Querschnittlähmung bei septischen Erkrankungen der Wirbelsäule

Background

Paraplegia of non-traumatic origin has an increasing incidence. Infection of the spine is a major contributor to the number of these cases. Besides adequate management of spinal cord injury, the treatment of these patients requires specific therapeutic techniques.

Patients and methods

Eighteen patients with acute pyogenic infection of the spine and spinal cord injury were admitted to our facility in the years 1997–2000. All except two patients were treated by surgical debridement and internal stabilisation.

Results

The infections healed after surgical treatment in all cases. Neurological function improved and no patient showed neurological deterioration. Both patients who were not fit for surgery died during treatment.

Conclusion

Surgical instrumentation and replacement of the destroyed vertebra, despite a pyogenic environment, resulted in permanent resolution of the infection. There is potential for neurological recovery but full recovery is rare.     

The pathological changes in the spinal cord after dural tear with and without autologous fascia repair

Purpose

Dural tear is one of the common complications of spinal surgery leading to cerebrospinal fluid leakage followed by serial secondary symptoms. However, little is known about pathological changes of the spinal cord after dural tear. In the present study, we aimed to study the pathological changes in the spinal cord after dural tear with and without autologous fascia repair.

Methods

Sixty Sprague–Dawley rats were used for dural tear and autologous fascia graft repair models. Three days and 1 week after surgery, the pathological changes in the spinal cord were analyzed by immunohistochemistry, Western blot, enzyme-linked immunosorbent assay and spinal somatosensory evoked potentials test.

Results

Neuroinflammation was found in the parenchyma of the spinal cord characterized by gliosis, increased expression of inflammatory factors and infiltration of exogenesis immunocells in the rats without repair, which impaired the sensory conduction function of the spinal cord at the early stage of injury. Repairing with autologous fascia could attenuate neuroinflammation and help to maintain normal sensory conduction function of the spinal cord.

Conclusion

Dural tear could cause a series of inflammatory reactions in the spinal cord and further impair its sensory conduction function at the early stage of injury. Repairing with autologous fascia was a necessary and effective way to prevent the neuroinflammation and to maintain the normal function of the spinal cord.     

Sclerostin: a candidate biomarker of SCI-induced osteoporosis

Summary

We assessed several circulating proteins as candidate biomarkers of bone status in men with chronic spinal cord injury. We report that sclerostin is significantly associated with bone mineral content and bone density at all skeletal sites tested. We found no association between bone and any other tested biomarker.

Introduction

Spinal cord injury results in severe osteoporosis. To date, no circulating biomarker of spinal cord injury (SCI)-induced osteoporosis has been identified. We recently reported that circulating sclerostin is associated with bone density in chronic SCI. In this study, we assessed several circulating proteins as candidate biomarkers of bone in men with chronic SCI.

Methods

We assessed the relationship between bone mineral content or bone density and the following circulating bone-related proteins: sclerostin, DKK-1, soluble receptor activator of nuclear factor kappa B ligand, osteoprotegerin, osteocalcin, and c-telopeptide in 39 men with chronic SCI and 10 men with no SCI.

Results

After adjusting for age, lower sclerostin levels were significantly associated with lower bone mineral content and bone density at all skeletal sites tested (p?=?0.0002?0.03). No other circulating protein was associated with bone mineral content or bone mineral density (p?=?0.18?0.99).

Conclusion

These findings suggest that circulating sclerostin reflects the severity of bone loss and is a candidate biomarker of osteoporosis severity in chronic SCI.     

Clinical applicability of magnetic resonance imaging in acute spinal cord trauma

Purpose

To assess the clinical application of magnetic resonance imaging (MRI) in patients with acute spinal cord trauma (SCT) according to the type, extension, and severity of injury and the clinical–radiological correlation.

Methods

Diagnostic imaging [computed tomography (CT) and MRI] tests of 98 patients with acute SCT were analyzed to assess their clinical diagnostic value. The following radiological findings of SCT were investigated: vertebral compression fractures, bursts and dislocations, posterior element fractures, C1 and C2 lesions, vertebral listhesis, bone swelling, spinal canal compression, disk herniation, extradural hematoma, spinal cord contusions, spinal cord swelling, and posterior ligamentous complex (PLC) injuries.

