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Anoushka Singh*, Lindsay Tetreault*, Suhkvinder Kalsi-Ryan, Aria Nouri, Michael G FehlingsToronto Western Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada *These authors contributed equally to this paper Background: Spinal cord injury (SCI) is a traumatic event that impacts a patient's physical, psychological, and social well-being and places substantial financial burden on health care systems. To determine the true impact of SCI, this systematic review aims to summarize literature reporting on either the incidence or prevalence of SCI. Methods: A systematic search was conducted using PubMed, MEDLINE, MEDLINE in process, EMBASE, Cochrane Controlled Trial Register, and Cochrane Database of Systematic Reviews to identify relevant literature published through June 2013. We sought studies that provided regional, provincial/state, or national data on the incidence of SCI or reported estimates of disease prevalence. The level of evidence of each study was rated using a scale that evaluated study design, methodology, sampling bias, and precision of estimates. Results: The initial search yielded 5,874 articles, 48 of which met the inclusion criteria. Forty-four studies estimated the incidence of SCI and nine reported the prevalence, with five discussing both. Of the incidence studies, 14 provided figures at a regional, ten at a state or provincial level and 21 at a national level. The prevalence of SCI was highest in the United States of America (906 per million) and lowest in the Rhone-Alpes region, France (250 per million) and Helsinki, Finland (280 per million). With respect to states and provinces in North America, the crude annual incidence of SCI was highest in Alaska (83 per million) and Mississippi (77 per million) and lowest in Alabama (29.4 per million), despite a large percentage of violence injuries (21.2%). Annual incidences were above 50 per million in the Hualien County in Taiwan (56.1 per million), the central Portugal region (58 per million), and Olmsted County in Minnesota (54.8 per million) and were lower than 20 per million in Taipei, Taiwan (14.6 per million), the Rhone-Alpes region in France (12.7 per million), Aragon, Spain (12.1 per million), Southeast Turkey (16.9 per million), and Stockholm, Sweden (19.5 per million). The highest national incidence was 49.1 per million in New Zealand, and the lowest incidences were in Fiji (10.0 per million) and Spain (8.0 per million). The majority of studies showed a high male-to-female ratio and an age of peak incidence of younger than 30 years old. Traffic accidents were typically the most common cause of SCI, followed by falls in the elderly population. Conclusion: This review demonstrates that the incidence, prevalence, and causation of SCI differs between developing and developed countries and suggests that management and preventative strategies need to be tailored to regional trends. The rising aging population in westernized countries also indicates that traumatic SCI secondary to falls may become an increasing public health challenge and that incidence among the elderly may rise with increasing life expectancy. Keywords: SCI, causation, epidemiology

Background and purposeDTI, magnetization transfer, T2*-weighted imaging, and cross-sectional area can quantify aspects of spinal cord microstructure. However, clinical adoption remains elusive due to complex acquisitions, cumbersome analysis, limited reliability, and wide ranges of normal values. We propose a simple multiparametric protocol with automated analysis and report normative data, analysis of confounding variables, and reliability.Materials and methodsForty healthy subjects underwent T2WI, DTI, magnetization transfer, and T2*WI at 3T in

Background and purposeT2*-weighted imaging provides sharp contrast between spinal cord GM and WM, allowing their segmentation and cross-sectional area measurement. Injured WM demonstrates T2*WI hyperintensity but requires normalization for quantitative use. We introduce T2*WI WM/GM signal-intensity ratio and compare it against cross-sectional area, the DTI metric fractional anisotropy, and magnetization transfer ratio in degenerative cervical myelopathy.Materials and methodsFifty-eight patients with degenerative cervical myelopathy and 40 healthy subjects underwent 3T MR imaging, covering C1-C7. Metrics were automatically extracted at maximally compressed and uncompressed rostral/caudal levels. Normalized metrics were compared with t tests, area under the curve, and logistic regression. Relationships with clinical measures were analyzed by using Pearson correlation and multiple linear regression.ResultsThe maximally compressed level cross-sectional area demonstrated superior differences (P = 1 × 10-13), diagnostic accuracy (area under the curve = 0.890), and univariate correlation with the modified Japanese Orthopedic Association score (0.66). T2*WI WM/GM showed strong differences (rostral: P = 8 × 10-7; maximally compressed level: P = 1 × 10-11; caudal: P = 1 × 10-4), correlations (modified Japanese Orthopedic Association score; rostral: -0.52; maximally compressed level: -0.59; caudal: -0.36), and diagnostic accuracy (rostral: 0.775; maximally compressed level: 0.860; caudal: 0.721), outperforming fractional anisotropy and magnetization transfer ratio in most comparisons and cross-sectional area at rostral/caudal levels. Rostral T2*WI WM/GM showed the strongest correlations with focal motor (-0.45) and sensory (-0.49) deficits and was the strongest independent predictor of the modified Japanese Orthopedic Association score (P = .01) and diagnosis (P = .02) in multivariate models (R2 = 0.59, P = 8 × 10-13; area under the curve = 0.954, respectively).ConclusionsT2*WI WM/GM shows promise as a novel biomarker of WM injury. It detects damage in compressed and uncompressed regions and contributes substantially to multivariate models for diagnosis and correlation with impairment. Our multiparametric approach overcomes limitations of individual measures, having the potential to improve diagnostics, monitor progression, and predict outcomes.

