164 results on '"Papadopoulos MC"'
Search Results
2. Acute, Severe Traumatic Spinal Cord Injury: Monitoring from the Injury Site and Expansion Duraplasty
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Saadoun, S and Papadopoulos, MC
- Abstract
We discuss 2 evolving management options for acute spinal cord injury that hold promise to further improve outcome: pressure monitoring from the injured cord and expansion duraplasty. Probes surgically implanted at the injury site can transduce intraspinal pressure, spinal cord perfusion pressure, and cord metabolism. Intraspinal pressure is not adequately reduced by bony decompression alone because the swollen, injured cord is compressed against the dura. Expansion duraplasty may be necessary to effectively decompress the injured cord. A randomized controlled trial called DISCUS is investigating expansion duraplasty as a novel treatment for acute, severe traumatic cervical spinal cord injury.
- Published
- 2021
3. Acute spinal cord injury: monitoring the lumbar cerebrospinal fluid provides limited information about the injury site
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Hogg, F, Gallagher, MJ, Kearney, S, Zoumprouli, A, Papadopoulos, MC, and Saadoun, S
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In some centers, monitoring the lumbar cerebrospinal fluid (CSF) is used to guide management of patients with acute traumatic spinal cord injuries (TSCI) and draining lumbar CSF to improve spinal cord perfusion. Here, we investigate whether the lumbar CSF provides accurate information about the injury site and the effect of draining lumbar CSF on injury site perfusion. In 13 TSCI patients, we simultaneously monitored lumbar CSF pressure (CSFP) and intraspinal pressure (ISP) from the injury site. Using CSFP or ISP, we computed spinal cord perfusion pressure (SCPP), vascular pressure reactivity index (sPRx) and optimum SCPP (SCPPopt). We also assessed the effect on ISP of draining 10mL CSF. Metabolites at the injury site were compared with metabolites in the lumbar CSF. We found that ISP was pulsatile, but CSFP had low pulse pressure and was non-pulsatile 21% of the time. There was weak or no correlation between CSFP versus ISP (R=-0.11), SCPP(csf) versus SCPP(ISP) (R=0.39) and sPRx(csf) versus sPRx(ISP) (R=0.45). CSF drainage caused no significant change in ISP in 7/12 patients, a significant drop by
- Published
- 2020
4. TP1-6 Pathological patterns of spinal cord blood flow after injury visualised with laser speckle contrast imaging
- Author
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Gallagher, MJ, primary, Hogg, FRA, additional, Saadoun, S, additional, and Papadopoulos, MC, additional
- Published
- 2019
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5. Microdialysis to optimize cord perfusion and drug delivery in spinal cord injury
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Phang, I, Zoumprouli, A, Papadopoulos, MC, and Saadoun, S
- Abstract
OBJECTIVE: There is lack of monitoring from the injury site to guide management of patients with acute traumatic spinal cord injury. Here we describe a bedside microdialysis monitoring technique for optimizing spinal cord perfusion and drug delivery at the injury site. METHODS: 14 patients were recruited within 72 hours of severe spinal cord injury. We inserted intradurally at the injury site a pressure probe, to monitor continuously spinal cord perfusion pressure, and a microdialysis catheter, to monitor hourly glycerol, glutamate, glucose, lactate and pyruvate. The pressure probe and microdialysis catheter were placed on the surface of the injured cord. RESULTS: Microdialysis monitoring did not cause serious complications. Spinal cord perfusion pressure 90 - 100 mmHg and tissue glucose >4.5 mM minimized metabolic derangement at the injury site. Increasing spinal cord perfusion pressure by ∼10 mmHg, increased the entry of intravenously administered dexamethasone at the injury site three-fold. INTERPRETATION: This study determined the optimum spinal cord perfusion pressure and optimum tissue glucose concentration at the injury site. We also identified spinal cord perfusion pressure as a key determinant of drug entry into the injured spinal cord. Our findings challenge current guidelines, which recommend maintaining mean arterial pressure at 85 - 90 mmHg for a week after spinal cord injury. We propose that future drug trials for spinal cord injury include pressure and microdialysis monitoring to optimize spinal cord perfusion and maximize drug delivery at the injury site. This article is protected by copyright. All rights reserved.
