Intraparenchymal hemorrhage (IPH) plays a significant role in the pathophysiology of traumatic spinal cord injury (SCI). Once IPH occurs following the initial mechanical trauma, the blood itself can trigger a secondary injury cascade that can worsen damage to surrounding neural tissue and lead to additional neurological deficits. Assessing IPH and its progression in the human setting is extremely challenging without performing serial imaging studies. This highlights the rationale for monitoring IPH in pre-clinical settings, where early changes can be studied and tracked more effectively. The aims of this study were to (1) characterize IPH progression during the first 7 h following SCI using high-frequency ultrasound (US) imaging in a porcine model and (2) develop and validate a semiautomated method for quantifying IPH using US. Seventeen female Yucatan miniature pigs were used in this study. Each animal underwent a weight-drop contusion-compression SCI followed by serial intraoperative US scanning during the first 7 h post-SCI, and then a final scan 7 days later. A semiautomated segmentation approach was developed and used to quantify early IPH progression, validated by the presence of red blood cells through hematoxylin and eosin staining. To assess the accuracy and reliability of the semiautomated method, we conducted inter-rater and intra-rater reliability assessments. IPH was consistently observed across all examined time points post-SCI. The expansion of IPH, in terms of both volume and length, occurred immediately following the injury, specifically at 0.5 h post-SCI. This expansion continued over the subsequent hours up to the 7-h time point, although at a slower rate. During this period, the expansion was primarily observed axially in the dorsal and ventral directions rather than along the rostral-caudal axis of the cord. The semiautomated quantification approach demonstrated excellent inter-rater and intra-rater reliability for IPH measurements, achieving greater consistency than traditional manual segmentation. In conclusion, we observed distinct regional patterns of IPH expansion over time, particularly in the dorsal and ventral areas during the early hours post-SCI, with no evident plateauing at 7 h post-injury (HPI). The implementation of a semiautomated quantification method marks a significant advancement in IPH assessment, enhancing measurement accuracy on US and indicating a move toward more objective IPH evaluations in SCI research.

Patients living with traumatic spinal cord injury (TSCI) often have multiple medical issues and chronic pain requiring potentially several prescription medications. Taking multiple medications can lead to adverse side effects and drug interactions. The main objective of this study is to measure polypharmacy among TSCI patients over a 20-year period and evaluate associated injury characteristics and clinical factors. This study is a retrospective analysis of a population-based cohort of patients with TSCI between 2001 and 2022. Utilizing linked health care data, patients with TSCI were identified. All community-dispensed medications were identified during the first 365 days after discharge. The cumulative polypharmacy method was utilized (average of ≥5 medications over four quarters of the year). Summary statistics were used to evaluate rates of polypharmacy. A multivariable logistic regression identified demographic and clinical characteristics associated with polypharmacy. A total of 3142 patients were identified, 964 (30.7%) patients had polypharmacy with ≥5 medications averaged per quarter in a 1-year period after discharge from the hospital. Factors associated with polypharmacy were age 65 and older (OR = 3.1, p < 0.001), female (OR = 1.5, p < 0.001), and a higher pre-existing comorbidity burden (OR = 3.8, p = 0.030). The study found that it is common for patients to experience polypharmacy in the first year after their injury. While polypharmacy is not inherently harmful, patients with polypharmacy should be identified and closely monitored for unnecessary medications, and policymakers should evaluate the role of regular medication reviews to avoid complications and poor outcomes.

