The posterior cervical transdural approach for retro-odontoid mass pseudotumor resection: report of three cases and discussion of the current literature.

OBJECTIVE: The treatment of a retro-odontoid pseudotumor mass associated with severe spinal cord compression is challenging due to the complex regional anatomy. Here, we present an attractive treatment option involving a single-stage posterior transdural microsurgical resection followed by instrumented cervical reconstruction. METHODS: We describe three patients presenting with clinical signs of cervical myelopathy and an imaging finding of mucoid and fibrous soft or semi-soft retro-odontoid pseudotumor mass with significant spinal cord compression at the C1/C2 level. Given the severity of the symptoms, surgical decompression was planned and fusion was necessitated by the severe degenerative osteoarthritis seen at the C1/C2 level with signs of instability. Using a standard posterior approach to the spine, a suboccipital decompression by craniectomy and laminectomy of C1, C2 and C3 was performed. The masses were visualized and confirmed with ultrasound imaging, and intraoperative neurosurgical monitoring was applied. The dura was then opened from the level of C0-C2. Exiting C2-C3 nerve roots were identified and protected throughout the procedure, and the dentate ligament was cut to facilitate access. Incision of the anterior dura provided easy access to the lesion for resection without any spinal cord retraction. Multiple intraoperative samples were sent to pathology for tissue diagnosis. The dura was closed with sutures and an overlay of fibrin sealant with collagen matrix sponge. The fusion procedures were performed using a standard occipital cervical plate and screws technique with contoured titanium rods. CONCLUSIONS: The posterior cervical transdural approach is a safe alternative procedure for mucoid and fibrous soft or semi-soft retro-odontoid pseudotumor mass removal. Preoperative CT scan can evaluate tissue characteristics and distinguish between a soft or ossified mass in front of the spinal cord. Local anatomical conditions facilitate less bleeding and adhesions, together with less spinal cord traction, in the intradural space. Cranio-cervical and suboccipital stabilization can be easily and safely performed with this exposure.

An analysis of ideal and actual time to surgery after traumatic spinal cord injury in Canada.

STUDY DESIGN: Retrospective analysis of a prospective registry and surgeon survey. OBJECTIVES: To identify surgeon opinion on ideal practice regarding the timing of decompression/stabilization for spinal cord injury and actual practice. Discrepancies in surgical timing and barriers to ideal timing of surgery were explored. SETTING: Canada. METHODS: Patients from the Rick Hansen Spinal Cord Registry (RHSCIR, 2004-2014) were reviewed to determine actual timing of surgical management. Following data collection, a survey was distributed to Canadian surgeons, asking for perceived to be the optimal and actual timings of surgery. Discrepancies between actual data and surgeon survey responses were then compared using χ2 tests and logistic regression. RESULTS: The majority of injury patterns identified in the registry were treated operatively. ASIA Impairment Scale (AIS) C/D injuries were treated surgically less frequently in the RHSCIR data and surgeon survey (odds ratio (OR)= 0.39 and 0.26). Significant disparities between what surgeons identified as ideal, actual current practice and RHSCIR data were demonstrated. A great majority of surgeons (93.0%) believed surgery under 24 h was ideal for cervical AIS A/B injuries and 91.0% for thoracic AIS A/B/C/D injuries. Definitive surgical management within 24 h was actually accomplished in 39.0% of cervical and 45.0% of thoracic cases. CONCLUSION: Ideal surgical timing for traumatic spinal cord injury (tSCI) within 24 h of injury was identified, but not accomplished. Discrepancies between the opinions on the optimal and actual timing of surgery in tSCI patients suggest the need for strategies for knowledge translation and reduction of administrative barriers to early surgery.