- Published
- 2016
6. Giant central lumbar disc herniations: a case for the transdural approach
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Tulloch, I, primary and Papadopoulos, MC, additional
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- 2018
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7. Neuromyelitis optica IgG causes placental inflammation and fetal death in mice
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Saadoun, S, Waters, P, Leite, MI, Bennett, JL, Vincent, A, and Papadopoulos, MC
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- 2016
8. Neutrophil protease inhibition reduces NMO-IgG-induced damage in mouse brain
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Papadopoulos, MC, Saadoun, S, MacDonald, C, Waters, P, Bell, BA, Vincent, A, and Verkman, AS
- Published
- 2016
9. Fusion surgery for lumbar spinal stenosis?
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Greenway, FEA and Papadopoulos, MC
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- 2016
10. Measurement of Intraspinal Pressure After Spinal Cord Injury: Technical Note from the Injured Spinal Cord Pressure Evaluation Study
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Werndle, MC, Saadoun, S, Phang, I, Czosnyka, M, Varsos, G, Czosnyka, Z, Smielewski, P, Jamous, A, Bell, BA, Zoumprouli, A, and Papadopoulos, MC
- Subjects
musculoskeletal, neural, and ocular physiology ,nervous system diseases - Abstract
Intracranial pressure (ICP) is routinely measured in patients with severe traumatic brain injury (TBI). We describe a novel technique that allowed us to monitor intraspinal pressure (ISP) at the injury site in 14 patients who had severe acute traumatic spinal cord injury (TSCI), analogous to monitoring ICP after brain injury. A Codman probe was inserted subdurally to measure the pressure of the injured spinal cord compressed against the surrounding dura. Our key finding is that it is feasible and safe to monitor ISP for up to a week in patients after TSCI, starting within 72 h of the injury. With practice, probe insertion and calibration take less than 10 min. The ISP signal characteristics after TSCI were similar to the ICP signal characteristics recorded after TBI. Importantly, there were no associated complications. Future studies are required to determine whether reducing ISP improves neurological outcome after severe TSCI.
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- 2016
11. No association between seniority of surgeon and postoperative recurrence of chronic subdural haematoma
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Phang, I, primary, Sivakumaran, R, additional, and Papadopoulos, MC, additional
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- 2015
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12. Increased aquaporin I water channel expression in human brain tumours
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Saadoun, S, Papadopoulos, MC, Davies, DC, Bell, BA, and Krishna, S
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- 2002
13. A novel and accurate diagnostic test for human African trypanosomiasis.
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Papadopoulos MC, Abel PM, Agranoff D, Stich A, Tarelli E, Bell BA, Planche T, Loosemore A, Saadoun S, Wilkins P, and Krishna S
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- 2004
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14. Penetrating head injury in planned and repetitive deliberate self-harm.
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Demetriades AK, Papadopoulos MC, Demetriades, Andreas K, and Papadopoulos, Marios C
- Abstract
44-year-old man presented to his local emergency department wearing a baseball cap and complaining of headaches that had progressively worsened over the preceding 11 weeks. After we provided generous analgesia and performed simple investigations that failed to identify a diagnosis, the patient removed his cap to reveal an assortment of metallic objects embedded in his scalp. Plain radiographs showed 11 nails penetrating into his brain. A detailed history revealed a diagnosis of paranoid schizophrenia, and the patient confirmed that he had hammered a nail into his head each week for the past 11 weeks to rid him of evil. The nails were removed with the patient under general anesthesia, and he made an uncomplicated recovery with no neurological deficits. [ABSTRACT FROM AUTHOR]
