Systemic hypothermia in acute cervical spinal cord injury: a case-controlled study

Abstract

Introduction: Systemic hypothermia remains a promising neuroprotective strategy. There has been recent interest in its use in patients with spinal cord injury (SCI). In this article, we describe our extended single center experience using intravascular hypothermia for the treatment of cervical SCI. Methods: Thirty-five acute cervical SCI patients received modest (33 1C) intravascular hypothermia for 48 h. Neurological outcome was assessed by the International Standards for Neurological Classification of Spinal Cord Injury scale (ISNCSCI) developed by the American Spinal Injury Association. Local and systemic complications were recorded. Results: All patients were complete ISNCSCI A on admission, but four converted to ISNCSCI B in o24 h post injury. Hypothermia was delivered in 5.76 ( ± 0.45) hours from injury if we exclude four cases with delayed admission (418 h). Fifteen of total 35 patients (43%) improved at least one ISNCSCI grade at latest follow up 10.07 ( ± 1.03) months. Even excluding those patients who converted from ISNCSCI A within 24 h, 35.5% (11 out of 31) improved at least one ISNCSCI grade. Both retrospective (n ¼ 14) and prospective (n ¼ 21) groups revealed similar number of respiratory complications. The overall risk of any thromboembolic complication was 14.2%. Conclusion:The results are promising in terms of safety and improvement in neurological outcome. To date, the study represents the largest study cohort of cervical SCI patients treated by modest hypothermia. A multi-center, randomized study is needed to determine if systemic hypothermia should be a part of SCI patients' treatment for whom few options exist. Spinal Cord (2013) 51, 395-400; doi:10.1038/sc.2012.161; published online 18 December 2012Keywords: acute cervical SCI; cooling catheter; systemic hypothermia INTRODUCTION Hypothermia continues to show promise in a variety of acute central nervous system injuries. Various factors need to be considered with systemic cooling of the spinal cord injury (SCI) patient, including methods of cooling, window from injury to initiation, duration and depth of hypothermia, and rate of re-warming. Two main methods of spinal cord cooling exist. Local cooling (epidural vs intradural) has a rich history with both experimental and clinical evidence supporting its use. 1 Systemic cooling may be applied either via a transcutaneous or intravascular route. Modern cooling blankets can be applied and have the advantage of being less invasive but also the disadvantage of being less precise with regards to temperature control. 2 While profound levels of hypothermia (T o32 1C) can be difficult to administer and are subject to increased complication rates, mild (modest) levels of hypothermia (T 32-34 1C) have been shown to provide significant protection against traumatic and ischemic neuronal cell death. 2,3 When administered after experimental acute SCI, there is a reduction in the volume of histopathological damage and a concomitant improvement in BBB walking index. 4,5 A recent study revealed beneficial effec...

Local cooling for traumatic spinal cord injury: outcomes in 20 patients and review of the literature

“…There has, over the years, been modest interest in therapeutic hypothermia for traumatic SCI, 27 with interest more recently focusing on systemic cooling. 12,26 Hypothermia has been shown to have beneficial effects in trauma as diverse as reducing tissue metabolic demand, decreasing hemorrhage and edema formation, moderating apoptosis and excitotoxicity, reducing glial cell activation, decreasing the strength of the inflammatory response, and preserving blood vessel and blood-brain barrier structure. 53,62 Much modern research focuses on the therapeutic potential of mild systemic hypothermia (that is, a body temperature of 32°-35°C).…”

The “Cold Cord”: A Review of Therapeutic Hypothermia for Traumatic Spinal Cord Injuries

“…Of the research studies completed, a total of 5 were retrieved (Table 1): 1 prospective case series, 4 1 combined prospective and retrospective study, 22 2 retrospective case series of the same patient population in a phase 1 feasibility study reviewing complications 19 then outcomes after 1 year, 20 and 1 case report.…”

“…21 Levi et al 19,20 used an Alsius CoolGard catheter in the femoral vein starting at postinjury hour 9.17 (SD, 2.24 hours) for a total of 47.6 hours (SD, 3.1 hours). Dididze et al 22 also used an Alsius CoolGard catheter initiated at postinjury hour 7.76 (SD, 1.09 hours) for 46.77 hours (SD, 1.71 hours). Hansebout and Hansebout 4 used a spinal cord cooling saddle and initiated cooling at 7.1 hours (mean) for 3.7 hours (mean).…”

“…Dididze et al 22 reported that 4 patients had converted to AIS grade B within 24 hours, and 15 of 35 patients had improved by at least 1 grade by 10.07 months (SD, 1.03 months). Most complications were pulmonary, and both prospectively and retrospectively analyzed patients had comparable odds of complications developing.…”

Targeting the blood-spinal cord barrier: A therapeutic approach to spinal cord protection against ischemia-reperfusion injury

“…Holzer et al reported that therapeutic mild hypothermia (target temperature, 32°C to 34°C) increased the rate of a favorable neurologic outcome and reduced mortality in patients successfully resuscitated after cardiac arrest due to ventricular fibrillation [33]. The neurological outcome of patients with acute cervical spinal cord injury was improved by receiving modest (33°C) intravascular hypothermia for 48 h [34]. Moreover, local deep cooling (dural temperature 6°C) could improve the neurological outcome of patients with a neurologically complete spinal cord injury [35].…”