The effect of hypothermia on regional spinal cord blood flow in rats

The use of systemic hypothermia for the treatment of an acute cervical spinal cord injury in a professional football player

STUDY DESIGN

Case Report.

OBJECTIVE

We will describe the injury and clinical course of an NFL Football player who sustained a complete spinal cord injury and was treated with conventional care in addition to modest systemic hypothermia.

SUMMARY OF BACKGROUND DATA

Systemically induced moderate hypothermia is a potentially neuroprotective intervention in acute spinal cord injury. However, case descriptions of human patients receiving systemic hypothermia after spinal cord injuries are lacking in the literature.

METHODS

Here, we present the case of a National Football League player who sustained a complete (ASIA A) spinal cord injury from a C3/4 fracture dislocation. Moderate systemic hypothermia was instituted immediately after his injury, in addition to standard medical/surgical treatment, including, surgical decompression and intravenous methylprednisolone.

RESULTS

The patient experienced significant and rapid neurologic improvement, and within weeks of his injury was walking with harness assistance. Since that time, the patient has continued to make significant progress in his rehabilitation (now ASIA D).

CONCLUSION

The extent to which this hypothermia contributed to his neurologic recovery is difficult to determine. It is hoped that this case will draw attention to the need for further preclinical and clinical studies to elucidate the role of hypothermia in acute spinal cord injury. Until these studies are completed, it is impossible to advocate for systemic hypothermia as a standard of care.

Spinal cord blood flow changes following systemic hypothermia and spinal cord compression injury: an experimental study in the rat using Laser-Doppler flowmetry

STUDY DESIGN

It is well known that changes of the body temperature as well as trauma influence the blood flow in the brain and spinal cord. However, there is still a lack of knowledge concerning the levels of blood flow changes, especially during hypothermia.

OBJECTIVES

This investigation was carried out to examine the effects of systemic hypothermia and trauma on spinal cord blood flow (SCBF).

METHODS

Twenty-four rats were randomized either to thoracic laminectomy only (Th VII-IX) or to 35 g spinal cord compression trauma. The animals were further randomized to either constant normothermia (38 degrees C) or to a systemic cooling procedure, ie reduction of the esophageal temperature from 38 to 30 degrees C. SCBF was recorded 5 mm caudal to the injury zone using Laser-Doppler flowmetry which allows a non-invasive continuous recording of local changes in the blood flow. The autoregulation ability was tested at the end of the experiments by inducing a 30-50 mmHg blood-pressure fall, using blood-withdrawal from the carotid artery.

RESULTS

The mean SCBF decreased 2.8% and 3.5% per centigrade reduction of esophageal temperature in the animals sustained to hypothermia with and without trauma, respectively. This could be compared to a decrease of 0.2%/min when only trauma was applied. No significant differences were seen between the groups concerning auto regulatory ability.

CONCLUSIONS

Our results indicate that the core temperature has a high impact on the SCBF independent of previous trauma recorded by Laser-Doppler flowmetry. This influence exceeds the response mediated by moderate compression trauma alone.

Noncontusive segmental spinal cord injury using radiofrequency current

OBJECTIVE

To develop a nondisruptive model for the study of spinal cord injury.

METHODS

A 2-MHz radiofrequency heating chamber was mounted over the rat T13-L1 vertebral column via a short dorsal incision. Epidural temperature at chamber level was monitored via a small proximal laminotomy. Forty-three rats were studied using time-temperature heating regimens from 45 to 48.5 degrees C and 4 to 15 minutes. A blinded numerical hind limb impairment score (Neurologic Impairment Score) was determined at intervals up to 2 weeks after injury. Segmental spinal cord blood flow was measured using [14C]butanol tissue uptake in injured and control rats.

RESULTS

Above the injury threshold, increasing the time-temperature regimens was associated with a progressively worse Neurologic Impairment Score (r = 0.73-0.87 up to 24 hours after injury). Cord blood flow was unchanged at 2 hours but was 44% depressed at the injury level 6 hours after injury (p < 0.01). Histologically, injury extended minimally beyond the injured segment. Vascular thrombosis was not seen.

CONCLUSION

This comparatively noninvasive model does not mechanically disrupt cord components and results in progressive neurologic impairment that correlates with the time-temperature regimen used for injury. It should be useful in identifying secondary phenomena that worsen functional status after cord trauma.

In vitro investigations of the effects of nonfreezing low temperatures on lesioned and uninjured mammalian spinal neurons

This two-part investigation explored the parameters and mechanisms of: (1) injury to spinal cord (SC) neurons by nonfreezing low temperatures, and (2) hypothermic protection of SC neurons subjected to a defined, physical injury (dendrite transection). Conclusions from the studies of hypothermic injury were: (1) morphologic and ultrastructural signs of stress developed in SC neurons as the temperature was decreased below 17 degrees C; (2) most neurons showing stress during cooling died upon rewarming to 37 degrees C; (3) spontaneous SC network activity was not significantly changed by cooling to 17 degrees C for 2 hours and rewarming, but cooling to 10 degrees C for 1 hour caused a reduction of burst frequency after rewarming, and cooling to 10 degrees C for 2 hours resulted in electrical silence after rewarming; and (4) application of N-methyl-D-aspartate (NMDA) antagonists before cooling prevented neuronal death, ultrastructural damage, and loss of activity upon rewarming, but application after cooling (before rewarming) was not protective. Conclusions from the studies of hypothermic protection were: (1) cooling at 17 degrees C for 2 hours followed by rewarming to 37 degrees C significantly increased lesioned neuron survival, but protection was lost when the period at 17 degrees C was increased to 6 hours; (2) NMDA blockade under normothermic (37 degrees C) or hypothermic (17 degrees C or 10 degrees C for 2 hours) conditions was not more protective of lesioned neurons than cooling to 17 degrees C (no NMDA antagonist); and (3) 200 microM thiopental or 100 microM pentobarbital increased lesioned neuron survival to a degree comparable to cooling for 2 hours at 17 degrees C.

