Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2016

Open Access 01-12-2016 | Viewpoint

Spinal cord injury: is monitoring from the injury site the future?

Authors: Samira Saadoun, Marios C. Papadopoulos

Published in: Critical Care | Issue 1/2016

Login to get access

Abstract

This paper challenges the current management of acute traumatic spinal cord injury based on our experience with monitoring from the injury site in the neurointensive care unit. We argue that the concept of bony decompression is inadequate. The concept of optimum spinal cord perfusion pressure, which differs between patients, is introduced. Such variability suggests individualized patient treatment. Failing to optimize spinal cord perfusion limits the entry of systemically administered drugs into the injured cord. We conclude that monitoring from the injury site helps optimize management and should be subjected to a trial to determine whether it improves outcome.
Literature
1.
Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord. 2014;52:110–6.CrossRefPubMed
2.
Fehlings MG, Rabin D, Sears W, Cadotte DW, Aarabi B. Current practice in the timing of surgical intervention in spinal cord injury. Spine (Phila Pa 1976). 2010;35:S166–73.CrossRef
3.
Werndle MC, Zoumprouli A, Sedgwick P, Papadopoulos MC. Variability in the treatment of acute spinal cord injury in the United Kingdom: results of a national survey. J Neurotrauma. 2012;29:880–8.CrossRefPubMed
4.
Fehlings MG, Vaccaro A, Wilson JR, Singh A, Cadotte WD, Harrop JS, Aarabi B, Shaffrey C, Dvorak M, Fisher C, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7:e32037.CrossRefPubMedPubMedCentral
5.
van Middendorp JJ, Hosman AJ, Doi SA. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma. 2013;30:1781–94.CrossRefPubMed
6.
Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS, Eisenberg HM, Flamm E, Leo-Summers L, Maroon J, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990;322:1405–11.CrossRefPubMed
7.
Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M, Fehlings M, Herr DL, Hitchon PW, Marshall LF, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. Natl Acute Spinal Cord Inj Study JAMA. 1997;277:1597–604.
8.
Bydon M, Lin J, Macki M, Gokaslan ZL, Bydon A. The current role of steroids in acute spinal cord injury. World Neurosurg. 2014;82:848–54.CrossRefPubMed
9.
Hurlbert RJ, Hamilton MG. Methylprednisolone for acute spinal cord injury: 5-year practice reversal. Can J Neurol Sci. 2008;35:41–5.CrossRefPubMed
10.
Cozzens JW, Prall JA, Holly L. The 2012 guidelines for the management of acute cervical spine and spinal cord injury. Neurosurgery. 2013;72 Suppl 2:2–3.PubMed
11.
Katoh S, el Masry WS. Motor recovery of patients presenting with motor paralysis and sensory sparing following cervical spinal cord injuries. Paraplegia. 1995;33:506–9.CrossRefPubMed
12.
Saadoun S, Bell BA, Verkman AS, Papadopoulos MC. Greatly improved neurological outcome after spinal cord compression injury in AQP4-deficient mice. Brain. 2008;131:1087–98.CrossRefPubMed
13.
Werndle MC, Saadoun S, Phang I, Czosnyka M, Varsos GV, Czosnyka ZH, Smielewski P, Jamous A, Bell BA, Zoumprouli A, et al. Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study. Crit Care Med. 2014;42:646–55.CrossRefPubMed
14.
Varsos GV, Werndle MC, Czosnyka ZH, Smielewski P, Kolias AG, Phang I, Saadoun S, Bell BA, Zoumprouli A, Papadopoulos MC, et al. Intraspinal pressure and spinal cord perfusion pressure after spinal cord injury: an observational study. J Neurosurg Spine. 2015;23:763–71.CrossRefPubMed
15.
16.
Saadoun S, Werndle MC, Lopez de Heredia L, Papadopoulos MC. The dura causes spinal cord compression after spinal cord injury. Br J Neurosurg. 2016;30:582–4.CrossRefPubMed