Electrocardiographic abnormalities in the early stage following traumatic spinal cord injury.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Although cardiac arrhythmias are relatively well recognized in the chronic stage after spinal cord injury (SCI), little is known regarding its occurrence during the early stage. The objective of this study was to examine electrocardiogram changes within the first 72 h after acute traumatic SCI. SETTING: Acute spine trauma center, Toronto, Ontario, CanadaMethods:This study included all consecutive patients with spine trauma admitted to our institution from January 1998 to June 2007 who had an electrocardiogram within the first 72 h post trauma. Patients were divided into four groups: (I) patients with motor complete SCI at T6 or above; (II) patients with motor incomplete SCI at T6 or above; (III) patients with spine trauma but no/minor SCI at T6 or above; and (IV) patients with SCI below T6. RESULTS: There were 69 men and 20 women with mean age of 53.8 years (16-88 years). All groups were comparable regarding age, sex, pre-existing comorbidities and cause of SCI. There were no significant differences among the groups regarding predominant rhythm, PR interval, atrial-ventricular conduction, ventricular rate, QRS axis and intraventricular conduction abnormalities. Nonetheless, patients in Group I had longer RR interval (P=0.016), longer QTc (P=0.025) and more prolonged duration of the longest QRS (P=0.017) in comparison with the other groups. CONCLUSIONS: Our results indicate that electrocardiogram abnormalities are more common within the first 72 h following acute traumatic, motor complete, cervical or high-thoracic SCI. This may represent early manifestations of autonomic dysfunction due to disruption of descending cardiovascular pathways in individuals with severe SCI at T6 or above.

Predicting task performance from upper extremity impairment measures after cervical spinal cord injury.

BACKGROUND: Automated sensor-based assessments of upper extremity (UE) function after cervical spinal cord injury (SCI) could provide more detailed tracking of individual recovery profiles than is possible with existing assessments, and optimize the delivery and assessment of new interventions. The design of reliable automated assessments requires identifying the key variables that need to be measured to meaningfully quantify UE function. An unanswered question is to what extent measures of sensorimotor impairment can quantitatively predict performance on functional tasks. OBJECTIVE: The objective was to define the predictive value of impairment measures for concurrent functional task performance in traumatic cervical SCI, as measured by the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP). SETTING: Retrospective analysis. METHODS: A data set of 138 GRASSP assessments was analyzed. The Strength and Sensation modules were used as measures of impairment, whereas the concurrent Prehension Performance module was used as the surrogate measure of function. Classifiers were trained to predict the scores on each of the six individual tasks in the Prehension Performance module. The six scores were added to obtain a total score. RESULTS: The Spearman's ρ between predicted and actual total Prehension Performance scores was 0.84. Predictions using both the Strength and Sensation scores were not found to be superior to predictions using the Strength scores alone. CONCLUSIONS: Measures of UE motor impairment are highly predictive of functional task performance after cervical SCI. Automated sensor-based assessments of UE motor function after SCI can rely on measuring only impairment and estimating functional performance accordingly.

Rationale, design and critical end points for the Riluzole in Acute Spinal Cord Injury Study (RISCIS): a randomized, double-blinded, placebo-controlled parallel multi-center trial.

BACKGROUND: Riluzole is a sodium channel-blocking agent used in treating amyotrophic lateral sclerosis. It has been approved by the U.S. Food and Drug Administration, Canadian and Australian authorities, and in many other countries. A phase I trial of riluzole for acute spinal cord injury (SCI) provided safety and pharmacokinetic data and suggested neuroprotective benefits. A phase IIB/III double-blinded randomized controlled trial (RCT) started in January 2014 (https://clinicaltrials.gov, NCT01597518). This article describes the pathophysiological rationale, preclinical experience and design of the phase IIB/III RCT of Riluzole in Acute Spinal Cord Injury Study (RISCIS). OBJECTIVES: The primary objective of the trial is to evaluate the superiority of riluzole, at a dose of 100 mg BID in the first 24 h followed by 50 mg BID for the following 13 days post injury, compared with placebo in improving neurological motor outcomes in patients with C4-C8 level, International Standards for Neurological Classification of Spinal Cord Injury Examination (ISNCSCI) grade A, B or C acute (within 12 h post injury) SCI. SETTING: Acute trauma centers worldwideMethods:A double-blind, multi-center, placebo-controlled RCT will enroll 351 participants randomized 1:1 to riluzole and placebo. The primary end point is the change between 180 days and baseline in ISNCSCI Motor Score. This study has 90% power to detect a change of nine points in ISNCSCI Motor Score at one-sided α=0.025. RESULTS: Currently enrolling in 11 centers. CONCLUSION: This study will provide class I evidence regarding the safety and neuroprotective efficacy of riluzole in patients with acute cervical SCI.

