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Sarigul B, Sirinoglu D, Hawryluk G. Adherence to Traumatic Brain Injury Guidelines in Turkey: A National Survey Study. Turk Neurosurg 2024; 34:135-141. [PMID: 38282592 DOI: 10.5137/1019-5149.jtn.42852-22.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
AIM To discuss adherence to guidelines for the management of traumatic brain injury (TBI) in Türkiye and physicians' attitudes toward standardized, evidence-based medical practice. MATERIAL AND METHODS Survey questions were uploaded on the website www.surveymonkey.com and sent to the participants via e-mail or social media applications. The first 10 questions were about the participants' profiles, and the rest were purposed on presenting the physicians' viewpoint on and barriers against CPG adherence. SPSS version 17.0 for Windows was used for statistical analysis. RESULTS A total of 404 physicians (neurosurgeons, 59.5%; anesthesiologists, 16.7%; and emergency medicine practitioners, 23.9%) who were involved in TBI management were included in this study. Of them, 61.7% stated that they frequently adhere to the CPG recommendations for TBI. In their own experience, most of the respondents agreed that CPGs frequently improve outcomes. They stated that they would occasionally or never adopt recommendations with weak evidence. Physicians reached a consensus on individualizing the decision-making along with the CPG recommendations. CONCLUSION Of the participants, 61% adopted the CPG recommendations. The main barriers to the implementation of the CPGs are the strength of evidence levels and the affordability of the recommendations.
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Affiliation(s)
- Buse Sarigul
- Tuzla Public Hospital, Department of Neurosurgery, Istanbul, Türkiye
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 168] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Mee H, Castano Leon A, Timofeev I, Adeleye A, Devi I, Marklund N, Muehlschlegel S, Bond K, Clement C, Grieve K, Owen N, Whiting G, Turner C, Rubiano A, Shukla D, Paul M, Allanson J, Pomeroy V, Viaroli E, Warburton E, Wells A, Hawryluk G, Helmy A, Anwar F, Honeybul S, Hutchinson P, Kolias A. Study Protocol: Core Outcome Set for cranioplasty following stroke or TBI 'COAST Study'. JMIR Res Protoc 2022; 12:e37442. [PMID: 35759752 PMCID: PMC10152332 DOI: 10.2196/37442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/15/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Core Outcome sets (COS) are important and necessary as they help standardize reporting in research studies. Cranioplasty following traumatic brain injury or stroke is becoming increasingly common leading to an ever growing clinical and research interest especially regarding the optimal material, cost-effectiveness, and timing of cranioplasty concerning neurological recovery and complications. Consequently, heterogeneous reporting of outcomes from such diverse studies has led to a limited meta-analysis ability, with the ongoing risk of outcome reporting bias. OBJECTIVE To define a standardized COS for reporting in all future TBI and stroke cranioplasty studies. METHODS An international steering committee has been formed to guide the development of the COS. In addition, recommendations from other clinical initiatives such as COMET (Core Outcomes and Effectiveness Trials) and OMERACT (Outcome Measures in Rheumatology) have been adhered to. The first phase of the project is data-collection through a systematic review and qualitative study. The second phase will be the COS-formation through a Delphi survey and consensus meeting. A definition of consensus will be decided and agreed upon before the Delphi survey begins to avoid bias, which is planned for the end of 2021. RESULTS The development of a cranioplasty COS that can be applied in future research, helping to align future studies, building an increased understanding of cranioplasty and its impact on a patients function and recovery. CONCLUSIONS This study should result in consensus on a COS for cranioplasty following TBI or stroke. CLINICALTRIAL The study has been registered on the Core Outcome Measures in Effectiveness Trials (COMET) database for COS development.
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Affiliation(s)
- Harry Mee
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Box 167, A blockAddenbrookes Hospital, Cambridge, GB.,Division of Rehabilitation Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Box 167, Level 4, AblockAddenbrookes Hosital, Cambridge, GB.,NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, GB
| | | | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | | | - Indira Devi
- Department of Neurosurgery, Nimhans, Bangalore, IN
| | | | | | - Katie Bond
- Division of Rehabilitation Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Clare Clement
- Bristol Trials Centre, Bristol Medical School, Bristol, GB
| | - Kirsty Grieve
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Nicola Owen
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Gemma Whiting
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Carole Turner
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB.,NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, GB
| | - Andres Rubiano
- Department of Neurosciences and Neurosurgery, Valle Salud IPS Network, Cali, CO
| | | | | | - Judith Allanson
- Division of Anaesthesia, University of Cambridge, Cambridge, GB
| | - Valerie Pomeroy
- Neurorehabilitation Department, University of East Anglia, Norwich, GB
| | - Edoardo Viaroli
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Elizabeth Warburton
- Division of Stroke Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Adam Wells
- University of Adelaide, The Royal Adelaide Hospital, Adelaide, AU
| | | | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | - Fahim Anwar
- Division of Rehabilitation Medicine, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB
| | | | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB.,NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, GB
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital NHS Foundation Trust, Cambridge, GB.,NIHR Global Health Research Group on NeuroTrauma, University of Cambridge, Cambridge, GB
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Li B, Hawryluk G, Mummaneni PV, Wang M, Mehra R, Wang M, Lau D, Mayer R, Fu KM, Chou D. Utility of the MISDEF2 Algorithm and Extent of Fusion in Open Adult Spinal Deformity Surgery With Minimum 2-Year Follow-up. Neurospine 2022; 18:824-832. [PMID: 35000336 PMCID: PMC8752706 DOI: 10.14245/ns.2142508.254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 10/07/2021] [Indexed: 11/19/2022] Open
Abstract
Objective Long-segment fusion in adult spinal deformity (ASD) is often needed, but more focal surgeries may provide significant relief with less morbidity. The minimally invasive spinal deformity surgery (MISDEF2) algorithm guides minimally invasive ASD surgery, but it may be useful in open ASD surgery. We classified ASD patients undergoing focal decompression, limited decompression and fusion, and full correction according to MISDEF2 and correlated outcomes.