Chronic high-level spinal cord injury (SCI) leads to a complex phenotype of long-term cardio-autonomic dysregulation. In the initial hours post-injury, cardio-centric management with dobutamine (DOB) can optimize cardiovascular haemodynamics and mitigate secondary injury compared with standard vasopressor-based management (i.e. norepinephrine, NE) in a porcine model of T2 SCI; however, any potential long-term benefits remain to be determined. We therefore sought to assess whether acute DOB treatment could mitigate cardiovascular dysfunction in the chronic setting of high-level SCI. Seventeen Yucatan minipigs with T2 SCI received acute management with DOB (2.5 µg kg-1 min-1, n = 6), NE (4.25 µg kg-1 min-1, n = 6) or no management (CON, n = 5) from 30 min until 6 h post-SCI, then were recovered and housed for 12 weeks. Outcome assessments were performed at 12 weeks post-SCI, including left ventricular (LV), Swan-Ganz and arterial catheterization to characterize cardiac and peripheral haemodynamics. Resting mean arterial pressure (MAP) was higher in both treatment groups (DOB:80 ± 9 mmHg, NE:88 ± 11 mmHg vs. CON:65 ± 3 mmHg; P = 0.0147 for DOB, P = 0.00679 for NE), and DOB-treated animals had greater stroke volume (33 ± 4 ml vs. NE:25 ± 5 ml, P = 0.0269), while NE-treated animals had elevated total peripheral resistance (41 ± 11 mmHg l-1 min-1 vs. CON:24 ± 4 mmHg l-1 min-1, P = 0.0345) and arterial elastance (3.60 ± 0.95 mmHg ml-1 vs. CON:2.08 ± 0.34 mmHg ml-1, P = 0.0258 vs. CON). Dynamic LV function was also preserved in DOB-treated animals, with greater contractile responses during the DOB stress test (end-systolic elastance; +8.96 mmHg ml-1 vs. CON:+1.28 mmHg ml-1, P = 0.036) and modified Oxford challenges (preload-adjusted maximal rate of pressure development (dp/dtmax-EDV) vs. MAP; -0.56 ± 0.33 ml s-1 vs. CON:0.04 ± 0.05 mls-1, P = 0.044). Collectively, these findings demonstrate that acute cardio-centric management with DOB provides a viable alternative for haemodynamic management following high-thoracic SCI. KEY POINTS: Spinal cord injuries (SCIs) at or above the mid-thoracic level lead to long-term heart and circulatory complications. This research primarily sought to understand whether a heart-focused treatment (dobutamine, DOB) could support long-term cardiovascular benefits when compared with current standard treatments (norepinephrine, NE) in a pig model with a high-thoracic SCI. Treatments were administered from 30 min to 6 h post-injury, and after 12 weeks' survival both DOB and NE animals had improved blood pressure. However, the DOB group additionally had preserved reflexive heart function when compared with control animals. Animals treated with DOB also exhibited more white matter sparing at study termination compared with animals treated with NE, implying superior neuroprotection.

BACKGROUND CONTEXT Acute traumatic spinal cord injury (SCI) requires timely, evidence-based management to optimize neurological recovery and minimize secondary injury. Updated clinical practice guidelines are needed to reflect evolving evidence and standardize care. PURPOSE To present the 2024 AO Spine/Praxis Spinal Cord Institute Clinical Practice Guidelines for the acute management of traumatic SCI. STUDY DESIGN/SETTING Evidence-based clinical practice guidelines. PATIENT SAMPLE N/A. OUTCOME MEASURES N/A. METHODS Recommendations were developed through systematic review and meta-analysis of the literature, with expert panel consensus to formulate evidence-based and consensus-driven guidance. RESULTS The guidelines emphasize early surgical decompression within 24 hours of injury when medically feasible, supported by evidence demonstrating improved neurological outcomes. Blood pressure management is conditionally recommended, with mean arterial pressure targets of 75–80 mmHg to 90–95 mmHg for 3 to 7 days post-injury, based on associations between hypotension, hypertension, and neurological outcomes. A novel addition includes guidance on intraoperative SCI, including formal definition, risk factors, and recommendations for intraoperative neurophysiological monitoring (IONM) in high-risk procedures such as intramedullary tumor resection and complex deformity correction. A care pathway and checklist for intraoperative monitoring changes are also introduced. CONCLUSIONS The 2024 AO Spine/Praxis guidelines provide updated, evidence-based recommendations for the management of acute SCI, incorporating new data on early surgery and hemodynamic targets while introducing guidance for intraoperative SCI. These guidelines serve as a framework to optimize patient care globally while highlighting areas requiring further research, including ultra-early intervention, management of milder injury patterns, and spinal cord perfusion monitoring. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.

Finite element (FE) models are used to study spinal cord biomechanics and injury mechanisms. However, most existing models incorporate full vertebral geometry, substantially increasing computational cost and limiting the ability to perform large-scale parametric studies or apply modeling in clinically feasible timelines. In central cord syndrome, movement of the vertebrae is important while vertebral deformation contributes minimally to cord biomechanics. This study tested whether modeling the spinal canal geometry alone (versus full vertebral geometry) is sufficient to capture spinal cord stresses and strains under extension loading, offering a computationally efficient alternative to high-fidelity subject-specific models. Two FE models were developed: (1) a high-fidelity model including vertebrae, discs, ligaments, and neurological tissues, and (2) a computationally efficient (CE) model retaining only the spinal canal, with boundary conditions applied to represent the kinematics of each vertebra. Tissue-level stress and strain distributions, and computational performance were evaluated under extension. The CE model reproduced whole-cord and tissue-level stresses within 15

