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spinal_cord_injury

Spinal cord injury (SCI)

Refers to any injury to the spinal cord that is caused by trauma instead of disease.

Total health care costs related to TSCIs exceed $10 billion annually in the United States alone, and lifetime per person direct and indirect costs can exceed $3 million 1) 2).

Epidemiology

Traumatic spinal cord injuries (TSCIs) affect up to 500,000 people worldwide each year, and their high morbidity is associated with substantial individual and societal burden and socioeconomic impact 3) 4).

TSCIs most commonly affect young males and result from road traffic accidents, but recent reports also highlight their increasing incidence in older adults as a result of low-energy falls 5) 6) 7).

Classification

Etiology

Spinal cord injuries have many causes, but are typically associated with major trauma from motor vehicle accidents, falls, sports injuries, and violence.

see Spinal stab wound.

Multiple cellular, molecular, and biochemical changes contribute to the etiology and treatment outcome of contusion spinal cord injury (SCI). MicroRNAs (miRNAs) aberrant expression have been found after SCI 8).

Pathophysiology

Spinal cord injury induces the disruption of blood-spinal cord barrier and triggers a complex array of tissue responses, including endocytoplasmic reticulum (ER) stress and autophagy. However, the roles of ER stress and autophagy in blood-spinal cord barrier disruption have not been discussed in acute spinal cord trauma.

Signaling pathways

Although many scholars have utilized high-throughput microarrays to delineate gene expression patterns after spinal cord injury (SCI), no study has evaluated gene changes in nucleus raphe magnus (RM) and somatomotor cortex (SMTC), two areas in brain primarily affected by SCI. In present study, we aimed to analyze the differentially expressed genes (DEGs) of RM and SMTC between SCI model and sham injured control at 4, 24 h, 7, 14, 28 days, and 3 months using microarray dataset GSE2270 downloaded from gene expression omnibus and unpaired significance analysis of microarray method. Protein-protein interaction (PPI) network was constructed for DEGs at crucial time points and significant biological functions were enriched using DAVID. The results indicated that more DEGs were identified at 14 days in RM and at 4 h/3 months in SMTC after SCI. In the PPI network for DEGs at 14 days in RM, interleukin 6, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), FBJ murine osteosarcoma viral oncogene homolog (FOS), tumor necrosis factor, and nuclear receptor subfamily 3, group C, member 1 (glucocorticoid receptor) were the top 5 hub genes; In the PPI network for DEGs at 3 months in SMTC, the top 5 hub genes were ubiquitin B, Ras-related C3 botulinum toxin substrate 1 (rho family, small GTP binding protein Rac1), FOS, Janus kinase 2 and vascular endothelial growth factor A. Hedgehog and Wnt signaling pathways were the top 2 significant pathways in RM. These hub DEGs and pathways may be underlying therapeutic targets for SCI 9).

Clinical evaluation

Depending on where the spinal cord and nerve roots are damaged, the symptoms can vary widely, from pain to paralysis to incontinence.

In the Hospital

ASIA impairment scale

Evaluation of reflexes

Abdominal reflexes…..

Diagnosis

Treatment

Urologic Health Condition

Urinary incontinence (UI) rate is high among SCI patients, and more common in females with fairly good proportion of patients using incontinence medication. Main bladder management method was clean intermittent catheterization (CIC) and more prevalent in males, although the use of CIC decreased with time. Urinary stone surgery was the leading surgical procedure 10).

Rehabilitation

Spinal cord injury (SCI) rehabilitation remains a major clinical challenge, especially in cases involving chronic, complete injury. Existing interventions for assisting patients with SCI in walking, including body weight support systems, robotic assistance, and functional electrostimulation of the legs, have not shown evidence of generating significant clinical improvement in somatosensory function below the level of the injury. In the past 2 decades, brain machine interfaces (BMIs) have become popular tools for restoring limb function in paralyzed patients, although no study has suggested that long-term training with BMI-based paradigms and physical training could trigger neurological recovery, particularly in patients with complete SCI

Outcome

Spinal cord injury (SCI) often results in irreversible and permanent neurological deficits and long-term disability. Vasospasm, hemorrhage, and loss of microvessels create an ischemic environment at the site of contusive or compressive SCI and initiate the secondary injury cascades leading to progressive tissue damage and severely decreased functional outcome.

They have a tremendous impact on individuals, families, and society as a whole, and they frequently require complex long-term multidisciplinary care 11) 12).

