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The American Journal of Medicine Jan 2020Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency...
BACKGROUND
Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED.
METHODS
We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality.
RESULTS
We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess).
CONCLUSION
We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed.
Topics: Catheters, Indwelling; Cauda Equina Syndrome; Emergency Service, Hospital; Epidural Abscess; Humans; Low Back Pain; Prevalence; Risk Factors; Spinal Cord Compression; Spinal Fractures; Spinal Neoplasms; Substance Abuse, Intravenous; Vascular Access Devices
PubMed: 31278933
DOI: 10.1016/j.amjmed.2019.06.005 -
Journal of Vascular Surgery Apr 2022The rate of endovascular repair of thoracoabdominal aortic aneurysms (TAAA-ER) has increased considerably in recent years. Although the mortality and morbidity rates... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The rate of endovascular repair of thoracoabdominal aortic aneurysms (TAAA-ER) has increased considerably in recent years. Although the mortality and morbidity rates have improved, the incidence of spinal cord ischemia (SCI) has not declined significantly. The aim of the present systematic review and meta-analysis was to examine the SCI rates with respect to the efficacy of the different approaches.
METHODS
Cohort studies and case series (>20 patients) reporting SCI rates after TAAA-ER were eligible for inclusion. The primary outcome measure was the evaluation of SCI. The moderators considered were primarily the staged vs nonstaged approach, the use of cerebrospinal fluid drainage (CSFD), and TAAA extension. The permanent SCI and mortality rates were extracted.
RESULTS
A total of 27 studies with 2333 patients were included in the meta-analysis. The pooled estimate for SCI was 11% (95% confidence interval [CI], 8%-15%; I, 79%). For extent I, II, III, and V TAAA, the pooled SCI rate was 13% (95% CI, 10%-17%; I, 69%). For extent IV TAAA, the pooled SCI rate was 6% (95% CI, 3%-10%; I, 62%). A staged TAAA-ER approach was used in 20 studies and a nonstaged approach in 8 (1 study had included both). A lower pooled SCI rate was identified after staged than after nonstaged TAAA-ER (9% vs 18%, respectively; P = .02). Staging was accomplished in >1 month in nine studies and ≤1 month in two studies, leading to similar SCI rates (7% vs 11%, respectively; P = .26). The method of staging (thoracic endoprosthesis or temporary aortic sac perfusion) did not affect the SCI rates. Symptomatic CSFD was associated with a similar pooled rate of SCI compared with prophylactic CSFD (10% vs 10%, respectively; P = .99). The pooled permanent SCI rate was 6% (6% for extent I, II, III, and V TAAA; and 3% for extent IV TAAA). The pooled rate of 30-day mortality was 7%, with a similar incidence for the staged and nonstaged approaches (6% vs 9%, respectively). Interstage mortality was reported in 9 studies, with a pooled estimate rate of 1.6%.
CONCLUSIONS
SCI had occurred in 11% of TAAA-ER, and one half of these cases were permanent. A staged approach can reduce SCI rates independently of the timing and method adopted. The overall mortality rate for staged TAAA-ER was 7%, with one fifth of the deaths (1.6%) occurring between stages.
Topics: Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Cerebrospinal Fluid Leak; Endovascular Procedures; Humans; Retrospective Studies; Risk Factors; Spinal Cord Ischemia; Time Factors; Treatment Outcome
PubMed: 34736999
DOI: 10.1016/j.jvs.2021.10.015 -
Journal of Clinical Medicine Aug 2022Intramedullary spinal cord abscess (ISCA) is a rare clinical pathology of the central nervous system that usually accompanies other underlying comorbidities.... (Review)
Review
Intramedullary spinal cord abscess (ISCA) is a rare clinical pathology of the central nervous system that usually accompanies other underlying comorbidities. Traditionally it has been associated with significant mortality and neurological morbidities because it is often difficult to diagnose promptly, owing to its nonspecific clinical and neuroimaging features. The mortality rate and the outcome of these infections have been improved by the introduction into clinical practice of antibiotics, advanced neuroimaging modalities, and immediate surgery. We report the case of a 65-year-old male patient who presented with a progressive spastic gait and lumbar pain, predominantly in the left leg. An MRI image revealed an expansile intramedullary cystic mass in the thoracic spinal cord, which was initially diagnosed as a spinal tumor. He underwent laminectomy and myelotomy, and eventually the pus was drained from the abscess. The follow-up MRI showed improvement, but the patient's paraplegia persisted. In light of his persistent hypoesthesia and paraplegic gait with developing neuropathic pain, he was readmitted, and an MRI of his lumbar spine revealed multilevel degenerative disease and tethered spinal cord syndrome with compression of the medulla at the L2-L3 level. The patient underwent central flavectomy with bilateral foraminotomy at the L2-L3 level, and the medulla was decompressed. Postoperatively, his neurological symptoms were significantly improved, and he was discharged from hospital on the third day after admission. In support of our case, we systematically reviewed the recent literature and analyzed cases published between 1949 and May 2022, including clinical features, mechanisms of infection, predisposing factors, radiological investigations, microbial etiologies, therapies and their duration, follow-ups, and outcomes. Initial clinical presentation can be misleading, and the diagnosis can be challenging, because this condition is rare and coexists with other spinal diseases. Hence, a high index of suspicion for making an accurate diagnosis and timely intervention is required to preclude mortality and unfavorable outcomes. Our case is a clear example thereof. Long-term follow-up is also essential to monitor for abscess recurrences.