- Published
- 2007
15. Identification of diagnostic markers for tuberculosis by proteomic fingerprinting of serum.
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Agranoff D, Fernandez-Reyes D, Papadopoulos MC, Rojas SA, Herbster M, Loosemore A, Tarelli E, Sheldon J, Schwenk A, Pollok R, Rayner CFJ, Krishna S, Agranoff, Dan, Fernandez-Reyes, Delmiro, Papadopoulos, Marios C, Rojas, Sergio A, Herbster, Mark, Loosemore, Alison, Tarelli, Edward, and Sheldon, Jo
- Abstract
Background: We investigated the potential of proteomic fingerprinting with mass spectrometric serum profiling, coupled with pattern recognition methods, to identify biomarkers that could improve diagnosis of tuberculosis.Methods: We obtained serum proteomic profiles from patients with active tuberculosis and controls by surface-enhanced laser desorption ionisation time of flight mass spectrometry. A supervised machine-learning approach based on the support vector machine (SVM) was used to obtain a classifier that distinguished between the groups in two independent test sets. We used k-fold cross validation and random sampling of the SVM classifier to assess the classifier further. Relevant mass peaks were selected by correlational analysis and assessed with SVM. We tested the diagnostic potential of candidate biomarkers, identified by peptide mass fingerprinting, by conventional immunoassays and SVM classifiers trained on these data.Findings: Our SVM classifier discriminated the proteomic profile of patients with active tuberculosis from that of controls with overlapping clinical features. Diagnostic accuracy was 94% (sensitivity 93.5%, specificity 94.9%) for patients with tuberculosis and was unaffected by HIV status. A classifier trained on the 20 most informative peaks achieved diagnostic accuracy of 90%. From these peaks, two peptides (serum amyloid A protein and transthyretin) were identified and quantitated by immunoassay. Because these peptides reflect inflammatory states, we also quantitated neopterin and C reactive protein. Application of an SVM classifier using combinations of these values gave diagnostic accuracies of up to 84% for tuberculosis. Validation on a second, prospectively collected testing set gave similar accuracies using the whole proteomic signature and the 20 selected peaks. Using combinations of the four biomarkers, we achieved diagnostic accuracies of up to 78%.Interpretation: The potential biomarkers for tuberculosis that we identified through proteomic fingerprinting and pattern recognition have a plausible biological connection with the disease and could be used to develop new diagnostic tests. [ABSTRACT FROM AUTHOR]- Published
- 2006
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16. Evolving trends in the surgical, anaesthetic, and intensive care management of acute spinal cord injuries in the UK.
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Asif H, Tsan SEH, Zoumprouli A, Papadopoulos MC, and Saadoun S
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- Humans, Methylprednisolone therapeutic use, Critical Care, United Kingdom epidemiology, Spinal Cord Injuries epidemiology, Spinal Cord Injuries surgery, Anesthetics therapeutic use
- Abstract
Purpose: We surveyed the treatment of acute spinal cord injuries in the UK and compared current practices with 10 years ago., Methods: A questionnaire survey was conducted amongst neurosurgeons, neuroanaesthetists, and neurointensivists that manage patients with acute spinal cord injuries. The survey gave two scenarios (complete and incomplete cervical spinal cord injuries). We obtained opinions on the speed of transfer, timing and aim of surgery, choice of anaesthetic, intraoperative monitoring, targets for physiological parameters, and drug treatments., Results: We received responses from 78.6% of UK units that manage acute spinal cord injuries (33 neurosurgeons, 56 neuroanaesthetists/neurointensivists). Most neurosurgeons operate within 12 h for incomplete (82%) and complete (64%) injuries. There is a significant shift from 10 years ago, when only 61% (incomplete) and 30% (complete) of neurosurgeons operated within 12 h. The preferred anaesthetic technique in 2022 is total intravenous anaesthesia (TIVA), used by 69% of neuroanaesthetists. Significantly more intraoperative monitoring is now used at least sometimes, including bispectral index (91%), non-invasive cardiac output (62%), and neurophysiology (73-77%). Methylprednisolone is no longer used by surgeons. Achieving at least 80 mmHg mean arterial blood pressure is recommended by 70% neurosurgeons, 62% neuroanaesthetists, and 75% neurointensivists., Conclusions: Between 2012 and 2022, there was a paradigm shift in managing acute spinal cord injuries in the UK with earlier surgery and more intraoperative monitoring. Variability in practice persists due to lack of high-quality evidence and consensus guidelines., (© 2024. The Author(s).)