Study Design Review of the literature with critical appraisal and clinical recommendations.Objective To highlight contemporary concepts involving adjunctive medical and non-surgical therapies in the management of acute traumatic spinal cord injury (tSCI) that may be integrated into clinical practice.Methods Three recent articles relating to the management of acute tSCI were selected and critically appraised. Clinical practice recommendations were developed and evaluated using the GRADE criteria.Results Article 1: A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management. Conditional recommendation to augment mean arterial blood pressure to at least 75-80 mmHg but not higher than 90-95 mmHg for a duration of 3-7 days to optimize spinal cord perfusion in acute tSCI. Article 2: Spinal Cord Perfusion Pressure Predicts Neurologic Recovery in Acute Spinal Cord Injury. No recommendation can be made at this time in the utilization of SCPP-guided hemodynamic management as an adjunctive strategy in the acute care of tSCI. Article 3: Safety and Efficacy of Riluzole in Acute Spinal Cord Injury Study (RISCIS). No recommendation can currently be made on the routine use of riluzole to patients with acute cervical tSCI.Conclusions The management of tSCI extends beyond the operating room. The development of emerging medical and non-surgical treatments to augment timely and adequate decompression requires critical consideration as new data becomes available. While some topics do not have the scientific backing to be able to make a recommendation at this time, they point towards areas of future study.

Specialized acute and rehabilitation care for traumatic spinal cord injury aims to improve outcomes. This study assessed whether receiving specialized acute and rehabilitation care for incomplete traumatic spinal cord injury was associated with a lower risk of having one or more readmissions within one year post-discharge, compared with receiving care in partially specialized or non-specialized settings. Administrative healthcare datasets from British Columbia were linked with the Rick Hansen Spinal Cord Injury Registry to identify individuals who sustained an incomplete traumatic spinal cord injury between 2001 and 2017. The association between the setting of care and the risk of unplanned readmissions was measured and the causes of those unplanned readmissions were described. A total of 1,733 patients were included. After adjusting for group differences, receiving non-specialized acute care (with or without non-specialized rehabilitation, N = 810) was statistically significantly associated with higher odds of one-year unplanned readmissions compared with receiving specialized care (including both acute and rehabilitation care, N = 421) (OR = 2.06; p < 0.01). The odds of one-year unplanned readmissions were also higher among individuals who received partial specialized care (either only specialized acute care (OR = 1.59, p = 0.05, N = 411), or only specialized rehabilitation care (OR = 2.54, p = 0.02, N = 38)) compared with those who received both specialized acute and rehabilitation care. There were 536 unplanned readmissions identified during the 17-year study period. The most common cause of unplanned readmissions among patients who received specialized care was urinary tract infection, while the most common cause among patients who received non-specialized care was injury/complications of surgery (e.g. femur fractures, complications with internal orthopedic prosthetic devices, implants or grafts). These findings emphasize the benefits of both acute and rehabilitation specialized care in reducing unplanned readmissions and provide information on the causes of readmissions following incomplete traumatic spinal cord injury.

Study designProtocolObjectivesDegenerative cervical myelopathy (DCM) is caused by degenerative changes of the spinal column that lead to progressive spinal cord compression. Early identification of DCM is paramount to ensure appropriate specialist referral, timely intervention, and optimal treatment outcomes. Unfortunately, diagnosis of DCM is often delayed and may be missed entirely. A lack of screening or referral criteria has been identified as a major contributor of diagnostic delay. The objective of this study is to outline the methodology that will be used to develop screening criteria for DCM.MethodsWe propose a three-step approach for establishing screening criteria for DCM using data-driven and expert-based methods that includes a combination of patient-reported symptoms and clinical signs obtained from physical examination. Our approach includes: (i) an initial scoping review of inclusion criteria used in DCM research studies; (ii) criteria generation through systematic reviews of the literature as well as surveys of individuals with lived experience and international multidisciplinary experts in DCM; and (iii) criteria reduction via a consensus process.ConclusionsOur framework intends to foster the development of valid, reliable and sustainable screening criteria that could improve awareness of DCM, influence practice decisions and reduce delays to diagnosis .

