Diffusion Tensor Imaging in Diagnosing and Evaluating Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review. OBJECTIVE: Degenerative cervical myelopathy (DCM) is a common spinal cord disorder necessitating surgery. We aim to explore how effectively diffusion tensor imaging (DTI) can distinguish DCM from healthy individuals and assess the relationship between DTI metrics and symptom severity. METHODS: We included studies with adult DCM patients who had not undergone decompressive surgery and implemented correlation analyses between DTI parameters and severity, or compared healthy controls and DCM patients. RESULTS: 57 studies were included in our meta-analysis. At the maximal compression (MC) level, fractional anisotropy (FA) exhibited lower values in DCM patients, while apparent diffusion coefficient (ADC), mean diffusivity (MD), and radial diffusivity (RD) were notably higher in the DCM group. Moreover, our investigation into the diagnostic utility of DTI parameters disclosed high sensitivity, specificity, and area under the curve values for FA (.84, .80, .83 respectively) and ADC (.74, .84, .88 respectively). Additionally, we explored the correlation between DTI parameters and myelopathy severity, revealing a significant correlation of FA (.53, 95% CI:0.40 to .65) at MC level with JOA/mJOA scores. CONCLUSION: Current guidelines for DCM suggest decompressive surgery for both mild and severe cases. However, they lack clear recommendations on which mild DCM patients might benefit from conservative treatment vs immediate surgery. ADC's role here could be pivotal, potentially differentiating between healthy individuals and DCM. While it may not correlate with symptom severity, it might predict surgical outcomes, making it a valuable imaging biomarker for clearer management decisions in mild DCM.

Comparison of Traumatic Spinal Fracture Patterns Between Motorcyclists and Occupants of Other Non-heavy Motor Vehicles: A Report from the National Spinal Cord and Column Injury Registry of Iran (NSCIR-IR).

OBJECTIVES: To compare traumatic spinal injury patterns between motorcyclists and occupants of other non-heavy motor vehicles using data from the National Spinal Cord and Column Injury Registry of Iran (NSCIR-IR). METHODS: All drivers/riders and passengers of motorcycles, cars, pick-up trucks, and vans registered between January 2017 to July 2023, met the inclusion criteria for the present study. The logistic regression models were used to compare the patterns of vertebral fracture between the two groups. RESULTS: 1726 spinal fracture patients were identified, 385 (22.3%) motorcyclists and 1341 (77.7%) car occupants with mean ages 33.2±14.3 and 36.1±13.6 years, respectively (P<0.001). Only 45 (11.7%) motorcyclists used helmets, whereas 856 (63.8%) car occupants used seat belts (P<0.001). The average numbers of fractured vertebrae were 3.9±1.4 and 3.7±1.1 among car occupants and motorcyclists, respectively (P=0.004). The proportions of motorcyclists and car occupants with injuries in each spinal region are as follows: lumbar (50.5% of motorcyclists vs. 40.4% of car occupants; P=0.003), thoracic (39.2% vs. 30.9%; P=0.01), cervical (24.3% vs. 37.0%; P<0.001) and sacral (1.3% vs. 7.5%; P<0.001). The AO Spine type C injuries were present in 6.1% of motorcyclists and 10.1% of car occupants (P=0.03). CONCLUSION: Motorcyclists were younger, less educated, had a higher proportion of males, and less commonly used safety devices than car occupants. The most commonly fractured spine region among both groups was the lumbar region. The cervical and sacral vertebrae fractures were significantly more common in car occupants, whereas the thoracic and lumbar vertebrae fractures were significantly more common in motorcyclists.

Patterns and outcomes of patients with abdominal injury: a multicenter study from Iran.