17.
Phang I, Papadopoulos MC. Intraspinal pressure monitoring in a patient with spinal cord injury reveals different intradural compartments: Injured Spinal Cord Pressure Evaluation (ISCoPE) study. Neurocrit Care. 2015;23:414–8.CrossRefPubMed
18.
Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC. Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study. J Neurotrauma. 2015;32:865–74.CrossRefPubMedPubMedCentral
19.
Phang I, Zoumprouli A, Saadoun S, Papadopoulos MC. Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study. J Neurosurg Spine. 2016;25:398–405.CrossRefPubMed
20.
Phang I, Zoumprouli A, Papadopoulos MC, Saadoun S. Microdialysis to optimize cord perfusion and drug delivery in spinal cord injury. Ann Neurol. 2016. EPub. doi:10.​1002/​ana.​24750.
21.
Chen S, Phang I, Zoumprouli A, Papadopoulos MC, Saadoun S. Metabolic profile of injured human spinal cord determined using surface microdialysis. J Neurochem. 2016, in press.
22.
Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, et al. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012;367:2471–81.CrossRefPubMedPubMedCentral
23.
Yuan Q, Wu X, Cheng H, Yang C, Wang Y, Wang E, Qiu B, Fei Z, Lan Q, Wu S, et al. Is intracranial pressure monitoring of patients with diffuse traumatic brain injury valuable? An observational multicenter study. Neurosurgery. 2016;78:361–8. discussion 368–9.CrossRefPubMed
24.
Han J, Yang S, Zhang C, Zhao M, Li A. Impact of intracranial pressure monitoring on prognosis of patients with severe traumatic brain injury: a PRISMA systematic review and meta-analysis. Medicine (Baltimore). 2016;95:e2827.CrossRef
25.
26.
Werndle MC, Saadoun S, Phang I, Czosnyka M, Varsos G, Czosnyka Z, Smielewski P, Jamous A, Bell BA, Zoumprouli A, et al. Measurement of intraspinal pressure after spinal cord injury: technical note from the injured spinal cord pressure evaluation study. Acta Neurochir Suppl. 2016;122:323–8.CrossRefPubMed
27.
Smith JS, Anderson R, Pham T, Bhatia N, Steward O, Gupta R. Role of early surgical decompression of the intradural space after cervical spinal cord injury in an animal model. J Bone Joint Surg Am. 2010;92:1206–14.CrossRefPubMedPubMedCentral
28.
Jones CF, Newell RS, Lee JH, Cripton PA, Kwon BK. The pressure distribution of cerebrospinal fluid responds to residual compression and decompression in an animal model of acute spinal cord injury. Spine (Phila Pa 1976). 2012;37:E1422–31.CrossRef
29.
Awwad W, Bassi M, Shrier I, Al-Ahaideb A, Steele RJ, Jarzem PF. Mitigating spinal cord distraction injuries: the effect of durotomy in decreasing cord interstitial pressure in vitro. Eur J Orthop Surg Traumatol. 2014;24 Suppl 1:S261–7.CrossRefPubMed
30.
Iannotti C, Zhang YP, Shields LB, Han Y, Burke DA, Xu XM, Shields CB. Dural repair reduces connective tissue scar invasion and cystic cavity formation after acute spinal cord laceration injury in adult rats. J Neurotrauma. 2006;23:853–65.CrossRefPubMed
31.
Hawryluk G, Whetstone W, Saigal R, Ferguson A, Talbott J, Bresnahan J, Dhall S, Pan J, Beattie M, Manley G. Mean arterial blood pressure correlates with neurological recovery after human spinal cord injury: analysis of high frequency physiologic data. J Neurotrauma. 2015;32:1958–67.CrossRefPubMed
32.
Inoue T, Manley GT, Patel N, Whetstone WD. Medical and surgical management after spinal cord injury: vasopressor usage, early surgerys, and complications. J Neurotrauma. 2014;31:284–91.CrossRefPubMed
33.
Readdy WJ, Whetstone WD, Ferguson AR, Talbott JF, Inoue T, Saigal R, Bresnahan JC, Beattie MS, Pan JZ, Manley GT et al. Complications and outcomes of vasopressor usage in acute traumatic central cord syndrome. J Neurosurg Spine. 2015;23:574–80.CrossRef
34.