BACKGROUND:Surgical delays are common in public health care systems such as Canada's. Trends in wait times for elective spine surgery and their impact on outcomes remain uncharacterized. METHODS:We performed a single-centre analysis of elective spine surgery data between 2009 and 2020. We assessed wait times between referral and initial consultation (T1), consultation and surgical booking (interval wait time; Ti), and booking and surgery (T2) in terms of trends and impact on perioperative outcomes (adverse events and hospital length of stay [LOS]). RESULTS:In total, 2041 patients were included. Over the study period, total wait time (T1+Ti+T2) increased 5.6% annually (p < 0.001). Specifically, T1 decreased 4.8% (p < 0.001), Ti increased 14.9% (p < 0.001), and T2 increased 8.5% (p < 0.001) from year to year. The cumulative increase in total wait time was 72.4%, and the cumulative increase in Ti was 301.1% over the 10-year period. Longer total wait time and Ti were associated with increased rate of adverse events (p < 0.001 and p < 0.001, respectively) and odds of adverse events (p < 0.001 and p < 0.001, respectively). Delays in all wait time intervals were associated with longer LOS (p < 0.001), with T2 having the largest effect of a 10.8% increase in LOS per 100 days of T2 (p < 0.001). CONCLUSION:Total wait times (T1+Ti+T2) for elective spine surgery significantly increased between 2009 and 2020. Ti showed the largest increase over the study period and was associated with a significant increase in adverse events. Future studies should investigate the impact of various efforts implemented and whether this translates to improved surgical outcomes and resource management.

In acute spinal cord injury (SCI) patients who had lumbar intrathecal catheters inserted for cerebrospinal fluid (CSF) drainage and augmentation of spinal cord perfusion pressure (SCPP), we sought to characterize how neurologic recovery was related to aspects of this hemodynamic management approach. This prospective multi-center nonrandomized interventional clinical trial was conducted at eight level-1 trauma centers in North America with specialized units for SCI care. Twenty-seven patients presenting with motor-sensory complete SCI (AIS grade A) had catheters inserted for up to 7-days post-injury for CSF drainage and SCPP augmentation. Mean arterial pressure, intrathecal pressure (ITP), SCPP, ITP waveform morphology, and CSF drainage volume were collected hourly. Neurologic assessments were repeated at 6-months post-injury to determine if AIS grade conversion/improvement had occurred. Hemodynamic measures associated with the outcome of being an AIS grade "converter" or "non-converter" were compared. Of the 27 AIS A participants at baseline, 8 experienced neurologic recovery reflected by AIS grade conversion at 6-month follow-up (converters); 19 remained AIS A (non-converters). Converters were characterized by a higher ITP, lower SCPP, greater CSF drainage volume, and a more pulsatile ITP waveform morphology than nonconverters. In patients with AIS A SCI, AIS grade conversion at 6 months was associated with a specific pattern of hemodynamic measures that we hypothesize reflect a complete decompression and restoration of CSF flow in the subarachnoid space at the injury site. These metrics may provide guidance and/or targets for future studies on the management of acute SCI.

Study DesignLiterature review of key topics related to degenerative cervical myelopathy (DCM) with critical appraisal and clinical recommendations.ObjectiveThis article summarizes several key current topics related to the management of DCM.MethodsRecent literature related to the management of DCM was reviewed. Four articles were selected and critically appraised. Recommendations were graded as Strong or Conditional.ResultsArticle 1: The Relationship Between pre-operative MRI Signal Intensity and outcomes. Conditional recommendation to use diffusion-weighted imaging MR signal changes in the cervical cord to evaluate prognosis following surgical intervention for DCM. Article 2: Efficacy and Safety of Surgery for Mild DCM. Conditional recommendation that surgery is a valid option for mild DCM with favourable clinical outcomes. Article 3: Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial. Strong recommendation that there is equipoise in the outcomes of anterior vs posterior surgical approaches in cases where either technique could be used. Article 4: Machine learning-based cluster analysis of DCM phenotypes. Conditional recommendation that clinicians consider pain, medical frailty, and the impact on health-related quality of life when counselling patients.ConclusionsDCM requires a multidimensional assessment including neurological dysfunction, pain, impact on health-related quality of life, medical frailty and MR imaging changes in the cord. Surgical treatment is effective and is a valid option for mild DCM. In patients where either anterior or posterior surgical approaches can be used, both techniques afford similar clinical benefit albeit with different complication profiles.

