Traumatic Spinal Cord Injury.

OBJECTIVE: This article provides a review of the initial clinical and radiologic evaluation and treatment of patients with traumatic spinal cord injuries. It specifically highlights essential knowledge for neurologists who encounter patients with these complex injuries. LATEST DEVELOPMENTS: There has been improvement in the care of patients with traumatic spinal cord injuries, particularly in the prehospital evaluation, approach for immediate immobilization, standardized spinal clearance, efficient triage, and transportation of appropriate patients to traumatic spinal cord injury specialized centers. Advancements in spinal instrumentation have improved the surgical management of spinal fractures and the ability to manage patients with spinal mechanical instability. The clinical evidence favors performing early surgical decompression and spine stabilization within 24 hours of traumatic spinal cord injuries, regardless of the severity or location of the injury. There is no evidence that supports the use of neuroprotective treatments to improve outcomes in patients with traumatic spinal cord injuries. The administration of high-dose methylprednisolone, which is associated with significant systemic adverse effects, is strongly discouraged. Early and delayed mortality rates continue to be high in patients with traumatic spinal cord injuries, and survivors often confront substantial long-term physical and functional impairments. Whereas the exploration of neuroregenerative approaches, such as stem cell transplantation, is underway, these methods remain largely investigational. Further research is still necessary to advance the functional recovery of patients with traumatic spinal cord injuries. ESSENTIAL POINTS: Traumatic spinal cord injury is a complex and devastating condition that leads to long-term neurologic deficits with profound physical, social, and vocational implications, resulting in a diminished quality of life, particularly for severely affected patients. The initial management of traumatic spinal cord injuries demands comprehensive interdisciplinary care to address the potentially catastrophic multisystem effects. Ongoing endeavors are focused on optimizing and customizing initial management approaches and developing effective therapies for neuroprotection and neuroregeneration to enhance long-term functional recovery.

Intraoperative Monitoring of Scoliosis Surgery in Young Patients.

SUMMARY: Intraoperative neurophysiologic monitoring has added substantially to the safety of spinal deformity surgery correction since its introduction over four decades ago. Monitoring routinely includes both somatosensory evoked potentials and motor evoked potentials. Either modality alone will detect almost all instances of spinal cord injury during deformity correction. The combined use of the two modalities provides complementary information, can permit more rapidly identification of problems, and enhances safety though parallel redundancy should one modality fail. Both techniques are well established and continue to be refined. Although there is room for provider preference, proper monitoring requires attention to technical detail, understanding of the underlying physiology, and familiarity with effects of commonly used anesthetic agents.

Arabic version of the SF-Qualiveen: cross-cultural adaptation, translation, and validation of urinary disorder-specific instruments in patients with spinal cord injury.

BACKGROUND: The Short-Form Qualiveen (SF-Qualiveen) questionnaire assesses the effect of bladder and urinary symptoms on patients' quality of life (QoL) with urological impairment caused by neurological diseases. There is no validated SF-Qualiveen questionnaire in Arabic, so this study aims to provide a translated and validated version of the SF-Qualiveen questionnaire among Arabic patients experiencing spinal cord injury (SCI). METHODS: Psychometric features such as content and construct validity, test-retest reliability, and internal consistency were analyzed. Construct validity was evaluated by contrasting the SF-Qualiveen with the Neurogenic Bladder Symptom Score Short-Form (NBSS-SF) questionnaire. Internal consistency was measured using Cronbach's alpha, whereas the intraclass correlation coefficient (ICC) was employed to assess the test-retest reliability. Factorial validity was established by principal component analysis (PCA). RESULTS: The internal consistency of the total SF-Qualiveen and the domains "Bother with limitations," "Fear," "Feeling," and "Frequency of limitations" showed good internal consistency (Cronbach's alpha of > 0.7). ICC was 0.90 for the total score, 0.83 for the bother with limitations, 0.80 for fears, 0.84 for feeling, and 0.81 for frequency of limitations. The correlation analysis revealed a positive association between the total scores on the NBSS-SF and the domains of the SF-Qualiveen, comprising bother with limitations (r = 0.53, p = 0.02), fears (r = 0.44, p = 0.03), feelings (r = 0.49, p = 0.04), and frequency of limitations (r = 0.46, p = 0.02). The best-fit four-factor model for confirming overall item communalities ranged from 0.552 to 0.814, which indicates moderate to high communalities, and confirms the homogeneity of the SF-Qualiveen using PCA. CONCLUSIONS: The findings of this validation study revealed that the SF-Qualiveen is a reliable and valid instrument appropriate for Arabic-speaking patients with SCI in both research and clinical practices.

