Anesthetic considerations for patients with acute cervical spinal cord injury

Anesthesiologists work to prevent or minimize secondary injury of the nervous system and improve the outcome of medical procedures.To this end,anesthesiologists must have a thorough understanding of pathophysiology and optimize their skills and equipment to make an anesthesia plan.Anesthesiologists should conduct careful physical examinations of patients and consider neuroprotection at preoperative interviews,consider cervical spinal cord movement and compression during airway management,and suggest awake fiberoptic bronchoscope intubation for stable patients and direct laryngoscopy with manual in-line immobilization in emergency situations.During induction,anesthesiologists should avoid hypotension and depolarizing muscle relaxants.Mean artery pressure should be maintained within 85–90 mmHg（1 mmHg = 0.133 kPa; vasoactive drug selection and fluid management）.Normal arterial carbon dioxide pressure and normal blood glucose levels should be maintained.Intraoperative neurophysiological monitoring is a useful option.Anesthesiologists should be attentive to postoperative respiratory insufficiency（carefully considering postoperative extubation）,thrombus,and infection.In conclusion,anesthesiologists should carefully plan the treatment of patients with acute cervical spinal cord injuries to protect the nervous system and improve patient outcome.

Effects of decompression joint Governor Vessel electro-acupuncture on rats with acute upper cervical spinal cord injury

Decompression is the major therapeutic strategy for acute spinal cord injury,but there is some debate about the time window for decompression following spinal cord injury.An important goal and challenge in the treatment of spinal cord injury is inhibiting or reversing secondary injury.Governor Vessel electroacupuncture can improve symptoms of spinal cord injury by inhibiting cell apoptosis and improving the microenvironment of the injured spinal cord.In this study,Governor Vessel electroacupuncture combined with decompression at different time points was used to treat acute spinal cord injury.The rat models were established by inserting a balloon catheter into the atlanto-occipital space.The upper cervical spinal cord was compressed for 12 or 48 hours prior to decompression.Electroacupuncture was conducted at the acupoints Dazhui（GV14） and Baihui（GV 20）（2 Hz,15 minutes） once a day for 14 consecutive days.Compared with decompression alone,hind limb motor function recovery was superior after decompression for 12 and 48 hours combined with electroacupuncture.However,the recovery of motor function was not significantly different at 14 days after treatment in rats receiving decompression for 12 hours.Platelet-activating factor levels and caspase-9 protein expression were significantly reduced in rats receiving electroacupuncture compared with decompression alone.These findings indicate that compared with decompression alone,Governor Vessel electroacupuncture combined with delayed decompression（48 hours） is more effective in the treatment of upper cervical spinal cord injury.Governor Vessel electroacupuncture combined with early decompression（12 hours） can accelerate the recovery of nerve movement in rats with upper cervical spinal cord injury.Nevertheless,further studies are necessary to confirm whether it is possible to obtain additional benefit compared with early decompression alone.

Cervical Spine Cord Injury Associated with Klippel-Feil Syndrome: A Case Report

Background: Klippel Feil syndrome (KFS) is a congenital malformation characterised by the presence of, at least, one fused cervical segment and results from faulty segmentation along the embryo’s developing axis during weeks 3 - 8 of gestation. The KFS increases the risk for spinal cord injury after minor trauma as a result of the disturbance of the biomechanics of the cervical spine. Persons with KFS often have associated congenital anomalies. Aim: The purpose of this study was to show the surgical management difficulties of this pathology in a low income country such as Senegal and to make a review of the literature. Case presentation: A 32-year-old man developed a tetraparesis secondary to a fall from his height while carrying a bag of rice on his head. Radiological explorations revealed fusedC2-C3 and C4-C5 vertebral bodies with a C3-C4 disc herniation associated to a spine contusion. The patient underwent surgical removal of the herniated disc via an anterior approach followed by interbody fusion and anterior plating. A complete recovery was noted at 4 months follow-up. Conclusion: Understanding of the cervical spine biomechanics of Klippel-Feil anomaly may allow an optimal management of patients. Patients with KFS should be warned of the increased risk of spinal cord injury after a low velocity trauma. Timing for surgery should be shortened.