Acutely after traumatic spinal cord injury (SCI), the immune system responds with an inflammatory cascade that promotes secondary damage to the spinal cord and systemic inflammation, which promotes persistent medical consequences. Here, we combined clinical and research data to evaluate cellular and molecular changes in the systemic immune system of individuals with SCI (SCI, N = 36) within 0-4 days after injury compared to uninjured individuals (CTL, N = 36). Analyzing blood samples by bulk-RNA Seq, 4752 differentially expressed (DE) gene transcripts were identified in SCI compared with CTLs, including increased expression of genes associated with inflammation and innate immunity (e.g., Neutrophil degranulation, Toll-Like Receptor signaling). Most participants with SCI had complete blood count data available, of whom 36% had elevated white blood cell and neutrophil counts, 24% had elevated monocytes, and 36% had lymphopenia. Significantly reduced expression of canonical natural killer (NK) cell, T cell and dendritic cell (DC) genes were identified, consistent with reduced frequencies of these cell types, determined by flow cytometry. Some molecular changes appeared to be influenced by motor completeness of injury. C-reactive protein, a validated clinical biomarker of inflammation, was significantly elevated after SCI, with levels higher in motor complete compared to motor incomplete injuries. This was also apparent for several other proinflammatory cytokines (e.g., High Mobility Group Box 1 protein, IL-6, IL-8). These data confirm and extend prior observations of cellular and molecular immunological changes, that may serve as potential biomarkers of injury severity, or as future therapeutic targets to improve health.

Study DesignReview of the literature with critical appraisal and clinical recommendations.ObjectiveTo highlight contemporary concepts relating to surgical care for acute traumatic spinal cord injury (SCI) based on recent evidence that may be integrated into clinical practice.MethodsThree recent articles relating to the surgical management of acute traumatic SCI were selected and critically appraised. Clinical practice recommendations were developed and graded as strong or conditional.ResultsArticle 1: Early vs late surgical decompression for central cord syndrome. Strong recommendation to consider early surgery (<24 hours) as an option in patients with ASIA Impairment Scale (AIS) grade C central cord syndrome. Article 2: Extent of decompression in motor complete SCI. Conditional recommendation to consider laminectomy, with or without anterior surgery, to achieve circumferential decompression of the spinal cord. Article 3: Use of intra-operative ultrasound. Conditional recommendation to use ultrasound intra-operatively to confirm the adequacy of surgical decompression.ConclusionsTimely and adequate decompression of the spinal cord are critical priorities in the management of acute traumatic SCI. The importance of timeliness extends to central cord syndrome. Careful consideration and use of operative techniques (e.g., addition of laminectomy) and adjuncts (e.g., intra-operative ultrasound) help achieve safe and adequate decompression of the spinal cord.

Introduction MRI is increasingly recognised as a valuable tool for assessing prognosis and predicting outcomes following traumatic spinal cord injury (SCI). Several potential MRI biomarkers have been identified, but efforts are still needed to improve the accuracy and feasibility of these biomarkers in clinical practice. This study aims to build a national Canadian SCI imaging repository for storing and analysing imaging data for SCI, with the goal of improving SCI MRI biomarkers to predict outcomes and inform clinical management.Method and analysis As a substudy of the Rick Hansen SCI Registry (RHSCIR), this retrospective multisite study includes individuals who sustained a traumatic cervical SCI between 2015 and 2021, were previously enrolled in RHSCIR, and had MRI scans acquired within 72 hours of injury and before any surgical intervention. Individuals with a penetrating trauma and/or with any prior spine surgery are excluded. The study principal investigator and research associates, experienced with data curation and with the standardised format and specifications of the Brain Imaging Data Structure standard, guide the site’s curator on the steps to perform image deidentification and curation to create standardised datasets across all sites. These datasets are transferred to a Digital Research Alliance of Canada (‘the Alliance’) server designated for this project and concatenated to form the national Canadian SCI imaging repository (Neurogitea). We are using a semiautomated processing pipeline to quantify lesion morphology, together with additional imaging measures that are manually extracted from the images (for instance, the relative maximal spinal cord compression and the maximum canal compromise). Through linkage to RHSCIR clinical and epidemiological data already available on eligible participants, regression analysis is planned to predict neurological outcomes at discharge, including the American Spinal Injury Association Impairment Scale grade, upper and lower extremity motor and sensory scores.Ethics and dissemination This protocol has been submitted by the participating sites to obtain ethics and institutional approvals prior to the study initiation at each site. All 12 sites across Canada have now obtained ethics and institutional approvals. Study results will be disseminated at local, national and international conferences and by journal publications.

