The acute phase management of spinal cord injury affecting polytrauma patients: the ASAP study

Abstract

Background Few data on the management of acute phase of traumatic spinal cord injury (tSCI) in patients suffering polytrauma are available. As the therapeutic choices in the first hours may have a deep impact on outcome of tSCI patients, we conducted an international survey investigating this topic. Methods The survey was composed of 29 items. The main endpoints of the survey were to examine: (1) the hemodynamic and respiratory management, (2) the coagulation management, (3) the timing of magnetic resonance imaging (MRI) and spinal surgery, (4) the use of corticosteroid therapy, (5) the role of intraspinal pressure (ISP)/spinal cord perfusion pressure (SCPP) monitoring and (6) the utilization of therapeutic hypothermia. Results There were 171 respondents from 139 centers worldwide. A target mean arterial pressure (MAP) target of 80–90 mmHg was chosen in almost half of the cases [n = 84 (49.1%)]. A temporary reduction in the target MAP, for the time strictly necessary to achieve bleeding control in polytrauma, was accepted by most respondents [n = 100 (58.5%)]. Sixty-one respondents (35.7%) considered acceptable a hemoglobin (Hb) level of 7 g/dl in tSCI polytraumatized patients. An arterial partial pressure of oxygen (PaO2) of 80–100 mmHg [n = 94 (55%)] and an arterial partial pressure of carbon dioxide (PaCO2) of 35–40 mmHg [n = 130 (76%)] were chosen in most cases. A little more than half of respondents considered safe a platelet (PLT) count > 100.000/mm3 [n = 99 (57.9%)] and prothrombin time (PT)/activated partial thromboplastin time (aPTT) < 1.5 times the normal control [n = 85 (49.7%)] in patients needing spinal surgery. MRI [n = 160 (93.6%)] and spinal surgery [n = 158 (92.4%)] should be performed after intracranial, hemodynamic, and respiratory stabilization by most respondents. Corticosteroids [n = 103 (60.2%)], ISP/SCPP monitoring [n = 148 (86.5%)], and therapeutic hypothermia [n = 137 (80%)] were not utilized by most respondents. Conclusions Our survey has shown a great worldwide variability in clinical practices for acute phase management of tSCI patients with polytrauma. These findings can be helpful to define future research in order to optimize the care of patients suffering tSCI.

DJ-1 Alleviates Neuroinflammation and the Related Blood-Spinal Cord Barrier Destruction by Suppressing NLRP3 Inflammasome Activation via SOCS1/Rac1/ROS Pathway in a Rat Model of Traumatic Spinal Cord Injury

“…Methylprednisolone sodium succinate was one of the first drugs used clinically to prevent secondary damage, by stabilizing cell membranes and providing anti-inflammatory effects, but with clinical efficacy and unavoidable side effects [24]. There have been many subsequent clinical studies targeting multiple drugs including COX inhibitors [25], corticosteroids [26], and minocycline [27], but none of them have achieved satisfactory results. The underlying reason is that the cognition of the mechanism of inflammation is not comprehensive and clear, and appropriate targets and drugs have not been found.…”

Continuous improvement in optimizing the timing of axial, hip, and femoral fracture fixation

“…7,11,14 Fixation within 36 to 48 hours of injury has been associated with fewer complications and shorter lengths of stay in multiple recent reports. 5,7,11,13,14,22,32-36…”

“…Recent large database studies within Canada, Japan, and the USA have further affirmed these concepts. 8,16,22,23,25,26,41 Surgery within 24 to 36 hours following injury is advocated. Many centres employ team-based care with algorithms to direct and expedite preoperative risk stratification and mitigation.…”

“…Many centres employ team-based care with algorithms to direct and expedite preoperative risk stratification and mitigation. 3,10,16,22,23,25,26,40,42…”

“…7,11,14 Application of these principles has advanced beyond femoral shaft fractures to include fractures of the thoracolumbar spine, pelvis ring, acetabulum, and proximal femur, which carry a similar burden for the patient. 4,14,[16][17][18][19][20][21][22][23] More recent literature supports the efficacy of these strategies in reducing complications, hospital stays, and costs. 14,15,[19][20][21] Extending these principles outside of single trauma centres, and sometimes beyond individual orthopaedic trauma surgeons working at a specific centre, entails development of networks of care with detailed algorithms and quality assessment processes.…”