BACKGROUND: Injury is one of the leading causes of death worldwide, and the abdomen is the most common area of trauma after the head and extremities. Abdominal injury is often divided into two categories: blunt and penetrating injuries. This study aims to determine the epidemiological and clinical characteristics of these two types of abdominal injuries in patients registered with the National Trauma Registry of Iran (NTRI). METHODS: This multicenter cross-sectional study was conducted with data from the NTRI from July 24, 2016, to May 21, 2023. All abdominal trauma patients defined by the International Classification of Diseases; 10th Revision (ICD-10) codes were enrolled in this study. The inclusion criteria were one of the following: hospital length of stay (LOS) of more than 24 h, fatal injuries, and trauma patients transferred from the ICU of other hospitals. RESULTS: Among 532 patients with abdominal injuries, 420 (78.9%) had a blunt injury, and 435 (81.7%) of the victims were men. The most injured organs in blunt trauma were the spleen, with 200 (47.6%) and the liver, with 171 (40.7%) cases, respectively. Also, the colon and small intestine, with 42 (37.5%) cases, had the highest number of injuries in penetrating injuries. Blood was transfused in 103 (23.5%) of blunt injured victims and 17 (15.2%) of penetrating traumas (p = 0.03). ICU admission was significantly varied between the two groups, with 266 (63.6%) patients in the blunt group and 47 (42%) in penetrating (p < 0.001). Negative laparotomies were 21 (28%) in penetrating trauma and only 11 (7.7%) in blunt group (p < 0.001). In the multiple logistic regression model after adjusting, ISS ≥ 16 increased the chance of ICU admission 3.13 times relative to the ISS 1-8 [OR: 3.13, 95% CI (1.56 to 6.28), P = 0.001]. Another predictor was NOM, which increased ICU chance 1.75 times more than OM [OR: 1.75, 95% CI (1.17 to 2.61), p = 0.006]. Additionally, GCS 3-8 had 5.43 times more ICU admission odds than the GCS 13-15 [OR:5.43, 95%CI (1.81 to 16.25), P = 0.002] respectively. CONCLUSION: This study found that the liver and spleen are mostly damaged in blunt injuries. Also, in most cases of penetrating injuries, the colon and small intestine had the highest frequency of injuries compared to other organs. Blunt abdominal injuries caused more blood transfusions and ICU admissions. Higher ISS, lower GCS, and NOM were predictors of ICU admission in abdominal injury victims.

Which Demographic and Clinical Characteristics Can Better Predict the Length of Hospital Stay among Traumatic Patients? A Retrospective Single-Center, Registry-Based Study.

Background: Lengthy hospitalization may lead to an increased hospital-acquired patient complication, including infections, as well as increased costs for both healthcare systems and patients. A few studies evaluated the impact of various clinical and demographic variables on patients' length of stay (LOS). Hence, in this study, we aimed to investigate the impact of various variables on traumatic patients' LOS. Methods: This is a retrospective single-center, registry-based study of traumatic patients admitted to Taleqani, a major trauma center in Kermanshah, Iran. A Minimal Dataset (MDS) was developed to retrieve traumatic data on demographic and clinical aspects. We used univariable and multiple quantile regression models to evaluate the association between independent variables, including ISS, GCS, and SBP, with LOS. LOS is practically defined as the time interval between hospital admission and discharge. The LOS durations have been presented as median (Q1 to Q3) hours. A p-value of <0.05 was considered statistically significant. Results: A total of 2708 cases were included in this study, with 1989 (73.4%) of them being male. The median LOS was 87.00 (48.00 to 144.00) hours. When adjusted for systolic blood pressure (SBP), Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and cause of injury, the two characteristics of spine/back and multiple trauma were significantly associated with the higher LOS, with 43 (20.5 to 65.48) and 24 (10.39 to 37.60) hours more than extremities (P < 0.001 and P = 0.005). Besides, the patients admitted due to road traffic injuries (RTI) were discharged 16 and 41 hours later than falling and cutting/stabbing (P = 0.008 and < 0.001, respectively). Moreover, the patients with ISS≥16 and 9≤ISS≤15 had a median of 51 (21 to 80) and 34 (22 to 45) LOS hours more, compared to 1≤ISS≤8, respectively (P < 0.001). The trauma cases experiencing SBP ≤ 90 mmhg on admission had a median of 41 (20 to 62) hours more hospitalization period than those with SBP> 90 mmhg (P < 0.001). At last, the patients with GCS of 9 to 12 and GCS of 3 to 8 were hospitalized for 39 and 266 hours more than GCS of 13 to 15 (P < 0.001). Conclusion: Determining independent determinants of prolonged LOS may lead to better identifying at-risk patients on admission. Trauma care providers should consider the following risk factors for increased LOS: higher ISS, Lower GCS, and SBP, multiple trauma or spine injury, and trauma resulting from falling or cutting/stabbing. As a result, the impact of extended LOS might be reduced by intervening in the related influencing factors.

