showed a high potential of assisting physicians in managing SCI patients in ICU and make full use of medical resources.Level of Evidence: 3.