Study Type Retrospective cohort. Introduction The treatment of rare neoplastic conditions is challenging, especially because studies providing high levels of evidence are often lacking. Such is the case with primary tumors of the spine (PTS), which have a

STUDY DESIGN: Retrospective cohort study supplemented by analysis of postmortem spinal cord tissue. OBJECTIVES: This study examines the frequency of hyponatremia in early stage (2 weeks) after cervical spinal cord injury (SCI), and the relationship between integrity of key autonomic pathways and hyponatremia. SUMMARY OF BACKGROUND DATA: Interruption of key circuits in the spinal cord can induce autonomic dysfunction with disordered metabolic and physiologic homeostasis. Given that hyponatremia may be a common electrolyte disorder during the acute stage post-SCI, we hypothesized that disconnection of descending sympathetic renal spinal cord tracts may be associated with hyponatremia after SCI. METHODS: Consecutive individuals with cervical spine trauma were included in our cohort of patients, which was divided into a SCI group and a control group (patients with spine trauma without SCI). Also, postmortem spinal cord sections from individuals with cervical, motor complete SCI, and control cases without CNS trauma were evaluated regarding the extent of axonal preservation within the descending vasomotor pathways, the descending renal sympathetic pathways (DRSPs), the corticospinal tracts, and the dorsal columns. RESULTS: There were 21 SCI individuals (6 women, 15 men; ages, 17-83 years; mean, 57.1) and 12 patients in the control spine trauma group who did not have SCI (4 women, 8 men; ages 18-90 years; mean, 45.9). Patients had either motor complete (7/21) or motor incomplete (14/21) tetraplegia. Hyponatremia occurred in 85.7% after SCI, which was significantly more frequent than the control group. Postmortem analysis included 5 control cases and 6 SCI individuals of whom 3 developed hyponatremia. The number of preserved axons within the DRSPs from normonatremic SCI patients was significantly lower than the number of axons within DRSPs from hyponatremic SCI patients, but development of hyponatremia was not associated with the integrity of the descending vasomotor pathways. Hyponatremic SCI individuals also showed greater evidence of neurogenic hypotension than normonatremic SCI individuals. CONCLUSION: Hyponatremia is common in the early stage post-SCI. Our results also suggest that hyponatremia is associated with the integrity of descending renal sympathetic circuits which mediate the renin-angiotensin response to neural injury, in the setting of neurogenic hypotension with cardiovascular dysfunction. [ABSTRACT FROM AUTHOR]

Cell transplantation holds great promise as a treatment strategy for human spinal cord injury (SCI). We review the pathophysiology of SCI and its implications for cell transplantation as well as the merits of specific cell types and, where understood, the mechanisms of action. Past, current, and future trials are also discussed. Unfortunately the majority of trials to date have been hampered by the lack of a rigorous scientific approach, which clouds their interpretation and utility to the field. Nonetheless, there is clear reason for researchers, clinicians, and patients to be optimistic about the potential of this novel therapeutic paradigm. [ABSTRACT FROM AUTHOR]

