Spinal cord injury

In the UK, the annual incidence of acute spinal cord injury (SCI) is 19 new cases per million population, contributing to an estimated 50,000 people who are currently living with SCI. Trauma is the most common cause of SCI, predominantly from falls and road traffic accidents. Damage to the spinal cord occurs both at the time of injury (primary) and in its aftermath (secondary). Effectively treating and preventing secondary cord injury, and managing complications associated with SCI, can make a significant improvement to patient outcomes. Improving outcomes in this patient population mean more patients with established SCIs are presenting for routine operations. Anaesthetists should be aware of the unique challenges posed by these patients, both in the acute and chronic settings.     

Bisphosphonate Use in Acute and Chronic Spinal Cord Injury: A Systematic Review

Background/Objective: Bone density loss occurs rapidly after traumatic spinal cord injury (SCI) and is associated with low-energy fractures below the level of injury, commonly occurring around the knee. Bisphosphonates have been tested as potential agents to prevent bone loss after SCI, but no guidelines exist for clinical use of bisphosphonates in these patients. The objective of this study was to systematically review and evaluate evidence quality in studies of bisphosphonate use in patients with post-treatment follow-up of sublesional bone mineral density.

Methods: Literature search in MEDLINE/PubMed and ISI database using key words bisphosphonates, spinal cord injury, quadriplegia, paraplegia, and tetraplegia.

Results: The search identified 6 experimental studies and 1 quasi-experimental study of bisphosphonate therapy in patients with acute and chronic SCI. The studies were small and of fair or poor quality, and none included fracture outcomes. Mild attenuation of bone density loss with acute administration of bisphosphonates after SCI was found at some measurement sites but was not always maintained during follow-up.

Conclusions: Data were insufficient to recommend routine use of bisphosphonates for fracture prevention in these patients. Current studies are limited by heterogeneity of patient populations and outcome measures. Uniform bone density measurement sites with rigorous quality control and compliance monitoring are needed to improve reliability of outcomes. Future studies should address specific populations (acute or chronic SCI) and should assess fracture outcomes.     

Bisphosphonate Use in Acute and Chronic Spinal Cord Injury: A Systematic Review

Background/Objective:

Bone density loss occurs rapidly after traumatic spinal cord injury (SCI) and is associated with low-energy fractures below the level of injury, commonly occurring around the knee. Bisphosphonates have been tested as potential agents to prevent bone loss after SCI, but no guidelines exist for clinical use of bisphosphonates in these patients. The objective of this study was to systematically review and evaluate evidence quality in studies of bisphosphonate use in patients with post-treatment follow-up of sublesional bone mineral density.

Methods:

Literature search in MEDLINE/PubMed and ISI database using key words bisphosphonates, spinal cord injury, quadriplegia, paraplegia, and tetraplegia.

Results:

The search identified 6 experimental studies and 1 quasi-experimental study of bisphosphonate therapy in patients with acute and chronic SCI. The studies were small and of fair or poor quality, and none included fracture outcomes. Mild attenuation of bone density loss with acute administration of bisphosphonates after SCI was found at some measurement sites but was not always maintained during follow-up.

Conclusions:

Data were insufficient to recommend routine use of bisphosphonates for fracture prevention in these patients. Current studies are limited by heterogeneity of patient populations and outcome measures. Uniform bone density measurement sites with rigorous quality control and compliance monitoring are needed to improve reliability of outcomes. Future studies should address specific populations (acute or chronic SCI) and should assess fracture outcomes.     

