Traumatic Spinal Cord Injury

After traumatic spinal cord injury (SCI), the initial dam- age to the parenchyma at the lesion site is followed by a complex cascade of secondary events including break- down of the blood spinal cord barrier (BSB) and infiltra- tion of blood-derived inflammatory cells, oedema, excitotoxicity and ischemia. Experimental investigations have revealed that this phase of secondary parenchymal damage spans the first 48–72 hours post injury and is fol- lowed by the removal of tissue debris over subsequent weeks. Finally, the lesion site of severely injured tissue becomes dominated by scar tissue comprised of connec- tive tissue, including Schwann cells and meningeal fibrob- lasts, and fluid-filled cysts, surrounded by a dense astroglial scar [1]. Remodelling of the extracellular matrix (ECM) plays an important role in most of these events Matrix metalloproteinases (MMPs) are a family of extra- cellular zinc- and calcium-dependent endopeptidases that degrade the extracellular matrix and other extracellular proteins [2]. The 23 mammalian MMPs can be placed into sub-groups based on structural similarities and substrate specificity and they are capable of degrading virtually all extracellular proteins. Once activated, MMPs are subject to inhibition by 4 different tissue inhibitors of metallo- proteinases (TIMPs) that bind MMPs non-covalently [3]. MMPs are involved in events requiring matrix remodel- ling in developmental processes, wound healing and repair throughout life. In the nervous system, these enzymes play a role in the migration of precursor cells to their destination and are directly involved in axonal out- growth during development [4]. However, the aberrant expression of members of this protein family is involved in disease processes such as cancer metastasis and CNS disorders including multiple sclerosis, stroke, Alzheimer's disease and trauma [4,5]. Recent experimental SCI inves- tigations have demonstrated an involvement of MMPs in the post-traumatic events. In a mouse spinal cord com- pression injury model, a significant up-regulation of 11 MMPs was demonstrated [6]. Most of the proteins, includ- ing MMP-3, -9 and -10, showed an early induction, start- ing 24 hours after injury whereas the expression of other MMPs, including MMP-2, -12 and -13, was delayed until 5 days after trauma. Further studies into the role of MMP- 12, the most markedly up-regulated MMP, demonstrated improved recovery in MMP-12 null mice, most likely due to a reduction of the lesion-induced permeability of the blood spinal cord barrier (BSB) and a reduced density of microglia/macrophages at the lesion site [6]. An investiga- tion into the role of MMP-9 in SCI showed similar results in a contusion injury model, with improved locomotor function in MMP-9 null mice as compared to wild-type animals. Again, a reduction of the lesion-induced perme- ability of the BSB and a resulting attenuation of inflam- matory cell infiltration were suggested to be the likely

The purpose of the study was to analyse on pain following traumatic spinal cord in- jury, its prevalence, the types of pain present, the common treatments used and their perceived effectiveness in the management of these reported pain types. A cross sec- tional study was carried out at St Giles Rehabilitation Centre and from members of the Spinal Injuries Association of Zimbabwe (SIAZ). A researcher-administered questionnaire was used to collect data from 24 participants with traumatic spinal cord injury. The questionnaire elicited information on demographic data, pain cha- racteristics and the perceived effectiveness of the common treatments used. Among the 24 participants in the study, 17 were males (70.8%) and 7 were females (29.2%). Pain prevalence was 79.2% among the study participants and approximately a fifth (21.03%) of all participants rated their pain as severe. Eight (33.3%) of the partici- pants had neuropathic pain while 11 (45.8%) had both nociceptive and neuropathic pain types. However, no association was found between sex, age, time post injury when tested against the presence of pain (p > 0.05). Weather changes aggravated al- most every type of pain reported. Both pharmacological and non-pharmacological methods were used to manage the pain but their perceived effectiveness was rated as low. The majority of the traumatic spinal cord injured people experienced some pain and this pain was severe in a fifth of all participants. Pain significantly affected their quality of life. Physiotherapists and other medical professionals need to be aware of this and should employ pain reducing modalities and empathy when dealing with these patients.