Results

The radiological findings were better visualized using MRI, except for the posterior elements (p = 0.001), which were better identified with CT. A total of 271 lesions were diagnosed as follows: 217 using MRI, 154 using CT, and 100 (36.9 %) using both MRI and CT. MRI detected 117 more lesions than CT.

Conclusion

MRI was significantly superior to CT in the diagnosis of bone swelling, PLC injury, disk herniation, spinal canal compression, spinal cord contusion and swelling present in SCT. MRI detected a larger number of lesions than CT and is highly useful for the diagnosis of soft tissue and intrathecal injuries.     

The kinetics of autophagy in the lung following acute spinal cord injury in rats

Background Context

Lung injury is a major cause of respiratory complications following an acute spinal cord injury (ASCI), which are associated with a high mortality rate. Autophagy has been shown to be involved in a variety of lung diseases; however, whether autophagy is activated in the lung following ASCI remains unknown.

Does laminoplasty really improve neurological status in patients with cervical spinal cord injury without bone and disc injury? A prospective study about neurological recovery and early complications

Purpose

Cervical spinal cord injury without bone and disc injury in patients with spinal cord compression is a fairly common problem in Japan. Because elderly Japanese population tend to have cervical spinal canal stenosis. However, there has been no consensus in the treatment of these patients. We conducted a prospective study to evaluate treatment outcomes and complications of these patients.

Methods

Twenty-five patients had been enrolled in this study. Patients who had paralysis of ASIA impairment scale (AIS) A, B or C were included. With each new patient, we alternated whether he/she received surgical treatment (group S) or conservative treatment (group C). Eleven patients were assigned to each group. We compared the two groups’ courses of treatment and complications by evaluating their neurological symptoms using the AIS and ASIA motor score (MS) documenting them at the time of injury and 3 months later.

Results

The majority of clinical paralysis was found at the C3/4 level for both the groups. According to complications, there were seven urinary tract infections and four pneumonias in group S and one urinary tract infection and three pneumonias in group C. Both groups had an average MS of 42 at the time of injury. Three months later, the average MSs were 59 points in group S and 65 points in group C.

Conclusions

In the present study, we found no significant difference in paralysis improvement between surgical and conservative treatment, although we observed a higher frequency of complications with surgery.     

Down-regulation of the Wnt, estrogen receptor, insulin-like growth factor-I, and bone morphogenetic protein pathways in osteoblasts from rats with chronic spinal cord injury

Objectives

To investigate the anabolic response of osteoblasts to chronic spinal cord injury and to identify potential signaling pathways that are associated with the osteogenic response after spinal cord injury by using in-house microarray analyses in osteoblasts.

Methods

Ten young male Sprague-Dawley rats were randomized into spinal cord injury (SCI) and SHAM groups. The tibiae were assessed for DXA and bone histomorphometry, and osteoblasts from femora were used for microarray analysis.

Results

SCI rats showed lower BMD and deteriorated microstructure in the proximal tibiae as compared with SHAM rats. The Wnt, BMP/TGF, estrogen receptor (ER), and IGF-I pathways were down-regulated in osteoblasts from spinal cord-injured rats.

Conclusion

Down-regulation of the Wnt, BMP/TGF, ER, and growth hormone/IGF-I pathways is associated with decreased bone formation after spinal cord injury.     

Aspirationspneumonie nach HWS-Verletzung

Background

Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia.

Patients and methods

In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention.

Results

A total of 27?patients with a cervical cord injury (tetraplegia) were identified. Of these 20?patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9?patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6?patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group.

Conclusion

A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.     