PubMed: 36079075
DOI: 10.3390/jcm11175148 -
The Journal of Spinal Cord Medicine 2021The COVID-19 pandemic has created opportunity for multiple rehabilitation science learners and clinicians to critically evaluate and synthesize published research in the...
BACKGROUND
The COVID-19 pandemic has created opportunity for multiple rehabilitation science learners and clinicians to critically evaluate and synthesize published research in the field of spinal cord injury (SCI) rehabilitation.
OBJECTIVE
To provide a step-by-step guide for rehabilitation science learners and clinicians outlining how to conduct rigorous systematic reviews in the field of SCI.
RESULTS
Steps for conducting a systematic review (SR) include: (1) formation of the SR team consisting of interprofessional experts; (2) formulation of the research question(s) with patient/population/problem, Intervention, Comparison, and Outcome (PICO) specification; (3) determination of inclusion and exclusion criteria; (4) development of SR protocol and registration; (5) development of the search strategies (database specific); (6) screening of titles and abstracts (level 1 screening), and full-texts (level 2 screening); (7) quality assessment of the included studies; (8) data extraction; (9) summary of findings and discussion; and, (10) dissemination of results.
CONCLUSIONS
The enclosed ten steps for conducting SRs in SCI rehabilitation research have the potential to significantly improve the quality of evidence synthesis and the associated inferences. The importance of assembling team with diverse expertise is emphasized to assure a quality product with the potential to influence practice and inform the content of clinical practice recommendations.
Topics: COVID-19; Humans; Pandemics; SARS-CoV-2; Spinal Cord Injuries
PubMed: 34038338
DOI: 10.1080/10790268.2021.1923261 -
Neuromodulation : Journal of the... Oct 2023Falls in extrapyramidal disorders, particularly Parkinson's disease (PD), multisystem atrophy (MSA), and progressive supranuclear palsy (PSP), are key milestones... (Review)
Review
BACKGROUND
Falls in extrapyramidal disorders, particularly Parkinson's disease (PD), multisystem atrophy (MSA), and progressive supranuclear palsy (PSP), are key milestones affecting patients' quality of life, incurring increased morbidity/mortality and high healthcare costs. Unfortunately, gait and balance in parkinsonisms respond poorly to currently available treatments. A serendipitous observation of improved gait and balance in patients with PD receiving spinal cord stimulation (SCS) for back pain kindled an interest in using SCS to treat gait disorders in parkinsonisms.
OBJECTIVES
We reviewed preclinical and clinical studies of SCS to treat gait dysfunction in parkinsonisms, covering its putative mechanisms and efficacies.
MATERIALS AND METHODS
Preclinical studies in animal models of PD and clinical studies in patients with PD, PSP, and MSA who received SCS for gait disorders were included. The main outcome assessed was clinical improvement in gait, together with outcome measures used and possible mechanism of actions.
RESULTS
We identified 500 references, and 45 met the selection criteria and have been included in this study for analysis. Despite positive results in animal models, the outcomes in human studies are inconsistent.
CONCLUSIONS
The lack of blind and statistically powered studies, the heterogeneity in patient selection and study outcomes, and the poor understanding of the underlying mechanisms of action of SCS are some of the limiting factors in the field. Addressing these limitations will allow us to draw more reliable conclusions on the effects of SCS on gait and balance in extrapyramidal disorders.
Topics: Humans; Parkinson Disease; Spinal Cord Stimulation; Quality of Life; Parkinsonian Disorders; Multiple System Atrophy; Gait
PubMed: 37452800
DOI: 10.1016/j.neurom.2023.06.003 -
Neuromodulation : Journal of the... Oct 2023This study aims to describe the state of literature regarding the use of intraoperative neurophysiological monitoring (IONM) during spinal cord stimulator surgery. (Review)
Review
OBJECTIVES
This study aims to describe the state of literature regarding the use of intraoperative neurophysiological monitoring (IONM) during spinal cord stimulator surgery.