There was a small degree of neurologic recovery (between 1 and 5 y postinjury) after a traumatic SCI. Late conversion, between 1 and 5 years, from a neurologically complete to an incomplete injury occurred in 5.6% of cases, but in only up to 2.1% was there a conversion from motor complete to motor incomplete status. Limitations of this study included changes in the ASIA classification during the study and in the intra- and interrater reliability typically seen in longitudinal studies of the ASIA standards. Functional changes were not studied. Knowledge of the degree of late recovery may help in analyzing newer interventions to enhance recovery 13).


There is sparse data regarding the impact of alcohol on in-hospital complications associated with traumatic spinal cord injuries (TSCI).

The National Trauma Data Bank (NTDB) Research Data Set (RDS) version 7.2 (2000-2006) was utilized to gather data between 2007 and 2009.

Extracted cases of TSCI (ICD-9-CM codes 806.xx) without concurrent traumatic brain injury. Outcomes of interest were mortality, length of stay (LOS), ICU days, ventilator days, and complications. Continuous outcomes such as LOS, ICU days, and ventilator days were analyzed using linear regression. Risk adjusted analysis of risk factors for mortality and complication rates were performed using multiple logistic regression. Of the 10,611 persons identified in the NTDB, alcohol was present in approximately a fifth of all cases (20.76%). A majority of TSCI patients were young (mean age 39) Caucasian (65.07%) males (75.93%). Blunt injury was the most common mechanism of injury. The presence of alcohol did not significantly affect mortality or neurological complications. Alcohol in the blood was associated with extended LOS, longer ICU stays, more days spent ventilated, and increased risk of all-type complications. Furthermore, there was a statistically significant association with the presence alcohol and increased risk for pulmonary, pneumonia, DVT/PE, UTI, and ulcer/skin complications. Alcohol intoxication is associated with increased in-hospital morbidity. The significant association with in hospital complications increases health resource utilization after spinal cord injury 14).

Complications

Scoliosis

Almost all pediatric patients who incur a spinal cord injury (SCI) will develop scoliosis, and younger patients are at highest risk for curve progression requiring surgical intervention. Although the use of pedicle screws is increasing in popularity, their impact on SCI-related scoliosis has not been described.

Hwang et al. retrospectively reviewed the radiographic outcomes of pedicle screw-only constructs in all patients who had undergone SCI-related scoliosis correction at a single institution.

Medical records and radiographs from Shriner's Hospital for Children-Philadelphia for the period between November 2004 and February 2011 were retrospectively reviewed.

Thirty-seven patients, whose mean age at the index surgery was 14.91 ± 3.29 years, were identified. The cohort had a mean follow-up of 33.2 ± 22.8 months. The mean preoperative coronal Cobb angle was 65.5° ± 25.7°, which corrected to 20.3° ± 14.4°, translating into a 69% correction (p < 0.05). The preoperative coronal balance was 24.4 ± 22.6 mm, with a postoperative measurement of 21.6 ± 20.7 mm (p = 1.00). Preoperative pelvic obliquity was 12.7° ± 8.7°, which corrected to 4.1° ± 3.8°, translating into a 68% correction (p < 0.05). Preoperative shoulder balance, as measured by the clavicle angle, was 8.2° ± 8.4°, which corrected to 2.7° ± 3.1° (67% correction, p < 0.05). Preoperatively, thoracic kyphosis measured 44.2° ± 23.7° and was 33.8° ± 11.5° postoperatively. Thoracolumbar kyphosis was 18.7° ± 12.1° preoperatively, reduced to 8.1° ± 7.7° postoperatively, and measured 26.8° ± 20.2° at the last follow-up (p < 0.05). Preoperatively, lumbar lordosis was 35.3° ± 22.0°, which remained stable at 35.6° ± 15.0° postoperatively.

Pedicle screw constructs appear to provide better correction of coronal parameters than historically reported and provide significant improvement of sagittal kyphosis as well. Although pedicle screws appear to provide good radiographic results, correlation with clinical outcomes is necessary to determine the true impact of pedicle screw constructs on SCI-related scoliosis correction 15).