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- 2024
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17. Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS).
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Picetti E, Demetriades AK, Catena F, Aarabi B, Abu-Zidan FM, Alves OL, Ansaloni L, Armonda RA, Badenes R, Bala M, Balogh ZJ, Barbanera A, Bertuccio A, Biffl WL, Bouzat P, Buki A, Castano-Leon AM, Cerasti D, Citerio G, Coccolini F, Coimbra R, Coniglio C, Costa F, De Iure F, Depreitere B, Fainardi E, Fehlings MJ, Gabrovsky N, Godoy DA, Gruen P, Gupta D, Hawryluk GWJ, Helbok R, Hossain I, Hutchinson PJ, Iaccarino C, Inaba K, Ivanov M, Kaprovoy S, Kirkpatrick AW, Klein S, Kolias A, Konovalov NA, Lagares A, Lippa L, Loza-Gomez A, Luoto TM, Maas AIR, Maciejczak A, Maier RV, Marklund N, Martin MJ, Melloni I, Mendoza-Lattes S, Meyfroidt G, Munari M, Napolitano LM, Okonkwo DO, Otomo Y, Papadopoulos MC, Petr O, Peul WC, Pudkrong AK, Qasim Z, Rasulo F, Reizinho C, Ringel F, Rizoli S, Rostami E, Rubiano AM, Russo E, Sarwal A, Schwab JM, Servadei F, Sharma D, Sharif S, Shiban E, Shutter L, Stahel PF, Taccone FS, Terpolilli NA, Thomé C, Toth P, Tsitsopoulos PP, Udy A, Vaccaro AR, Varon AJ, Vavilala MS, Younsi A, Zackova M, Zoerle T, and Robba C
- Subjects
- Adult, Humans, Consensus, Spinal Cord Injuries complications, Spinal Cord Injuries surgery, Multiple Trauma surgery
- Abstract
Background: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies., Methods: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted., Results: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak)., Conclusions: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients., (© 2024. The Author(s).)
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- 2024
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18. Adverse Effect of Neurogenic, Infective, and Inflammatory Fever on Acutely Injured Human Spinal Cord.
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Visagan R, Kearney S, Blex C, Serdani-Neuhaus L, Kopp MA, Schwab JM, Zoumprouli A, Papadopoulos MC, and Saadoun S
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- Humans, Body Temperature, Inflammation, Oxygen, Spinal Cord metabolism, Spinal Cord Injuries metabolism
- Abstract
This study aims to determine the effect of neurogenic, inflammatory, and infective fevers on acutely injured human spinal cord. In 86 patients with acute, severe traumatic spinal cord injuries (TSCIs; American Spinal Injury Association Impairment Scale (AIS), grades A-C) we monitored (starting within 72 h of injury, for up to 1 week) axillary temperature as well as injury site cord pressure, microdialysis (MD), and oxygen. High fever (temperature ≥38°C) was classified as neurogenic, infective, or inflammatory. The effect of these three fever types on injury-site physiology, metabolism, and inflammation was studied by analyzing 2864 h of intraspinal pressure (ISP), 1887 h of MD, and 840 h of tissue oxygen data. High fever occurred in 76.7% of the patients. The data show that temperature was higher in neurogenic than non-neurogenic fever. Neurogenic fever only occurred with injuries rostral to vertebral level T4. Compared with normothermia, fever was associated with reduced tissue glucose (all fevers), increased tissue lactate to pyruvate ratio (all fevers), reduced tissue oxygen (neurogenic + infective fevers), and elevated levels of pro-inflammatory cytokines/chemokines (infective fever). Spinal cord metabolic derangement preceded the onset of infective but not neurogenic or inflammatory fever. By considering five clinical characteristics (level of injury, axillary temperature, leukocyte count, C-reactive protein [CRP], and serum procalcitonin [PCT]), it was possible to confidently distinguish neurogenic from non-neurogenic high fever in 59.3% of cases. We conclude that neurogenic, infective, and inflammatory fevers occur commonly after acute, severe TSCI and are detrimental to the injured spinal cord with infective fever being the most injurious. Further studies are required to determine whether treating fever improves outcome. Accurately diagnosing neurogenic fever, as described, may reduce unnecessary septic screens and overuse of antibiotics in these patients.