Factors affecting sexual health in individuals with spinal cord injury: A systematic scoping review.

PURPOSE: This study aims to review the literature to explore some factors affecting sexual and partnership adjustment in individuals with spinal cord injury (SCI). METHODS: This study was based on the methodological framework of scoping reviews, including 3 methodological steps: (1) identifying relevant studies (searching for related studies); (2) selecting related studies; (3) collecting key findings, summarizing, and reporting the results. The electronic databases were searched including Medline (PubMed), Scopus, Web of Science, Embase, and Cochrane Library. Studies were included if they reported data about the related factors of sexual and partnership adjustment in individuals with SCI. No limitations were considered in terms of time or methodology of the search. RESULTS: After the full-text screening, 52 studies were included from the year of 1978 - 2019 with various methodologies. The present review demonstrated that proper sexual health among individuals with SCI is related to several factors including the anatomical factor, level of the injury, completeness of the injury, psycho-social factor, socio-economic status, and type of relationship. CONCLUSION: With consideration of factors affecting sexual and partnership adjustment in individuals with SCI, a better estimation of sexual health can be achieved in clinical to improve the relationship and quality of life.

Revealing the role of material properties in impact-related injuries: Investigating the influence of brain and skull density variations on head injury severity.

Traumatic brain injuries (TBI) resulting from head impacts are a major public health concern, which prompted our research to investigate the complex relationship between the material properties of brain tissue and the severity of TBI. The goal of this research is to investigate how variations in brain and skull density influence the vulnerability of brain tissue to traumatic injury, thereby enhancing our understanding of injury mechanism. To achieve this goal, we employed a well-validated finite element head model (FEHM). The current investigation was divided into two phases: in the first one, three distinct brain viscoelastic materials that had been utilized in prior studies were analyzed. The review of the properties of these three materials has been meticulous, encompassing both the spectrum of mechanical properties and the behaviors that are relevant to the way in which brain tissue reacts to traumatic loading conditions. In the second phase, the material properties of both the brain and skull tissue, alongside the impact conditions, were held constant. After this step, the focus was directed towards the variation of density in the brain and skull, which was consistent with the results obtained from previous experimental investigations, in order to determine the precise impact of these variations in density. This approach allowed a more profound comprehension of the impacts that density had on the simulation results. In the first phase, Material No. 2 exhibited the highest maximum first principal strain value in the frontal region (εmax=15.41%), indicating lower stiffness to instantaneous deformation. This characteristic suggests that Material No. 2 may deform more extensively upon impact, potentially increasing the risk of injury due to its viscoelastic behavior. In contrast, Material No. 1, with a lower maximum first principal strain in the frontal region (εmax=7.87%), displayed greater stiffness to instantaneous deformation, potentially reducing the risk of brain injury upon head impact. The second phase provided quantitative findings revealing a proportional relationship between brain tissue density and the pressures experienced by the brain. A 2 % increase in brain tissue density corresponded to approximately a 1 % increase in pressure on the brain tissue. Similarly, changes in skull density exhibited a similar quantitative relationship, with a 6 % increase in skull density leading to a 2.5 % increase in brain pressure. This preliminary approximate ratio of 2 to 1 between brain and skull density variations provides an initial quantitative framework for assessing the impact of density changes on brain vulnerability. These findings have several implications for the development of protective measures and injury prevention strategies, particularly in contexts where head trauma is a major issue.

The prevalence of helmet use in motorcyclists around the world: a systematic review and meta-analysis of 5,006,476 participants.

Road traffic injuries present a significant public health burden, especially in developing countries. This systematic review and meta-analysis synthesized global evidence on motorcycle helmet use prevalence by including 299 records across 249 articles involving 5,006,476 participants from 1982 to 2022. The findings revealed a declining trend in helmet use prevalence over the past four decades, with an overall prevalence of 48.71%. The meta-regression analysis did not find any statistically significant change in the overall prevalence. Subgroup analysis showed higher helmet use prevalence in observation/survey records (54.29%) compared to crashed patient records (44.84%). Riders/Motorcyclists demonstrated a higher likelihood of wearing helmets than passengers in both observation/survey records (62.61 vs. 28.23%) and crashed patient records (47.76 vs. 26.61%). Countries with mandatory helmet use laws had higher helmet usage prevalence compared to those without (52.26 vs. 37.21%). The African continent had the lowest helmet use rates, while Latin America and the Caribbean regions had higher rates. This study provides a comprehensive overview of global helmet use prevalence, emphasizing disparities between high and low-income countries, variations in law enforcement, and trends over four decades. Targeted interventions are necessary to improve helmet-wearing habits, especially among passengers and regions with low usage rates. Effective legislation and awareness campaigns are crucial for promoting helmet use and reducing road traffic injuries burden.