Intraoperative neurophysiological monitoring and spinal cord stimulator implantation.

INTRODUCTION: Spinal cord injury (SCI) is one of the most dreaded complications after spinal cord stimulation (SCS) implantation surgery. As a result, intraoperative neurophysiological monitoring (IONM) has been proposed to avoid accidental damage to nervous structures under anesthesia and confirm positioning for optimal stimulation. Our study uses a large administrative claims database to determine the 30-day risk of SCI after SCS implantation. METHODS: This retrospective cohort study used the IBM MarketScan Commercial and Medicare Supplemental Databases from 2016 to 2019. Adult patients undergoing SCS surgical procedures with at least 90 days of follow-up, IONM use, the type of sedation used during the procedure, and subsequent SCI were identified using administrative codes. In addition, logistic regression was used to examine the relationship between various risk factors and subsequent SCI. RESULTS: A total of 9676 patients underwent SCS surgery (64.7% percutaneous implants) during the study period. Nine hundred and forty-four (9.75%) patients underwent SCS implantation with IONM. Conscious sedation, Monitored Anesthesia Care anesthesia, and general anesthesia were used in patients with 0.9%, 60.2%, and 28.6%, respectively. Eighty-one (0.8%) patients developed SCI within 30 days after SCS implant surgery. The SCI rate was higher in the group that underwent IONM (2% vs 0.7%, p value <0.001) during the implantation procedure, reflecting the underlying risk. After adjustment for other factors, the OR of SCI is 2.39 (95% CI: 1.33 to 4.14, p value=0.002) times higher for those with IONM than those without IONM. CONCLUSIONS: Increased SCI risk among patients with IONM likely reflects higher baseline risk, and further research is needed for risk mitigation.

Neutrophil-to-lymphocyte ratio at admission for early diagnosis, severity assessment, and prognosis of acute traumatic spinal cord injury.

STUDY DESIGN: A retrospective study. OBJECTIVE: This study examined the value of neutrophil-to-lymphocyte ratio at admission for early diagnosis, severity assessment, and prognosis of acute traumatic SCI. SETTING: The First People's Hospital of Neijiang, China. METHODS: This was a single-center, retrospective, cohort study of patients treated within 12 h of acute SCI between January 2018 and October 2022. Ninety-four SCI patients were selected as the Observation group, including 26 with complete injury (AIS grade A) and 68 with incomplete injury (AIS grade B-D), while 94 patients with simple spinal fracture were randomly selected as the Control group. Eighty-one observation group patients underwent surgical treatment, of which 33 had a higher AIS grade (Good prognosis subgroup) and 48 a lower or equal grade post-surgery (Poor prognosis subgroup). Univariate and multivariate analyses were performed to assess predictors of early diagnosis, severity, and 6-month outcome. RESULTS: Initial white blood cell count, neutrophil count, monocyte count, and NLR were higher in the Observation group than the Control group, while lymphocyte count was lower in the Observation group. Multivariate logistic regression analysis identified NLR as an independent predictor of early diagnosis. Spinal canal encroachment ≥50%, neutrophil count, and NLR were higher in the complete injury subgroup, and spinal canal encroachment ≥50% was an independent predictor of complete injury, while NLR was not. The NLR was higher in the poor prognosis subgroup and was an independent risk factor. CONCLUSIONS: Peripheral blood NLR is useful for early diagnosis of acute SCI and is predictive of clinical outcome.

A future blood test for acute traumatic spinal cord injury.