Acute Treatment Options for Spinal Cord Injury

Most treatment options for acute traumatic spinal cord injury (SCI) are directed at minimizing progression of the initial injury and preventing secondary injury. Failure to adhere to certain guiding principles can be detrimental to the long-term neurologic and functional outcome of these patients. Therapy for the hyperacute phase of traumatic SCI focuses on stabilizing vital signs and follows the Advanced Trauma Life Support (ATLS) algorithm for ensuring stability of airway, breathing and circulation, and disability (neurologic evaluation)—with spinal stabilization—and exposure. Spinal stabilization, with cervical collars and long backboards, is used to prevent movement of a potentially unstable spinal column injury to prevent further injury to the spinal cord and nerve roots, especially during prehospital transport. Surgery to stabilize the spine is undertaken after life-threatening injuries (hemorrhage, evacuation of intracranial hemorrhage, acute vascular compromise) are addressed. Intensive care unit (ICU) admission is to be considered for all patients with high SCI or hemodynamic instability, as well as those with other injuries that independently warrant ICU admission. Avoidance of hypotension and hypoxia may minimize secondary neurologic injury. Elevating the mean arterial pressure above 85 mmHg for 7 days should be considered, to allow for spinal cord perfusion. The use of intravenous steroids (methylprednisolone) is controversial. Early tracheostomy in patients with lesions above C5 may reduce the number of ventilator days and the incidence of ventilator-associated pneumonia. Select patients may benefit from the placement of a diaphragmatic pacer. Aggressive measures, including CoughAssist and Intermittent Positive Pressure Breaths (IPPB), should be used to maintain lung recruitment and aid in the mobilization of secretions. Some patients with high SCI who are dependent on mechanical ventilation can eventually be liberated from the ventilator with consistent efforts from both the patient and the caregiver, along with some patience. Intermittent catheterization by the patient or a caregiver may be associated with a lower incidence of urinary tract infections, compared with an in-dwelling urinary catheter. Early mobilization of patients and a multidisciplinary approach (including respiratory therapists, nutritional experts, physical therapists, and occupational therapists) can streamline care and may improve long-term outcomes. A number of investigational drugs and therapies offer hope of neurologic recovery for some patients.     

大鼠脊髓横断后蛋白质的双向电泳分析及质谱鉴定

目的建立急性脊髓损伤双向电泳图，分析损伤后脊髓内蛋白质的差异表达。方法使用裂解液提取脊髓蛋白，以双向电泳技术分离蛋白质，凝胶染色、图象分析后选取蛋白点，通过质谱技术获取肽质量指纹谱，在蛋白质数据库中查询蛋白质。结果成功建立重复性较好的脊髓蛋白质组双向电泳图，找出13个表达明显变化的蛋白点并获得这些蛋白质的肽质量指纹谱，成功鉴定出11个蛋白质。结论成功构建大鼠正常脊髓与损伤脊髓双向电泳图，用质谱技术鉴定了部分蛋白质。这些蛋白质的有些功能最近才被人们认识。相信在脊髓损伤后的继发性损伤中这些蛋白质可能会起到重要的作用。     

Efficacy of Surgical Decompression in the Setting of Complete Thoracic Spinal Cord Injury

Abstract

Background/Objective: An assessment of neurological improvement after surgical intervention in the setting of traumatic thoracic spinal cord injury (SCI).

Methods: A retrospective evaluation of a nonconsecutive cohort of patients with a thoracic SCI from T2 to T11. The analysis included a total of 12 eligible patients. The neurologic and functional outcomes were recorded from the acute hospital admission to the most recent follow-up. Data included patient age, level of injury, neurologic examination according to the Frankel grading system, the performance of surgery, and the mechanism of the time-related SCI decompression.

Results: All patients had a complete thoracic SCI. The median interval from injury to surgery was 11 days (range, 1-36 days). Decompression, bone fusion, and instrumentation were the most common surgical procedures performed. The median length of follow-up was 18 months after surgery (range, 9-132 months). Motor functional improvement was seen in 1 patient (Frankel A to C).

Conclusion: Surgical decompression and fusion imparts no apparent benefit in terms of neurologic improvement (spinal cord) in the setting of a complete traumatic thoracic SCI. To better define the role of surgical decompression and stabilization in the setting of a complete SCI, randomized, controlled, prospective studies are necessary.     