study did not have access to participants with possible bony lesions admitted directly to the orthopedic spine wards. They may also be change in the trend of the pres- entation with more participants presenting with intra- dural lesions. Our results highlight the increasing significance of MRI among patients with non-traumatic SCI admitted on in the medical or neurology ward since over 60% of the patients will not benefit from the radiation-based investigations X rays and CT. The differ- ential diagnosis of non-traumatic spinal cord injury is wide [1, 8]. This provides a challenge in choosing the ap- propriate cheaper investigational modalities. Hence, MRI provides a diagnostic entry point that can guide the use of other investigative modalities for conditions like, in- fections, demyelination or vascular causes [7, 17]. Prioritization of MRI over CT is mainly in patients with suspected non-bone extradural lesions and intradural lesions which include the younger age groups. Aside from the cost, there is no radiation exposure in MRI.

A cross sectional observational study was carried out at Department of Physical Medicine and Rehabilitation, All India Institute of Physical Medicine and Rehabilitation, Mumbai over a period of two years from April 2012 to April 2014. Patients suffering from neurogenic bladder secondary to traumatic spinal cord injury, coming to our institute from all over India were included in the study. Patients who visited the outpatient department or admitted for long term inpatient rehabilitation were counselled and written informed consent was taken prior to urodynamic study, before enrolment in study group. We recorded detailed history of patient’s current illness with emphasis on history pertaining to bladder and bowel habits. Thorough neurological examination of each patient was performed and classified according to American Spinal Injury Association (ASIA) impairment scale (© 2020 American Spinal Injury Association). 13

Despite advances made in rehabilitation medicine, which brought an increase in life expectancy and a reduction in mortality rates, SCI remains one of the most devastating health injuries often producing permanent disability. According to limited availability of data on epidemiological studies, the incidence of spinal trauma in Russian industrial cities is 5–6 per 100 000 [3, 4]. Although there are no accurate and up-to-date formal country-level statistical data on the average age of traumatic spinal cord injury (TSCI) patients, different separate

Background: Road collisions remain the leading cause of traumatic spinal cord injury (TSCI) in the world. Half of all TSCIs in Ireland in 2000 were caused by road collisions. Since then, there has been a downward trend in road fatalities coincident with implemented road safety strategies. Objective: To examine the incidence of TSCI resulting from road collisions from 2001 to 2010. Method: This is a retrospective study using the hospital inpatient enquiry database of the tertiary referral center, which houses the national spinal injuries unit. Information retrieved included total numbers of patients with TSCI and number of TSCIs due to road collisions from 2001 through 2010, age groups affected, and the gender balance. Results: Over the 10-year period studied, the incidence rate of TSCI due to road collisions declined, although this did not reach statistical significance. The largest numbers of all TSCIs and TSCIs due to road collisions were in the 20- to 29-year age category and the male gender. Conclusions: As mortality due to road collisions declined, so did the number of TSCIs from the same etiology. An impactful road safety campaign is likely to have influenced these trends. Key words: epidemiology, road collisions, road safety, traumatic spinal cord injury

Traumatic spinal cord injury (TSCI) has a devastating effect on the patient’s quality of life, family, and society (1-3). Current clinical therapies attempt to prevent progression of secondary injuries that initiate after acute mechanical insult. However, the results of clinical trials suggest that current therapies are not sufficiently effective. In this regard, new therapeutic approaches, such as cell therapies, gene therapies, and tissue engineering have been proposed to compensate neuronal loss and inhibitory environment of the injured tissue. Detailed understanding of the time-dependent pathophysiological events after TSCI in animal studies may help scientists to accurately decide the time and type of intervention. However, despite abundant studies evaluating the TSCI pathophysiology, there is a controversy about neuronal death following mechanical insult. Some evidence suggests the immediate and immense neuronal death (4, 5), while there is other