Comparison of nine trauma scoring systems in prediction of inhospital outcomes of pediatric trauma patients: a multicenter study.

Hereby, we aimed to comprehensively compare different scoring systems for pediatric trauma and their ability to predict in-hospital mortality and intensive care unit (ICU) admission. The current registry-based multicenter study encompassed a comprehensive dataset of 6709 pediatric trauma patients aged ≤ 18 years from July 2016 to September 2023. To ascertain the predictive efficacy of the scoring systems, the area under the receiver operating characteristic curve (AUC) was calculated. A total of 720 individuals (10.7%) required admission to the ICU. The mortality rate was 1.1% (n = 72). The most predictive scoring system for in-hospital mortality was the adjusted trauma and injury severity score (aTRISS) (AUC = 0.982), followed by trauma and injury severity score (TRISS) (AUC = 0.980), new trauma and injury severity score (NTRISS) (AUC = 0.972), Glasgow coma scale (GCS) (AUC = 0.9546), revised trauma score (RTS) (AUC = 0.944), pre-hospital index (PHI) (AUC = 0.936), injury severity score (ISS) (AUC = 0.901), new injury severity score (NISS) (AUC = 0.900), and abbreviated injury scale (AIS) (AUC = 0.734). Given the predictive performance of the scoring systems for ICU admission, NTRISS had the highest predictive performance (AUC = 0.837), followed by aTRISS (AUC = 0.836), TRISS (AUC = 0.823), ISS (AUC = 0.807), NISS (AUC = 0.805), GCS (AUC = 0.735), RTS (AUC = 0.698), PHI (AUC = 0.662), and AIS (AUC = 0.651). In the present study, we concluded the superiority of the TRISS and its two derived counterparts, aTRISS and NTRISS, compared to other scoring systems, to efficiently discerning individuals who possess a heightened susceptibility to unfavorable consequences. The significance of these findings underscores the necessity of incorporating these metrics into the realm of clinical practice.

Development and psychometric properties of appraisals of post traumatic spinal cord injury health scale in Iran.

STUDY DESIGN: Development and psychometrics study OBJECTIVE: To evaluate the reliability and validity of a new version of Appraisals of Post-Traumatic Spinal Cord Injury Health Scale (APTSCIHS) in the Persian language for persons with spinal cord injury (SCI). SETTING: The persons were selected from National Spinal Cord Injury Registry of Iran (NSCIR-IR) and Brain and Spinal Cord Injury Research center (BASIR). METHOD: This was a mixed sequential exploratory study that performed in two phases. In the qualitative phase, a systematic scoping review and 12 interviews with the participants were done. Finally, items were generated. In the quantitative phase, face, content, construct and convergent validity were assessed to evaluate validity. To evaluate construct validity, a cross-sectional study was conducted on 305 persons with TSCI along with internal consistency and stability assessments. All quantitative data analyses were conducted using SPSS 22 software. RESULTS: The content validity and reliability were indicated by Scale's Content Validity Ratio (S-CVR) = 0.73 and Scale's Content Validity Index (S-CVI) = 0.86, Cronbach's α = 0.9 and the Test re-test reliability using intra-class correlations were (ICC) = 0.97 to 0.98. Exploratory factor analysis determined eight factors which showed more than 52% of the variance. APTSCIHS had a significant and strong correlation with Appraisals of DisAbility Primary and Secondary Scale (ADAPSS) (r = 0.475, P < 0.001). CONCLUSION: Results showed the 36 items APTSCIHS tool had an acceptable validity and reliability in Iran, and it can help health care providers or even administrators improve the quality of the rehabilitation services and quality of life.