Medical co-morbidities,secondary complications,and mortality in elderly with acute spinal cord injury

Despite an increasing incidence of spinal cord injury (SCI) in the elderly and evidence that age appears to influence outcome after neurotrauma, surprisingly little is known regarding clinical outcomes and secondary complications in elderly with an acute SCI. This study was undertaken to evaluate the effect of age on clinical outcomes after acute traumatic SCI managed in an acute care unit by a multidisciplinary team. A retrospective chart review of all patients with acute SCI admitted to an acute care unit at a university hospital between 1998 and 2000 was performed. Data on clinical outcomes and secondary complications in younger individuals (group 1: age < 60 years) were compared to elderly subjects (group 2: age > or = 60 years). There were 28 elderly (age 60-89 years) and 30 younger (age 17-56 years) individuals. The severity and level of SCI were similar in both groups (p = 0.11; p = 0.93). Co-morbidities were more frequent in the elderly (p < 0.01). There was a trend, which did not achieve significance, for an increased incidence of secondary complications in the elderly (57.1% versus 33.3%; p = 0.11). The most common secondary complications in both groups were infections, psychiatric disorders, pressure sores, and cardiovascular complications. Mortality rates in elderly and younger individuals with acute SCI (p = 0.41) were not significantly different. Our data suggest that rigorous attention to principles of acute SCI care can minimize previously reported higher susceptibility for secondary complications in the elderly. A multidisciplinary team approach to the management of the elderly with acute SCI is essential to minimize or prevent secondary complications.     

Spinal cord infarction following vertebral angiography: clinical and pathological findings

Spinal cord damage from radiographic contrast material has been known to occur in both spinal and nonspinal angiographic procedures. Reported here is cervical spinal cord injury (SCI) during vertebral angiography. During the procedure, the patient displayed signs of acute cervical spinal cord irritation that should have been taken as a warning of impending injury. Autopsy 9 years later showed evidence of central cervical spinal cord necrosis. The pathological findings are similar to those seen in animal models of contrast media-induced SCI; and the pathophysiological mechanisms of such injury are discussed.     

腺苷在继发性脊髓损伤中的作用及其机制

目的 通过观察大鼠脊髓损伤后内源性腺苷含量的变化,以及外源性腺苷地脊髓损伤后神经功能的影响,探讨腺苷在髓继发性损伤中的作用。方法 采用大鼠Ｔ１３脊髓腹侧压迫模型,用微透析技术每２０分钟连续收集脊髓损伤后脊髓组织细胞上液,用高效液相色谱仪紫外检测法检测细胞外液腺式的含量;伤前１４分钟蛛网膜下腔给予非特异性腺苷受体激动剂２－氯腺苷,观察伤后神经功能评分、倾斜平面临界角和组织学变化。结果 脊髓损伤后腺苷     

急性脊髓损伤并应激性溃疡的高危因素分析

目的探讨急性脊髓损伤(ASCI)并应激性溃疡的发病因素及预防措施。方法162例ASCI患者,并发应激性溃疡21例,分析其发病的相关高危因素。结果ASCI合并应激性溃疡的发生率与脊髓损伤的部位、程度、低血压、代谢性酸中毒等差异有显著性(P<0·05),与患者是否手术、高热、有无预防性应用甲氰咪呱等差异无显著性(P>0·05)。结论对ASCI后应激性溃疡的预防,应重视原发脊髓损伤与继发性病理生理的早期处理。     

乌司他丁对急性脊髓伤神经细胞保护作用的实验研究

目的研究乌司他丁对急性脊髓损伤大鼠微环境调控的影响及神经功能的预防和保护作用。方法选用SD大鼠80只，采用改良Allen重物打击法制成脊髓损伤模型，随机分为4组：脊髓损伤组（SCI组，n=20）；使用乌司他丁组（U组，n=20）；使用甲基强的松龙组（M组，n=20）；乌司他丁＋甲基强的松龙联合用药组（U＋M组，n=20），所有给药组在脊髓损伤后0．5h、4h、8h、24h、36h、48h、60h、72h给药。在脊髓损伤后24h、72h、1周、2周、3周5个时间段进行神经功能评分、脊髓病理形态学观察。结果使用乌司他丁可明显改善损伤脊髓的病理形态；神经功能评分明显增高。结论大鼠急性脊髓损伤后使用乌司他丁能有效的保护神经细胞，抑制细胞进一步衰亡。     