Acute spinal cord injury (SCI) requires prompt diagnosis and intervention to minimize the risk of permanent neurologic deficit. Presently, SCI diagnosis and interventional planning rely on magnetic resonance imaging (MRI), which is not always available or feasible for severely injured patients. Detection of disease-specific biomarkers in biofluids via liquid biopsy may provide a more accessible and objective means of evaluating patients with suspected SCI. Cell-free DNA, which has been used for diagnosing and monitoring oncologic disease, may detect damage to spinal cord neurons via tissue-specific methylation patterns. Other types of biomarkers, including proteins and RNA species, have also been found to reflect neuronal injury and may be included as part of a multi-analyte assay to improve liquid biopsy performance. The feasibility of implementing liquid biopsy into current practices of SCI management is supported by the relative ease of blood sample collection as well as recent advancements in droplet digital polymerase chain reaction technology. In this review, we detail the current landscape of biofluid biomarkers for acute SCI and propose a framework for the incorporation of a putative blood test into the clinical management of SCI.

[Initial Medical Care for Spinal Injury].

Neurosurgeons who treat head traumas often encounter cervical spinal injuries. They should be aware of the neurological symptoms, the severity of the symptoms, and the imaging features of cervical injuries. When surgery is required, fixation is often performed.

Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial.

BACKGROUND: Cervical traumatic spinal cord injury is a devastating condition. Current management (bony decompression) may be inadequate as after acute severe TSCI, the swollen spinal cord may become compressed against the surrounding tough membrane, the dura. DISCUS will test the hypothesis that, after acute, severe traumatic cervical spinal cord injury, the addition of dural decompression to bony decompression improves muscle strength in the limbs at 6 months, compared with bony decompression alone. METHODS: This is a prospective, phase III, multicenter, randomized controlled superiority trial. We aim to recruit 222 adults with acute, severe, traumatic cervical spinal cord injury with an American Spinal Injury Association Impairment Scale grade A, B, or C who will be randomized 1:1 to undergo bony decompression alone or bony decompression with duroplasty. Patients and outcome assessors are blinded to study arm. The primary outcome is change in the motor score at 6 months vs. admission; secondary outcomes assess function (grasp, walking, urinary + anal sphincters), quality of life, complications, need for further surgery, and mortality, at 6 months and 12 months from randomization. A subgroup of at least 50 patients (25/arm) also has observational monitoring from the injury site using a pressure probe (intraspinal pressure, spinal cord perfusion pressure) and/or microdialysis catheter (cord metabolism: tissue glucose, lactate, pyruvate, lactate to pyruvate ratio, glutamate, glycerol; cord inflammation: tissue chemokines/cytokines). Patients are recruited from the UK and internationally, with UK recruitment supported by an integrated QuinteT recruitment intervention to optimize recruitment and informed consent processes. Estimated study duration is 72 months (6 months set-up, 48 months recruitment, 12 months to complete follow-up, 6 months data analysis and reporting results). DISCUSSION: We anticipate that the addition of duroplasty to standard of care will improve muscle strength; this has benefits for patients and carers, as well as substantial gains for health services and society including economic implications. If the addition of duroplasty to standard treatment is beneficial, it is anticipated that duroplasty will become standard of care. TRIAL REGISTRATION: IRAS: 292031 (England, Wales, Northern Ireland) - Registration date: 24 May 2021, 296518 (Scotland), ISRCTN: 25573423 (Registration date: 2 June 2021); ClinicalTrials.gov number : NCT04936620 (Registration date: 21 June 2021); NIHR CRN 48627 (Registration date: 24 May 2021).

Spinal cord tethering and syringomyelia after trauma: impact of age and surgical outcome.

Posttraumatic spinal cord tethering and syringomyelia frequently lead to progressive neurological loss. Although several studies demonstrated favourable outcome following spinal cord detethering with/without shunting, additional research is required as no clear consensus exists over the ideal treatment strategy and knowledge about prognostic demographic determinants is currently limited. In this investigation, we retrospectively investigated 67 patients (56 men, 11 women) who were surgically treated and followed for symptomatic spinal cord tethering and syringomyelia from 2012 to 2022 at our center. Age (B-coefficient 0.396) and severity of trauma to the spinal cord (B-coefficient - 0.462) have been identified as independent predictors for the rate of development of symptomatic spinal cord tethering and syringomyelia (p < 0.001). Following untethering surgery including expansion duraplasty with/without shunting, 65.9% of patients demonstrated an improvement of neurological loss (p < 0.001) whereas 50.0% of patients displayed amelioration of spasticity and/or neuropathic pain (p < 0.001). Conclusively, active screening for symptomatic spinal cord tethering and syringomyelia, particularly in younger patients with severe spinal trauma, is crucial as surgical untethering with/without shunting is able to achieve favourable clinical outcomes. This knowledge may enable clinicians to tailor treatment strategies in spinal cord injury patients suffering from progressive neurological loss towards a more optimal and personalized patient care.

