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Balas M, Jaja BNR, Harrington EM, Jack AS, Hofereiter J, Malhotra AK, Jaffe RH, He Y, Byrne JP, Wilson JR, Witiw CD. Earlier Tracheostomy Reduces Complications in Complete Cervical Spinal Cord Injury in Real-World Practice: Analysis of a Multicenter Cohort of 2001 Patients. Neurosurgery 2023; 93:1305-1312. [PMID: 37341486 DOI: 10.1227/neu.0000000000002575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/03/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES It is believed that early tracheostomy in patients with traumatic cervical spinal cord injury (SCI) may lessen the risk of developing complications and reduce the duration of mechanical ventilation and critical care stay. This study aims to assess whether early tracheostomy is beneficial in patients with traumatic cervical SCI. METHODS We conducted a retrospective cohort study using data from the American College of Surgeons Trauma Quality Improvement Program database from 2010 to 2018. Adult patients with a diagnosis of acute complete (ASIA A) traumatic cervical SCI who underwent surgery and tracheostomy were included. Patients were stratified into those receiving early (at or before 7 days) and delayed tracheostomy. Propensity score matching was used to assess the association between delayed tracheostomy and the risk of in-hospital adverse events. Risk-adjusted variability in tracheostomy timing across trauma centers was investigated using mixed-effects regression. RESULTS The study included 2001 patients from 374 North American trauma centers. The median time to tracheostomy was 9.2 days (IQR: 6.1-13.1 days), with 654 patients (32.7%) undergoing early tracheostomy. After matching, the odds of a major complication were significantly lower for early tracheostomy patients (OR: .90; 95% CI: .88-.98). Patients were also significantly less likely to experience an immobility-related complication (OR: .90; 95% CI: .88-.98). Patients in the early group spent 8.2 fewer days in the critical care unit (95% CI: -10.2 to -6.61) and 6.7 fewer days ventilated (95% CI: -9.44 to -5.23). There was significant variability in tracheostomy timeliness between trauma centers with a median odds ratio of 12.2 (95% CI: 9.7-13.7), which was not explained by case-mix and hospital-level characteristics. CONCLUSION A 7-day threshold to implement tracheostomy seems to be associated with reduced in-hospital complications, time in the critical care unit, and time on mechanical ventilation.
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Affiliation(s)
- Michael Balas
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
| | - Blessing N R Jaja
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto , Ontario , Canada
| | - Erin M Harrington
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
| | - Andrew S Jack
- Division of Neurosurgery, University of Alberta, Edmonton , Alberta , Canada
| | - Johann Hofereiter
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
| | - Armaan K Malhotra
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
| | - Rachael H Jaffe
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
| | - Yingshi He
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
| | - James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore , Maryland , USA
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
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Kumar A, Khandelwal A, Jamil S. Ventilatory Strategies in Traumatic Cervical Spinal Cord Injury: Controversies and Current Updates. Asian Spine J 2023; 17:615-619. [PMID: 37614075 PMCID: PMC10460671 DOI: 10.31616/asj.2023.0094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 08/31/2023] Open
Abstract
Ventilatory management of patients with traumatic cervical spinal cord injury (CSCI) is a complex and controversial area of critical care medicine. Despite significant advances in our understanding of the pathophysiology of CSCI and the development of novel interventions, there remains a lack of consensus about the optimal approach to ventilatory management in these patients. Some of the key controversies in CSCI ventilatory management include timing of tracheal intubation, non-invasive ventilation versus invasive ventilation, high versus low tidal volume, and early versus late tracheostomy. The objective of this review is to discuss the existing controversies and provide an insight on the current evidence.