Impact of psychological characteristics in self-management in individuals with traumatic spinal cord injury.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: To examine the association between psychological characteristics in self-management and probable depression status in individuals with a traumatic spinal cord injury (SCI). SETTING: Community-dwelling individuals with traumatic SCI living across Canada. METHODS: Individuals with SCI were recruited by email via the Rick Hansen Institute as well as an outpatient hospital spinal clinic. Data were collected by self-report using an online survey. Standardized questionnaires were embedded within a larger survey and included the Hospital Anxiety and Depression Scale (HADS), the short version of the Patient Activation Measure (PAM), the Moorong Self-Efficacy Scale (MSES) and the Pearlin-Schooler Mastery Scale (PMS). RESULTS: Individuals with probable depression (n=25) had lower self-efficacy (67.9 vs 94.2, P<0.0001), mastery (18.9 vs 22.9, P<0.0001) and patient activation (60.4 vs 71.6, P<0.0001) as well as higher anxiety (9.0 vs 5.5, P<0.0001), compared with their non-depressed counterparts (n=75). A logistic regression determined that lower self-efficacy and mastery scores as well as less time since injury were associated with depression status (P=0.002; P=0.02 and P=0.02, respectively). Individuals with higher anxiety scores were almost 1.5 times more likely to be depressed, while older age was positively associated with depression status (P=0.016 and P=0.024, respectively). CONCLUSION: Interventions for depression in SCI, including a self-management program, should target factors such as self-efficacy and mastery, which could improve secondary medical complications and overall quality of life.

Pathobiology of radiation myelopathy and strategies to mitigate injury.

STUDY DESIGN: This is a narrative review of the literature. OBJECTIVES: The objectives of this study were to review the current concepts underlying the pathobiology of radiation-induced spinal cord injury; to discuss potential biologic strategies to mitigate spinal cord injury following radiation; and to provide an update on the clinical guidelines to prevent injury in the era of image-guided stereotactic body radiotherapy (SBRT). SETTING: This study was conducted in Toronto, Canada. METHODS: A MEDLINE search was performed using the following terms: radiation injury; radiation myelopathy; CNS radiation injury; brain necrosis, radiation; demyelination, radiation; blood-brain barrier, radiation; white matter necrosis; and SBRT. RESULTS AND CONCLUSION: The biologic response of the spinal cord after radiation is a continuously evolving process. Death of vascular endothelial cells and disruption of the blood-spinal cord barrier leads to a complex injury response, resulting in demyelination and tissue necrosis. At present, there is no evidence that the pathobiology of cord injury after SBRT is different from that after standard fractionation. Although permanent myelopathy has become a rare complication following conventional fractionated radiation treatment, cases of radiation myelopathy have re-emerged with the increasing role of spine stereotactic body radiation therapy and reirradiation. Experimental biologic strategies targeting the injury response pathways hold promise in mitigating this dreaded late effect of radiation treatment.

International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set.

STUDY DESIGN: Survey of expert opinion, feedback and final consensus. OBJECTIVE: To describe the development and the variables included in the International Spinal Cord Injury (SCI) Spinal Interventions and Surgical Procedures Basic Data set. SETTING: International working group. METHODS: A committee of experts was established to select and define data elements. The data set was then disseminated to the appropriate committees and organizations for comments. All suggested revisions were considered and both the International Spinal Cord Society and the American Spinal Injury Association endorsed the final version. RESULTS: The data set consists of nine variables: (1) Intervention/Procedure Date and start time (2) Non-surgical bed rest and external immobilization, (3) Spinal intervention-closed manipulation and/or reduction of spinal elements, (4) Surgical procedure-approach, (5) Date and time of the completion of the intervention or surgical closure; (6) Surgical procedure-open reduction, (7) Surgical procedure-direct decompression of neural elements, and (8 and 9) Surgical procedure-stabilization and fusion (spinal segment number and level). All variables are coded using numbers or characters. Each spinal intervention and procedure is coded (variables 1 through 7) and the spinal segment level is described (variables 8 and 9). Sample clinical cases were developed to illustrate how to complete it. CONCLUSION: The International SCI Spinal Interventions and Surgical Procedures Basic Data Set was developed to facilitate comparisons of spinal interventions and surgical procedures among studies, centers and countries.

The current state-of-the-art of spinal cord imaging: methods.