The validity and reliability of the Arabic version of the short form of neurogenic bladder symptoms score in patients with spinal cord injury.

BACKGROUND: The Neurogenic Bladder Symptom Score-Short Form (NBSS-SF) evaluates the impact of disease-specific symptoms on the quality of life in individuals with neurogenic bladder (NB). There is no data on the validity and reliability of the NBSS-SF questionnaire in the Arabic language, so this study aimed to examine the psychometric characteristics of the Arabic NBSS-SF in patients with spinal cord injury (SCI). METHODS: International standards were followed when culturally adapting the questionnaire. The Arabic version was conducted in patients with neurogenic bladder caused by SCI twice within a 14 day period. Psychometric properties such as content validity, construct validity, internal consistency, and test-retest reliability were tested. Internal consistency and test-retest reliability was evaluated using Cronbach's alpha, and the Intraclass Correlation Coefficient (ICC), respectively. Construct validity was assessed by comparing the NBSS-SF with the Short Form (SF-12) and the Qualiveen questionnaire. RESULTS: One hundred and one patients with SCI participated in the study. The internal consistency for the overall NBSS-SF score (Cronbach's α of 0.82) and for each subdomain was variable (urinary incontinence 0.84; storage/voiding 0.72; consequences 0.57). ICC was 0.91 for the overall score and 0.94 for the urinary incontinence subdomain, 0.72 for storage/voiding, and 0.90 for consequences. The correlation analysis showed that the Arabic version of NBSS-SF has good construct validity. CONCLUSION: Our results showed that the Arabic version of NBSS-SF is a valid and reliable instrument for evaluating NB symptoms in the Arabic population suffering from SCI.

Identification of immunodiagnostic blood biomarkers associated with spinal cord injury severity.

Blood always shows some immune changes after spinal cord injury (SCI), and detection of such changes in blood may be helpful for diagnosis and treatment of SCI. However, studies to date on blood immune changes after SCI in humans are not comprehensive. Therefore, to obtain the characteristics of blood immune changes and immunodiagnostic blood biomarkers of SCI and its different grades, a human blood transcriptome sequencing dataset was downloaded and analyzed to obtain differentially expressed immune-related genes (DEIGs), related functions and signaling pathways related to SCI and its various grades. Characteristic biomarkers of SCI and its different grades were identified by using weighted gene coexpression network analysis (WGCNA) and least absolute shrinkage and selection operator (LASSO) logistic regression. Expression of biomarkers was verified through experiments. The area under the curve (AUC) of biomarkers was calculated to evaluate their diagnostic value, and differences in immune cell content were examined. In this study, 17 kinds of immune cells with different contents between the SCI group and healthy control (HC) group were identified, with 7 immune cell types being significantly increased. Differences in the content of immune cells between different grades of SCI and the HC group were also discovered. DEIGs were identified, with alteration in some immune-related signaling pathways, vascular endothelial growth factor signaling pathways, and axon guidance signaling pathways. The SCI biomarkers identified and those of American Spinal Injury Society Impairment Scale (AIS) A and AIS D of SCI have certain diagnostic sensitivity. Analysis of the correlation of immune cells and biomarkers showed that biomarkers of SCI, AIS A grade and AIS D grade correlated positively or negatively with some immune cells. CKLF, EDNRB, FCER1G, SORT1, and TNFSF13B can be used as immune biomarkers for SCI. Additionally, GDF11and HSPA1L can be used as biomarkers of SCI AIS A grade; PRKCA and CMTM2 can be used as biomarkers of the SCI AIS D grade. Detecting expression of these putative biomarkers and changes in related immune cells may be helpful for predicting the severity of SCI.

Congenital and Acquired Spinal Cord Injury and Dysfunction.