The pathway that an injured patient follows from the in- cident location to definitive care can be variable and cover large geographical distances in Australia. Patients with traumatic spinal cord injury (TSCI) require skilled assessment, appropriate management and timely access to specialist treatment. This is most vital in the immedi- ate post injury phase, where failure to adhere to evidence based guidelines and standards poses serious risk of secondary neurological deterioration [1]. Inconsistencies in acute care protocols and health service pathways to access specialist care have been identified in this injury group, prompting calls for nationally consistent care standards [2]. The risk of secondary complications in patients with TSCI is increased for those who do not obtain acute care in a specialist spinal cord injury unit (SCIU) within 24 h from the time of injury [3, 4]. Parent et al. have also systematically reviewed the impact of SCIU care on TSCI complications and mortality, conclud- ing that it reduced lengths of stay, mortality risk and the number and severity of complications [5]. The extent to which these findings impact the pre-hospital, emergency and surgical clinical practice and transfer decisions of senior clinicians in Australia is unknown.

To our knowledge, this is the first study assessing survival rate of Iranian patients after chronic traumatic spinal cord injury, referred to a tertiary clinic. During the follow-up period, 22 cases died, and the most common cause of death was sepsis (59%). In a previous study, medical records of TSCI cases in Norway were reviewed and found cardiovascular events and suicide as the leading causes of death (2). Including patients with TSCI survived one-year post-injury, respiratory prob- lems, cardiovascular events, and systemic neo- plasms were reported as the leading causes of death in British TSCI patients(18). In Germany, the most frequent causes of death were septicemia, influenza/pneumonia, and suicide in TSCI cases with tetraplegia, and ischemic heart disease, neoplasms, and septicemia in those with paraplegia (19) . In Denmark, urinary system

Nurse are people who spend more time with the patient than any other member of the rehabilitations. In this context, she has a more role as representing each member to some extent. Her role extends from nutrition to helping the patient and their relatives to adjust to the psychological trauma of the injury & to give suggestions to vocational evaluator about his or her interests in jobs and to occupational therapist about the usefulness or devices in her absentia. 62

manager participants, but not to the same extent as it was in the SCI-caregiver dyads. It is argued that the other sub-themes of wellness awareness, monitoring for secondary complications, and independence-dependence conflict also reflect internal responsibility attribution as some of these sub-themes correspond with the findings on internal responsibility attribution in a recent qualita- tive study [21]. For example, Audulv and colleagues [21] determined that those individuals who attributed re- sponsibility to internal factors (e.g., beliefs and attitudes that one is an active agent in his or her own life) had a multi-faceted self-management regimen including a wide range of self-management behaviors in order to facilitate physical and mental well-being. It was further deter- mined among those individuals who had a multi-faceted self-management regimen that there was an alternating between reflexive and routine strategies. With a reflexive strategy, self-management is closely evaluated and new information is sought and incorporated with an individ- ual’s own experiences. With a routine strategy, self- management becomes a course of daily habits and rou- tines. Thus, the themes identified by Audulv and colleagues [21] as being associated with internal responsibility attribu- tion correspond with the sub-themes identified in the current study including monitoring for secondary compli- cations (i.e., multi-faceted self-management regimen), which also involved specific routines (i.e., routine strategies) and a rediscovery of themselves post-injury (i.e., reflexive strategies), as well as wellness awareness (i.e., multi-faceted self-management regimen in order to facilitate physical and mental well-being). Wellness awareness as a component of the meaning of self-management according to the SCI and caregiver participants will be further discussed below as it contrasts to the manager participants’ meaning of self- management comprising established chronic disease self- management programs.