A first-ever spinal cord imaging meeting was sponsored by the International Spinal Research Trust and the Wings for Life Foundation with the aim of identifying the current state-of-the-art of spinal cord imaging, the current greatest challenges, and greatest needs for future development. This meeting was attended by a small group of invited experts spanning all aspects of spinal cord imaging from basic research to clinical practice. The greatest current challenges for spinal cord imaging were identified as arising from the imaging environment itself; difficult imaging environment created by the bone surrounding the spinal canal, physiological motion of the cord and adjacent tissues, and small cross-sectional dimensions of the spinal cord, exacerbated by metallic implants often present in injured patients. Challenges were also identified as a result of a lack of "critical mass" of researchers taking on the development of spinal cord imaging, affecting both the rate of progress in the field, and the demand for equipment and software to manufacturers to produce the necessary tools. Here we define the current state-of-the-art of spinal cord imaging, discuss the underlying theory and challenges, and present the evidence for the current and potential power of these methods. In two review papers (part I and part II), we propose that the challenges can be overcome with advances in methods, improving availability and effectiveness of methods, and linking existing researchers to create the necessary scientific and clinical network to advance the rate of progress and impact of the research.

The current state-of-the-art of spinal cord imaging: applications.

A first-ever spinal cord imaging meeting was sponsored by the International Spinal Research Trust and the Wings for Life Foundation with the aim of identifying the current state-of-the-art of spinal cord imaging, the current greatest challenges, and greatest needs for future development. This meeting was attended by a small group of invited experts spanning all aspects of spinal cord imaging from basic research to clinical practice. The greatest current challenges for spinal cord imaging were identified as arising from the imaging environment itself; difficult imaging environment created by the bone surrounding the spinal canal, physiological motion of the cord and adjacent tissues, and small crosssectional dimensions of the spinal cord, exacerbated by metallic implants often present in injured patients. Challenges were also identified as a result of a lack of "critical mass" of researchers taking on the development of spinal cord imaging, affecting both the rate of progress in the field, and the demand for equipment and software to manufacturers to produce the necessary tools. Here we define the current state-of-the-art of spinal cord imaging, discuss the underlying theory and challenges, and present the evidence for the current and potential power of these methods. In two review papers (part I and part II), we propose that the challenges can be overcome with advances in methods, improving availability and effectiveness of methods, and linking existing researchers to create the necessary scientific and clinical network to advance the rate of progress and impact of the research.

Blood alcohol concentration as a determinant of outcomes after traumatic spinal cord injury.

BACKGROUND: Pre-clinical studies indicate a potential detrimental effect of ethanol on tissue sparing and locomotor recovery in animal models of spinal cord injury (SCI). Given this, an examination of whether blood alcohol concentration (BAC) is a potential determinant of survival and neurological and functional recovery after acute traumatic SCI was carried out. METHODS: All patients who were enrolled in the Third National Spinal Cord Injury Study (NASCIS-3) were included. The study population was divided into 'non-alcohol' (BAC equal to 0‰), 'legal' (BAC greater than 0 up to 0.8‰) and 'illegal' (BAC greater than 0.8‰) subgroups. Outcome measures included survival, NASCIS motor and sensory scores, NASCIS pain scores and Functional Independence Measure (FIM) determinants at baseline and at 6 weeks, 6 months and 1 year post-SCI. Analyses were adjusted for major potential confounders: age, sex, ethnicity, trial protocol, Glasgow coma score, and cause, level and severity of SCI. RESULTS: Among 499 patients (423 males and 76 females; ages from 14 to 92 years), the mean BAC was 0.054 ± 0.006‰ (range 0-1). The survival at 1 year (94.4%) was not associated with the BAC (P = 0.374). Moreover, BAC was not significantly correlated with motor recovery (P > 0.166), sensory recovery (P > 0.323), change in pain score (P > 0.312) or functional recovery (P > 0.133) at 6 weeks, 6 months and 1 year post-SCI. CONCLUSIONS: Our results, for the first time, show that the BAC at emergency admission does not adversely affect the patients' mortality, neurological impairment or functional disability over the course of the first year after SCI.

Management strategies to optimize clinical outcomes after acute traumatic spinal cord injury: integration of medical and surgical approaches.

Although spinal cord injury (SCI) is approximately one-tenth as common as traumatic brain injury, its effects, at both a personal and societal level, are particularly devastating. At present, there is no single therapy that has demonstrated a uniform ability to improve neurological outcomes for SCI patients at long-term follow-up. In spite of this, the last 30 years have borne witness to numerous incremental advances within the field of spinal trauma including the incorporation of standardized neurological assessment tools, the completion of several large therapeutic efficacy trials and the development of modern day surgical classification systems. In this article we review the current evidence surrounding the medical and surgical management of SCI, as well as identify areas where future research is needed.