Effect of vocal respiratory training on respiratory function and respiratory neural plasticity in patients with cervical spinal cord injury:a randomized controlled trial

In previous studies,researchers have used singing to treat respiratory function in patients with spinal cord injury.However,few studies have examined the way in which vocal training affects respiratory neural plasticity in patients with spinal cord injury.Vocal respiratory training(VRT)is a type of vocal muscle-related treatment that is often a component of music therapy(MT)and focuses on strengthening respiratory muscles and improving lung function.In this randomized controlled study,we analyzed the therapeutic effects of VRT on respiratory dysfunction at 3 months after cervical spinal cord injury.Of an initial group of 37 patients,26 completed the music therapy intervention,which comprised five 30-minute sessions per week for 12 weeks.The intervention group(n=13)received VRT training delivered by professional certified music therapists.The control group(n=13)received respiratory physical therapy delivered by professional physical therapists.Compared with the control group,we observed a substantial increase in respiratory function in the intervention group after the 12-week intervention.Further,the nerve fiber bundles in the respiratory center in the medulla exhibited a trend towards increased diversification,with an increased number,path length,thickness,and density of nerve fiber bundles.These findings provide strong evidence for the effect of music therapeutic VRT on neural plasticity.This study was approved by the Ethics Committee of China Rehabilitation Research Center(approval No.2020-013-1)on April 1,2020,and was registered with the Chinese Clinical Trial Registry(registration No.Chi CTR2000037871)on September 2,2020.

New perspectives for investigating respiratory failure induced by cervical spinal cord injury

Traumatic cervical spinal cord injury （SCI）, with an annual incidence of 12,000 new cases in USA （NSCISC 2013）, causes devastating locomotor and respiratory paralysis and unfortunately compromises the human patient＇s lifespan. The severity of the injury depends on the degree and the extent of the initial trauma. In fact, respiratory failure is the leading cause of mortality following upper cervical SCI. However, 80% of the injuries are incomplete, allowing some modest spontaneous recovery. To date, no effective treatment is available in order to restore the loss of function.

Cervical spinal cord injury: tailoring clinical trial endpoints to reflect meaningful functional improvements

Cervical spinal cord injury （SCI） results in partial to full paralysis of the upper and lower extrem- ities. Traditional primary endpoints for acute SCI clinical trials are too broad to assess functional recovery in cervical subjects, raising the possibility of false positive outcomes in trials for cervical SCI. Endpoints focused on the recovery of hand and arm control （e.g., upper extremity motor score, motor level change） show the most potential for use as primary outcomes in upcoming trials of cervical SCI. As the field moves forward, the most reliable way to ensure meaningful clinical testing in cervical subjects may be the development of a composite primary endpoint that measures both neurological recovery and functional improvement.

Establishment and verification of a surgical prognostic model for cervical spinal cord injury without radiological abnormality