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Affiliation(s)
- Ashutosh Kumar
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Nagpur, India
| | - Ankur Khandelwal
- Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences (AIIMS), Guwahati, India
| | - Shaista Jamil
- Department of Anaesthesiology and Critical Care, School of Medical Sciences and Research, Sharda University, Greater Noida, India
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Esmorís-Arijón I, Galeiras R, Ferreiro Velasco ME, Pértega Díaz S. Predictors of Intensive Care Unit Stay in Patients with Acute Traumatic Spinal Cord Injury Above T6. World Neurosurg 2022; 166:e681-e691. [PMID: 35872126 DOI: 10.1016/j.wneu.2022.07.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of this study was to identify factors associated with the intensive care unit (ICU) length of stay (LOS) of patients with an acute traumatic spinal cord injury above T6. METHODS We performed a retrospective, observational study of patients admitted to an ICU between 1998 and 2017 (n = 241). The LOS was calculated using a cumulative incidence function, with events of death being considered a competing event. Factors associated with the LOS were analyzed using both a cause-specific Cox proportional hazards regression model and a competing risk model. A multistate approach was also used to analyze the impact of nosocomial infections on the LOS. RESULTS A total of 211 patients (87.5%) were discharged alive from the ICU (median LOS = 23 days), and 30 (12.4%) died (median LOS = 11 days). In the multivariate analysis after adjusting for variables collected 4 days after the ICU admission, a higher American Spinal Injury Association motor score (subdistribution hazards ratio [sHR] = 1.01), neurological level C5-C8 (HR = 0,64), and lower Sequential Organ Failure Assessment score (sHR = 0.82) and fluid balance (sHR = 0.95) on day 4 were linked to a lower LOS in this unit. In the multivariate analysis, the onset of an infection was significantly associated with a longer LOS when adjusting for variables collected both at ICU admission (adjusted sHR = 0.62; 95% confidence interval = 0.50-0.77) and on day 4 (adjusted hazards ratio = 0.65; 95% confidence interval = 0.52-0.80). CONCLUSIONS After adjusting the data for conventional variables, we identified a lower American Spinal Injury Association motor score, injury level C5-C8, a higher Sequential Organ Failure Assessment score on day 4, a more positive fluid balance on day 4, and the onset of an infection as factors independently associated with a longer ICU LOS.
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Affiliation(s)
| | - Rita Galeiras
- Critical Care Unit, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | - María Elena Ferreiro Velasco
- Spinal Cord Injury Unit (SCIU), Complexo Hospitalario Universitario A Coruña, Sergas, Universidade de A Coruña, A Coruña, Spain
| | - Sonia Pértega Díaz
- Research Support Unit, Nursing and Healthcare Research Group, Rheumatology and Health Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña, A Coruña, Spain
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Foran SJ, Taran S, Singh JM, Kutsogiannis DJ, McCredie V. Timing of tracheostomy in acute traumatic spinal cord injury: A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:223-231. [PMID: 34508010 PMCID: PMC8677619 DOI: 10.1097/ta.0000000000003394] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/04/2021] [Accepted: 08/20/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with acute traumatic cervical or high thoracic level spinal cord injury (SCI) typically require mechanical ventilation (MV) during their acute admission. Placement of a tracheostomy is preferred when prolonged weaning from MV is anticipated. However, the optimal timing of tracheostomy placement in patients with acute traumatic SCI remains uncertain. We systematically reviewed the literature to determine the effects of early versus late tracheostomy or prolonged intubation in patients with acute traumatic SCI on important clinical outcomes. METHODS Six databases were searched from their inception to January 2020. Conference abstracts from relevant proceedings and the gray literature were searched to identify additional studies. Data were obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale. RESULTS Seventeen studies (2,804 patients) met selection criteria, 14 of which were published after 2009. Meta-analysis showed that early tracheostomy was not associated with decreased short-term mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.39-1.79; p = 0.65; n = 2,072), but was associated with a reduction in MV duration (mean difference [MD], 13.1 days; 95% CI, -6.70 to -21.11; p = 0.0002; n = 855), intensive care unit length of stay (MD, -10.20 days; 95% CI, -4.66 to -15.74; p = 0.0003; n = 855), and hospital length of stay (MD, -7.39 days; 95% CI, -3.74 to -11.03; p < 0.0001; n = 423). Early tracheostomy was also associated with a decreased incidence of ventilator-associated pneumonia and tracheostomy-related complications (RR, 0.86; 95% CI, 0.75-0.98; p = 0.02; n = 2,043 and RR, 0.64; 95% CI, 0.48-0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the Newcastle Ottawa Scale. CONCLUSION Early tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical entilation, length of intensive care unit stay, and length of hospital stay. Current studies highlight the lack of high-level evidence to guide the optimal timing of tracheostomy in acute traumatic SCI. Future research should seek to understand whether early tracheostomy improves patient comfort, decreases duration of sedation, and improves long-term outcomes. LEVEL OF EVIDENCE Systematic Review, level III.