The differently expressed proteins in MSCs of degenerative scoliosis

Purpose

Degenerative scoliosis (DS) is an important degenerative lumbar disease causing spinal dysfunction. The true reason or pathogenesis of DS is still unknown. Bone marrow-derived mesenchymal stem cells (BM-MSCs) are the stem/progenitor cells of the osteoblasts. The diseases associated with osteogenesis could be caused by abnormality of the MSCs. The purpose of this study was to find the differential proteins expressed in MSCs of patients with DS.

Methods

We collected and cultured the MSCs from 12 DS patients and 12 age- and gender-matched patients with lumbar spinal stenosis. Then the MSC samples were analyzed with 2D-DIGE and MALDI-TOF–MS to find the differential proteins which were further validated by Western blot.

Results

We found 115 spots that were differently expressed in the MSC of DS patients with 2D-DIGE, and 44 proteins were identified from samples of DS and control using MALDI-TOF–MS. Of these proteins, PIAS2, NDUFA2, and TRIM 68, which were up-regulated in DS more than 4 times were validated by Western blot.

Conclusions

The information obtained with this proteomics analysis will be useful in understanding the pathophysiology of DS. Further investigations on the functioning pathway, the specificity and the mechanism of these proteins will be carried out.     

Adiponectin is associated with bone strength and fracture history in paralyzed men with spinal cord injury

Summary

We explored the association between adiponectin levels and bone strength in paralyzed men with spinal cord injury. We found that bone strength was inversely associated with circulating adiponectin levels. Thus, strength estimates and adiponectin levels may improve fracture risk prediction and detection of response to osteogenic therapies following spinal cord injury.

Purpose

Previous research has demonstrated an inverse relationship between circulating adiponectin and bone mineral density, suggesting that adiponectin may be used as a biomarker for bone health. However, this relationship may reflect indirect effects on bone metabolism via adipose-mediated mechanical pathways rather than the direct effects of adipokines on bone metabolism. Thus, we explored the association between circulating adiponectin levels and bone strength in 27 men with spinal cord injury.

Methods

Plasma adiponectin levels were quantified by ELISA assay. Axial stiffness and maximal load to fracture of the distal femur were quantified via finite element analysis using reconstructed 3D models of volumetric CT scans. We also collected information on timing, location, and cause of previous fractures.

Results

Axial stiffness and maximal load were inversely associated with circulating adiponectin levels (R ²?=?0.44, p?=?0.01; R ²?=?0.58, p?=?0.05) after adjusting for injury duration and lower extremity lean mass. In individuals with post-SCI osteoporotic fractures, distal femur stiffness (p?=?0.01) and maximal load (p?=?0.005) were lower, and adiponectin was higher (p?=?0.04) than those with no fracture history.

Conclusions

Based on these findings, strength estimates may improve fracture risk prediction and detection of response to osteogenic therapies following spinal cord injury. Furthermore, our findings suggest that circulating adiponectin may indeed be a feasible biomarker for bone health and osteoporotic fracture risk in paralyzed individuals with spinal cord injury.     

Spinal cord injury causes rapid osteoclastic resorption and growth plate abnormalities in growing rats (SCI-induced bone loss in growing rats)

Summary

Spinal cord injury causes severe bone loss. We report osteoclast resorption with severe trabecular and cortical bone loss, decreased bone mineral apposition, and growth plate abnormalities in a rodent model of contusion spinal cord injury. These findings will help elucidate the mechanisms of osteoporosis following neurological trauma.

Introduction

Limited understanding of the mechanism(s) that underlie spinal cord injury (SCI)-induced bone loss has led to few treatment options. As SCI-induced osteoporosis carries significant morbidity and can worsen already profound disability, there is an urgency to advance knowledge regarding this pathophysiology.

Methods

A clinically relevant contusion model of experimental spinal cord injury was used to generate severe lower thoracic SCI by weight-drop (10 g?×?50 mm) in adolescent male Sprague-Dawley rats. Body weight and gender-matched naïve (no surgery) rats served as controls. Bone microarchitecture was determined by micro-computed tomographic imaging. Mature osteoclasts were identified by TRAP staining and bone apposition rate was determined by dynamic histomorphometry.