Development of a regional-based predictive model of incidence of traumatic spinal cord injury using machine learning algorithms.

Objective: To develop a predictive model of incidence of traumatic spinal cord injury (TSCI). Methods: The data for training the model included both the incidence data and the covariates. The incidence data were extracted from systematic reviews and the covariates were extracted from data available in the international road federation database. Then the feature processing measures were taken. First we defined a hyper-parameter, missing-value threshold, in order to eliminate features that exceed this threshold. To tackle the problem of overfitting of model we determined the Pearson correlation of features and excluded those with more than 0.7 correlation. After feature selection three different models including simple linear regression, support vector regression, and multi-layer perceptron were examined to fit the purposes of this study. Finally, we evaluated the model based on three standard metrics: Mean Absolute Error, Root Mean Square Error, and R2. Results: Our machine-learning based model could predict the incidence rate of TSCI with the mean absolute error of 4.66. Our model found "Vehicles in use, Total vehicles/Km of roads", "Injury accidents/100 Million Veh-Km", "Vehicles in use, Vans, Pick-ups, Lorries, Road Tractors", "Inland surface Passengers Transport (Mio Passenger-Km), Rail", and "% paved" as top predictors of transport-related TSCI (TRTSCI). Conclusions: Our model is proved to have a high accuracy to predict the incidence rate of TSCI for countries, especially where the main etiology of TSCI is related to road traffic injuries. Using this model, we can help the policymakers for resource allocation and evaluation of preventive measures.

An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery.

STUDY DESIGN: Clinical practice guideline development. OBJECTIVES: Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). METHODS: A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS: The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. CONCLUSIONS: It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery.

STUDY DESIGN: Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. OBJECTIVE: The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. METHODS: All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. RESULTS: Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. CONCLUSION: We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.

Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury in the Setting of Spine Surgery: A Proposed Care Pathway.

STUDY DESIGN: This study is a mixed methods approach. OBJECTIVES: Intraoperative spinal cord injury (ISCI) is a challenging complication in spine surgery. Intra-operative neuromonitoring (IONM) has been developed to detect changes in neural function. We report on the first multidisciplinary, international effort through AO Spine and the Praxis Spinal Cord Institute to develop a comprehensive guideline and care pathway for the prevention, diagnosis, and management of ISCI. METHODS: Three literature reviews were registered on PROSPERO (CRD 42022298841) and performed according to PRISMA guidelines: (1) Definitions, frequency, and risk factors for ISCI, (2) Meta-analysis of the accuracy of IONM for diagnosis of ISCI, (3) Reported management approaches for ISCI and related events. The results were presented in a consensus session to decide the definition of IONM and recommendation of its use in high-risk cases. Based on a literature review of management strategies for ISCI, an intra-operative checklist and overall care pathway was developed by the study team. RESULTS: An operational definition and high-risk patient categories for ISCI were established. The reported incidence of deficits was documented to be higher in intramedullary tumour spine surgery. Multimodality IONM has a high sensitivity and specificity. A guideline recommendation of IONM to be employed for high-risk spine cases was made. The different sections of the intraoperative checklist include surgery, anaesthetic and neurophysiology. The care pathway includes steps (1) initial clinical assessment, (2) pre-operative planning, (3) surgical/anaesthetic planning, (4) intra-operative management, and (5) post-operative management. CONCLUSIONS: This is the first evidence based comprehensive guideline and care pathway for ISCI using the GRADE methodology. This will facilitate a reduction in the incidence of ISCI and improved outcomes from this complication. We welcome the wide implementation and validation of these guidelines and care pathways in prospective, multicentre studies.

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management.

STUDY DESIGN: Clinical practice guideline development following the GRADE process. OBJECTIVES: Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets. METHODS: A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences. RESULTS: The GDG suggested that MAP should be augmented to at least 75-80 mmHg as the "lower limit," but not actively augmented beyond an "upper limit" of 90-95 mmHg in order to optimize spinal cord perfusion in acute traumatic SCI. The quality of the evidence around the "target MAP" was very low, and thus the strength of this recommendation is weak. For duration of hemodynamic management, the GDG "suggested" that MAP be augmented for a duration of 3-7 days. Again, the quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence. CONCLUSION: We provide new recommendations for blood pressure management after acute SCI that acknowledge the limitations of the current evidence on the relationship between MAP and neurologic recovery. It was felt that the low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines. While important knowledge gaps still remain regarding hemodynamic management, these recommendations represent current perspectives on the role of MAP augmentation for acute SCI.