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Wang XR, Zhang Q, Ding WS, Zhang W, Zhou M, Wang HB. Comparison of clinical outcomes of tracheotomy in patients with acute cervical spinal cord injury at different timing. Clin Neurol Neurosurg 2021; 210:106947. [PMID: 34583275 DOI: 10.1016/j.clineuro.2021.106947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022]
Abstract
Respiratory failure is the leading cause of early death after acute CSCI. Tracheotomy is an effective approach to reduce mortality and improve the clinical outcomes. However, the optimal timing for tracheotomy remains controversial. Hence, the study aimed to compare the clinical outcomes of tracheotomy in patients with acute cervical spinal cord injury (CSCI) at different timing. A retrospectively review was performed of acute CSCI patients who underwent tracheotomy in the intensive care unit of Haian Hospital between January 2014 and June 2019. 124 CSCI patients were included and stratified into three groups based on the timing of tracheotomy: early group (≤4 days from initial intubation), medium group (4-10 days from initial intubation), and late group (≥10 days from initial intubation). The clinical outcomes and functional outcomes were analyzed. No significant intergroup differences in baseline characteristics were observed. The late group needed significantly longer duration of mechanical ventilation, longer ICU stay, and suffered higher ICU mortality, higher pneumonia after tracheotomy than the early and medium groups. More patients in the early and medium groups successfully weaned from mechanical ventilation. The early and medium groups achieved better improvement of JOA and NDI scores than the late group at one year after surgery and at the final follow-up. Early to medium term tracheotomy may lead to better clinical and functional outcomes in patients with acute CSCI who require prolonged mechanical ventilation.
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Affiliation(s)
- Xiao-Ran Wang
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Qiang Zhang
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Wen-Sen Ding
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Wei Zhang
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Min Zhou
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China
| | - Hai-Bo Wang
- Department of Intensive Care Unit, Affiliated Haian Hospital of Nantong University, Nantong 226001, China.
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Mubashir T, Arif AA, Ernest P, Maroufy V, Chaudhry R, Balogh J, Suen C, Reskallah A, Williams GW. Early Versus Late Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis. Anesth Analg 2021; 132:384-394. [PMID: 33009136 DOI: 10.1213/ane.0000000000005212] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute traumatic spinal cord injuries (SCIs) often result in impairments in respiration that may lead to a sequelae of pulmonary dysfunction, increased risk of infection, and death. The optimal timing for tracheostomy in patients with acute SCI is currently unknown. This systematic review and meta-analysis aims to assess the optimal timing of tracheostomy in SCI patients and evaluate the potential benefits of early versus late tracheostomy. METHODS We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, and PsycINFO for published studies. We included studies on adults with SCI who underwent early or late tracheostomy and compared outcomes. In addition, studies that reported a concomitant traumatic brain injury were excluded. Data were extracted independently by 2 reviewers and copied into R software for analysis. A random-effects meta-analysis was performed to estimate the pooled odds ratio (OR) or mean difference (MD). RESULTS Eight studies with a total of 1220 patients met our inclusion criteria. The mean age and gender between early and late tracheostomy groups were similar. The majority of the studies performed an early tracheostomy within 7 days from either time of injury or tracheal intubation. Patients with a cervical SCI were twice as likely to undergo an early tracheostomy (OR = 2.13; 95% confidence interval [CI], 1.24-3.64; P = .006) compared to patients with a thoracic SCI. Early tracheostomy reduced the mean intensive care unit (ICU) length of stay by 13 days (95% CI, -19.18 to -7.00; P = .001) and the mean duration of mechanical ventilation by 18.30 days (95% CI, -24.33 to -12.28; P = .001). Although the pooled risk of in-hospital mortality was lower with early tracheostomy compared to late tracheostomy, the results were not significant (OR = 0.56; 95% CI, 0.32-1.01; P = .054). In the subgroup analysis, mortality was significantly lower in the early tracheostomy group (OR = 0.27; P = .006). Finally, no differences in pneumonia between early and late tracheostomy groups were noted. CONCLUSIONS Based on the available data, patients with early tracheostomy within the first 7 days of injury or tracheal intubation had higher cervical SCI, shorter ICU length of stay, and shorter duration of mechanical ventilation compared to late tracheostomy. The risk of in-hospital mortality may be lower following an early tracheostomy. However, due to the quality of studies and insufficient clinical data available, it is challenging to make conclusive interpretations. Future prospective trials with a larger patient population are needed to fully assess short- and long-term outcomes of tracheostomy timing following acute SCI.
