Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury.

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research.

Positive airway pressure for sleep-disordered breathing in acute quadriplegia: a randomised controlled trial.

RATIONALE: Highly prevalent and severe sleep-disordered breathing caused by acute cervical spinal cord injury (quadriplegia) is associated with neurocognitive dysfunction and sleepiness and is likely to impair rehabilitation. OBJECTIVE: To determine whether 3 months of autotitrating CPAP would improve neurocognitive function, sleepiness, quality of life, anxiety and depression more than usual care in acute quadriplegia. METHODS AND MEASUREMENTS: Multinational, randomised controlled trial (11 centres) from July 2009 to October 2015. The primary outcome was neurocognitive (attention and information processing as measure with the Paced Auditory Serial Addition Task). Daytime sleepiness (Karolinska Sleepiness Scale) was a priori identified as the most important secondary outcome. MAIN RESULTS: 1810 incident cases were screened. 332 underwent full, portable polysomnography, 273 of whom had an apnoea hypopnoea index greater than 10. 160 tolerated at least 4 hours of CPAP during a 3-day run-in and were randomised. 149 participants (134 men, age 46±34 years, 81±57 days postinjury) completed the trial. CPAP use averaged 2.9±2.3 hours per night with 21% fully 'adherent' (at least 4 hours use on 5 days per week). Intention-to-treat analyses revealed no significant differences between groups in the Paced Auditory Serial Addition Task (mean improvement of 2.28, 95% CI -7.09 to 11.6; p=0.63). Controlling for premorbid intelligence, age and obstructive sleep apnoea severity (group effect -1.15, 95% CI -10 to 7.7) did not alter this finding. Sleepiness was significantly improved by CPAP on intention-to-treat analysis (mean difference -1.26, 95% CI -2.2 to -0.32; p=0.01). CONCLUSION: CPAP did not improve Paced Auditory Serial Addition Task scores but significantly reduced sleepiness after acute quadriplegia. TRIAL REGISTRATION NUMBER: ACTRN12605000799651.

Spinal cord injury in patients with ankylosing spondylitis: a 10-year review.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the clinical and functional outcomes in patients with spinal cord injury (SCI) and preexisting ankylosing spondylitis (AS). SUMMARY OF BACKGROUND DATA: AS alters the strength and biomechanical properties of the spine that renders it susceptible to fracture with minimal trauma. Neurologic involvement is common and outcomes largely depend on the early recognition and appropriate management. METHODS: A 10-year review (1996-2005) was carried out to identify all patients admitted with SCI associated with AS. The cause of injury, prehospital and emergency management, definitive treatment of fracture, final neurology, and functional outcomes were ascertained. Reasons for neurologic deterioration were determined. RESULTS: Eighteen patients were identified. In 15 patients, the injury resulted from trauma (fall 14, road accident 1) and in 3 the SCI followed spinal surgical interventions. Twelve of the 15 patients with traumatic injuries were able to walk immediately after the fall but subsequently deteriorated for various reasons. Spinal epidural hematomas developed in 3 patients (2 traumatic, 1 spinal intervention). The fractures were managed surgically in 3 patients, halo jacket was used in 2, and the remainder were managed expectantly on traction. Four patients died before discharge, 4 were able to walk with an aid at discharge, and the others were wheel chair dependent. CONCLUSION: Neurologic deficits were often subtle on initial presentation, resulting in many injuries being missed because of a low index of suspicion and poor visualization of lower cervical fractures on conventional radiographs. Extension of the ankylosed kyphotic cervical spine during conventional immobilization or for radiologic procedures resulted in neurologic deficits. Patients with an ankylosed cervical spine are normally unable to see the ceiling lying supine because of cervicothoracic kyphosis and use pillows to support their head. Cervical spine alignment in a similar flexed position is essential during immobilization or imaging. Medical alert cards as for patients with diabetes would be a way forward in correctly identifying patients with AS so that appropriate precautions can be instituted by emergency services.