Results

At 10 days post-injury we detected a marked 48% decrease in trabecular bone and a 35% decrease in cortical bone at the distal femoral metaphysis by micro-CT. A 330% increase in the number of mature osteoclasts was detected at the growth plate in the injured animals that corresponded with cellular disorganization at the chondro-osseous junction. Appositional growth studies demonstrated decreased new bone formation with a mineralization defect indicative of osteoblast dysfunction.

Conclusions

Contusion SCI results in a rapid bone loss that is the result of increased bone resorption and decreased bone formation.     

Failed videolaryngoscope intubation in a patient with diffuse idiopathic skeletal hyperostosis and spinal cord injury

Purpose

A case of difficult intubation in a patient with cervical spinal cord injury with diffuse idiopathic skeletal hyperostosis (DISH) is described. The trachea could not be intubated with a videolaryngoscope, and successful intubation was achieved with a laryngeal mask airway device (LMAD) and a fibreoptic bronchoscope (FOB).

Clinical features

A 65-yr-old male developed sudden tetraplegia after a fall. Initial attempts at securing his airway were unsuccessful with a videolaryngoscope, but success was achieved with a LMAD and a FOB. Diagnostic imaging revealed no cervical spine fracture but demonstrated severe airway distortion from DISH and a spinal cord contusion accounting for his tetraplegia. Subcutaneous neck emphysema likely secondary to difficult intubation was also identified, but it did not result in additional morbidity.

Conclusions

Although often considered to be a benign entity, DISH can predispose patients to catastrophic cervical injury and difficult airway management. Careful review of plain radiographs in the spinal cord injury patient may assist with appropriate selection of airway interventions. The videolaryngoscope is useful for difficult airways, but its effectiveness may be compromised with an anteriorly displaced airway in combination with restricted cervical movement and limited oropharyngeal airspace.     

Enhanced neuroregenerative effects by scaffold for the treatment of a rat spinal cord injury with Wnt3a-secreting fibroblasts

Background

Wnt proteins are bifunctional axon guidance molecules, several of which appear to mediate guidance of corticospinal tract axons along the spinal cord. Here, we studied increasing effect on regeneration by Wnt-containing alginate scaffolds on spinal cord injury (SCI).

Methods

A total of 32 rats were injured at the T7–8 level with an NYU impactor. According to transplantation materials, rats were classified into four groups: a Wnt3a-secreting fibroblast transplantation group (Wnt group, n?=?8), a Wnt3a-secreting fibroblast with alginate transplantation group (Wnt + alginate group, n?=?8), an alginate transplantation group (alginate group, n?=?8), and a contusion-only group (sham group, n?=?8). Behavioral tests were performed on the first, second, and third days after injury, and then weekly for 8 weeks. Five of the eight rats from each group were selected for manganese-enhanced magnetic resonance imaging (ME-MRI). Two rats from each group were examined for GAP43 and MAP2 expression using monoclonal and polyclonal primary antibodies, respectively.

Results

Seven weeks after transplantation (8 weeks after SCI), Wnt + alginate group rats achieved an average Basso–Beattie–Bresnahan locomotor score of 19.0, which was significantly higher than that of other groups. ME-MRI at 8 weeks after SCI revealed significantly higher relative signal intensities in the Wnt + alginate group. Gap43 and Map2 immunostaining, showed strong positive in the Wnt + alginate group.

Conclusion

The Wnt + alginate complex exerted significantly enhanced recovery in a rat SCI model compared to alginate or Wnt3a alone. These results suggest that alginate scaffolds facilitate the regeneration of axon working with Wnt3a protein that promotes regeneration of the injured spinal cord.     

Predictors of hospital mortality and mechanical ventilation in patients with cervical spinal cord injury

Purpose

The objective of this study was to identify predictors of death and mechanical ventilation in patients with traumatic cervical spinal cord injury.

Methods

From 1981 to 1994, 72 patients with traumatic cervical spinal cord injury resulting in neurological deficits were identified in this retrospective study. For each patient, neurological and associated injuries, physiological variables, complications, hospital mortality and the need for mechanical ventilation were recorded. Univariate and multivariate logistic regression analyses were done to identify predictors of mortality and the need for mechanical ventilation.