MATERIALS AND METHODS
A systematic review of the use of IONM during spinal cord stimulation (SCS) surgery was performed using the following three data bases: PubMed, Ovid MEDLINE, and Embase. Research techniques included systematic research following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol by Cochrane, and backward searching. Qualitative analysis of included articles was performed using the methodologic index for nonrandomized studies assessment tool. Direction of effect, consistency across studies, and cost-effectiveness were narratively synthesized.
RESULTS
A total of 15 records were identified through data base searching. All records used IONM methods under general anesthesia for guidance of epidural lead placement. IONM techniques used for determining lateralization in the found articles were compound muscle action potentials (CMAPs) (n = 8), somatosensory evoked potentials (SSEPs) (n = 3) or both (n = 4). Motor evoked potentials were used in three trials for neuroprotection purposes. Two studies were comparative, and 12 were noncomparative.
CONCLUSIONS
We found a good body of level II evidence that using IONM during SCS surgery is a valid alternative to awake surgery and may even be superior regarding pain management, cost-effectiveness, and postoperative neurologic deficits. In direct comparison, the found evidence suggested using CMAP provided more consistently favorable results than using SSEP for midline placement of epidural leads under general anesthesia. Selection of IONM modality should be made on the basis of pathophysiology of disease, individual IONM experience, and the individual patient.
Topics: Humans; Intraoperative Neurophysiological Monitoring; Spinal Cord Stimulation; Brain Neoplasms; Wakefulness; Neurosurgical Procedures; Evoked Potentials, Motor; Retrospective Studies
PubMed: 37802585
DOI: 10.1016/j.neurom.2023.06.010 -
Journal of Vascular Surgery Mar 2022Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who...
OBJECTIVE
Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who develop SCI have a poor prognosis, with mortality rates reaching 75% within the first year after surgery. Many factors have been shown to increase the risk of this complication, including the extent of TAA repair, length of aortic and collateral network coverage, embolization, and reduced spinal cord perfusion pressure. As a result, a variety of treatment strategies have been developed. We aimed to provide an up-to-date review of SCI rates with associated treatment algorithms from open and endovascular DTA and TAA repair.
METHODS
Using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, a literature review with the MeSH (medical subject headings) terms "spinal cord ischemia," "spinal cord ischemia prevention and mitigation strategies," "spinal cord ischemia rates," and "spinal cord infarction" was performed in the Cochrane and PubMed databases to find all peer-reviewed studies of DTA and TAA repair with SCI complications reported. The search was limited to 2012 to 2021 and English-language reports. MeSH subheadings, including diagnosis, complications, physiopathology, surgery, mortality, and therapy, were used to further restrict the included studies. Studies were excluded if they were not of humans, had not pertained to SCI after DTA or TAA operative repair, and if the study had primarily discussed neuromonitoring techniques. Additionally, studies with <40 patients or limited information regarding SCI protection strategies were excluded. Each study was individually reviewed by two of us (S.L. and A.D.) to assess the type and extent of aortic pathology, operative technique, SCI protection or mitigation strategies, rates of overall and permanent SCI symptoms, associations with SCI on multivariate analysis, and mortality.
RESULTS
Of the 450 studies returned by the MeSH search strategy, 41 met the inclusion criteria and were included in the final analysis. For the endovascular DTA repair patients, the overall SCI rates ranged from 0% to 10.6%, with permanent SCI symptoms ranging from 0% to 5.1%. The rate of overall SCI after endovascular and open TAA repair was 0% to 35%. The permanent SCI symptom rate was reported by only one study of open repair at 1.1%. The permanent SCI symptom rate after endovascular TAA repair was 2% to 20.5%.
CONCLUSIONS
The present review has provided an up-to-date review of the current rates of SCI and the prevention and mitigation strategies used during DTA and TAA repair. We found that a multimodal approach, including a bundled institutional protocol, staging of multiple repairs, preservation of the collateral blood flow network, augmented spinal cord perfusion, selective cerebrospinal fluid drainage, and distal aortic perfusion during open TAA repairs, appears to be important in reducing the risk of SCI.
Topics: Algorithms; Aorta, Thoracic; Aortic Diseases; Blood Vessel Prosthesis Implantation; Decision Support Techniques; Endovascular Procedures; Humans; Risk Assessment; Risk Factors; Spinal Cord Ischemia; Time Factors; Treatment Outcome
PubMed: 34740806
DOI: 10.1016/j.jvs.2021.10.039 -
Revista Espanola de Cirugia Ortopedica... Oct 2023Systematic review and meta-analysis. (Review)
Review
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
To compare early (<24h) versus late (>24h) spinal cord decompression on neurological recovery in patients with acute spinal cord injury.