Objective: To refine the Graded and Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) as a measure of upper limb impairment following cervical SCI. Method: A cross-sectional study assessed a cohort of neurologically stable patients with tetraplegia using a preliminary version of the GRASSP. Regression analysis was performed to determine the association between subcomponents of the GRASSP (impairment) and measures of function. The GRASSP was modified based on results. Results: Eliminated static two-point discrimination, tone, and one muscle. Conclusion: The GRASSP Version I consists of Semmes Weinstein monofilaments, manual muscle testing, and qualitative and quantitative prehension testing. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Reliability study. OBJECTIVE: To assess the intrarater and interrater reliability of a recently described technique to measure of maximum canal compromise (MCC) and maximum spinal cord compression (MSCC) using digitized and magnified images in the setting of traumatic cervical spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: The extent of MCC and MSCC is of clinical and prognostic value in the setting of traumatic cervical SCI. However, concerns remain regarding the accuracy of measurements based on hard copy images. We hypothesized that the interrater and intrarater reliability of these assessments would be enhanced using magnified digitized images and software-based measurement tools. METHODS: Midsagittal MRI and CT images of cervical spine were selected from 5 individuals with acute traumatic cervical SCI. Measurements of MCC using CT scan and T1-weighted MRI and measurements of MSCC based on T2-weighted MR images were independently estimated by 13 raters on 10 occasions. RESULTS: The intrarater reliability for CT-MCC, T1-weighted MRI-MCC and T2-weighted MRI-MSCC was high in the 10 rounds in each patient. In addition, the mean intrarater interclass correlation coefficient was 0.72 +/- 0.05 for the CT-MCC, 0.70 +/- 0.07 for the T1-weighted MRI-MCC, and 0.68 +/- 0.11 for the T2-weighted MRI-MSCC. The mean interrater interclass correlation coefficients were 0.43 +/- 0.02 for the CT-MCC, 0.61 +/- 0.03 for the T1-weighted MRI-MCC, and 0.55 +/- 0.05 for the evaluation of T2-weighted MRI-MSCC. CONCLUSION: Our study has demonstrated that the intrarater reliability for the instrument to assess MCC and MSCC in the setting of traumatic SCI was high. The interrater ICCs at a moderate level of reliability combined with our results using analysis of variance with post hoc tests indicate that the measurements of MCC and MSCC are reproducible, which supports the use of these radiologic parameters in the clinical and research settings. [ABSTRACT FROM AUTHOR]

Study Design. Systematic review.Objective. To examine the evidence to support practice guidelines for screening for DVT in asymptomatic adults with acute traumatic spinal cord injury (SCI) who undergo pharmacologic thromboprophylaxis.Summary of Background Data. Despite the fact that pharmacologic thromboprophylaxis has been widely used since the 1980s, deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) still account for approximately 10% of deaths during the first year following SCI.Methods. MEDLINE and EMBASE were searched from the earliest achievable date to December 2005. We only included clinical studies that used a screening test for DVT and the gold standard diagnostic tests for DVT (i.e., lower limb venography) and for PE (i.e., lung arteriogram) in adults with traumatic SCI who underwent drug thromboprophylaxis during the acute stage after SCI.Results. The search yielded 188 articles, of which 9 articles fulfilled the criteria to be included in our review. Screening for DVT was performed in 3 randomized clinical trials and 6 case series. The protocol of these studies included the use of D-Dimer (1 of 9),1251-labeled fibrinogen (2 of 9), ultrasound (1 of 9), impedance plethysmography (1 of 9), impedance plethysmography and Doppler in combination (1 of 9), Duplex (1 of 9) or venography (2 of 9) as screening test for DVT. Based on the pooled data of these studies, asymptomatic DVT was detected in 16.9% of SCI population. Only 4 studies reported the occurrence of PE in 4.4% of cases.Conclusion. There is insufficient evidence to support (or refute) a recommendation for routine screening for DVT in adults with acute traumatic SCI under thromboprophylaxis. However, there is level 11-2 evidence that screening could detect asymptomatic DVT in 22.7% of those individuals. Although additional investigation is needed, we hypothesize that weekly screening for DVT during the first 13 weeks post-SCI could detect most of the asymptomatic DVT events in this patient population. D-Dimer, ultrasound, and MR venography could be considered as potentially useful screening tests for DVT in the SCI population in future research studies. [ABSTRACT FROM AUTHOR]

Despite intensive preventive efforts, acute spinal cord injury remains a significant public health problem. The pathophysiology of this type of injury involves both the primary, or initial, mechanical injury and secondary injury mechanisms such as ischemia, lipid peroxidation and intracellular calcium influx. Initial management includes immobilization of the injured spine, maintenance of the airway, systemic oxygen delivery and treatment of neurogenic shock. All patients with acute spinal cord injury should receive an intravenous bolus of methylprednisolone, 30 mg per kg, within eight hours of injury, followed by an infusion of 5.4 mg per kg per hour for 23 hours. Transfer to a regional acute spinal cord injury unit for definitive management should be accomplished as soon as the patient's condition is stabilized. [ABSTRACT FROM AUTHOR]