A prospective evaluation of hemodynamic management in acute spinal cord injury patients

Kong, Christopher; Hosseini, Ali Masih; Bélanger, Lise; Ronco, Juan J.; Paquette, Scott; Boyd, Michael; Dea, Nicolas; Street, John; Fisher, Charles G.; Dvorak, Marcel F.; Kwon, Brian K.

doi:10.1038/sc.2013.32

Cited by 36 publications

(16 citation statements)

References 21 publications

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“…For example, if a patient arrives in the early morning or many hours following with cervical SCIs, particularly given the significant hypotension that complicates these injuries. 23,24 Another key area associated with surgical delay was the time taken to reach the operating theatre following admission to a surgical centre (median time 12.5 hours). The bulk of this time occurred following medical stabilisation, assessment and investigation.…”

Section: Discussionmentioning

confidence: 99%

Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery

Battistuzzo

Armstrong

Clark

et al. 2016

Journal of Neurotrauma

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Early decompression may improve neurological outcome after spinal cord injury (SCI), but is often difficult to achieve because of logistical issues. The aims of this study were to 1) determine the time to decompression in cases of isolated cervical SCI in Australia and New Zealand and 2) determine where substantial delays occur as patients move from the accident scene to surgery. Data were extracted from medical records of patients aged 15-70 years with C3-T1 traumatic SCI between 2010 and 2013. A total of 192 patients were included. The median time from accident scene to decompression was 21 h, with the fastest times associated with closed reduction (6 h). A significant decrease in the time to decompression occurred from 2010 (31 h) to 2013 (19 h, p = 0.008). Patients undergoing direct surgical hospital admission had a significantly lower time to decompression, compared with patients undergoing pre-surgical hospital admission (12 h vs. 26 h, p < 0.0001). Medical stabilization and radiological investigation appeared not to influence the timing of surgery. The time taken to organize the operating theater following surgical hospital admission was a further factor delaying decompression (12.5 h). There was a relationship between the timing of decompression and the proportion of patients demonstrating substantial recovery (2-3 American Spinal Injury Association Impairment Scale grades). In conclusion, the time of cervical spine decompression markedly improved over the study period. Neurological recovery appeared to be promoted by rapid decompression. Direct surgical hospital admission, rapid organization of theater, and where possible, use of closed reduction, are likely to be effective strategies to reduce the time to decompression.

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Section: Discussionmentioning

confidence: 99%

Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery

Battistuzzo

Armstrong

Clark

et al. 2016

Journal of Neurotrauma

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“…AMS is more reliable than the more popular ASIA grade because it allows for each limb to be scored separately increasing its sensitivity and has thus been found to be the best indicator for observing the effects of therapeutic interventions. [ 19 20 21 ] AMS is calculated by assessing function in 5 key muscle groups per extremity, each muscle group with a maximum score of 5, creating a total body maximum score of 100. [ 7 ]…”

Section: Methodsmentioning

confidence: 99%

“…[ 8 ] There have been several published studies on the effect of blood pressure management in acute SCI, the largest of which contained 103 patients, 41 of which required vasopressors. [ 9 10 11 12 13 14 15 16 17 18 19 ] Despite this, there only exists Level III evidence suggesting a target mean arterial pressure (MAP) goal of 85-90 mmHg. [ 9 ]…”

Section: Introductionmentioning

confidence: 99%

Increased mean arterial pressure goals after spinal cord injury and functional outcome