Pediatric spinal cord injury and dysfunction (SCI/D) can result from atypical embryologic development or be acquired as the result of trauma, infection, autoimmune conditions, and tumors. The age of onset and causal mechanism of SCI/D has dramatic implications for function and risk of comorbidities throughout the lifespan. Optimal care of children with SCI/D is multidisciplinary and the pediatrician is a very important member of this team. This review highlights functional prognosis and important health maintenance issues to prevent complications and maximize independence. It is intended to assist the pediatrician in the care of this unique patient population.

Is procalcitonin a reliable indicator of sepsis in spinal cord injury patients: an observational cohort study.

STUDY DESIGN: Prospective observational cohort study. OBJECTIVE: To understand if serum procalcitonin (PCT) is a reliable indicator of sepsis in spinal cord injury (SCI) patients for better prognosis and earlier diagnosis when compared with other common biomarkers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), blood culture and body temperature. METHODS: From March 2021 to August 2022, data were collected for SCI patients who developed septicaemia. In addition to neurology and admission, the following blood samples were collected on day one of infection: PCT, CRP and WBC. Linear regression analysis was performed to determine the relationship between PCT, CRP and WBC. RESULTS: A total of 27 SCI patients had an infection during their stay in the regional centre; however, only 10 developed septicaemias. 100% of SCI individuals with sepsis had elevated PCT levels, whilst 60% had elevated CRP and 30% had elevated WBC levels. There was a strong positive correlation between PCT and CRP (R2 = 0.673, CI = 95%, 5.5-22.8, p < 0.05) and a weaker positive correlation between PCT and WBC (R2 = 0.110, CI = 95%, 4.2-10.9, p < 0.05). CONCLUSION: In SCI individuals, there was a correlation between serum PCT levels and septicaemia. Alongside this, PCT appeared to be more consistent throughout the study population when compared with CRP and WBC. However, this was a preliminary study and further research is required on a larger scale.

Characteristics of the cervical spine and cervical cord injuries in older adults with cervical ossification of the posterior longitudinal ligament.

Although the incidence of cervical spinal cord injury (CSCI) with ossification of the posterior longitudinal ligament (OPLL) has increased in older adults, its etiology and neurological outcomes remain unknown. We identified OPLL characteristics and determined whether they influence neurological severity and improvement of CSCI in older patients. This multicenter retrospective cohort study identified 1512 patients aged ≥ 65 years diagnosed with CSCI on admission during 2010-2020. We analyzed CSCI etiology in OPLL patients. We performed propensity score-adjusted analyses to compare neurological outcomes between patients with and without OPLL. Cases were matched based on variables influencing neurological prognosis. The primary neurological outcome was rated according to the American Spine Injury Association (ASIA) impairment scale (AIS) and ASIA motor score (AMS). In 332 OPLL patients, the male-to-female ratio was approximately 4:1. Half of all patients displayed low-energy trauma-induced injury and one-third had CSCI without a bony injury. Propensity score matching created 279 pairs. There was no significant difference in the AIS grade and AMS between patients with and without OPLL during hospitalization, 6 months, and 12 months following injury. OPLL patients tended to exhibit worse neurological findings during injury; nevertheless, OPLL was not associated with poor neurological improvement in older CSCI patients.

Glial fibrillary acidic protein is a robust biomarker in cerebrospinal fluid and peripheral blood after traumatic spinal cord injury: a prospective pilot study.

PURPOSE: Biochemical biomarkers to determine the injury severity and the potential for functional recovery of traumatic spinal cord injury (TSCI) are highly warranted; however, it remains to be clarified whether cerebrospinal fluid (CSF) or peripheral blood (PB) is the ideal sample media. This study aims to measure and compare biomarker concentrations in CSF and PB and to explore associations between biomarker concentrations and injury severity, i.e., American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade, and biomarker concentrations and clinical outcome, i.e., AIS grade improvement and Spinal Cord Independent Measure version III (SCIM-III) score. METHODS: From 2018 to 2020, we conducted a single-center prospective pilot study of TSCI patients (n=15) and healthy controls (n=15). Sample collection and clinical outcome assessment were performed at median 13 h [IQR: 19], 9 days [IQR: 2], and 148 days [IQR: 49] after TSCI. Concentrations of neuron-specific enolase (NSE); glial fibrillary acid protein (GFAP); neurofilament light chain (NfL); interferon-γ (IFN-γ); interleukin (IL)-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, and IL-13; and tumor necrosis factor α (TNF-α) were measured and associated to clinical outcomes. RESULTS: The biomarker concentrations were higher in CSF than PB. CSF concentrations of GFAP, NSE, IFN-y, TNF-a, IL-2, IL-12p70, IL-4, IL-10, and IL-13 and PB concentrations of GFAP and IFN-y were significantly associated with AIS grade, but not with AIS grade improvement or SCIM-III score. CONCLUSIONS: Our results support GFAP as a potential diagnostic biomarker that may be measured in CSF as well as PB.