1)
DeVivo M.J. (1997). Causes and costs of spinal cord injury in the United States. Spinal Cord 35, 809–813
2)
Krueger H., Noonan V.K., Trenaman L.M., Joshi P., Rivers C.S. (2013). The economic burden of traumatic spinal cord injury in Canada. Chronic Inj. Can. 33, 113–122
3)
WHO. Spinal Cord Injury, Fact Sheet. Available at 2013 http://www.who.int/mediacentre/factsheets/fs384/en/
4)
Singh A., Tetreault L., Kalsi-Ryan S., Nouri A., Fehlings M.G. (2014). Global prevalence and incidence of traumatic spinal cord injury. Clin. Epidemiol. 6, 309–331
5)
Noonan V.K., Fingas M., Farry A., Baxter D., Singh A., Fehlings M.G., Dvorak M.F. (2012). Incidence and prevalence of spinal cord injury in Canada: a national perspective. Neuroepidemiology 38, 219–226
6)
Selvarajah S., Hammond E.R., Haider A.H., Abularrage C.J., Becker D., Dhiman N., Hyder O., Gupta D., Black J.H., 3rd, Schneider E.B. (2014). The burden of acute traumatic spinal cord injury among adults in the United States: an update. J. Neurotrauma 31, 228–238
7)
Wyndaele M., Wyndaele J.J. (2006). Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal Cord 44, 523–529
8)
Zhu H, Xie R, Liu X, Shou J, Gu W, Gu S, Che X. MicroRNA-494 improves functional recovery and inhibits apoptosis by modulating PTEN/AKT/mTOR pathway in rats after spinal cord injury. Biomed Pharmacother. 2017 Jun 7;92:879-887. doi: 10.1016/j.biopha.2017.05.143. [Epub ahead of print] PubMed PMID: 28601045.
9)
Xia X, Qu B, Ma Y, Yang LB, Huang HD, Cheng JM, Yang T, Kong B, Liu EY, Zhao K, He WQ, Xing XM, Liang L, Fan KX, Sun HD, Zhou HT, Cheng L, Gu JW, Kuang YQ. Analyzing time-series microarray data reveals key genes in spinal cord injury. Mol Biol Rep. 2014 Jul 26. [Epub ahead of print] PubMed PMID: 25063577.
10)
Cetinel B, Onal B, Turegun FA, Erdogan S. Urologic health condition of spinal cord-injured patients living in Turkey. Spinal Cord. 2014 Jan 21. doi: 10.1038/sc.2013.173. [Epub ahead of print] PubMed PMID: 24445977.
11)
Dvorak M.F., Noonan V.K., Fallah N., Fisher C.G., Rivers C.S., Ahn H., Tsai E.C., Linassi A.G., Christie S.D., Attabib N., Hurlbert R.J., Fourney D.R., Johnson M.G., Fehlings M.G., Drew B., Bailey C.S., Paquet J., Parent S., Townson A., Ho C., Craven B.C., Gagnon D., Tsui D., Fox R., Mac-Thiong J.M., Kwon B. (2014). Minimizing errors in acute traumatic spinal cord injury trials by acknowledging the heterogeneity of spinal cord anatomy and injury severity: an observational Canadian cohort analysis. J. Neurotrauma 31, 1540–1547
12)
Noonan V.K., Fallah N., Park S.E., Dumont F.S., Leblond J., Cobb J., Noreau L. (2014). Health care utilization in persons with traumatic spinal cord injury: the importance of multimorbidity and the impact on patient outcomes. Top Spinal Cord Inj. Rehabil. 20, 289–301
13)
Kirshblum S, Millis S, McKinley W, Tulsky D. Late neurologic recovery after traumatic spinal cord injury. Arch Phys Med Rehabil. 2004 Nov;85(11):1811-7. PubMed PMID: 15520976.
14)
Crutcher CL, Ugiliweneza B, Hodes JE, Kong M, Boakye M. Alcohol Intoxication and its Effects on Traumatic Spinal Cord Injury Outcomes. J Neurotrauma. 2014 Mar 11. [Epub ahead of print] PubMed PMID: 24617326.
15)
Hwang SW, Safain MG, King JJ, Kimball JS, Ames R, Betz RR, Cahill PJ, Samdani AF. Management of spinal cord injury-related scoliosis using pedicle screw-only constructs. J Neurosurg Spine. 2015 Feb;22(2):185-91. doi: 10.3171/2014.10.SPINE14185. Epub 2014 Nov 21. PubMed PMID: 25415486.
spinal_cord_injury.txt · Last modified: 2018/05/13 20:08 by administrador