characterized by the deterioration of skeletal mass and thereby a reduction in supporting structures to withstand a mechanical insult, potentially influencing risk of TSCI in geriatric populations (i.e., the host/person ) (Pintar et al. 1998; Silver and Einhorn 1995; Madureira et al. 2007; Maki et al. 1994). Occurring most often in older ages, the vehicles through which injury occurs are low-level falls due to tripping (same-level fall) or tripping down the stairs, which could be due to declining leg strength neces- sary for fall prevention (Pijnappels et al. 2008; Stevens et al. 2014). A study by Chen et al. found an increase in falls with increasing age due to tripping on stairs/steps and same-level falls (Chen et al. 2015). As the number of older adults increases, so too does the magnitude of TSCIs due to falls, therefore prevention strategies aimed at the elderly or aging population is imperative. Hinting towards this is a recent study by Bjørnshave Noe et al. which found that over the past twelve years, the median age at injury has in- creased along with the percentage of falls, with incidence rate ratios (IRRs) for fall-related TSCIs more than two times greater in the last time period (1990–1994) as com- pared to the first (1990–1994) (adjusted for age and gen- der) (Bjornshave Noe et al. 2015). Previous research has identified many measures that could be taken during the pre-event phase that would reduce the risk of falling among geriatric populations (Kannus et al. 2005). For example, towards the reduction of the proportion of SCIs due to falling in the pre-event phase , prevention efforts could focus on strength, balance and resistance training for the host/person , the addition of handrails or level seats could modify the vehicle , and home hazard assessment and modification such as the removal of loose carpets and clutter, the physical environment (Demura et al. 2011; WHO 2013; Robertson et al. 2002). vitamin D supplemen- tation during the pre-event phase could in turn modify the risk of injury to the host/person during the event phase , as it has been found to be helpful in reducing the risk of fall- related fractures and the rate of falls among individuals with reduced levels of vitamin D (Gillespie et al. 2009). Additionally, during the event phase , the use of anti-slip shoe devices worn by the host/person could help reduce the rate of falls in icy conditions (Gillespie et al. 2009), as well as modifications to the social environment such as anti-slip flooring requirements.

Imaging technology is an important part of the diagnosis and management of spinal trauma. However, many efforts have been made to develop new diagnostic biomarkers through advanced imaging techniques. Unfortunately, there is still no consensus for practical use of biomarkers in SCI patients. The authors conducted an all-encompassing literature review and relevant images were included as examples. Spinal cord and soft-tissue injuries are best evaluated by magnetic resonance imaging (MRI). However, advanced MRI techniques provide researchers with a non- invasive approach that allows evaluation of physiological and biochemical condition of the spinal cord and the brain at cellular and molecular level. The advent of new rehabilitation and treatment strategies could demand more precise and advanced techniques to approach the pathophysiology and anatomy of the spinal cord, offering more accurate and non-invasive support to research and clinical follow up.

In our series, complete injuries were mainly associated with traffic accidents, falls from high places and diving injuries, while incomplete injuries were associated with falls in older people. Despite the increased frequency of incomplete cervical spinal cord injuries associated with the elderly population, which is in agreement with re- cent studies [5, 8, 9, 11, 14, 17, 21], in our series, a sig- nificant number of complete thoracic spinal cord injuries also occurred. This, together with the reduction in the number of lumbar spinal cord injuries, which are usually incomplete, is responsible for the fact that complete spinal injuries predominated in our study. This reality has meant that the expected functional improve- ment in patients due to the increase in incomplete cer- vical spinal cord lesions did not occur in our population. Regarding spinal cord injury severity, we observed a prevalence of ASIA A (52.1%) followed by ASIA D injuries, a finding that was in agreement with other series, such as those in the USA (48.7%) [12] or Italy (54.7%) [22].