Reprogramming of astrocytes to neuronal-like cells in spinal cord injury: a systematic review.

STUDY DESIGN: A Systematic Review OBJECTIVES: To determine the therapeutic efficacy of in vivo reprogramming of astrocytes into neuronal-like cells in animal models of spinal cord injury (SCI). METHODS: PRISMA 2020 guidelines were utilized, and search engines Medline, Web of Science, Scopus, and Embase until June 2023 were used. Studies that examined the effects of converting astrocytes into neuron-like cells with any vector in all animal models were included, while conversion from other cells except for spinal astrocytes, chemical mechanisms to provide SCI models, brain injury population, and conversion without in-vivo experience were excluded. The risk of bias was calculated independently. RESULTS: 5302 manuscripts were initially identified and after eligibility assessment, 43 studies were included for full-text analysis. After final analysis, 13 manuscripts were included. All were graded as high-quality assessments. The transduction factors Sox2, Oct4, Klf4, fibroblast growth factor 4 (Fgf4) antibody, neurogenic differentiation 1 (Neurod1), zinc finger protein 521 (Zfp521), ginsenoside Rg1, and small molecules (LDN193189, CHIR99021, and DAPT) could effectively reprogramme astrocytes into neuron-like cells. The process was enhanced by p21-p53, or Notch signaling knockout, valproic acid, or chondroitin sulfate proteoglycan inhibitors. The type of mature neurons was both excitatory and inhibitory. CONCLUSION: Astrocyte reprogramming to neuronal-like cells in an animal model after SCI appears promising. The molecular and functional improvements after astrocyte reprogramming were demonstrated in vivo, and further investigation is required in this field.

Correlation Between Pre-Operative Diffusion Tensor Imaging Indices and Post-Operative Outcome in Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review. OBJECTIVES: The correlation between pre-operative diffusion tensor imaging (DTI) metrics and post-operative clinical outcomes in patients with degenerative cervical myelopathy (DCM) has been widely investigated with different studies reporting varied findings. We conducted a systematic review to determine the association between DTI metric and clinical outcomes after surgery. METHODS: We identified relevant articles that investigated the relationship between pre-operative DTI indices and post-operative outcome in DCM patients by searching PubMed/MEDLINE, Web of Science, Scopus, and EMBASE from inception until October 2023. In addition, quantitative synthesis and meta-analyses were performed. RESULTS: FA was significantly correlated with postoperative JOA or mJOA across all age and follow up subgroups, changes observed in JOA or mJOA from preoperative to postoperative stages (Δ JOA or Δ mJOA) in subgroups aged 65 and above and in those with a follow-up period of 6 months or more, as well as recovery rate in all studies pooled together and also in the under-65 age bracket. Additionally, a significant correlation was demonstrated between recovery rate and ADC across all age groups. No other significant correlations were discovered between DTI parameters (MD, AD, and ADC) and post-operative outcomes. CONCLUSION: DTI is a quantitative noninvasive evaluation tool that correlates with severity of DCM. However, the current evidence is still elusive regarding whether DTI metric is a validated tool for predicting the degree of post-operative recovery, which could potentially be useful in patient selection for surgery.

Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran.

PURPOSE: This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI). METHODS: The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews. RESULTS: We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%. CONCLUSION: Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

The Prevalence of Asymptomatic Cervical Spinal Cord Compression in Individuals Presenting With Symptomatic Lumbar Spinal Stenosis: A Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: The aim of this study was to determine the prevalence of asymptomatic cervical spinal cord compression (CSCC) in individuals with lumbar spinal stenosis (LSS). METHODS: A systematic electronic search was conducted in Medline, EMBASE, Scopus, and Web of Science without language restriction, with no starting date limit to June 8, 2023, to define the prevalence of asymptomatic CSCC in symptomatic LSS patients. Asymptomatic CSCC was defined based on radiographic studies. All types of studies were included in the review. Meta-analysis was performed on the reported prevalence of asymptomatic CSCC in LSS. RESULTS: The database search yielded 10,272 articles. After a full-text review, five studies were included in the final review, comprising a total of 1043 cases. Two studies had a low risk for bias, two moderate, and one estimated to be high risk. The range of prevalence of asymptomatic CSCC in LSS in the five included studies was between 24% and 61%. Meta-analysis on the reported prevalence of asymptomatic CSCC patients with symptomatic LSS demonstrated that the random pooled prevalence was 35% (95% CI: 23 to 48). CONCLUSIONS: Asymptomatic CSCC appears to occur in a high number of patients, with this study noting its presence in one-third of patients with LSS. Based on these findings, we strongly recommend that spine surgeons exercise particular caution during the positioning of patients who are undergoing surgery for lumbar stenosis. Furthermore, it is imperative to monitor individuals with symptomatic LSS closely for any potential signs of emerging myelopathy.