Methods A retrospective study of ASD patients treated by 2 surgeons at our hospital was performed. Inclusion criteria were: age > 50, minimum 2-year follow-up, and open ASD surgery. Tumor, trauma, and infections were excluded. Patients had open surgery including focal decompression, short segment fusion, or full scoliosis correction. All patients were categorized by MISDEF2 into 4 classes based upon spinopelvic parameters. Perioperative metrics were assessed. Radiographic correction, complications and reoperation were recorded.
Results A total of 136 patients met inclusion criteria. Mean follow-up was 46±15.8 months (range, 24–118 months). Forty-seven underwent full deformity correction, 71 underwent short segment fusion, and 18 underwent decompression alone. There were 24 cases of class I, 66 cases of class II, 23 cases of class III, and 23 cases of class IV patients. Patients in class I and II had perioperative complication rates of 0% and 16.7% and revision rates of 8% and 21.2% when undergoing focal decompression or limited fusion. However, class II patients undergoing full correction had higher perioperative complications rate (p=0.03) and revision surgery rates (p=0.047). This difference was not seen in class III patients (p>0.05). All class IV patients underwent full correction, but they had higher perioperative complication rates (p<0.019), comparable revision surgery rates (p=0.27), and better radiographic realignment (p<0.001). In addition, full deformity correction was associated with longer length of stay, increased blood loss, and longer operative time (p<0.001).
Conclusion The MISDEF2 algorithm may help guide ASD surgical decision making even in open surgery, with focal treatment used in class I and II patients as a viable alternative and full correction implemented in class IV patients because of severe malalignment. However, class II patients with ASD undergoing full deformity correction do have higher complication rates.
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Affiliation(s)
- Bo Li
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA.,Department of Clinic of Spine Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Gregory Hawryluk
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Michael Wang
- Department of Neurosurgery, University of Miami, Coral Gables, FL, USA
| | - Ratnesh Mehra
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Minghao Wang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Darryl Lau
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Rory Mayer
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Kai-Ming Fu
- Department of Neurosurgery, Weill Cornell Medical College, New York, NY, USA
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
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5
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Saraceno G, Servadei F, Terzi DI Bergamo L, Iaccarino C, Rubiano AM, Zoia C, Raffa G, Hawryluk G, Grotenhuis A, Demetriades AK, Sala F, Belotti F, Zanin L, Doglietto F, Panciani PP, Biroli A, Agosti E, Serioli S, Rasulic L, Bruneau M, Germano IM, Bosnjak R, Thomé C, Regli L, Vukic M, Tessitore E, Schaller K, Chaurasia B, El-Ghandour NMF, DI Ieva A, Bongetta D, Borghesi I, Fazio M, Esene IN, Rosseau G, El Abbadi N, Baccanelli M, Vajkoczy P, Fontanella MM. Do neurosurgeons follow the guidelines? A world-based survey on severe traumatic brain injury. J Neurosurg Sci 2021; 65:465-473. [PMID: 34814649 DOI: 10.23736/s0390-5616.21.05475-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is going to be the third-leading cause of death worldwide, according to the WHO. Two European surveys suggested that adherence to brain trauma guidelines is poor. No study has compared compliance between low- (LMICs) and high-income (UHICs) countries. Hence, this study aimed to investigate differences in the management of severe TBI patients, comparing low- and high-income, and adherence to the BTF guidelines. METHODS A web-based survey was spread through the Global Neuro Foundation, different neurosurgical societies, and social media. RESULTS A total of 803 neurosurgeons participated: 70.4 from UHICs and 29.6% from LMICs. Hypertonic was administered as an early measure by the 73% and 65% of the responders in LMICs and UHICs, respectively (P=0.016). An invasive intracranial pressure monitoring was recommended by the 66% and 58% of the neurosurgeons in LMICs and UHICs, respectively (P<0.001). Antiseizure drugs (P<0.001) were given most frequently in LMICs as, against recommendations, steroids (87% vs. 61% and 86% vs. 81%, respectively). In the LMICs both the evacuation of the contusion and decompressive craniectomy were performed earlier than in UHICs (30% vs. 17% with P<0.001 and 44% vs. 28% with P=0.006, respectively). In the LMICs, the head CT control was performed mostly between 12 and 24 hours from the first imaging (38% vs. 23%, P<0.001). CONCLUSIONS The current Guidelines on TBI do not always fit to both the resources and circumstances in different countries. Future research and clinical practice guidelines should reflect the greater relevance of TBI in low resource settings.