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- 2023
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19. Extradural hematoma from trauma to midline skull tumour.
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Abdalla MA, Omer Z, Bashir SH, and Papadopoulos MC
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- Humans, Cranial Sinuses surgery, Craniotomy methods, Skull surgery, Male, Adult, Hematoma, Epidural, Cranial diagnostic imaging, Hematoma, Epidural, Cranial etiology, Hematoma, Epidural, Cranial surgery, Skull Fractures surgery, Skull Neoplasms diagnostic imaging, Skull Neoplasms surgery
- Abstract
We present a case of extradural hematoma resulting from a relatively minor closed injury over the vertex where a plasma cell tumour had invaded the superior sagittal sinus. The patient underwent an emergency craniotomy and evacuation of the hematoma. Hemostasis and prevention of recollection of the hematoma were hampered by the erosion of the sagittal sinus making its direct repair impossible. This was achieved by hitching up the dura lateral to the sinus to become its lateral wall reinforced by hemostatic agents. The patient made a full recovery. Malignant tumours invading the dural venous sinuses and eroding the skull can cause life-threatening intracranial bleeding after relatively minor trauma.
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- 2023
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20. Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study.
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Visagan R, Boseta E, Zoumprouli A, Papadopoulos MC, and Saadoun S
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- Humans, Perfusion, Respiration, Diaphragm diagnostic imaging, Spinal Cord Injuries
- Abstract
Objective: This study aims to determine the relationship between spinal cord perfusion pressure (SCPP) and breathing function in patients with acute cervical traumatic spinal cord injuries., Methods: We included 8 participants without cervical TSCI plus 13 patients with cervical traumatic spinal cord injuries, American Spinal Injury Association Impairment Scale grades A-C. In the TSCI patients, we monitored intraspinal pressure from the injury site for up to a week and computed the SCPP as mean arterial pressure minus intraspinal pressure. Breathing function was quantified by diaphragmatic electromyography using an EDI (electrical activity of the diaphragm) nasogastric tube as well as by ultrasound of the diaphragm and the intercostal muscles performed when sitting at 20°-30°., Results: We analysed 106 ultrasound examinations (total 1370 images/videos) and 198 EDI recordings in the patients with cervical traumatic spinal cord injuries. During quiet breathing, low SCPP (< 60 mmHg) was associated with reduced EDI-peak (measure of inspiratory effort) and EDI-min (measure of the tonic activity of the diaphragm), which increased and then plateaued at SCPP 60-100 mmHg. During quiet and deep breathing, the diaphragmatic thickening fraction (force of diaphragmatic contraction) plotted versus SCPP had an inverted-U relationship, with a peak at SCPP 80-90 mmHg. Diaphragmatic excursion (up and down movement of the diaphragm) during quiet breathing did not correlate with SCPP, but diaphragmatic excursion during deep breathing plotted versus SCPP had an inverse-U relationship with a peak at SCPP 80-90 mmHg. The thickening fraction of the intercostal muscles plotted versus SCPP also had inverted-U relationship, with normal intercostal function at SCPP 80-100 mmHg, but failure of the upper and middle intercostals to contract during inspiration (i.e. abdominal breathing) at SCPP < 80 or > 100 mmHg., Conclusions: After acute, cervical traumatic spinal cord injuries, breathing function depends on the SCPP. SCPP 80-90 mmHg correlates with optimum diaphragmatic and intercostal muscle function. Our findings raise the possibility that intervention to maintain SCPP in this range may accelerate ventilator liberation which may reduce stay in the neuro-intensive care unit., (© 2023. BioMed Central Ltd., part of Springer Nature.)