Some studies have suggested that early surgical treatment can effectively improve the prognosis of cervical spinal cord injury without radiological abnormality, but no research has focused on the development of a prognostic model of cervical spinal cord injury without radiological abnormality. This retrospective analysis included 43 patients with cervical spinal cord injury without radiological abnormality. Seven potential factors were assessed: age, sex, external force strength causing damage, duration of disease, degree of cervical spinal stenosis, Japanese Orthopaedic Association score, and physiological cervical curvature. A model was established using multiple binary logistic regression analysis. The model was evaluated by concordant profiling and the area under the receiver operating characteristic curve. Bootstrapping was used for internal validation. The prognostic model was as follows: logit(P) =-25.4545 + 21.2576 VALUE + 1.2160SCORE-3.4224 TIME, where VALUE refers to the Pavlov ratio indicating the extent of cervical spinal stenosis, SCORE refers to the Japanese Orthopaedic Association score(0–17) after the operation, and TIME refers to the disease duration(from injury to operation). The area under the receiver operating characteristic curve for all patients was 0.8941(95% confidence interval, 0.7930–0.9952). Three factors assessed in the predictive model were associated with patient outcomes: a great extent of cervical stenosis, a poor preoperative neurological status, and a long disease duration. These three factors could worsen patient outcomes. Moreover, the disease prognosis was considered good when logit(P) ≥-2.5105. Overall, the model displayed a certain clinical value. This study was approved by the Biomedical Ethics Committee of the Second Affiliated Hospital of Xi'an Jiaotong University, China(approval number: 2018063) on May 8, 2018.

Pathophysiological mechanisms of chronic compressive spinal cord injury due to vascular events

Cervical spondylotic myelopathy is the main cause of non-traumatic spinal cord injury,with chronic static and/or dynamic compressive spinal cord injury as the unique pathogenesis.In the progression of this condition,the microvascular network is compressed and destroyed,resulting in ischemia and hypoxia.The main pathological changes are inflammation,damage to the blood spinal cord barriers,and cell apoptosis at the site of compression.Studies have confirmed that vascular regeneration and remodeling contribute to neural repair by promoting blood flow and the reconstruction of effective circulation to meet the nutrient and oxygen requirements for nerve repair.Surgical decompression is the most effective clinical treatment for this condition;however,in some patients,residual neurological dysfunction remains after decompression.Facilitating revascularization during compression and after decompression is therefore complementary to surgical treatment.In this review,we summarize the progress in research on chronic compressive spinal cord injury,covering both physiological and pathological changes after compression and decompression,and the regulatory mechanisms of vascular injury and repair.

Peripheral T-Cell Lymphoma of Cervical Spine

Peripheral T-cell lymphoma is a rather uncommon non-Hodgkin’s lymphoma with the initial manifestation of spinal cord compression. Herein, we reported a 74-year-old woman with sustained neck pain radiating into the right shoulder and arm and weakness of the right upper extremity. A mass that had invaded the C5 and C6 vertebral bodies, causing a kyphotic curvature and compressing the spinal cord, was discovered with magnetic resonance imaging. The patient then underwent anterior corpectomy at C5 and C6, and reconstruction with a titanic rod and bone cement. The pathology confirmed a diagnosis of peripheral T-cell lymphoma after serial H & E and immunohistochemical staining. She recovered well from her profound neurological deficit. Both chemotherapy and radiotherapy were used postoperatively. Surgical intervention is indicated in these cases to decompress the cord, remove the majority of the tumor mass, stabilize the spine and obtain tissue for pathological diagnosis.

Peripheral blood RNA biomarkers can predict lesion severity in degenerative cervical myelopathy

Degenerative cervical myelopathy is a common cause of spinal cord injury,with longer symptom duration and higher myelopathy severity indicating a worse prognosis.While numerous studies have investigated serological biomarkers for acute spinal cord injury,few studies have explored such biomarkers for diagnosing degenerative cervical myelopathy.This study involved 30 patients with degenerative cervical myelopathy(51.3±7.3 years old,12 women and 18 men),seven healthy controls(25.7±1.7 years old,one woman and six men),and nine patients with cervical spondylotic radiculopathy(51.9±8.6 years old,three women and six men).Analysis of blood samples from the three groups showed clear differences in transcriptomic characteristics.Enrichment analysis identified 128 differentially expressed genes that were enriched in patients with neurological disabilities.Using least absolute shrinkage and selection operator analysis,we constructed a five-gene model(TBCD,TPM2,PNKD,EIF4G2,and AP5Z1)to diagnose degenerative cervical myelopathy with an accuracy of 93.5%.One-gene models(TCAP and SDHA)identified mild and severe degenerative cervical myelopathy with accuracies of 83.3%and 76.7%,respectively.Signatures of two immune cell types(memory B cells and memory-activated CD4^(+)T cells)predicted levels of lesions in degenerative cervical myelopathy with 80%accuracy.Our results suggest that peripheral blood RNA biomarkers could be used to predict lesion severity in degenerative cervical myelopathy.