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Affiliation(s)
- Giorgio Saraceno
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Franco Servadei
- Humanitas Reasearch Hospital-IRCCS and Humanitas University, Rozzano, Milan, Italy
| | | | - Corrado Iaccarino
- Division of Neurosurgery, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Andrés M Rubiano
- Neuroscience Institute, El Bosque University, Bogotà, Colombia.,Meditech Foundation, Cali, Colombia
| | - Cesare Zoia
- Department of Neurosurgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Giovanni Raffa
- Department of Neurosurgery, Messina University Hospital, Messina, Italy
| | - Gregory Hawryluk
- Section of Neurosurgery Winnipeg Health Sciences Center, University of Manitoba, Winnipeg, MB, Canada
| | - André Grotenhuis
- Department of Neurosurgery, Radboud University, Nijmegen, the Netherlands
| | | | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, Verona University Hospital, Verona, Italy
| | - Francesco Belotti
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy -
| | - Luca Zanin
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Pier Paolo Panciani
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Biroli
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Edoardo Agosti
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Simona Serioli
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Lukas Rasulic
- Clinic for Neurosurgery, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Michaël Bruneau
- Department of Neurosurgery, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roman Bosnjak
- Department of Neurosurgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Miroslav Vukic
- Department of Neurosurgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Enrico Tessitore
- Unit of Neurosurgery, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Karl Schaller
- Unit of Neurosurgery, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Bipin Chaurasia
- Department of Neurosurgery, Bhawani Hospital and Research Center, Saraiyaganj, Muzaffarpur, Birgunj, Nepal
| | | | - Antonio DI Ieva
- Department of Clinical Medicine, Faculty of Medicine, Human and Health Sciences, Macquarie University, Sydney, Australia
| | - Daniele Bongetta
- Department of Neurosurgery, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ignazio Borghesi
- Department of Neurosurgery, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Marco Fazio
- Department of Neurosurgery, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Ignatius N Esene
- Division of Neurosurgery, Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon
| | - Gail Rosseau
- Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Najia El Abbadi
- Department of Neurosurgery, International Cheikh Zaid Hospital, Abulcassis University of Health Sciences, Rabat, Morocco
| | - Matteo Baccanelli
- Department of Neurosurgery, Buenos Aires Italian Hospital, Buenos Aires, Argentina
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Medical University, Berlin, Germany
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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6
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Menacho S, Hawryluk G. Failure of an effective physiologic threshold compliance tool to demonstrate benefit in a clinical trial of traumatic brain injury patients. J Clin Neurosci 2021; 88:113-119. [PMID: 33992169 DOI: 10.1016/j.jocn.2021.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Better physiologic threshold compliance holds promise for improving outcomes in neurocritical care patients. METHODS Our group developed a threshold compliance tool. This software computes and displays the proportion of values out of range in real time. We captured intracranial pressure (ICP) measures in our patients before and after implementation of this technology. Ten months after the threshold compliance tool was introduced we initiated a randomized controlled trial involving acute traumatic brain injury (TBI) patients to assess whether the tool was effective at reducing out-of-range ICP values. RESULTS A total of 54 patients with ICP monitors were included in our analysis, 42 of whom sustained a TBI. Implementation of the threshold compliance tool was associated with an 85.3% reduction in ICP values exceeding 22 mmHg in neurocritical care patients (p = 0.004) and a 76.8% reduction in patients with TBI (p = 0.043). Out-of-range values in an area-under-the-curve analysis were reduced by 78.8% in all patients (p = 0.009) and in TBI patients by 77.9% (p = 0.051). Out-of-range values were not further reduced during our randomized controlled trial examining the threshold compliance tool, and a difference between treatment groups was not suggested. CONCLUSIONS Implementation of a threshold compliance tool was associated with a marked and significant reduction in out-of-range ICP values. Benefit was, however, not evident in a randomized controlled trial. Our analysis provides a unique perspective on our failure to detect an apparent true difference and may provide insights into other neurotrauma trial failures.
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Affiliation(s)
- Sarah Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, Clinical Neurosciences Center, University of Utah, USA.
| | - Gregory Hawryluk
- Section of Neurosurgery, University of Manitoba, Canada; Uniformed Services University, USA.
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7
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Depreitere B, Citerio G, Smith M, Adelson PD, Aries MJ, Bleck TP, Bouzat P, Chesnut R, De Sloovere V, Diringer M, Dureanteau J, Ercole A, Hawryluk G, Hawthorne C, Helbok R, Klein SP, Neumann JO, Robba C, Steiner L, Stocchetti N, Taccone FS, Valadka A, Wolf S, Zeiler FA, Meyfroidt G. Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians. Neurocrit Care 2021; 34:731-738. [PMID: 33495910 PMCID: PMC8179892 DOI: 10.1007/s12028-020-01185-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty. AIM To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities. METHODS A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants. RESULTS Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence. CONCLUSION The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.
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Affiliation(s)
- B Depreitere
- Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - G Citerio
- Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - M Smith
- Neurocritical Care Unit, National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - P David Adelson
- Barrow Neurological Institute At Phoenix Childrens Hospital, Department of Child Health/Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Neurosurgery, Mayo Clinic School of Medicine, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - M J Aries
- Department of Intensive Care, Maastricht University Medical Center, University of Maastricht, Maastricht, The Netherlands
| | - T P Bleck
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P Bouzat
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France
| | - R Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - V De Sloovere
- Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - M Diringer
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - J Dureanteau
- Université Paris Sud - Hôpitaux Universitaires Paris-Sud, Paris, France
| | - A Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - G Hawryluk
- Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada
| | - C Hawthorne
- Head and Neck Anaesthesia and Neurocritical Care, Institute of Neurological Sciences, Glasgow, UK
| | - R Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - S P Klein
- Neurosurgery, University Hospital Brussels, Brussels, Belgium
| | - J O Neumann
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - C Robba
- Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - L Steiner
- Anesthesiology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - N Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - A Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - S Wolf
- Department of Neurosurgery, University Hospital Berlin Charité, Berlin, Germany
| | - F A Zeiler
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - G Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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8
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Zeiler FA, Ercole A, Czosnyka M, Smielewski P, Hawryluk G, Hutchinson PJA, Menon DK, Aries M. Continuous cerebrovascular reactivity monitoring in moderate/severe traumatic brain injury: a narrative review of advances in neurocritical care. Br J Anaesth 2020; 124:440-453. [PMID: 31983411 DOI: 10.1016/j.bja.2019.11.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 12/18/2022] Open
Abstract
Impaired cerebrovascular reactivity in adult moderate and severe traumatic brain injury (TBI) is known to be associated with worse global outcome at 6-12 months. As technology has improved over the past decades, monitoring of cerebrovascular reactivity has shifted from intermittent measures, to experimentally validated continuously updating indices at the bedside. Such advances have led to the exploration of individualised physiologic targets in adult TBI management, such as optimal cerebral perfusion pressure (CPP) values, or CPP limits in which vascular reactivity is relatively intact. These targets have been shown to have a stronger association with outcome compared with existing consensus-based guideline thresholds in severe TBI care. This has sparked ongoing prospective trials of such personalised medicine approaches in adult TBI. In this narrative review paper, we focus on the concept of cerebral autoregulation, proposed mechanisms of control and methods of continuous monitoring used in TBI. We highlight multimodal cranial monitoring approaches for continuous cerebrovascular reactivity assessment, physiologic and neuroimaging correlates, and associations with outcome. Finally, we explore the recent 'state-of-the-art' advances in personalised physiologic targets based on continuous cerebrovascular reactivity monitoring, their benefits, and implications for future avenues of research in TBI.