Martin

Kepler

Zubair

et al. 2015

J Emerg Trauma Shock

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Introduction:Acute spinal cord injury (SCI) is often treated with induced hypertension to enhance spinal cord perfusion. The optimal mean arterial pressure (MAP) likely varies between patients. Arbitrary goals are often set, frequently requiring vasopressors to achieve, with no clear evidence supporting this practice. We hypothesize that increased MAP goals and episodes of relative hypotension do not affect hospital outcome.Materials and Methods:All cervical and thoracic SCI patients treated at a level one trauma and regional SCI center over at 2.5-year period were retrospectively reviewed. Lowest and average hourly MAP was recorded for the first 72 h of hospitalization, allowing for quantification of mean MAP and the total number of episodic relative hypotensive events. These data were further compared to daily American spinal injury association motor score (AMS), which was used to determine the severity of SCI and improvement/decline during hospitalization. Patient's data were finally analyzed at theoretic MAP set points.Results:One hundred and five patients had complete data during the study period. At higher theoretic MAP set points (85 and 90), increased number of relative hypotensive episodes correlated with lower admission AMS (85 mmHg: <10 episodes, AMS 66.2; >50 episodes, 22.0; P < 0.001) and the need for vasopressors (P < 0.03) but showed no statistical change in AMS by hospital discharge. The need for vasopressors correlated with the number of hypotensive episodes and inversely related to admission AMS at all theoretic MAP goal set points but was not correlated with the change in AMS during the hospitalization.Conclusions:The frequency of relative hypotension and the need for vasopressors are progressively related to more severe SCI, as denoted by lower admission AMS. However, episodes of hypotension and the need for vasopressors did not affect the change in AMS during the acute hospitalization, regardless of theoretic MAP goal set-point. Arbitrarily elevated MAP goals may not be efficacious.

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“…3 The influence of hemodynamic manipulation on neurological recovery after tSCI also remains uncertain. 4,5 The decision to operate rather than to pursue nonsurgical treatment, although still controversial, 6 has gained popularity because of patterns of surgical practice, expert opinion, and resource availability that has tended to favor surgery. 7 The influence of surgical decompression and stabilization, particularly when it is performed early after the injury, has recently gained some support as an intervention that may benefit neurological recovery.…”

Section: Introductionmentioning

confidence: 99%

The Influence of Time from Injury to Surgery on Motor Recovery and Length of Hospital Stay in Acute Traumatic Spinal Cord Injury: An Observational Canadian Cohort Study

Dvorak

Noonan

Fallah

et al. 2015

Journal of Neurotrauma

186

151

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To determine the influence of time from injury to surgery on neurological recovery and length of stay (LOS) in an observational cohort of individuals with traumatic spinal cord injury (tSCI), we analyzed the baseline and follow-up motor scores of participants in the Rick Hansen Spinal Cord Injury Registry to specifically assess the effect of an early (less than 24 h from injury) surgical procedure on motor recovery and on LOS. One thousand four hundred and ten patients who sustained acute tSCIs with baseline American Spinal Injury Association Impairment Scale (AIS) grades A, B, C, or D and were treated surgically were analyzed to determine the effect of the timing of surgery (24, 48, or 72 h from injury) on motor recovery and LOS. Depending on the distribution of data, we used different types of generalized linear models, including multiple linear regression, gamma regression, and negative binomial regression. Persons with incomplete AIS B, C, and D injuries from C2 to L2 demonstrated motor recovery improvement of an additional 6.3 motor points (SE=2.8 p<0.03) when they underwent surgical treatment within 24 h from the time of injury, compared with those who had surgery later than 24 h post-injury. This beneficial effect of early surgery on motor recovery was not seen in the patients with AIS A complete SCI. AIS A and B patients who received early surgery experienced shorter hospital LOS. While the issues of when to perform surgery and what specific operation to perform remain controversial, this work provides evidence that for an incomplete acute tSCI in the cervical, thoracic, or thoracolumbar spine, surgery performed within 24 h from injury improves motor neurological recovery. Early surgery also reduces LOS.

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A prospective evaluation of hemodynamic management in acute spinal cord injury patients

Cited by 36 publications

References 21 publications

Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery

Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery

Increased mean arterial pressure goals after spinal cord injury and functional outcome

The Influence of Time from Injury to Surgery on Motor Recovery and Length of Hospital Stay in Acute Traumatic Spinal Cord Injury: An Observational Canadian Cohort Study

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