Imaging diagnosis of cervical spine and spinal cord injuries in children

Objective: To provide the experience in imaging diagnosis of cervical spine and spinal cord injuries in children. Methods: Imaging data of cervical spine and spinal cord injuries in 62 children were retrospectively reviewed. The routine radiography including the lateral, anteroposterior and open-mouth odontoid views were performed in all the patients. Tomography was available for 25 patients, and flexion-extension lateral views for 28 patients, CT scanning for 21 patients, MRI for 26 patients. Results: Of these patients, 46 patients were identified with injuries of upper cervical spine (9 with atlantal arch fracture, seven with axial fracture, 21 with odontoid fracture, 1 with atlantal arch fracture combining with odontoid fracture, and 1 with atlantal transverse ligament disruption); 7 patients sustained injuries of lower cervical spine (3 fractures of vertebral body, 2 dislocations and 6 fracture-dislocations); 2 patients had multiple noncontiguous cervical injuries; and 3 had cervical spinal cord injury without radiographic abnormalities (SCIWORA). Conclusions: Imaging assessment is of great importance in the diagnosis of cervical spine and spinal cord injuries in children. Whenever cervical spine and spinal cord injuries are suspected for children patients, and the three-views should be routinely indicated. MRI should be routinely performed in all children with cervical SCIWORA.

Effect of platelet activating factor on blood spinal cord barrier following cervical cord injury

Effect of platelet activating factor(PAF) on blood spinal cord barrier in cervical cord injury was investigated. Methods: Spinal cord injury at C6 segment was induced with Allen’s ’method in cats. PAF and PAF receptor antagonist BN52021 were administered by arachnoid space and intravenous injection respectively, and their effects on PAF levels, blood spinal cord barrier and cervical cord edema in the injuried zone and adjacent cervical cord tissue following cervical cord injury were investigated. Results: PAF levels, Evens content and water content in the injuried and adjacent cervical cord tissues significantly increased following trauma. PAF levels, Evens content and water content were evidently elevated with PAF by arachnoid space injection. PAF receptor antagonist BN52021 could inhibit the increase in PAF levels and reduce Evens and water content in the cervical cord tissue following trauma. Conclusion: PAF is an important contributing factor causing post-traumatic damage to the blood spinal cord barrier, while PAF receptor antagonist can effectively relieve post-traumatic damage to the blood spinal cord barrier.

Spinal cord injury in Parkour sport （free runn,ng）： a rare case report

A 24-year-old male was transferred to the emergency department while being in the state of quadriplegia with a history of performing Parkour sport, which is also called double front flip. Neurological examination revealed that the patient＇s muscle power was 0/5 at all extremities. The patient did not show any sense of light touch or pain in his extremities. In radiological studies, cervical spine X-ray and CT scan images showed C4-C5 subluxation with bilateral locked facets and spinal cord injury. The results of this very rare case study revealed that exercising Parkour sport without taking into account safety standards could result in irreversible injuries to the cervical spinal cord with fatal outcome.