Comprehensive landscape of immune-based classifier related to early diagnosis and macrophage M1 in spinal cord injury.

Numerous studies have documented that immune responses are crucial in the pathophysiology of spinal cord injury (SCI). Our study aimed to uncover the function of immune-related genes (IRGs) in SCI. Here, we comprehensively evaluated the transcriptome data of SCI and healthy controls (HC) obtained from the GEO Database integrating bioinformatics and experiments. First, a total of 2067 DEGs were identified between the SCI and HC groups. Functional enrichment analysis revealed substantial immune-related pathways and functions that were abnormally activated in the SCI group. Immune analysis revealed that myeloid immune cells were predominantly upregulated in SCI patients, while a large number of lymphoid immune cells were dramatically downregulated. Subsequently, 51 major IRGs were screened as key genes involved in SCI based on the intersection of the results of WGCNA analysis, DEGs, and IRGs. Based on the expression profiles of these genes, two distinct immune modulation patterns were recognized exhibiting opposite immune characteristics. Moreover, 2 core IRGs (FCER1G and NFATC2) were determined to accurately predict the occurrence of SCI via machine learning. qPCR analysis was used to validate the expression of core IRGs in an external independent cohort. Finally, the expression of these core IRGs was validated by sequencing, WB, and IF analysis in vivo. We found that these two core IRGs were closely associated with immune cells and verified the co-localization of FCER1G with macrophage M1 via IF analysis. Our study revealed the key role of immune-related genes in SCI and contributed to a fresh perspective for early diagnosis and treatment of SCI.

International Spinal Cord Injury Core Data Set (version 3.0)-including standardization of reporting.

STUDY DESIGN: Expert opinion, feedback, revisions and final consensus. OBJECTIVES: To update the International Spinal Cord Injury (SCI) Core Data Set while still retaining recommended standardization of data reporting. SETTING: International. METHODS: Comments on the data elements received from the SCI community were discussed in the International Core Data Set working group. The suggestions from this group were iteratively reviewed. The final version was circulated for final approval. RESULTS: The International SCI Core Data Set (Version 3.0) consists of 21 variables. The variable 'Gender' has been changed to 'Sex assigned at birth'; for the variable 'Spinal Cord Injury Etiology', the item, 'Sports or exercise during leisure time', has been clarified as 'including during leisure time'; for the variables 'Vertebral injury' and 'Associated injuries', the item 'Unknown' is reworded into: 'Not applicable (non-traumatic case)' and 'Unknown'; the variable 'Spinal surgery' has been expanded to include surgeries for individuals with non-traumatic SCI; for the variables related to the International Standards for Neurological Classification of SCI only the neurological level of injury (NLI) and the American Spinal Injury Association (ASIA) Impairment Scale (AIS) are to be reported, and a separate variable is included indicating if the NLI or the AIS or both are impacted by a non-SCI condition. CONCLUSION: The International SCI Core Data Set (Version 3.0) should be collected and reported for all studies of SCI to facilitate uniform descriptions of SCI populations and facilitate comparison of results collected worldwide.

Preoperative electrodiagnostic planning for upper limb peripheral nerve transfers in cervical spinal cord injury: A narrative review.