Epidural perfusion cooling protection against protracted spinal cord ischemia in rabbits

The protective effect of a modified epidural cooling technique was assessed in a rabbit spinal cord ischemia model. The epidural space around the lumbar segments with induced ischemia was continually perfused with cold (5 degrees C) isotonic saline via two communicating spinal canal openings. This procedure allowed the spinal cord to be kept deeply hypothermic (< 15 degrees C within central gray matter) during the ischemic period. The animals were subjected to either normothermic ischemia (Group A) or hypothermic ischemia (Group B). Each group contained three subgroups of animals undergoing 20, 40, or 60 minutes of aortic ligation. Their neurological outcomes were evaluated up to 48 hours postischemia, and the intergroup differences were compared. Two days postischemia, all of the animals were sacrificed by transcardial perfusion-fixation and their lumbar segments were processed for histopathological examination. In addition, in animals with 60-minute ischemia, spinal somatosensory evoked potentials were recorded during surgical intervention and again after 48 hours. In the normothermic animals, a high incidence of paraplegia was detected: in 40% after 20 minutes of ischemia, in 75% after 40 minutes, and in 100% after 60 minutes. In contrast, all of the hypothermic animals exhibited full neurological recovery even after 60 minutes of ischemia. Both electrophysiological and histological observations clearly correlated with the neurological findings. The results suggest that deep spinal cord hypothermia produced by epidural perfusion cooling provides effective protection against protracted spinal cord ischemia in rabbits.

The effects of lumbar sympathectomy on regional spinal cord blood flow in rats during acute hemorrhagic hypotension

It has not previously been determined whether the sympathetic nervous system has a role in the regulation of regional blood flow in the spinal cord. The authors used 14C-butanol distribution to measure regional spinal cord blood flow at seven cord levels, in the sciatic nerve, and in the biceps femoris muscle in 36 rats, 18 of which had undergone excision of both lumbar sympathetic chains at least 6 days previously. Blood flows were measured during pentobarbital anesthesia. Mean arterial blood pressure (MABP) was monitored and arterial pO2, pCO2, and pH were determined prior to flow measurement. Anesthetic dose and duration were controlled. Measurements were made in normotensive rats and in rats with MABP maintained at either 69 +/- 3 mm Hg or 48 +/- 3 mm Hg for 1 hour by the withdrawal of arterial blood. One-half of the rats in each group had undergone sympathectomy. The resting cord blood flow was lower than control values following sympathectomy only at the S1-4 cord level (p less than 0.01) and cauda equina (p less than 0.01), and was marginally lower at the L1-2 and L3-6 levels (p less than 0.1). Cord blood flow was unaffected by sympathectomy during moderate hypotension. During severe hypotension, cord blood flow was less than control at the C3-5 level (p less than 0.05), but did not differ from control at the other six levels. Flows in nerve and muscle were consistent with known effects of sympathectomy on peripheral tissues. It is concluded that, at most, sympathectomy may moderately decrease resting blood flow in the cord levels caudal to L-1. Sympathectomy has no major effect on regional spinal cord blood flow in rats stressed by either moderate or severe arterial hemorrhage.

[Methods for measuring spinal cord blood flow]

This study aimed to review the techniques used most currently for measuring spinal cord blood blow flow (SCBF) in animals, i.e. the hydrogen clearance, labelled microspheres, 133Xe clearance and 14C-antipyrine autoradiographic methods. All four techniques may only be used in animals, because of their invasiveness. Flow figures varied greatly with the method, the spinal level at which measurements were carried out, and the species of animal. However, results tend to suggest that SCBF is very similar to cerebral blood flow in that it is controlled by chemical, autoregulatory and metabolic factors. Approaches to measuring SCBF in man may be made using stable xenon-enhanced computed tomographic imaging (Xes-CT) in the same way as for measuring cerebral blood flow. The calculation of SCBF is based on Fick's principle transformed by Kety and Schmidt. After a reference CT section has been obtained, twelve 8 mm thick sections are carried out whilst the patient breathes a 30% xenon-70% air/oxygen mixture. This series of views enables the SCBF to be calculated in four steps. Quantitative analysis in eight human subjects gave a mean SCBF of 58.8 +/- 5.96 ml x 100 g-1 x min-1. However, this method has a low signal to noise ratio. Moreover, the qualitative analysis of the parametric views of flow demonstrate tissue heterogeneity, partly due to the patient's movements (breathing movements). However, the method is non invasive, safe, and reproducible. As it can measure very low values of blood flow, the study of ischaemic spinal lesions is made possible, although some technical and software improvements are still required.

Paradoxical effect of hypothermia on survival of lesioned and uninjured mammalian spinal neurons

Survival of cultured spinal neurons 2 h after dendrotomy increased significantly when the temperature was reduced to 17 degrees C or 7 degrees C. Survival of lesioned neurons maintained at 17 degrees C for 2 h and then at 37 degrees C for 22 h was still significantly higher than survival of neurons maintained at 37 degrees C for 24 h. Below 17 degrees C both lesioned and uninjured neurons swelled. Upon rewarming to 37 degrees C, many swollen neurons died. Ketamine prevented hypothermic swelling and neuronal death.