Damage control of multiple injuries headed by cervica spinal cord injury

Objective ： To explore the strategy of damage control in clinical treatment of multiple injuries headed by cervical spinal cord injury. Methods： A retrospective analysis was performed in 32 patients. Cervical fractures associated with tetraplegia occurred in 18 patients, traumatic intervectebral disk hernia associated with tetraplegia in 2 patients, and cervical fractures and dislocation associated with tetraplegia in 12 patients. Seventeen cases were combined with craniocerebral injury, 7 combined with pulmonary contusion, multi-fractures of rib or hemopneumothorax, 2 combined with pelvic fracture and other 8 combined with fracture of limbs. The neural function was assessed by the American Spinal Injury Association （ASIA） scale. Results： Thirty-one patients were followed up for an average of 14 months. Of them, 10 got complete recovery, 13 obtained improvement of more than one ASIA grade, 8 did not improve, and 1 died. Conclusions ： For the emergency treatment of multiple injuries headed by cervical spinal cord injury, the damage control strategy is the principle to follow. The final operations are preferably performed within 5 to 10 days after injury so as to raise the successful rate of remedy.

A novel mouse model of central cord syndrome

Patients with potential spinal stenosis are susceptible to central cord syndrome induced by blunt trauma.Suitable animal models are helpful for studying the pathogenesis and treatment of such injuries.In this study,we established a mouse model of acute blunt traumatic spinal cord injury by compressing the C6 spinal cord with 5 and 10 g/mm~2 compression weights to simulate cervical central cord syndrome.Behavioral testing confirmed that this model exhibited the characteristics of central cord syndrome because motor function in the front paws was impaired,whereas basic motor and sensory functions of the lower extremities were retained.Hematoxylin-eosin staining showed that the diseased region of the spinal cord in this mouse model was restricted to the gray matter of the central cord,whereas the white matter was rarely affected.Magnetic resonance imaging showed a hypointense signal in the lesion after mild and severe injury.In addition,immunofluorescence staining showed that the degree of nerve tract injury in the spinal cord white matter was mild,and that there was a chronic inflammation reaction.These findings suggest that this mouse model of central cord syndrome can be used as a model for preclinical research,and that gray matter is most vulnerable to injury in central cord syndrome,leading to impaired motor function.

Compression analysis of the gray and white matter of the spinal cord

The spinal cord is composed of gray matter and white matter.It is well known that the properties of these two tissues differ considerably.Spinal diseases often present with symptoms that are caused by spinal cord compression.Understanding the mechanical properties of gray and white matter would allow us to gain a deep understanding of the injuries caused to the spinal cord and provide information on the pathological changes to these distinct tissues in several disorders.Previous studies have reported on the physical properties of gray and white matter,however,these were focused on longitudinal tension tests.Little is known about the differences between gray and white matter in terms of their response to compression.We therefore performed mechanical compression test of the gray and white matter of spinal cords harvested from cows and analyzed the differences between them in response to compression.We conducted compression testing of gray matter and white matter to detect possible differences in the collapse rate.We found that increased compression(especially more than 50%compression)resulted in more severe injuries to both the gray and white matter.The present results on the mechanical differences between gray and white matter in response to compression will be useful when interpreting findings from medical imaging in patients with spinal conditions.

Evaluation of Therapeutic Effect of Maneuver-Dominated Method in 30 Cases of Cervical Spondylotic Myelopathy

Thirty cases of cervical spondylotic myelopathy (CSM) were treated by a maneuver-dominated non-surgical therapy. Eighteen cases were recovered to grade E according to the criteria set by the American Spinal Injury Association. The effect was definite. Indications and contraindications of the maneuver were proposed on the basis of the pathogenesis of CSM and the principles of this manual method.