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Affiliation(s)
- Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, Canada; Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK; Biomedical Engineering, Faculty of Engineering, Winnipeg, Canada; Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Section of Brain Physics, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Section of Brain Physics, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Gregory Hawryluk
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, Canada
| | - Peter J A Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, the Netherlands
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Abstract
PURPOSE OF REVIEW Spinal cord injury (SCI) shows an incidence of 10.4-83 cases/million/year globally and remains a significant source of morbidity and cost to society. Despite greater understanding of the pathophysiology of SCI, neuroprotective and regenerative approaches to treatment have had limited clinical utility to date. Here, we review the key components of supportive care that are thus the mainstay of therapy and that have improved outcomes for victims of acute SCI in recent decades. RECENT STUDIES Current management strategies for acute SCI involve early surgical decompression and fixation, the use of vasopressor medications for mean arterial blood pressure (MAP) augmentation to improve spinal cord perfusion, and corticosteroids. We highlight recent literature supporting the role of norepinephrine in acute SCI management and also an emerging neurocritical care strategy that seeks to optimize spinal cord perfusion pressure with the assistance of invasive monitoring. This review will highlight key pathophysiologic principles and targets for current acute clinical treatments in SCI, which include early surgical decompression, MAP augmentation, and corticosteroids. We discuss anticipated future research in these areas and focus on potential risks inherent to these treatments.
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Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1 - Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
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10
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Shah A, Almenawer S, Hawryluk G. Timing of Decompressive Craniectomy for Ischemic Stroke and Traumatic Brain Injury: A Review. Front Neurol 2019; 10:11. [PMID: 30740085 PMCID: PMC6355668 DOI: 10.3389/fneur.2019.00011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/07/2019] [Indexed: 11/23/2022] Open
Abstract
While studies have demonstrated that decompressive craniectomy after stroke or TBI improves mortality, there is much controversy regarding when decompressive craniectomy is optimally performed. The goal of this paper is to synthesize the data regarding timing of craniectomy for malignant stroke and traumatic brain injury (TBI) based on studied time windows and clinical correlates of herniation. In stroke patients, evidence supports that early decompression performed within 24 h or before clinical signs of herniation may improve overall mortality and functional outcomes. In adult TBI patients, published results demonstrate that early decompressive craniectomy within 24 h of injury may reduce mortality and improve functional outcomes when compared to late decompressive craniectomy. In contrast to the stroke data, preliminary TBI data have demonstrated that decompressive craniectomy after radiographic signs of herniation may still lead to improved functional outcomes compared to medical management. In pediatric TBI patients, there is also evidence for better functional outcomes when treated with decompressive craniectomy, regardless of timing. More high quality data are needed, particularly that which incorporates a broader set of metrics into decision-making surrounding cranial decompression. In particular, advanced neuromonitoring and imaging technologies may be useful adjuncts in determining the optimal time for decompression in appropriate patients.
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Affiliation(s)
- Aatman Shah
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Saleh Almenawer
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Gregory Hawryluk
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, United States
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11
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Enniss TM, Basiouny K, Brewer B, Bugaev N, Cheng J, Danner OK, Duncan T, Foster S, Hawryluk G, Jung HS, Lui F, Rattan R, Violano P, Crandall M. Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open 2018; 3:e000153. [PMID: 30023433 PMCID: PMC6018851 DOI: 10.1136/tsaco-2017-000153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/11/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years. Our objective is to conduct a prospectively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions. METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation methodology, we performed a systematic review of the literature to answer seven population, intervention, comparator, and outcomes (PICO) questions regarding concussion education, head protective equipment, rules prohibiting high-risk activity and neck strengthening exercise for prevention of contact sports-related concussion in pediatric and adult amateur athletes. A query of MEDLINE, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded, and all articles reviewed were written in English. RESULTS Thirty-one studies met the inclusion criteria and were applicable to our PICO questions. Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes. Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes. Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported. CONCLUSION Despite increasing scientific attention to sports-related concussion, studies evaluating preventive interventions remain relatively sparse. This systematic review serves as a call to focus research on primary prevention strategies for sports-related concussion. LEVEL OF EVIDENCE IV. PROSPERO REGISTRATION NUMBER #42016043019.
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Affiliation(s)
- Toby M Enniss
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Khaled Basiouny
- Department of Trauma Surgery, George Washington University School of Medicine and Health Sciences, Washington, Columbia, USA
| | - Brian Brewer
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nikolay Bugaev
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Julius Cheng
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Omar K Danner
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Thomas Duncan
- Department of Trauma Services, Ventura County Medical Center, Ventura, California, USA
| | - Shannon Foster
- Department of Trauma and Surgical Critical Care, University of Pennsylvania Reading Hospital, West Reading, Pennsylvania, USA
| | - Gregory Hawryluk
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Hee Soo Jung
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Felix Lui
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rishi Rattan
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pina Violano
- Injury Prevention, Community Outreach and Research, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Marie Crandall
- Department of Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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Nath S, Koziarz A, Badhiwala JH, Alhazzani W, Jaeschke R, Sharma S, Banfield L, Shoamanesh A, Singh S, Nassiri F, Oczkowski W, Belley-Côté E, Truant R, Reddy K, Meade MO, Farrokhyar F, Bala MM, Alshamsi F, Krag M, Etxeandia-Ikobaltzeta I, Kunz R, Nishida O, Matouk C, Selim M, Rhodes A, Hawryluk G, Almenawer SA. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet 2018; 391:1197-1204. [PMID: 29223694 DOI: 10.1016/s0140-6736(17)32451-0] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles. METHODS In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546. FINDINGS We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1-13·3) in the conventional needle group to 4·2% (3·3-5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34-0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29-0·64; p<0·0001), need for epidural blood patch (0·50, 0·33-0·75; p=0·001), any headache (0·50, 0·43-0·57; p<0·0001), mild headache (0·52, 0·38-0·70; p<0·0001), severe headache (0·41, 0·28-0·59; p<0·0001), nerve root irritation (0·71, 0·54-0·92; p=0·011), and hearing disturbance (0·25, 0·11-0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation. INTERPRETATION Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture. FUNDING None.