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Affiliation(s)
- Talha Mubashir
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Abdul A Arif
- Department of Life Science, University of Toronto, Toronto, Ontario, Canada
| | - Prince Ernest
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Vahed Maroufy
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Rabail Chaudhry
- Department of Anesthesiology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Julius Balogh
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Colin Suen
- Department of Anesthesiology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Alexander Reskallah
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - George W Williams
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
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Time to tracheostomy impacts overall outcomes in patients with cervical spinal cord injury. J Trauma Acute Care Surg 2020; 89:358-364. [PMID: 32744832 DOI: 10.1097/ta.0000000000002758] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The morbidity associated with cervical spine injury increases in the setting of concomitant cervical spinal cord injury (CSCI). A significant proportion of these patients require placement of a tracheostomy. However, it remains unclear if timing to tracheostomy following traumatic CSCI can impact outcomes. The aim of our study was to characterize outcomes associated with tracheostomy timing following traumatic CSCI. METHODS We performed a 5-year (2010-2014) analysis of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age, ≥18 years) trauma patients who had traumatic CSCI and received tracheostomy. Patients were subdivided into two groups: early tracheostomy (ET) (≤4 days from initial intubation) and late tracheostomy (LT) (>4 days). Outcome measures included respiratory complications, ventilator-free days, intensive care unit-free days and hospital length of stay, and mortality. Multivariate logistic regression analysis was performed. RESULTS A total of 5,980 patients were included in the study, of which 1,010 (17%) patients received ET, while 4,970 (83%) patients received LT. Mean age was 46 years, and 73% were men. In terms of CSCI location, 48% of the patients had high CSCI (C1-C4), while 52% had low CSCI (C5-C7). Patients in the ET group had lower rates of respiratory complications (30% vs. 46%, p = 0.01), higher ventilator-free days (13 days vs. 9 days; p = 0.02), intensive care unit-free days (11 days vs. 8 days; p = 0.01), and a shorter hospital length of stay (22 days vs. 29 days; p = 0.01) compared with those in the LT group. On regression analysis, ET was associated with lower rates of respiratory complications in patients with high CSCI (odds ratio, 0.55 [0.41-0.81]) and low CSCI (odds ratio, 0.93 [0.72-0.95]). However, no association was found between time to tracheostomy and in-hospital mortality. CONCLUSION Early tracheostomy regardless of CSCI level may lead to improved outcomes. Quality improvement efforts should focus on defining the optimal time to tracheostomy and considering ET as a component of SCI management bundle. LEVEL OF EVIDENCE Therapeutic, level IV.
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Early tracheostomy in patients with cervical spine injury reduces morbidity and improves resource utilization. Am J Surg 2020; 220:773-777. [PMID: 32057414 DOI: 10.1016/j.amjsurg.2020.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Aim of our study is to analyze the impact of Early Tracheostomy (ET) in patients with cervical-spine (C-spine) injuries. METHODS We analyzed seven-year (2010-2016) ACS-TQIP databank and included all non-TBI trauma patients diagnosed with c-spine injuries. Patients were stratified into two groups based on the timing of tracheostomy (Early; ≤7days: Late; >7days). Outcomes were complications, hospital and ICU stay. Regression analysis was performed. RESULTS We included 1139 patients. Mean age was 47 ± 12, median ISS was 18 [12-28], and median C-spine AIS was 4 [3-5]. 24.5% of the patients received ET. On regression analysis, patients who received ET had lower overall-complications (OR:0.57) and ventilator-associated pneumonia (OR:0.61). ET was associated with shorter duration of mechanical ventilation, and hospital and ICU stay. There was no difference in mortality rate. CONCLUSIONS Early tracheostomy in patients with C-spine injuries was associated with lower rates of ventilator-associated-pneumonia, shorter duration of mechanical ventilation, and ICU and hospital stay.
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Sacino A, Rosenblatt K. Critical Care Management of Acute Spinal Cord Injury-Part II: Intensive Care to Rehabilitation. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2019; 6:222-235. [PMID: 33907704 DOI: 10.1055/s-0039-1694686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Spinal cord injury is devastating to those affected due to the loss of motor and sensory function, and, in some cases, cardiovascular collapse, ventilatory failure, and bowel and bladder dysfunction. Primary trauma to the spinal cord is exacerbated by secondary insult from the inflammatory response to injury. Specialized intensive care of patients with acute spinal cord injury involves the management of multiple systems and incorporates evidence-based practices to reduce secondary injury to the spinal cord. Patients greatly benefit from early multidisciplinary rehabilitation for neurologic and functional recovery. Treatment of acute spinal cord injury may soon incorporate novel molecular agents currently undergoing clinical investigation to assist in neuroprotection and neuroregeneration.
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Affiliation(s)
- Amanda Sacino
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Kathryn Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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