创伤性颈脊髓损伤患者华勒氏变性的磁共振成像研究

目的探讨创伤性颈脊髓损伤患者脊髓华勒氏变性(WD)的磁共振成像(MRI)信号特点。方法回顾性分析2015年1月至2021年12月在北京博爱医院脊髓损伤康复科住院康复的191例创伤性颈脊髓损伤患者的临床资料,对常规颈椎MRI的矢状位及轴位T2加权像(T2WI)进行影像学评估,将其分为WD组和非WD组。比较两组性别、年龄、损伤机制、美国脊柱损伤协会残损分级(AIS)、神经平面、伤后获得MRI的时间差等,并分析WD在脊髓的背柱区(DC)、外侧脊髓丘脑束区(ST)和外侧皮质脊髓束区(CS)的信号特点。结果115例(60.2%)出现WD。WD组与非WD组年龄、损伤机制、AIS的等级分布和伤后获得MRI时间差有显著性差异(Z>3.820,χ2>9.104,P<0.05)。WD组中,在损伤部位的上方,DC、ST的WD发生率分别为100%和87%;在损伤部位的下方,CS的WD发生率为35.7%。根据WD信号出现的方式将其分为3组,只出现DC变化的15例(13%),DC合并ST发生变化为59例(51.3%),DC、ST、CS 3个位置均有变化的41例(35.7%)。3组间伤后获得MRI的时间差有显著性差异(H=90.794,P<0.05),3组间AIS等级分布无显著性差异(P>0.05)。结论创伤性颈脊髓损伤患者的常规MRI检查T2WI可检测到WD信号,且WD的发生与伤后时间存在关联。

益气活血通络方对脊髓型颈椎病模型大鼠miR-126a-5p及VEGF信号通路的影响

目的探讨益气活血通络方对脊髓型颈椎病模型大鼠微小RNA-126a-5p(miR-126a-5p)及血管内皮生长因子(VEGF)信号通路的影响。方法30只健康雄性SD大鼠按照随机数字表法均分为假手术组、模型组和中药组。模型组、中药组均制备脊髓型颈椎病模型。中药组给予益气活血通络方灌胃,假手术组、模型组给予生理盐水灌胃,均为12周。各组干预结束后进行大鼠行为学测试,测定机械性刺激阈值和热刺激回缩时间。处死大鼠,HE染色观察各组椎间盘软骨终板结构的差异。TUNEL染色观察大鼠椎间盘纤维环细胞变化。实时荧光定量聚合酶链式反应检测大鼠椎间盘纤维环组织miR-126a-5p和VEGF mRNA。采用Western blot法检测大鼠椎间盘纤维环组织VEGF蛋白表达。结果与假手术组比较,模型组大鼠椎间盘血管芽数目减少,大鼠椎间盘纤维环细胞破坏明显、大量凋亡且细胞密度降低;模型组和中药组机械性刺激阈值降低,热刺激回缩时间缩短,miR-126a-5p水平降低,VEGF mRNA和蛋白表达水平升高(P<0.05)。与模型组比较,中药组大鼠椎间盘血管芽数目增加,大鼠椎间盘纤维环细胞破坏减轻,大鼠椎间盘纤维环细胞凋亡减少且细胞密度增加,机械性刺激阈值升高,热刺激回缩时间延长,miR-126a-5p水平增加,VEGF mRNA和蛋白表达水平降低(P<0.05)。结论益气活血通络方治疗脊髓型颈椎病的机制可能与上调miR-126a-5p、下调VEGF表达有关。

体外膈肌起搏器联合人工膨肺技术对颈髓损伤气管切开患者肺功能康复的应用研究

目的探讨研究体外膈肌起搏器(EDP)联合人工膨肺技术(MHI)对颈髓损伤气管切开患者肺功能康复的应用效果。方法选取2021年4月至2022年4月于赣州市人民医院进行颈髓损伤气管切开治疗的50例患者作为研究对象,采用随机数字表法将其分为观察组(n=25)和对照组(n=25),对照组予以常规呼吸训练,观察组在对照组基础上联合EDP、MHI进行干预。比较两组患者治疗前后的肺功能变化。结果观察组治疗7、14、21、28 d的肺部感染评分均低于对照组,用力肺活量(FVC)水平均高于对照组,差异有统计学意义(P<0.05)。观察组治疗28 d的膈肌移动度、厚度均大于对照组,差异有统计学意义(P<0.05)。结论对于颈髓损伤气管切开患者,EDP联合MHI的应用能够有效改善患者肺功能,降低肺部感染风险,整体效果显著,值得推广。