Patients living with traumatic spinal cord injury (TSCI) have seen many improvements in care and treatment, but life expectancy still falls below the general population. Measuring long-term survival rates and characterizing causes of death are required to identify ways of improving well-being and reduce premature mortality. The study conducted a retrospective analysis of population-based administrative and clinical data from 2001 to 2021 to measure long-term survival of TSCI, mortality predictors, and cause of death. Population-based hospital records linked with administrative databases in British Columbia, Canada, were used to identify those with TSCIs. Demographic and clinical summary statistics were calculated. Mortality rates for 1-, 5-, 10-, 15-, and >15-year survival were calculated using Kaplan-Meier methods. Factors associated with mortality throughout the study period were identified with Cox models. During the study period, 3624 patients were identified with TSCI. The mean age was 51.1 years (SD 21.19) and 2718 (75.0%) were male. Mortality rates at 1, 5, 10, 15, and >15 years were 11.2%, 19.6%, 25.4%, 28.3%, and 29.1%, respectively. Factors associated with mortality included cervical spine injuries, more comorbidities, older age, lower household income, presence of traumatic brain injury, and greater severity of initial injury (p < 0.001). Cardiac disease (22.3%) was the most common cause of death in TSCI patients followed by respiratory diseases (10.2%) and neoplasms (8.5%). The long-term survival of TSCI patients is a significant concern, and preventative measures to avoid injury are critical. Among those suffering TSCI, particularly high death rates are observed in those with cervical injuries, multiple comorbidities, and advanced age. Interventions are needed to reduce premature death among TSCI patients compared with the population.

Traumatic spinal cord injury (TSCI) is a debilitating condition that can have significant effects on physical function and overall quality of life. Mechanisms of injury can vary from major trauma to low-energy falls. There has been a recent increase in the number of elderly patients with TSCI. A retrospective analysis of population-based hospital records linked with health care administrative datasets was conducted to measure age-standardized rates of TSCI over time. The study was conducted to describe the epidemiology and demographic characteristics of patients who experienced TSCI between 2001 and 2021 in the province of British Columbia, Canada. Demographic, clinical characteristics, and rates of TSCI were evaluated over time. Linear regression was used to assess changes over time. The study identified 3622 patients with TSCI. The average age at the time of injury was 51.1 (standard deviation [SD] 21.19) and 75.0% were males. The average annual age-standardized rate in this population was 35.4 per million. The overall rate remained stable throughout the study period. The mean age at injury increased from 41.9 to 57.5 over the study period of 2001-2021 (p < 0.001). The most frequent causes of injury were low-energy falls (49.9%) and motor vehicle injuries (36.6%). The proportion of injuries related to falls increased over the study period (p < 0.001). Motor and sensory complete TSCI were seen in higher rates among younger patients, and cervical spine injuries were most common among all age-groups. The rate of TCSI was consistent during the study period, though the demographic of patients and their injury mechanism changed considerably; elderly low-energy falls were an increasing proportion of cases. Continued vigilance in elderly fall prevention is needed to reduce the incidence of TCSI among the elderly.

STUDY DESIGN:Retrospective data analysis of a population-based observational cohort. Setting: TSCI in British Columbia, Canada Participants: 3,433 TSCI patients included in the study. METHODS:Hospital records linked with administrative databases were utilized to measure in-hospital mortality, adverse event rate, and LOS between 2001 and 2021. Adverse events included all documented complications during hospital admission. Multivariable logistic regression and Cox proportional hazard models were used to identify factors associated with mortality, adverse events, and LOS. RESULTS:All cause in-hospital mortality was 6.4%. The average age of patients was 53.2 years (SD 19.7), 75.4% were males and 70% incurred a cervical spinal cord injury. Multivariable analysis demonstrated that patients 35 years old, multiple medical comorbidities, cervical injury, neurologically complete, high injury severity score (25), concomitant brain injury, lower socioeconomic status, and no surgical management were at higher risk for death. Factors associated with adverse events were similar with the exception of non-operative patients who had lower adverse events. Cox modeling for LOS demonstrated similar findings to mortality analysis. CONCLUSIONS:This study found that spinal cord injury patients were more likely to have adverse outcomes with older age, cervical injury, multiple comorbidities, complete neurological injury, or higher severity initial traumatic injuries. This study identified risks associated with complications in TSCI, future research should address ways to improve outcomes in these targeted groups.