Peripheral nerve transfer (PNT) to improve upper limb function following cervical spinal cord injury (SCI) involves the transfer of supralesional donor nerves under voluntary control to intralesional or sublesional lower motor neurons not under voluntary control. Appropriate selection of donor and recipient nerves and surgical timing affect functional outcomes. Although the gold standard of nerve selection is intraoperative nerve stimulation, preoperative electrodiagnostic (EDX) evaluation may help guide surgical planning. Currently there is no standardized preoperative EDX protocol. This study reviews the EDX workup preceding PNT surgery in cervical SCI and proposes an informed EDX protocol to assist with surgical planning. The PICO (Population, Intervention, Comparison, Outcome) framework was used to formulate relevant Medical Subject Headings (MeSH) terms and identify published cases of PNT in cervical SCI in Medline, Embase, CINAHL, and Emcare databases in the last 10 years. The EDX techniques evaluating putative donor nerves, recipient nerve branches, time sensitivity of nerve transfer and other electrophysiological parameters were summarized to guide creation of a preoperative EDX protocol. Needle electromyography (EMG) was the most commonly used EDX technique to identify healthy donor nerves. Although needle EMG has also been used on recipient nerves, compound muscle action potential amplitudes may provide a more accurate determination of recipient nerve health and time sensitivity for nerve transfer. Although there has been progress in presurgical EDX evaluation, EMG and nerve conduction study approaches are variable, and each has limitations in their utility for preoperative planning. There is need for standardization in the EDX evaluation preceding PNT surgery to assist with donor and recipient nerve selection, surgical timing and to optimize outcomes. Based on results of this review, herein we propose the PreSCIse (PRotocol for Electrodiagnosis in SCI Surgery of the upper Extremity) preoperative EDX panel to achieve said goals through an interdisciplinary and patient-centered approach.

Subacute Posttraumatic Ascending Myelopathy: Case Report and Systematic Review of the Literature.

STUDY DESIGN: Case report and literature review. OBJECTION: Aim of this study was to summarize the current evidence base behind subacute posttraumatic ascending myelopathy (SPAM) including the epidemiology, presentation, diagnosis, prognosis, and etiology. SUMMARY OF BACKGROUND DATA: SPAM is a rare, potentially fatal disorder which is not attributable to ongoing mechanical instability, syrinx formation, or iatrogenic causes. METHODS: A systematic literature search on SPAM was performed on Medline, Ovid, Cochrane, Embase, and PubMed databases between 1969 and 2021. Cases were reviewed and the findings summarized. Further evidence was reviewed to support the hypothesis that disruption of cerebrospinal fluid (CSF) circulation is the underlying etiology of the condition. RESULTS: It is estimated to occur in 0.4%-0.7% of spinal cord injuries and may have a mortality of up to 10%. The most likely etiology disruption of CSF circulation leading to further damage to the spinal cord presumably through pressure mediated effects such as a reduction in cellular perfusion. CONCLUSION: There is effectively no treatment of this condition, however, with interest developing in monitoring of CSF pressures during spinal cord injury this may help confirm the etiology, and allow the suggestion of therapies such as drains or expansion duraplasty to reduce spinal cord pressures. LEVEL OF EVIDENCE: Level II-case report and systematic review.

Effectiveness of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for incomplete spinal cord injury: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To determine the effects of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for people with incomplete spinal cord injury. METHODS: PubMed, Embase, Web of Science, PEDro, CENTRAL and CINAHL were searched from inception until September 4, 2022. Randomized controlled trials that evaluated the effects of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for individuals with incomplete spinal cord injury were selected. Mean differences (MD) with 95% confidence interval (CI) were calculated. The methodological quality was evaluated by the Cochrane Risk of Bias 2.0 tool. Subgroup analyses were conducted according to the time since injury. RESULTS: In total 19 studies involving 770 patients were eligible for analysis. Individuals with acute incomplete spinal cord injury in robotic-assisted gait training groups showed significantly greater improvements in 6-minute walking test (MD 53.32; 95% CI 33.49 to 73.15; P < 0.001), lower extremity motor scale (MD 5.22; 95% CI 3.63 to 6.80; P < 0.001) and walking index for spinal cord injury II (MD 3.18; 95% CI 1.34 to 5.02; P < 0.001). Robotic-assisted gait training improved peak oxygen consumption to a greater degree for chronic incomplete spinal cord injury patients (MD 4.90; 95% CI 0.96 to 8.84; P = 0.01). CONCLUSION: Robot-assisted gait training may be a feasible and effective intervention in terms of cardiopulmonary fitness and exercise capacity for individuals with incomplete spinal cord injury.