Expansion Duroplasty Improves Intraspinal Pressure, Spinal Cord Perfusion Pressure, and Vascular Pressure Reactivity Index in Patients with Traumatic Spinal Cord Injury: Injured Spinal Cord Pressure Evaluation Study

Phang, Isaac; Werndle, Melissa C.; Saadoun, Samira; Varsos, Georgios V.; Czosnyka, Marek; Zoumprouli, Argyro; Papadopoulos, Marios C.

doi:10.1089/neu.2014.3668

Cited by 124 publications

(108 citation statements)

References 27 publications

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“…Therefore, not only hypoperfusion (SCPP below 90 mmHg), but also hyperperfusion (SCPP above 100 mmHg) may be detrimental for the injured spinal cord. This is consistent with our earlier report of a U-shaped relationship between the spinal pressure reactivity index and SCPP, which also indicated optimum SCPP around 90 mmHg 5,8,21 . After TSCI, ISP is 20 -30 mmHg and therefore SCPP 90 -100 mmHg corresponds to mean arterial pressure 110 -130 mmHg.…”

Section: Annals Of Neurologysupporting

confidence: 93%

“…We also showed that simultaneous monitoring of SCPP and microdialysis could be used to enhance drug entry at the injury site. Based on our current findings and earlier studies [4][5][6][7][8][9]20,21 , a large-scale study of outcome from TSCI in patients who have monitoring vs. those who do not is warranted.…”

Section: Annals Of Neurologymentioning

confidence: 62%

“…Mechanism of injury (number of patients) Fall (6), Road traffic accident (8) Age in years, mean (range) 38 ( …”

Section: Number Of Patients 14mentioning

confidence: 99%

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Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Phang

Zoumprouli

Papadopoulos

et al. 2016

Annals of Neurology

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OBJECTIVE:There is lack of monitoring from the injury site to guide management of patients with acute traumatic spinal cord injury. Here we describe a bedside microdialysis monitoring technique for optimizing spinal cord perfusion and drug delivery at the injury site.METHODS: 14 patients were recruited within 72 hours of severe spinal cord injury. We inserted intradurally at the injury site a pressure probe, to monitor continuously spinal cord perfusion pressure, and a microdialysis catheter, to monitor hourly glycerol, glutamate, glucose, lactate and pyruvate. The pressure probe and microdialysis catheter were placed on the surface of the injured cord. RESULTS:Microdialysis monitoring did not cause serious complications. Spinal cord perfusion pressure 90 -100 mmHg and tissue glucose >4.5 mM minimized metabolic derangement at the injury site. Increasing spinal cord perfusion pressure by ~10 mmHg, increased the entry of intravenously administered dexamethasone at the injury site three-fold. INTERPRETATION:This study determined the optimum spinal cord perfusion pressure and optimum tissue glucose concentration at the injury site. We also identified spinal cord perfusion pressure as a key determinant of drug entry into the injured spinal cord. Our findings challenge current guidelines, which recommend maintaining mean arterial pressure at 85 -90 mmHg for a week after spinal cord injury. We propose that future drug trials for spinal cord injury include pressure and microdialysis monitoring to optimize spinal cord perfusion and maximize drug delivery at the injury site.

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Section: Annals Of Neurologysupporting

confidence: 93%

Section: Annals Of Neurologymentioning

confidence: 62%

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Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Phang

Zoumprouli

Papadopoulos

et al. 2016

Annals of Neurology

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“…26 Our data showed that in addition to bony decompression, expansion duraplasty was also required to effectively reduce ISP, increase SCPP, and improve the pressure reactivity at the injury site. 20 Laminectomy with duraplasty after TSCI is analogous to decompressive craniectomy after TBI, which involves not only bony but also dural decompression. The dura is a major, but unappreciated, cause of spinal cord compression after TSCI 18 and may explain why the benefits of early bony decompression (without opening the dura) after TSCI remain controversial.…”