Background: Postoperative management following durotomy and subsequent repair typically involves inpatient admission for at least 24 hours. Spinal headaches are the principal symptom signifying ongoing CSF leak and require monitored activity restriction. More recently, patients are being discharged same-day following durotomy repair. The goal of this study was to assess the risk of readmission after same-day discharge following intraoperative durotomy and repair. Methods: In this retrospective review, 273 instances of durotomy and subsequent primary repair were identified out of 3,391 patients that underwent lumbar spine surgery at a single center between October 2012 and September 2017 were identified. Out of the 273 cases, 111 (40.7%) were planned as ambulatory day surgery. Fifty-two patients (46.8%) were discharged home as planned, while 59 (53.2%) were admitted postoperatively. Following the surgical encounter, patients that were readmitted within 30 days due to durotomy-related symptoms were identified. Relative risk ratios for readmission were assessed between patients who were discharged same-day versus admitted postoperatively. Results: Of the 52 patients discharged home same day, 2 were readmitted (3.8%); of the 59 patients admitted postoperatively, 5 were readmitted (8.5%). No dural tears required return to OR for management of complications, and there was an overall durotomy rate of 8.1%. Compared to patients discharged home same-day, patients admitted after durotomy repair were: older (p = .001), had a diagnosis of stenosis (vs herniated nucleus pulposus) (p = .004), had a laminectomy (vs a microdiscectomy) (p = .007), had surgery Monday-Thursday (p = .004), and had surgery by a lower volume surgeon (p = .016). The relative risk of readmission in patients admitted at the time of index procedure was not statistically different compared with those discharged the same-day as planned (RR: 2.20, 95% CI: 0.45,10.88). Conclusion: In patients undergoing outpatient spine procedures, discharge home after intraoperative durotomy and repair may not confer an increased risk of readmission. One factor that was not examined was subjective assessment of repair quality, which may imply more significant CSF leak, thus leading to admission. We believe this data suggests that postoperative course following durotomy repair may have similar outcomes-specifically readmission-whether or not a patient is admitted. This data may also influence direct cost savings due to decreased length of stay.

Wound healing after spinal cord injury involves highly coordinated interactions among multiple cell types, which are poorly understood. Astrocytes play a central role in creating a border against the non-neural lesion core. To do so, astrocytes undergo dramatic morphological changes by first thickening and elongating their processes and then overlapping them to form a physical barrier. We show here that the expression of a cell-surface receptor, Ryk, is induced in astrocytes after injury in both rodent and human spinal cords. Astrocyte-specific knockout of Ryk dramatically elongated the reactive astrocytes, accelerated the formation of the border, and reduced the size of the scar. Astrocyte-specific knockout of Ryk also accelerated the injury responses of multiple cell types. Single-cell transcriptomics analyses revealed a broad range of changes in cell signaling among astrocytes, microglia, fibroblasts, and endothelial cells after astrocyte-specific Ryk knockout, suggesting that Ryk not only regulates injury responses of astrocytes but may also regulate signals emanating from astrocytes and coordinate the responses of these cell types. The elongation of astrocyte processes is mediated by NrCAM, a cell adhesion molecule induced by astrocyte-specific conditional knockout of Ryk after spinal cord injury. Our findings suggest that Ryk is a promising therapeutic target to accelerate wound healing, promote neuronal survival, and enhance functional recovery.

A spinal cord injury (SCI) causes immediate and sustained hemodynamic instability that threatens neurological recovery and impacts quality of life. Here we establish the clinical burden of chronic hypotensive complications due to SCI in 1,479 participants and expose the ineffective treatment of these complications with conservative measures. To address this clinical burden, we developed a purpose-built implantable system based on biomimetic epidural electrical stimulation (EES) of the spinal cord that immediately triggered robust pressor responses. The system durably reduced the severity of hypotensive complications in people with SCI, removed the necessity for conservative treatments, improved quality of life and enabled superior engagement in activities of daily living. Central to the development of this therapy was the head-to-head demonstration in the same participants that EES must target the last three thoracic segments, and not the lumbosacral segments, to achieve the safe and effective regulation of blood pressure in people with SCI. These findings in 14 participants establish the path to designing a pivotal device trial that will evaluate the safety and efficacy of EES to treat the underappreciated, treatment-resistant hypotensive complications due to SCI.