The Rick Hansen Spinal Cord Injury Registry (RHSCIR): a national patient-registry.

STUDY DESIGN: Development of a prospective patient registry. OBJECTIVE: To develop a patient registry for persons with traumatic spinal cord injuries (SCI), which can be used to answer research questions and improve patient outcomes. SETTING: Nine provinces in Canada. METHODS: The Rick Hansen Spinal Cord Injury Registry (RHSCIR) is part of the Translational Research Program of the Rick Hansen Institute. The launch of RHSCIR in 2004 heralded the initiation of the first nation-wide SCI patient registry within Canada. Currently, RHSCIR is being implemented in 14 cities located in 9 provinces, and there are over 1500 individuals who have sustained an acute traumatic SCI registered to date. Data are captured from the pre-hospital, acute and rehabilitation phases of care, and participants are followed in the community at 1, 2, 5 and then every 5 years post-injury. RESULTS: During the development of RHSCIR, there were many challenges that were overcome in selecting data elements, establishing the governance structure, and creating a patient privacy and confidentiality framework across multiple provincial jurisdictions. The benefits of implementing a national registry are now being realized. The collection of an internationally standardized set of clinical information is helping inform clinicians of beneficial interventions and encouraging a shift towards evidence-based practices. Furthermore, through RHSCIR, a network is forming amongst SCI clinicians and researchers, which is fostering new collaborations and the launch of multi-center clinical trials. CONCLUSIONS: For networks that are establishing SCI registries, the experiences and lessons learned in the development of RHSCIR may provide useful insights and guidance.

International spinal cord injury spinal column injury basic data set.

STUDY DESIGN: Survey of expert opinion, feedback and final consensus. OBJECTIVES: To describe the development of the International Spinal Cord Injury (SCI) Spinal Column Injury Basic Data Set. SETTING: International working group. METHODS: A committee of experts was established to select and define data elements. The data set was then disseminated to the appropriate committees and organizations for comment. All suggested revisions were considered and the final version was endorsed by both the International Spinal Cord Society (ISCoS) and the American Spinal Injury Association (ASIA). RESULTS: The data set consists of seven variables: (1) penetrating or blunt injury, (2) spinal column injury(ies), (3) single or multiple level spinal column injury(ies), (4) spinal column injury level number, (5) spinal column injury level, (6) disc and/or posterior ligamentous complex injury and (7) traumatic translation. All variables are coded using numbers or characters. For variables 1, 2, 3, 4, 6 and 7, response categories are assigned a numeric point score. Variable 5 assigns both characters and numbers to identify level(s) of spinal injured vertebra(e). When there are several distinct and separate levels of injury, then each one is described using variables 4 through 7. CONCLUSION: The International SCI Spinal Column Injury Basic Data Set was developed to facilitate comparisons of spinal column injury data among studies, centres and countries. This data set is part of the National Institute of Neurological Disorders and Stroke Common Data Element project, and tools are now available to assist investigators in collecting this data in their SCI clinical studies.

Early versus late surgery for traumatic spinal cord injury: the results of a prospective Canadian cohort study.

STUDY DESIGN: A multicenter Canadian cohort study. OBJECTIVES: The objective of this study is to evaluate the impact of early versus late surgical decompression on motor neurological recovery after traumatic spinal cord injury (SCI). SETTING: Canadian acute care and SCI rehabilitation facilities. METHODS: A prospective cohort study of patients within the Ontario Spinal Cord Injury Registry program was performed. We considered SCI patients with an admission American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade of A through D, with magnetic resonance imaging-confirmed spinal cord compression. Grouped analysis was performed comparing the cohort of patients who received early surgery (<24 h after SCI) to those receiving delayed surgery (<24 h after SCI). The primary outcome was the change in ASIA motor score (AMS) occurring between hospital admission and rehabilitation discharge. RESULTS: A total of 35 (41.7%) patients underwent early surgery and 49 (58.3%) underwent late surgery. At admission, there was a greater proportion of patients within the early surgery group with more severe AIS grade A injuries. Of the 55 patients with neurological exam available at rehabilitation discharge, a greater proportion had at least a two-grade AIS improvement in the early-surgery group (P=0.01). The mean improvement in AMS at rehabilitation discharge was 20 points amongst early-surgery patients and 15 points amongst late-surgery patients (P=0.46). In the analysis investigating AMS improvement, adjusted for preoperative status and neurological level, there was a positive effect estimate for early surgical therapy that was statistically significant (P=0.01). CONCLUSION: The results here add weight to the growing body of literature, which supports the principle of early intervention in the setting of spinal trauma and SCI.