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Affiliation(s)
- Siddharth Nath
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Alex Koziarz
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Waleed Alhazzani
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Roman Jaeschke
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Laura Banfield
- Health Sciences Library, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Ashkan Shoamanesh
- Division of Neurology and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Sheila Singh
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Wieslaw Oczkowski
- Division of Neurology and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Côté
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Ray Truant
- Department of Biochemistry and Biomedical Sciences, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Kesava Reddy
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Maureen O Meade
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Jagiellonian University, Krakow, Poland
| | - Fayez Alshamsi
- Department of Internal Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Mette Krag
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Itziar Etxeandia-Ikobaltzeta
- Department of Health Research Methods, Evidence, and Impact, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Regina Kunz
- Evidence based Insurance Medicine, University Hospital of Basel, Basel, Switzerland
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, CT, USA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrew Rhodes
- Department of Anaesthesia and Intensive Care, St George's Hospital, University of London, London, UK
| | - Gregory Hawryluk
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Saleh A Almenawer
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
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13
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Fehlings MG, Tetreault LA, Wilson JR, Aarabi B, Anderson P, Arnold PM, Brodke DS, Burns AS, Chiba K, Dettori JR, Furlan JC, Hawryluk G, Holly LT, Howley S, Jeji T, Kalsi-Ryan S, Kotter M, Kurpad S, Marino RJ, Martin AR, Massicotte E, Merli G, Middleton JW, Nakashima H, Nagoshi N, Palmieri K, Singh A, Skelly AC, Tsai EC, Vaccaro A, Yee A, Harrop JS. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery. Global Spine J 2017; 7:195S-202S. [PMID: 29164024 PMCID: PMC5684850 DOI: 10.1177/2192568217706367] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. METHODS A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as "we recommend," whereas a weak recommendation is presented as "we suggest." RESULTS Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at 6 and 12 months in patients managed with early versus late surgery; and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations were: "We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome" and "We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level." Quality of evidence for both recommendations was considered low. CONCLUSIONS These guidelines should be implemented into clinical practice to improve outcomes in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies, and encouraging clinicians to make evidence-informed decisions.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, MD, PhD, FRCSC, FACS, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street (SCI-CRU, 11th Floor McLaughlin Pavilion), Toronto, Ontario M5T 2S8, Canada.
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University College Cork, Cork, Ireland
| | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | | | - Paul M. Arnold
- University of Kansas Medical Center, The University of Kansas, Kansas City, KS, USA
| | | | - Anthony S. Burns
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | | | | | | | - Susan Howley
- Christopher & Dana Reeve Foundation, Short Hills, NJ, USA
| | - Tara Jeji
- Ontario Neurotrauma Foundation, Toronto, Ontario, Canada
| | | | | | | | | | - Allan R. Martin
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eric Massicotte
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Geno Merli
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | | | - Narihito Nagoshi
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Keio University, Keio, Japan
| | | | - Anoushka Singh
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Eve C. Tsai
- University of Ottawa, Ottawa, Ontario, Canada
| | - Alexander Vaccaro
- Department of Orthopedic Surgery, Jefferson Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Albert Yee
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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14
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Fehlings MG, Wilson JR, Harrop JS, Kwon BK, Tetreault LA, Arnold PM, Singh JM, Hawryluk G, Dettori JR. Efficacy and Safety of Methylprednisolone Sodium Succinate in Acute Spinal Cord Injury: A Systematic Review. Global Spine J 2017; 7:116S-137S. [PMID: 29164020 PMCID: PMC5684849 DOI: 10.1177/2192568217706366] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE The objective of this study was to conduct a systematic review to assess the comparative effectiveness and safety of high-dose methylprednisolone sodium succinate (MPSS) versus no pharmacological treatment in patients with traumatic spinal cord injury (SCI). METHODS A systematic search was performed in PubMed and the Cochrane Collaboration Library for literature published between January 1956 and June 17, 2015. Included studies were critically appraised, and Grades of Recommendation Assessment, Development and Evaluation methods were used to determine the overall quality of evidence for primary outcomes. Previous systematic reviews on this topic were collated and evaluated using the Assessment of Multiple Systematic Reviews scoring system. RESULTS The search yielded 723 citations, 13 of which satisfied inclusion criteria. Among these, 6 were primary research articles and 7 were previous systematic reviews. Based on the included research articles, there was moderate evidence that the 24-hour NASCIS II (National Acute Spinal Cord Injury Studies) MPSS regimen has no impact on long-term neurological recovery when all postinjury time points are considered. However, there is also moderate evidence that subjects receiving the same MPSS regimen within 8 hours of injury achieve an additional 3.2 points (95% confidence interval = 0.10 to 6.33; P = .04) of motor recovery compared with patients receiving placebo or no treatment. CONCLUSION Although safe to administer, a 24-hour NASCIS II MPSS regimen, when all postinjury time points are considered, has no impact on indices of long-term neurological recovery. When commenced within 8 hours of injury, however, a high-dose 24-hour regimen of MPSS confers a small positive benefit on long-term motor recovery and should be considered a treatment option for patients with SCI.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jefferson R. Wilson