Valadka AB, Robertson CS. Surgery of cerebral trauma and associated critical care. Neurosurgery. 2007;61:203–20. discussion 220–1.CrossRefPubMed
35.
Czosnyka M, Brady K, Reinhard M, Smielewski P, Steiner LA. Monitoring of cerebrovascular autoregulation: facts, myths, and missing links. Neurocrit Care. 2009;10:373–86.CrossRefPubMed
36.
Aries MJ, Czosnyka M, Budohoski KP, Steiner LA, Lavinio A, Kolias AG, Hutchinson PJ, Brady KM, Menon DK, Pickard JD, et al. Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med. 2012;40:2456–63.CrossRefPubMed
37.
Kwon BK, Curt A, Belanger LM, Bernardo A, Chan D, Markez JA, Gorelik S, Slobogean GP, Umedaly H, Giffin M, et al. Intrathecal pressure monitoring and cerebrospinal fluid drainage in acute spinal cord injury: a prospective randomized trial. J Neurosurg Spine. 2009;10:181–93.CrossRefPubMed
38.
Fawcett JW, Curt A, Steeves JD, Coleman WP, Tuszynski MH, Lammertse D, Bartlett PF, Blight AR, Dietz V, Ditunno J, et al. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord. 2007;45:190–205.CrossRefPubMed
39.
Steeves JD, Lammertse D, Curt A, Fawcett JW, Tuszynski MH, Ditunno JF, Ellaway PH, Fehlings MG, Guest JD, Kleitman N, et al. Guidelines for the conduct of clinical trials for spinal cord injury (SCI) as developed by the ICCP panel: clinical trial outcome measures. Spinal Cord. 2007;45:206–21.CrossRefPubMed
40.
Tuszynski MH, Steeves JD, Fawcett JW, Lammertse D, Kalichman M, Rask C, Curt A, Ditunno JF, Fehlings MG, Guest JD, et al. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP Panel: clinical trial inclusion/exclusion criteria and ethics. Spinal Cord. 2007;45:222–31.CrossRefPubMed
41.
Lammertse D, Tuszynski MH, Steeves JD, Curt A, Fawcett JW, Rask C, Ditunno JF, Fehlings MG, Guest JD, Ellaway PH, et al. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: clinical trial design. Spinal Cord. 2007;45:232–42.CrossRefPubMed
42.
Nagoshi N, Fehlings MG. Investigational drugs for the treatment of spinal cord injury: review of preclinical studies and evaluation of clinical trials from Phase I to II. Expert Opin Investig Drugs. 2015;24:645–58.CrossRefPubMed
43.
Lassmann H. Hypoxia-like tissue injury as a component of multiple sclerosis lesions. J Neurol Sci. 2003;206:187–91.CrossRefPubMed
44.
Vender J, Waller J, Dhandapani K, McDonnell D. An evaluation and comparison of intraventricular, intraparenchymal, and fluid-coupled techniques for intracranial pressure monitoring in patients with severe traumatic brain injury. J Clin Monit Comput. 2011;25:231–6.CrossRefPubMed
Metadata
Title
Spinal cord injury: is monitoring from the injury site the future?
Authors
Samira Saadoun
Marios C. Papadopoulos
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2016
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-016-1490-3

Other articles of this Issue 1/2016

Critical Care 1/2016 Go to the issue

Commentary

Goal-directed therapy and acute kidney injury: as good as it gets?

Research

Effect of the Cardio First Angel™ device on CPR indices: a randomized controlled clinical trial

Research

Hydrocortisone treatment in early sepsis-associated acute respiratory distress syndrome: results of a randomized controlled trial

Research

Mechanical ventilation strategies for intensive care unit patients without acute lung injury or acute respiratory distress syndrome: a systematic review and network meta-analysis

Letter

The struggle to differentiate inflammation from infection in severely burned patients: time to send better biomarkers into the arena?

Research

The effect of camicinal (GSK962040), a motilin agonist, on gastric emptying and glucose absorption in feed-intolerant critically ill patients: a randomized, blinded, placebo-controlled, clinical trial