Myxopapillary ependymoma: correlation of clinical and imaging features with surgical resectability in a series with long-term follow-up.

STUDY DESIGN: Retrospective case series. OBJECTIVES: The objective of this study is to identify imaging and intraoperative characteristics that may predict surgical resection for myxopapillary ependymoma (MPE). The diffuse involvement in the conus-filum region makes complete resection challenging. The preoperative characteristics that may estimate the extent of resection has not been reported. SETTING: Toronto, Canada. METHODS: All MPE cases between 1972 and 2005 at a single institution were identified and reexamined by a neuropathologist. Neurological outcomes (Frankel scale), clinical features, operative findings, pre and postoperative imaging results were reviewed. RESULTS: A total of 18 operations were performed on 15 MPE patients (8 females/7 males; age range: 18-71 years). Median postoperative follow-up was 56 months. Three patients (17%) developed tumor regrowth requiring reoperations. Preoperative magnetic resonance imaging (MRI; in 14/18 procedures) determined that tumors involved the conus in 70% of cases, which was significantly associated with intraoperative findings (P=0.02). Complete microsurgical resection was accomplished in 4 out of 7 cases where conus was not involved, but in only 1 out of 10 cases with conus involvement (P=0.056). The degree of conus involvement in one case was unclear. None of patients with total surgical resection developed recurrence. All patients survived at long-term follow-up. CONCLUSION: Our series is the first to correlate MPE involvement to conus medullaris on preoperative MRI with intraoperative findings, and examine its significance on surgical resectability. This information could guide clinicians in preoperative planning and advising patients on treatment options and potential risks/benefits. MRI is very sensitive (100%) and moderately specific (67%) in detecting direct anatomical contact between conus and MPE tumors.

A systematic review of the evidence supporting a role for vasopressor support in acute SCI.

STUDY DESIGN: A systematic review of clinical and preclinical literature. OBJECTIVE: To critically evaluate the evidence supporting a role for vasopressor support in the management of acute spinal cord injury and to provide updated recommendations regarding the appropriate clinical application of this therapeutic modality. BACKGROUND: Only few clinical studies exist examining the role of arterial pressure and vasopressors in the context of spinal cord trauma. METHODS: Medical literature was searched from the earlier available date to July 2009 and 32 articles (animal and human literature) answering the following four questions were studied: what patient groups benefit from vasopressor support, which is the optimal hypertensive drug regimen, which is the optimal duration of the treatment and which is the optimal arterial blood pressure. Outcome measures used were the incidence of patients needing vasopressors, the increase of arterial blood pressure and neurologic improvement. RESULTS: Patients with complete cervical cord injuries required vasopressors more frequently than either incomplete injuries or thoracic/lumbar cord injuries (P<0.001). There was no statistical difference in neurologic improvement between patients on vasopressor support with a mean arterial pressure (MAP) of less than 85 mm Hg and those with MAP less than 90 mm Hg. Duration of treatment is often recommended between 5 and 7 days although this is not supported by high-level evidence and no single vasopressor appeared superior over the variety used in clinical treatment. CONCLUSION: There is currently no gold standard on vasopressor support. Based on non-randomized human studies, complete cervical cord injuries require vasopressors more frequently than other spinal cord injuries.

Diagnostic criteria of traumatic central cord syndrome. Part 2: a questionnaire survey among spine specialists.