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- St. Michael’s Hospital, Toronto, Ontario, Canada
| | - James S. Harrop
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian K. Kwon
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- University College Cork, Cork, Ireland
| | - Paul M. Arnold
- University of Kansas Medical Center, The University of Kansas, Kansas City, KS, USA
| | - Jeffrey M. Singh
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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15
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Fehlings MG, Tetreault LA, Aarabi B, Anderson P, Arnold PM, Brodke DS, Burns AS, Chiba K, Dettori JR, Furlan JC, Hawryluk G, Holly LT, Howley S, Jeji T, Kalsi-Ryan S, Kotter M, Kurpad S, Kwon BK, Marino RJ, Martin AR, Massicotte E, Merli G, Middleton JW, Nakashima H, Nagoshi N, Palmieri K, Singh A, Skelly AC, Tsai EC, Vaccaro A, Wilson JR, Yee A, Harrop JS. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis. Global Spine J 2017; 7:212S-220S. [PMID: 29164026 PMCID: PMC5684841 DOI: 10.1177/2192568217702107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The objective of this study is to develop evidence-based guidelines that recommend effective, safe and cost-effective thromboprophylaxis strategies in patients with spinal cord injury (SCI). METHODS A systematic review of the literature was conducted to address key questions relating to thromboprophylaxis in SCI. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest." RESULTS Based on conclusions from the systematic review and expert panel opinion, the following recommendations were developed: (1) "We suggest that anticoagulant thromboprophylaxis be offered routinely to reduce the risk of thromboembolic events in the acute period after SCI;" (2) "We suggest that anticoagulant thromboprophylaxis, consisting of either subcutaneous low-molecular-weight heparin or fixed, low-dose unfractionated heparin (UFH) be offered to reduce the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with the use of adjusted-dose UFH, we suggest against this option;" (3) "We suggest commencing anticoagulant thromboprophylaxis within the first 72 hours after injury, if possible, in order to minimize the risk of venous thromboembolic complications during the period of acute hospitalization." CONCLUSIONS These guidelines should be implemented into clinical practice in patients with SCI to promote standardization of care, decrease heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, MD, PhD, FRCSC, FACS, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street (SCI-CRU, 11th Floor McLaughlin Pavilion), Toronto, Ontario M5T 2S8, Canada.
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,School of Medicine, University College Cork, Cork, Ireland
| | - Bizhan Aarabi
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | - Anthony S. Burns
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | - Julio C. Furlan
- University of Toronto, Toronto, Ontario, Canada,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | - Susan Howley
- Christopher & Dana Reeve Foundation, Short Hills, NJ, USA
| | - Tara Jeji
- Ontario Neurotrauma Foundation, Toronto, Ontario, Canada
| | | | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Allan R. Martin
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eric Massicotte
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Geno Merli
- Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | | | - Narihito Nagoshi
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Keio University School of Medicine, Keio, Japan
| | | | - Anoushka Singh
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Eve C. Tsai
- University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St. Michael s Hospital, Toronto, Ontario, Canada
| | - Albert Yee
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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16
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Fehlings MG, Tetreault LA, Aarabi B, Anderson P, Arnold PM, Brodke DS, Chiba K, Dettori JR, Furlan JC, Harrop JS, Hawryluk G, Holly LT, Howley S, Jeji T, Kalsi-Ryan S, Kotter M, Kurpad S, Kwon BK, Marino RJ, Martin AR, Massicotte E, Merli G, Middleton JW, Nakashima H, Nagoshi N, Palmieri K, Singh A, Skelly AC, Tsai EC, Vaccaro A, Wilson JR, Yee A, Burns AS. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Rehabilitation. Global Spine J 2017; 7:231S-238S. [PMID: 29164029 PMCID: PMC5684839 DOI: 10.1177/2192568217701910] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The objective of this study is to develop guidelines that outline the appropriate type and timing of rehabilitation in patients with acute spinal cord injury (SCI). METHODS A systematic review of the literature was conducted to address key questions related to rehabilitation in patients with acute SCI. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the type and timing of rehabilitation. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest. RESULTS Based on the findings from the systematic review, our recommendations were: (1) We suggest rehabilitation be offered to patients with acute spinal cord injury when they are medically stable and can tolerate required rehabilitation intensity (no included studies; expert opinion); (2) We suggest body weight-supported treadmill training as an option for ambulation training in addition to conventional overground walking, dependent on resource availability, context, and local expertise (low evidence); (3) We suggest that individuals with acute and subacute cervical SCI be offered functional electrical stimulation as an option to improve hand and upper extremity function (low evidence); and (4) Based on the absence of any clear benefit, we suggest not offering additional training in unsupported sitting beyond what is currently incorporated in standard rehabilitation (low evidence). CONCLUSIONS These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, MD, PhD, FRCSC, FACS, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street (SCI-CRU, 11th Floor McLaughlin Pavilion), Toronto, Ontario M5T 2S8, Canada.