Predictors of Outcome After Surgical Decompression for mild degenerative Cervical Myelopathy -A Systematic Review.

STUDY DESIGN: Systematic Reviews. OBJECTIVES: To investigate predictors of surgical outcomes for mild Degenerative Cervical Myelopathy (DCM) by reviewing all related studies conducted at this point. METHODS: An electronic search was carried out in PubMed, EMBASE, Scopus, and Web of Science until June 23, 2021. Full-text articles reporting surgical outcome predictors of mild DCM cases were eligible. We included studies with mild DCM which was defined as a modified Japanese Orthopaedic Association score of 15 to 17 or a Japanese Orthopaedic Association score of 13 to 16. Independent reviewers screened all the records, and discrepancies between the reviewers were solved in a session with the senior author. For risk of bias assessment, RoB 2 tool was used for randomized clinical trials and ROBINS-I for non-randomized studies. RESULTS: After screening 6 087 manuscripts, only 8 studies met the inclusion criteria. Lower pre-operative mJOA scores and quality-of-life measurement scores were reported by multiple studies to predict better surgical outcomes compared to other groups. High-intensity pre-operative T2 magnetic resonance imaging (MRI) was also reported to predict poor outcomes. Neck pain before intervention resulted in improved patient-reported outcomes. Two studies also reported motor symptoms prior to surgery as outcome predictors. CONCLUSION: Lower quality of life before surgery, neck pain, lower pre-operative mJOA scores, motor symptoms before surgery, female gender, gastrointestinal comorbidities, surgical procedure and surgeon's experience with specific techniques, and high signal intensity of cord in T2 MRI were the surgical outcome predictors reported in the literature. Lower Quality of Life (QoL) score and neck prior to surgery were reported as predictors of the more improved outcome, but high cord signal intensity in T2 MRI was reported as an unfavorable outcome predictor.

Prognostic Value of Frailty for Outcome Following Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Frailty is a known predictor of negative health outcomes. The role of frailty in predicting outcomes after traumatic brain injury (TBI), however, is unclear. This systematic review aimed to evaluate the association between frailty and adverse outcomes in patients with TBI. We identified relevant articles that investigated the relationship between frailty and outcomes in patients with TBI by searching PubMed/MEDLINE, Web of Science, Scopus, and EMBASE from inception until 23 March 2023. To evaluate the risk of bias in the included studies, we utilized the Newcastle-Ottawa Scale (NOS). In addition, quantitative synthesis and meta-analyses were performed. We identified 12 studies that met our inclusion criteria; three were prospective. Of included studies, eight had low risk, three had moderate risk, and one had high risk of bias. Frailty was significantly associated with death in five studies, with an increased risk of in-hospital death and complications observed in frail patients. Frailty was associated with longer hospital stays and unfavorable outcome measured by the Extended Glasgow Outcome Scale (GOSE) in four studies. The meta-analysis found that higher frailty significantly increased the odds of non-routine discharge and unfavorable outcome as measured by GOSE scores of 4 or lower. The pooled odds ratio (OR) for non-routine discharge, was 1.80, with a 95% confidence interval (CI) of 1.15-2.84; and for unfavorable outcome, it was 1.91, with a 95% CI of 1.09-3.36. The analysis, however, did not find a significant predictive role for frailty on death (30-day or in-hospital death). The OR for higher frailty and death was 1.42 with a 95% CI of 0.92-2.19. Frailty should be considered in the evaluation of patients with TBI to identify those who may be at increased risk of negative outcomes.