STUDY DESIGN: A questionnaire survey. OBJECTIVES: To evaluate the need for the introduction of quantitative diagnostic criteria for the traumatic central cord syndrome (TCCS). SETTING: An online questionnaire survey with participants from all over the world. METHODS: An invitation to participate in an eight-item online survey questionnaire was sent to surgeon members of AOSpine International. RESULTS: Out of 3340 invited professionals, 157 surgeons (5%) from 41 countries completed the survey. Whereas most of the respondents (75%) described greater impairment of the upper extremities than of the lower extremities in their own TCCS definitions, symptoms such as sensory deficit (39%) and bladder dysfunctions (24%) were reported less frequently. Initially, any difference in motor strength between the upper and lower extremities was considered most frequently (23%) as a 'disproportionate' difference in power. However, after presenting literature review findings, the majority of surgeons (61%) considered a proposed difference of at least 10 points of power (based on the Medical Research Council scale) in favor of the lower extremities as an acceptable cutoff criterion for a diagnosis of TCCS. Most of the participants (40%) felt that applying a single criterion to the diagnosis of TCCS is insufficient for research purposes. CONCLUSION: Various definitions of TCCS were used by physicians involved in the spinal trauma care. The authors consider a difference of at least 10 motor score points between upper and lower extremity power a clear diagnostic criterion. For clinical research purposes, this diagnostic criterion can be considered as a face valid addendum to the commonly applied TCCS definition as introduced by Schneider et al.

Attitudes towards the older patients with spinal cord injury among registered nurses: a cross-sectional observational study.

STUDY DESIGN: Cross-sectional observational study. SETTING: Acute-care unit and tertiary rehabilitation centre in Ontario, Canada. OBJECTIVE: To evaluate attitudes towards older patients among nurses caring for individuals with spinal cord injury (SCI), and examine potential determinants of ageist attitudes. METHODS: Using Kogan's Old People Scale, this questionnaire-based survey assesses attitudes towards older patients among registered nurses working in an acute-care unit, registered nurses working in a rehabilitation centre and individuals with chronic SCI. RESULTS: Although individuals with SCI and nurses working in the rehabilitation setting were statistically comparable regarding their attitudes towards older patients, nurses working in the acute-care unit hold more ageist attitudes than their rehabilitation-nursing counterparts (P=0.003). Among nurses, a higher level of education and working in the rehabilitation setting were associated with fewer ageist attitudes (P<0.03). There was a trend for an association between older age and more positive attitudes towards older patients (P=0.069). CONCLUSIONS: Our questionnaire-based survey, which appears to represent the population of interest, identified significant differences in the attitudes towards older patients between nurses working in the acute-care setting versus rehabilitation setting who showed similar attitudes towards individuals with SCI. The most reliable factor associated with the nurses' attitudes was their level of education. Given that the practice of ageism has the potential to prejudice service provision and ultimately recovery of patients with SCI, further research and knowledge dissemination activities for nurses caring for elderly patients with SCI should be sought.

The p75 neurotrophin receptor is essential for neuronal cell survival and improvement of functional recovery after spinal cord injury.

The mechanisms initiating post-spinal cord injury (SCI) apoptotic cell death remain incompletely understood. The p75 neurotrophin receptor (p75(NTR)) has been shown to exert both pro-survival and pro-apoptotic effects on neural cells in vitro. While a previous study had shown that there is decreased oligodendrocyte apoptosis distal to a clean partial transection injury of the cord in mice with nonfunctional p75(NTR), most human spinal cord injuries do not involve partial transections but are rather due to compression/contusion injuries with significant perilesional ischemia. Therefore, we sought to examine the role of the p75(NTR) in a clinically relevant clip compression model of SCI in p75 null mice with an exon III mutation. Mice with a functional p75(NTR) had increased caspase-9 activation at 3 days after SCI in comparison to the functionally deficient p75(NTR) mice. However, at 7 days following SCI there was no difference in the activation of the effector caspases (caspase-3 and caspase-6) at the spinal cord lesion. Moreover, at 7 days after injury, there was increased terminal deoxynucleotidyl transferase-mediated dUTP nick-end (TUNEL) positive cell death at the injury site in the functionally deficient p75(NTR) mice. Using double labeling with TUNEL and cell specific markers we showed that the absence of p75(NTR) function increased the extent of neuronal but not oligodendroglial cell death at the injury site. This selective loss of neuronal cells after SCI was confirmed with a decrease in levels of microtubule-associated protein 2 in the p75 null mice. Furthermore, the wild-type animals had dramatically improved survival and enhanced locomotor recovery at 8 weeks after SCI when compared with the p75(NTR) null mice. Also at 8 weeks, there were significantly more neurons present at the injury site of wild-type mice when compared with p75 null mice. We conclude that the p75(NTR) receptor is integral to neuronal cell survival and endogenous reparative mechanisms after compressive/contusive SCI.