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University College Cork, Cork, Ireland
| | - Bizhan Aarabi
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | | - Julio C. Furlan
- University of Toronto, Toronto, Ontario, Canada,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | | | - Susan Howley
- Christopher & Dana Reeve Foundation, Short Hills, NJ, USA
| | - Tara Jeji
- Ontario Neurotrauma Foundation, Toronto, Ontario, Canada
| | | | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Allan R. Martin
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eric Massicotte
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Geno Merli
- Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | | | | | - Narihito Nagoshi
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Keio University School of Medicine, Keio, Japan
| | | | - Anoushka Singh
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Eve C. Tsai
- University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Albert Yee
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anthony S. Burns
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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17
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Fehlings MG, Wilson JR, Tetreault LA, Aarabi B, Anderson P, Arnold PM, Brodke DS, Burns AS, Chiba K, Dettori JR, Furlan JC, Hawryluk G, Holly LT, Howley S, Jeji T, Kalsi-Ryan S, Kotter M, Kurpad S, Kwon BK, Marino RJ, Martin AR, Massicotte E, Merli G, Middleton JW, Nakashima H, Nagoshi N, Palmieri K, Skelly AC, Singh A, Tsai EC, Vaccaro A, Yee A, Harrop JS. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Use of Methylprednisolone Sodium Succinate. Global Spine J 2017; 7:203S-211S. [PMID: 29164025 PMCID: PMC5686915 DOI: 10.1177/2192568217703085] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The objective of this guideline is to outline the appropriate use of methylprednisolone sodium succinate (MPSS) in patients with acute spinal cord injury (SCI). METHODS A systematic review of the literature was conducted to address key questions related to the use of MPSS in acute SCI. A multidisciplinary Guideline Development Group used this information, in combination with their clinical expertise, to develop recommendations for the use of MPSS. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest." RESULTS The main conclusions from the systematic review included the following: (1) there were no differences in motor score change at any time point in patients treated with MPSS compared to those not receiving steroids; (2) when MPSS was administered within 8 hours of injury, pooled results at 6- and 12-months indicated modest improvements in mean motor scores in the MPSS group compared with the control group; and (3) there was no statistical difference between treatment groups in the risk of complications. Our recommendations were: (1) "We suggest not offering a 24-hour infusion of high-dose MPSS to adult patients who present after 8 hours with acute SCI"; (2) "We suggest a 24-hour infusion of high-dose MPSS be offered to adult patients within 8 hours of acute SCI as a treatment option"; and (3) "We suggest not offering a 48-hour infusion of high-dose MPSS to adult patients with acute SCI." CONCLUSIONS These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in SCI patients.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, MD, PhD, FRCSC, FACS, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street (SCI-CRU, 11th Floor McLaughlin Pavilion), Toronto, Ontario M5T 2S8, Canada.
| | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University College Cork, Cork, Ireland
| | | | | | - Paul M. Arnold
- University of Kansas Medical Center, The University of Kansas, Kansas City, KS, USA
| | | | - Anthony S. Burns
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | | | | | - Julio C. Furlan
- University of Toronto, Toronto, Ontario, Canada,Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | | | | | - Susan Howley
- Christopher & Dana Reeve Foundation, Short Hills, NJ, USA
| | - Tara Jeji
- Ontario Neurotrauma Foundation, Toronto, Ontario, Canada
| | | | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Allan R. Martin
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eric Massicotte
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Geno Merli
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | | | - Narihito Nagoshi
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Keio University, Keio, Japan
| | | | | | - Anoushka Singh
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eve C. Tsai
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Albert Yee
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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18
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Fehlings MG, Martin AR, Tetreault LA, Aarabi B, Anderson P, Arnold PM, Brodke D, Burns AS, Chiba K, Dettori JR, Furlan JC, Hawryluk G, Holly LT, Howley S, Jeji T, Kalsi-Ryan S, Kotter M, Kurpad S, Kwon BK, Marino RJ, Massicotte E, Merli G, Middleton JW, Nakashima H, Nagoshi N, Palmieri K, Singh A, Skelly AC, Tsai EC, Vaccaro A, Wilson JR, Yee A, Harrop JS. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role of Baseline Magnetic Resonance Imaging in Clinical Decision Making and Outcome Prediction. Global Spine J 2017; 7:221S-230S. [PMID: 29164028 PMCID: PMC5684845 DOI: 10.1177/2192568217703089] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The objective of this guideline is to outline the role of magnetic resonance imaging (MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury (SCI). METHODS A systematic review of the literature was conducted to address key questions related to the use of MRI in patients with traumatic SCI. This review focused on longitudinal studies that controlled for baseline neurologic status. A multidisciplinary Guideline Development Group (GDG) used this information, their clinical expertise, and patient input to develop recommendations on the use of MRI for SCI patients. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest." RESULTS Based on the limited available evidence and the clinical expertise of the GDG, our recommendations were: (1) "We suggest that MRI be performed in adult patients with acute SCI prior to surgical intervention, when feasible, to facilitate improved clinical decision-making" (quality of evidence, very low) and (2) "We suggest that MRI should be performed in adult patients in the acute period following SCI, before or after surgical intervention, to improve prediction of neurologic outcome" (quality of evidence, low). CONCLUSIONS These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Michael G. Fehlings, MD, PhD, FRCSC, FACS, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street (SCI-CRU, 11th Floor McLaughlin Pavilion), Toronto, Ontario M5T 2S8, Canada.
| | - Allan R. Martin
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- University College Cork, Cork, Ireland
| | | | | | - Paul M. Arnold
- University of Kansas Medical Center, The University of Kansas, Kansas City, KS, USA
| | | | - Anthony S. Burns
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | - Julio C. Furlan
- University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | | | | | - Susan Howley
- Christopher & Dana Reeve Foundation, Short Hills, NJ, USA
| | - Tara Jeji
- Ontario Neurotrauma Foundation, Toronto, Ontario, Canada
| | | | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Eric Massicotte
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Geno Merli
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | | | - Narihito Nagoshi
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Keio University, Keio, Japan
| | | | - Anoushka Singh
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Eve C. Tsai
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Albert Yee
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Fehlings MG, Tetreault LA, Wilson JR, Kwon BK, Burns AS, Martin AR, Hawryluk G, Harrop JS. A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope. Global Spine J 2017; 7:84S-94S. [PMID: 29164036 PMCID: PMC5684846 DOI: 10.1177/2192568217703387] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute spinal cord injury (SCI) is a traumatic event that results in disturbances to normal sensory, motor, or autonomic function and ultimately affects a patient's physical, psychological, and social well-being. The management of patients with SCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding available management strategies for the treatment of SCI, including the use of corticosteroids such as methylprednisolone sodium succinate, the optimal timing of surgical intervention, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and among the various disciplines that encounter patients with SCI. The objective of this guideline is to form evidence-based recommendations for these areas of controversy and outline how to best manage patients with SCI. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.