Gelatin zymography shows that minocycline does not alter MMP-2 and -9 protein content Measurement of transcripts encoding MMPs provides a broad overview of the changes occurring to all known MMP members, since several individual MMPs continue to be difficult to measure using Western blot or activity assays. A reproducible and commonly used method for protein levels involves the determination of MMP-2 and MMP-9 by the method of gelatin zymography. Although we did not detect the elevation of their transcripts after SCI [Figure 1], MMP-9 protein can be made outside of the CNS, including in neutrophils, and then deposited into the lesion site. For these reasons, we examined the levels of MMP-2 and -9 protein using gelatin zymography. The pro-MMP-9 protein was minimally expressed in control uninjured spinal cord tissue [Figure 3A]. Injury resulted in an upregulation of both the pro- and active forms of MMP- 9 one day after injury. Minocycline treatment had no obvious effect on the injury-induced MMP-9. The pro-

time points ranging from 2 hours to 1 week postinjury. The study describes an initial very early pattern (t ⫽ 2 hours) of scattered focal gray matter hemorrhages, which rapidly evolve to diffuse hemorrhage throughout the white and gray matter, maximum at 12 hours. The acute spinal cord hemorrhage had specific signal-intensity characteristics, even at the earliest time point (t ⫽ 2 hours) appearing T2 hypointense. In con- trast, T2-hyperintense signal intensity correlated to areas of edema formation, white matter myelin degeneration sur- rounding the hemorrhage, and necrotic and inflammatory changes. Although it was not quantified, the investigators re- ported that surrounding white matter edema became most severe by 48 –72 hours after injury in lower severity contu- sions, with little additional change in sections obtained at 72 and 96 hours. Most interesting, in more severe contusions, the necrotic and infiltrative changes continued to progress in sec- tions obtained at 72 and 96 hours, suggesting that the time course of lesion evolution is dependent on injury severity.

The level of evidence of each study was evaluated using a scale developed for this review using guidelines from the Agency for Healthcare Research and Quality. This scale consisted of ten questions related to study design, sampling methodology, sampling bias, precision, and reliability of esti- mates. Further, two questions discussed whether the studies adequately defined SCI and whether patients who died at the site of injury were included in the incidence figure. The rating scale addresses all methodological components of epidemi- ology studies and was specifically developed to target SCI incidence and prevalence literature. Table 1 displays the rating scale as well as interpretations for each of the ten questions.

We retrospectively examined the charts of 245 patients with traumatic spinal cord injury who were admitted to our spinal unit between 1996 and 2011 for their first rehabilitation treatment after development of the lesion. Patients were admitted on a referral base. The inclusion criteria for admission to our unit were age over 12 years, being clinically stable, and having finished the surgical workout. The few cases that experienced progression of the lesion were excluded. Whenever a patient was discharged or had been transferred for more than 3 weeks, the readmission was considered a second admission, and the patient was excluded. The study was approved by the Institutional Review Board of the IRCCS S. Lucia Foundation. The research was carried out in compli- ance with the Helsinki Declaration.

Zhou Y conducted a study to describe the epidemiological profile of traumatic spinal cord injury (TSCI) in Tianjin Medical University General Hospital, China, from 2009 to 2014. Hospital medical records of patients with TSCI admitted to hospital from 1 January 2009 to 31 December 2014 were reviewed. Collected variables included gender, age, marital status, ethnic group, occupation, etiology, neurological level of injury, American Spinal Injury Association (ASIA)-ISCoS impairment scale at admission, the severity, death and its cause, concomitant injuries and treatment choice. During the study period, 354 cases were identified. Male- to-female ratio was 2.34:1, with a mean age of 50.1±15.5 years. Falls (55.1%), comprising low falls and high falls (33.6% and 21.5%, respectively), were the leading cause, followed by motor vehicle collisions (MVCs) (35.9%). The most common injury site was the cervical spinal cord, especially C4-C6, accounting for 59.3%. Surgery was the major treatment choice (57.6%). The number of TSCI patients increased annually in our center. The mean age at the time of injury was older, and the proportion of males was higher. The leading two causes were falls and MVCs. The SCIs caused by MVCs were increasing. Peasants, workers

Functional Electrical Stimulation (FES) can be used to assist patients with complete paraplegia arising from a traumatic spinal cord injury to stand.. In clinical practic[r]