Spinal Cord Infarction Following Vertebral Angiography: Clinical and Pathological Findings

Abstract

Spinal cord damage from radiographic contrast material has been known to occur in both spinal and nonspinal angiographic procedures. Reported here is cervical spinal cord injury (SCI) during vertebral angiography. During the procedure, the patient displayed signs of acute cervical spinal cord irritation that should have been taken as a warning of impending injury. Autopsy 9 years later showed evidence of central cervical spinal cord necrosis. The pathological findings are similar to those seen in animal models of contrast media-induced SCI; and the pathophysiological mechanisms of such injury are discussed.     

Sleep disordered breathing in spinal cord injury: A systematic review

Context: Spinal cord injury commonly results in neuromuscular weakness that impacts respiratory function. This would be expected to be associated with an increased likelihood of sleep-disordered breathing.

Objective: (1) Understand the incidence and prevalence of sleep disordered breathing in spinal cord injury. (2) Understand the relationship between injury and patient characteristics and the incidence of sleep disordered breathing in spinal cord injury. (3) Distinguish between obstructive sleep apnea and central sleep apnea incidence in spinal cord injury. (4) Clarify the relationship between sleep disordered breathing and stroke, myocardial infarction, metabolic dysfunction, injuries, autonomic dysreflexia and spasticity incidence in persons with spinal cord injury. (5) Understand treatment tolerance and outcome in persons with spinal cord injury and sleep disordered breathing.

Methods: Extensive database search including PubMed, Cochrane Library, CINAHL and Web of Science.

Results: Given the current literature limitations, sleep disordered breathing as currently defined is high in patients with spinal cord injury, approaching 60% in motor complete persons with tetraplegia. Central apnea is more common in patients with tetraplegia than in patients with paraplegia.

Conclusion: Early formal sleep study in patients with acute complete tetraplegia is recommended. In patients with incomplete tetraplegia and with paraplegia, the incidence of sleep-disordered breathing is significantly higher than the general population. With the lack of correlation between symptoms and SDB, formal study would be reasonable. There is insufficient evidence in the literature on the impact of treatment on morbidity, mortality and quality of life outcomes.     

Advances in monitoring for acute spinal cord injury: a narrative review of current literature

Spinal cord injury (SCI) is a devastating condition that affects about 17,000 individuals every year in the United States, with approximately 294,000 people living with the ramifications of the initial injury. After the initial primary injury, SCI has a secondary phase during which the spinal cord sustains further injury due to ischemia, excitotoxicity, immune-mediated damage, mitochondrial dysfunction, apoptosis, and oxidative stress. The multifaceted injury progression process requires a sophisticated injury-monitoring technique for an accurate assessment of SCI patients. In this narrative review, we discuss SCI monitoring modalities, including pressure probes and catheters, micro dialysis, electrophysiologic measures, biomarkers, and imaging studies. The optimal next-generation injury monitoring setup should include multiple modalities and should integrate the data to produce a final simplified assessment of the injury and determine markers of intervention to improve patient outcomes.     