Results

Fifteen patients (21%) died in The flirt three months after injury. Univariate analyses identified age, heart disease, neurological level at C₄ and above, GCS ≤ 13, forced vital capacity and cough, to be associated with mortality. Murtivanate logistic regression identified age (P = 0.01 ), neurological level (P = 0.03) and GCS (P = 0.05) as independent predictors of mortality. In 41 patients (57%), the lungs were mechanically ventilated. Univariate analyses identified The following predictors of the need for mechanical ventilation: neurological level at C₅ and above, complete cord lesions, copious sputum, pneumonia and lung collapse. Murtivariate logistic regression identified copious sputum (P = 0.01 ) and pneumonia (P = 0.01 ) as independent predictors of the need for mechanical ventilation.

Conclusion

Age, neurological level and GCS are independent predictors of mortality in patients with traumatic cervical spinal cord injury, Copious sputum and pneumonia are independent predictors of the need for mechanical ventilation.     

Secondary adrenal insufficiency after glucocorticosteroid administration in acute spinal cord injury: A case report

Context/background

A 61-year-old female with cervical stenosis underwent an elective cervical laminectomy with post-op worsening upper extremity weakness. Over the first 3 weeks post-op, she received two separate courses of intravenous steroids. Two days after cessation of steroids, she presented with non-specific symptoms of adrenal insufficiency (AI). Initial formal diagnostic tests of random cortisol level and 250 µg cosyntropin challenge were non-diagnostic; however, symptoms resolved with the initiation of empiric treatment with hydrocortisone. Ten days later, repeat cosyntropin (adrenocortocotropic hormone stimulation) test confirmed the diagnosis of AI.

Findings

AI is a potentially life-threatening complication of acute spinal cord injury (ASCI), especially in those receiving steroids acutely. Only three cases have been reported to date of AI occurring in ASCI after steroid treatment. The presenting symptoms can be non-specific (as in this patient) and easily confused with other common sequelae of ASCI such as orthostasis and diffuse weakness. The 250 µg cosyntropin simulation test may not the most sensitive test to diagnose AI in ASCI.

Conclusion

The non-specific presentations and variability of diagnosis criteria make diagnosis more difficult. One microgram cosyntropin simulation test may be more sensitive than higher dose. Clinicians should be aware that AI can be a potential life-threatening complication of ASCI post-steroid treatment. Prompt diagnosis and treatment can reverse symptoms and minimize mortality.     

Effect of norepinephrine on spinal cord blood flow and parenchymal hemorrhage size in acute-phase experimental spinal cord injury

Purpose

In the acute phase of spinal cord injury (SCI), ischemia and parenchymal hemorrhage are believed to worsen the primary lesions induced by mechanical trauma. To minimize ischemia, keeping the mean arterial blood pressure above 85 mmHg for at least 1 week is recommended, and norepinephrine is frequently administered to achieve this goal. However, no experimental study has assessed the effect of norepinephrine on spinal cord blood flow (SCBF) and parenchymal hemorrhage size. We have assessed the effect of norepinephrine on SCBF and parenchymal hemorrhage size within the first hour after experimental SCI.

Methods

A total of 38 animals were included in four groups according to whether SCI was induced and norepinephrine injected. SCI was induced at level Th10 by dropping a 10-g weight from a height of 10 cm. Each experiment lasted 60 min. Norepinephrine was started 15 min after the trauma. SCBF was measured in the ischemic penumbra zone surrounding the trauma epicenter using contrast-enhanced ultrasonography. Hemorrhage size was measured repeatedly on parasagittal B-mode ultrasonography slices.

Results

SCI was associated with significant decreases in SCBF (P = 0.0002). Norepinephrine infusion did not significantly modify SCBF. Parenchymal hemorrhage size was significantly greater in the animals given norepinephrine (P = 0.0002).