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Affiliation(s)
- Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, MD, PhD, FRCSC, FACS, Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street (SCI-CRU, 11th Floor McLaughlin Pavilion), Toronto, Ontario M5T 2S8, Canada.
| | - Lindsay A. Tetreault
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University College Cork, Cork, Ireland
| | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,St Michael’s Hospital, Toronto, Ontario, Canada
| | - Brian K. Kwon
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Allan R. Martin
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Hawryluk G, Whetstone W, Saigal R, Ferguson A, Talbott J, Bresnahan J, Dhall S, Pan J, Beattie M, Manley G. Mean Arterial Blood Pressure Correlates with Neurological Recovery after Human Spinal Cord Injury: Analysis of High Frequency Physiologic Data. J Neurotrauma 2015; 32:1958-67. [PMID: 25669633 DOI: 10.1089/neu.2014.3778] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Current guidelines for the care of patients with acute spinal cord injuries (SCIs) recommend maintaining mean arterial pressure (MAP) values of 85-90 mm Hg for 7 days after an acute SCI however, little evidence supports this recommendation. We sought to better inform the relationship between MAP values and neurological recovery. A computer system automatically collected and stored q1 min physiological data from intensive care unit monitors on patients with SCI over a 6-year period. Data for 100 patients with acute SCI were collected. 74 of these patients had American Spinal Injury Association Impairment Scale (AIS) grades determined by physical examination on admission and at time of hospital discharge. Average MAP values as well as the proportion of MAP values below thresholds were explored for values from 120 mm Hg to 40 mm Hg in 1 mm Hg increments; the relationship between these measures and outcome was explored at various time points up to 30 days from the time of injury. A total of 994,875 q1 min arterial line blood pressure measurements were recorded for the included patients amid 1,688,194 min of recorded intensive care observations. A large proportion of measures were below 85 mm Hg despite generally acceptable average MAP values. Higher average MAP values correlated with improved recovery in the first 2-3 days after SCI while the proportion of MAP values below the accepted threshold of 85 mm Hg seemed a stronger correlate, decreasing in strength over the first 5-7 days after injury. This study provides strong evidence supporting a correlation between MAP values and neurological recovery. It does not, however, provide evidence of a causal relationship. Duration of hypotension may be more important than average MAP. It provides support for the notion of MAP thresholds in SCI recovery, and the highest MAP values correlated with the greatest degree of neurological recovery. The results are concordant with current guidelines in suggesting that MAP thresholds >85 mm Hg may be appropriate after acute SCI.
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Affiliation(s)
- Gregory Hawryluk
- 1 Department of Neurosurgery, University of Utah , Salt Lake City, Utah.,3 Department of Brain and Spinal Cord Injury Center (BASIC), University of California , San Francisco, San Francisco, California.,4 Department of Neurosurgery, University of California , San Francisco, San Francisco, California
| | - William Whetstone
- 2 Department of Emergency Medicine, University of California , San Francisco, San Francisco, California
| | - Rajiv Saigal
- 3 Department of Brain and Spinal Cord Injury Center (BASIC), University of California , San Francisco, San Francisco, California.,4 Department of Neurosurgery, University of California , San Francisco, San Francisco, California
| | - Adam Ferguson
- 3 Department of Brain and Spinal Cord Injury Center (BASIC), University of California , San Francisco, San Francisco, California.,4 Department of Neurosurgery, University of California , San Francisco, San Francisco, California
| | - Jason Talbott
- 5 Department of Radiology, University of California , San Francisco, San Francisco, California
| | - Jacqueline Bresnahan
- 3 Department of Brain and Spinal Cord Injury Center (BASIC), University of California , San Francisco, San Francisco, California.,4 Department of Neurosurgery, University of California , San Francisco, San Francisco, California
| | - Sanjay Dhall
- 3 Department of Brain and Spinal Cord Injury Center (BASIC), University of California , San Francisco, San Francisco, California.,4 Department of Neurosurgery, University of California , San Francisco, San Francisco, California
| | - Jonathan Pan
- 6 Department of Anaesthesia, University of California , San Francisco, San Francisco, California
| | - Michael Beattie
- 3 Department of Brain and Spinal Cord Injury Center (BASIC), University of California , San Francisco, San Francisco, California.,4 Department of Neurosurgery, University of California , San Francisco, San Francisco, California
| | - Geoffrey Manley
- 3 Department of Brain and Spinal Cord Injury Center (BASIC), University of California , San Francisco, San Francisco, California.,4 Department of Neurosurgery, University of California , San Francisco, San Francisco, California
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Hawryluk G, Garber S. Provision of nutrients after acute spinal cord injury: the implications of feast and famine. Neural Regen Res 2015; 10:1061-2. [PMID: 26330824 PMCID: PMC4541232 DOI: 10.4103/1673-5374.160081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2015] [Indexed: 11/16/2022] Open
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Affiliation(s)
- Thomas Walter
- Department of Medical Oncology & Hematology, Princess Margaret Hospital, University of Toronto, Toronto, Canada.
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Hawryluk G, Fehlings M. Cellular Transplantation Approaches for Repair of the Injured Spinal Cord. Top Spinal Cord Inj Rehabil 2009. [DOI: 10.1310/sci1404-47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Moore AD, Stambrook M, Gill DD, Hawryluk G, Peters A, Lois C, Hymans MM. Factor structure of the wechsler adult intelligence scale-revised. In a tramaumatic brain injury sample. Arch Clin Neuropsychol 1991. [DOI: 10.1093/arclin/6.3.209a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Prigatano GP, Parsons O, Wright E, Levin DC, Hawryluk G. Neuropsychological test performance in mildly hypoxemic patients with chronic obstructive pulmonary disease. J Consult Clin Psychol 1983. [PMID: 6826857 DOI: 10.1037//0022-006x.51.1.108] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Prigatano GP, Parsons O, Wright E, Levin DC, Hawryluk G. Neuropsychological test performance in mildly hypoxemic patients with chronic obstructive pulmonary disease. J Consult Clin Psychol 1983; 51:108-16. [PMID: 6826857 DOI: 10.1037/0022-006x.51.1.108] [Citation(s) in RCA: 97] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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