扩大半椎板切除术治疗颈脊髓损伤

OBJECTIVE: To treat cervical spinal cord injury (SCI) accompanied with narrowing spinal canal by expanded hemilaminectomy. METHODS: From 1995 January to 1998 April 51 patients of cervical SCI were treated by expanded hemilaminectomy. Spinal injury classified in to 3 types: no fracture-dislocation (39 patients) fracture dislocation at the lower cervical spine (11), and burst fracture (1). The types of SCI included central cord injury (18 patients) incomplete cord injury (19), and complete cord injury (14). MR imaging in 23 patients showed degenerative changes with normal intensity of the cord in 14 patients, multiple level hyperintensity in 3, cystic changes in 3, myelomalasia in 3, and cord brocken in 1. Expanded hemilaminectomy was performed in 24 hours in 3 patients, in 48 hours in 9, in one week in 2, after one week in 35, and after one year in 2. The left or right laminae were removed from C(7) to C(3) in 42 patients, C(3) - T(1) in 3, C(2) - C(7) in 2, C(3) - C(6) in 3 and C(4) - C(7) in 3. Hemilaminectomy was expanded lateral to the inner of apophyseal joint and medial to the inner lamina beneath the spinal process. RESULTS: Follow-up lasted for 1 year and 7 months. Six patients with complete cord injury had of the no recovery lower extremity but recovery of the brachialis and extensor radial longus. 12 patients of central cord injury had full recovery except intrinsic muscles of the hand (5). They operated were on 2 weeks after injury. 17 patients of incomplete cord injury recovered to Frankel IV. CONCLUSIONS: Expanded hemilaminectomy is indicated for patients of cervical SCI with narrowing spinal canal or without fracture dislocation. Best results can be obtained in patients of central cord injury, and incomplete cord injury. Even in complete cord injury, 1 - 2 forearm muscle may recover (24.8%), securing a pinch grip reconstruction.     

Dalteparin Vs Low-Dose Unfractionated Heparin for Prophylaxis Against Clinically Evident Venous Thromboembolism in Acute Traumatic Spinal Cord Injury: A Retrospective Cohort Study

Background: When venous thromboembolism (VTE) includes deep-vein thrombosis (DVT) and pulmonary embolism (PE), patients with acute traumatic spinal cord injury (SCI) have the highest incidence of VTE among all hospitalized groups, with PE the third most common cause of death. Although low-molecular-weight heparin (LMWH) outperforms low-dose unfractionated heparin (LDUH) in other patient populations, the evidence in SCI remains less robust.

Objective: To determine whether the efficacy for LMWH shown in previous SCI surveillance studies (eg, routine Doppler ultrasound) would translate into real-world effectiveness in which only clinically evident VTE is investigated (ie, after symptoms or signs present).

Methods: A retrospective cohort study was conducted of 90 patients receiving LMWH dalteparin (5,000 U daily) or LDUH (5,000 U twice daily) for VTE prophylaxis after acute traumatic SCI. The incidence of radiographically confirmed VTE was primarily analyzed, and secondary outcomes included complications of bleeding and heparin-induced thrombocytopenia.

Results: There was no statistically significant association (p = 0.7054) between the incidence of VTE (7.78% overall) and the type of prophylaxis received (LDUH 3/47 vs dalteparin 4/43). There was no significant differences in complications, location of VTE, and incidence of fatal PE. Paraplegia (as opposed to tetraplegia) was the only risk factor identified for VTE.

Conclusions: There continues to be an absence of definitive evidence for dalteparin (or other LMWH) over LDUH as the choice for VTE prophylaxis in patients with SCI. Novel approaches to VTE prophylaxis are urgently required for this population, whose risk of fatal PE has not decreased over the last 25 years.     

腺苷治疗大鼠脊髓损伤的初步研究

目的 通过观察大鼠脊髓损伤后内源性细胞外腺苷含量的变化以及外源性腺苷对脊髓损伤后脊髓组织细胞外钙离子和神经功能的影响,探讨腺苷在脊髓继发性损伤中的作用。 方法 ＳＤ大鼠５８只,制作成Ｔ１３脊髓腹侧压迫模型,用微透析技术每２０ｍｉｎ连续收集脊髓损伤后脊髓组织细胞外液,用高效液相色谱法仪紫外检测法检测细胞外液腺苷的含量;伤前１５ｍｉｎ蛛网膜下给予非特异性腺苷受体激动剂２－氯腺苷,伤后立即开始每１０ｍｉ