METHODS
A systematic review was performed according to the PRISMA protocol to identify studies published up to December 2022. Prospective cohort studies and controlled trials comparing early versus delayed decompression on neurological recovery were included. Variables included number of patients, level of injury, treatment time, ASIA grade, neurological recovery, use of corticosteroids, and complications. For the meta-analysis, the «forest plot» graph was developed. The risk of bias of the included studies was assessed using the ROBINS-I22 and Rob223 tools.
RESULTS
Six of the seven studies selected for our review were included in the meta-analysis, with a total of 1188 patients (592 patients in the early decompression group and 596 in the delayed decompression group), the mean follow-up was 8 months, in 5 studies used methylprednisolone, the most reported complications were thromboembolic cardiopulmonary events. Five studies showed significant differences in favor of early decompression (risk difference 0.10, 95% confidence interval 0.07-0.14, heterogeneity 46%). The benefit was greatest in cervical and incomplete injuries.
CONCLUSION
There is scientific evidence to recommend early decompression in the first 24h after traumatic spinal cord injury, as it improves final neurological recovery, and it should be recommended whenever the patient and hospital conditions allow it to be safely done.
PubMed: 37805026
DOI: 10.1016/j.recot.2023.09.009 -
International Journal of Molecular... Jul 2023Recovery from a traumatic spinal cord injury (TSCI) is challenging due to the limited regenerative capacity of the central nervous system to restore cells, myelin, and... (Review)
Review
Recovery from a traumatic spinal cord injury (TSCI) is challenging due to the limited regenerative capacity of the central nervous system to restore cells, myelin, and neural connections. Cell therapy, particularly with mesenchymal stem cells (MSCs), holds significant promise for TSCI treatment. This systematic review aims to analyze the efficacy, safety, and therapeutic potential of MSC-based cell therapies in TSCI. A comprehensive search of PUBMED and COCHRANE databases until February 2023 was conducted, combining terms such as "spinal cord injury," "stem cells," "stem cell therapy," "mesenchymal stem cells," and "traumatic spinal cord injury". Among the 53 studies initially identified, 22 (21 clinical trials and 1 case series) were included. Findings from these studies consistently demonstrate improvements in AIS (ASIA Impairment Scale) grades, sensory scores, and, to a lesser extent, motor scores. Meta-analyses further support these positive outcomes. MSC-based therapies have shown short- and medium-term safety, as indicated by the absence of significant adverse events within the studied timeframe. However, caution is required when drawing generalized recommendations due to the limited scientific evidence available. Further research is needed to elucidate the long-term safety and clinical implications of these advancements. Although significant progress has been made, particularly with MSC-based therapies, additional studies exploring other potential future therapies such as gene therapies, neurostimulation techniques, and tissue engineering approaches are essential for a comprehensive understanding of the evolving TSCI treatment landscape.
Topics: Humans; Mesenchymal Stem Cell Transplantation; Spinal Cord Injuries; Cell- and Tissue-Based Therapy; Myelin Sheath; Mesenchymal Stem Cells; Spinal Cord
PubMed: 37511478
DOI: 10.3390/ijms241411719 -
Journal of Vascular Surgery Nov 2012The use of thoracic endovascular aneurysm repair (TEVAR) is increasing. Similar to open repair, TEVAR carries a risk of spinal cord ischemia (SCI). We undertook a... (Review)
Review
BACKGROUND
The use of thoracic endovascular aneurysm repair (TEVAR) is increasing. Similar to open repair, TEVAR carries a risk of spinal cord ischemia (SCI). We undertook a systematic review to determine whether preoperative cerebrospinal fluid (CSF) drainage reduces SCI.
METHODS
PubMed, the Cochrane Library, and conference abstracts were searched using the keywords thoracic endovascular aortic repair, cerebrospinal fluid, spinal cord ischaemia, TEVAR, and aneurysm. Studies reporting SCI rates and CSF drain rates for TEVAR patients were eligible for inclusion. SCI rates across studies were pooled using random-effects modeling. Study quality was evaluated using the Downs and Black score.
RESULTS
Study quality was generally poor to moderate (median Downs and Black score, 9). The systematic review identified 46 eligible studies comprising 4936 patients; overall, SCI affected 3.89% (95% confidence interval, 2.95.05%-4.95%). Series reporting routine prophylactic drain placement or no prophylactic drain placement reported pooled SCI rates of 3.2% and 3.47%, respectively. The pooled SCI rate from 24 series stating that prophylactic drainage was used selectively was 5.6%.
CONCLUSIONS
Spinal chord injury is uncommon after TEVAR. The role of prophylactic CSF drainage is difficult to establish from the available literature. High-quality studies are required to determine the role of prophylactic CSF drainage in TEVAR.
Topics: Aortic Aneurysm, Thoracic; Cerebrospinal Fluid; Drainage; Endovascular Procedures; Humans; Spinal Cord Ischemia
PubMed: 22884456
DOI: 10.1016/j.jvs.2012.05.075