Conclusion

In the rat, after a severe SCI at the Th10 level, injection of norepinephrine 15 min after SCI does not modify SCBF and increases the size of the parenchymal hemorrhage.     

Rat model of spinal cord injury preserving dura mater integrity and allowing measurements of cerebrospinal fluid pressure and spinal cord blood flow

Purposes

Cerebrospinal fluid (CSF) pressure elevation may worsen spinal cord ischaemia after spinal cord injury (SCI). We developed a rat model to investigate relationships between CSF pressure and spinal cord blood flow (SCBF).

Methods

Male Wistar rats had SCI induced at Th10 (n = 7) or a sham operation (n = 10). SCBF was measured using laser-Doppler and CSF pressure via a sacral catheter. Dural integrity was assessed using subdural methylene-blue injection (n = 5) and myelography (n = 5).

Results

The SCI group had significantly lower SCBF (p < 0.0001) and higher CSF pressure (p < 0.0001) values compared to the sham-operated group. Sixty minutes after SCI or sham operation, CSF pressure was 8.6 ± 0.4 mmHg in the SCI group versus 5.5 ± 0.5 mmHg in the sham-operated group. No dural tears were found after SCI.

Conclusion

Our rat model allows SCBF and CSF pressure measurements after induced SCI. After SCI, CSF pressure significantly increases.     

Effects of low intensity vibration on bone and muscle in rats with spinal cord injury

Summary

Spinal cord injury (SCI) causes rapid and marked bone loss. The present study demonstrates that low-intensity vibration (LIV) improves selected biomarkers of bone turnover and gene expression and reduces osteoclastogenesis, suggesting that LIV may be expected to benefit to bone mass, resorption, and formation after SCI.

Introduction

Sublesional bone is rapidly and extensively lost following spinal cord injury (SCI). Low-intensity vibration (LIV) has been suggested to reduce loss of bone in children with disabilities and osteoporotic women, but its efficacy in SCI-related bone loss has not been tested. The purpose of this study was to characterize effects of LIV on bone and bone cells in an animal model of SCI.

Methods

The effects of LIV initiated 28 days after SCI and provided for 15 min twice daily 5 days each week for 35 days were examined in female rats with moderate severity contusion injury of the mid-thoracic spinal cord.

Results

Bone mineral density (BMD) of the distal femur and proximal tibia declined by 5 % and was not altered by LIV. Serum osteocalcin was reduced after SCI by 20 % and was increased by LIV to a level similar to that of control animals. The osteoclastogenic potential of bone marrow precursors was increased after SCI by twofold and associated with 30 % elevation in serum CTX. LIV reduced the osteoclastogenic potential of marrow precursors by 70 % but did not alter serum CTX. LIV completely reversed the twofold elevation in messenger RNA (mRNA) levels for SOST and the 40 % reduction in Runx2 mRNA in bone marrow stromal cells resulting from SCI.

Conclusion

The findings demonstrate an ability of LIV to improve selected biomarkers of bone turnover and gene expression and to reduce osteoclastogenesis. The study indicates a possibility that LIV initiated earlier after SCI and/or continued for a longer duration would increase bone mass.     

Spinal anaesthesia for Caesarean section in a patient with a cervical arteriovenous malformation

Purpose

Arteriovenous malformations (AVM) of the spinal cord are rare. We report the successful management of a patient with a cervical spinal cord AVM undergoing Caesarean section delivery, using a spinal anaesthetic.

Clinical features

Based on previous radiological investigations, the patient was known to have an AVM at the third cervical level of her spinal cord. After application of monitors and intravenous administration of 1 L normal saline, a 25 g Whitacre needle was inserted into the subarachnoid space at the L_3–4 interspace. Spinal anaesthesia was established with a solution consisting of hyperbaric spinal bupivacaine 12 mg, fentanyl 12.5 μg and epidural morphine 0.25 mg. There was no neurological deficit during hospital stay or after discharge.

Conclusion

The safe outcome of spinal anaesthesia for our patient is encouraging. The presence of spinal cord AVM at the cervical region is not an absolute contraindication to spinal anaesthesia.