mentioning

confidence: 99%

Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

Phang

Zoumprouli

Saadoun

et al. 2016

SPI

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OBJECTIVE A novel technique for monitoring intraspinal pressure and spinal cord perfusion pressure in patients with traumatic spinal cord injury was recently described. This is analogous to monitoring intracranial pressure and cerebral perfusion pressure in patients with traumatic brain injury. Because intraspinal pressure monitoring is a new technique, its safety profile and impact on early patient care and long-term outcome after traumatic spinal cord injury are unknown. The object of this study is to review all patients who had intraspinal pressure monitoring to date at the authors' institution in order to define the accuracy of intraspinal pressure probe placement and the safety of the technique. METHODS At the end of surgery to fix spinal fractures, a pressure probe was inserted intradurally to monitor intraspinal pressure at the injury site. Postoperatively, CT scanning was performed within 48 hours and MRI at 2 weeks and 6 months. Neurointensive care management and complications were reviewed. The American Spinal Injury Association Impairment Scale (AIS) grade was determined on admission and at 2 to 4 weeks and 12 to 18 months postoperation. RESULTS To date, 42 patients with severe traumatic spinal cord injuries (AIS Grades A–C) had undergone intraspinal pressure monitoring. Monitoring started within 72 hours of injury and continued for up to a week. Based on postoperative CT and MRI, the probe position was acceptable in all patients, i.e., the probe was located at the site of maximum spinal cord swelling. Complications were probe displacement in 1 of 42 patients (2.4%), CSF leakage that required wound resuturing in 3 of 42 patients (7.1%), and asymptomatic pseudomeningocele that was diagnosed in 8 of 42 patients (19.0%). Pseudomeningocele was diagnosed on MRI and resolved within 6 months in all patients. Based on the MRI and neurological examination results, there were no serious probe-related complications such as meningitis, wound infection, hematoma, wound breakdown, or neurological deterioration. Within 2 weeks postoperatively, 75% of patients were extubated and 25% underwent tracheostomy. Norepinephrine was used to support blood pressure without complications. Overall, the mean intraspinal pressure was around 20 mm Hg, and the mean spinal cord perfusion pressure was around 70 mm Hg. In laminectomized patients, the intraspinal pressure was significantly higher in the supine than lateral position by up to 18 mm Hg after thoracic laminectomy and 8 mm Hg after cervical laminectomy. At 12 to 18 months, 11.4% of patients had improved by 1 AIS grade and 14.3% by at least 2 AIS grades. CONCLUSIONS These data suggest that after traumatic spinal cord injury intradural placement of the pressure probe is accurate and intraspinal pressure monitoring is safe for up to a week. In patients with spinal cord injury who had laminectomy, the supine position should be avoided in order to prevent rises in intraspinal pressure.

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“…It has long been recognized in the experimental setting that perfusion of the spinal cord is highly associated with outcome 16, 17, 18. Recent human and veterinary studies have furthered our understanding of the role of spinal cord perfusion and hemodynamic changes, as well as the benefits of taking appropriate measures to maintain optimal spinal cord blood flow 19, 20, 21, 22, 23. Spinal cord perfusion is dependent on the relationship between systemic blood pressure and intrathecal pressure, in the same way that cerebral perfusion pressure is defined by mean arterial blood pressure (MABP) and intracranial pressure 17, 19, 24.…”

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confidence: 99%

Associations Between Anesthetic Variables and Functional Outcome in Dogs With Thoracolumbar Intervertebral Disk Extrusion Undergoing Decompressive Hemilaminectomy

Fenn

Laber

Williams

et al. 2017

Veterinary Internal Medicne

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BackgroundOutcome of acute experimental spinal cord injury is strongly associated with tissue perfusion and oxygenation. Cardiopulmonary depression could affect outcome in dogs undergoing general anesthesia for surgical treatment of thoracolumbar intervertebral disk extrusion (IVDE).Hypothesis/ObjectivesTo evaluate the effects of general anesthesia on functional outcome in dogs undergoing surgery to treat thoracolumbar IVDE.AnimalsEighty‐four client‐owned dogs with acute thoracolumbar IVDE treated by decompressive hemilaminectomy.MethodsExploratory, retrospective observational study. Medical records were reviewed for clinical presentation and anesthetic monitoring variables, including duration of anesthesia and surgery, hypotension, bradycardia, temperature, and respiratory parameters. Multivariable regression tree analysis was performed to explore associations between anesthetic variables and functional outcome scores after 6 weeks, as well as return to ambulatory status.ResultsEpisodes of bradycardia (69%) and hypotension (57%) were frequent. Across all outcome measures, regression tree analysis highlighted functional grade at presentation as the primary determining factor, and among pain perception negative dogs, there was a possible association between increased duration of surgery and poorer outcome. In dogs with intact pain perception, duration of bradycardia, mean body temperature, and mean end‐tidal carbon dioxide were highlighted.Conclusions and Clinical ImportanceExploratory statistical methods can facilitate hypothesis‐generating studies to inform prospective investigations in veterinary medicine. Although the mechanism is uncertain, increased duration of surgery might be associated with poorer outcome in pain perception negative dogs with thoracolumbar IVDE.

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Expansion Duroplasty Improves Intraspinal Pressure, Spinal Cord Perfusion Pressure, and Vascular Pressure Reactivity Index in Patients with Traumatic Spinal Cord Injury: Injured Spinal Cord Pressure Evaluation Study

Cited by 124 publications

References 27 publications

Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

Associations Between Anesthetic Variables and Functional Outcome in Dogs With Thoracolumbar Intervertebral Disk Extrusion Undergoing Decompressive Hemilaminectomy

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