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- 2023
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21. Feasibility of comparing medical management and surgery (with neurosurgery or stereotactic radiosurgery) with medical management alone in people with symptomatic brain cavernoma - protocol for the Cavernomas: A Randomised Effectiveness (CARE) pilot trial.
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Loan JJM, Bacon A, van Beijnum J, Bhatt P, Bjornson A, Broomes N, Bullen A, Bulters D, Cahill J, Chavredakis E, Colombo F, Danciut M, Digpal R, Edwards RJ, Ferguson L, Forsyth L, Fouyas I, Ganesan V, Grover P, Gurusinghe N, Hall PS, Harkness K, Harris LS, Hayton T, Helmy A, Holsgrove D, Hutchinson PJ, Israni A, Kinsella E, Lewis S, Majeed S, Mallucci C, Mukerji N, Nair R, Neilson AR, Papadopoulos MC, Radatz M, Rossdeutsch A, Raza-Knight S, Stephen J, Stoddart A, Teo M, Turner C, Wade J, Walsh D, White D, White P, Wildman J, Wroe Wright O, Uff C, Ushewokunze S, Vindlacheruvu R, Kitchen N, and Al-Shahi Salman R
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- Adult, Child, Humans, Feasibility Studies, Pilot Projects, Brain, Randomized Controlled Trials as Topic, Neurosurgery, Radiosurgery
- Abstract
Introduction: The top research priority for cavernoma, identified by a James Lind Alliance Priority setting partnership was 'Does treatment (with neurosurgery or stereotactic radiosurgery) or no treatment improve outcome for people diagnosed with a cavernoma?' This pilot randomised controlled trial (RCT) aims to determine the feasibility of answering this question in a main phase RCT., Methods and Analysis: We will perform a pilot phase, parallel group, pragmatic RCT involving approximately 60 children or adults with mental capacity, resident in the UK or Ireland, with an unresected symptomatic brain cavernoma. Participants will be randomised by web-based randomisation 1:1 to treatment with medical management and with surgery (neurosurgery or stereotactic radiosurgery) versus medical management alone, stratified by prerandomisation preference for type of surgery. In addition to 13 feasibility outcomes, the primary clinical outcome is symptomatic intracranial haemorrhage or new persistent/progressive focal neurological deficit measured at 6 monthly intervals. An integrated QuinteT Recruitment Intervention (QRI) evaluates screening logs, audio recordings of recruitment discussions, and interviews with recruiters and patients/parents/carers to identify and address barriers to participation. A Patient Advisory Group has codesigned the study and will oversee its progress., Ethics and Dissemination: This study was approved by the Yorkshire and The Humber-Leeds East Research Ethics Committee (21/YH/0046). We will submit manuscripts to peer-reviewed journals, describing the findings of the QRI and the Cavernomas: A Randomised Evaluation (CARE) pilot trial. We will present at national specialty meetings. We will disseminate a plain English summary of the findings of the CARE pilot trial to participants and public audiences with input from, and acknowledgement of, the Patient Advisory Group., Trial Registration Number: ISRCTN41647111., Competing Interests: Competing interests: PW declares institutional unrestricted educational grant funding for a stroke reperfusion course from Stryker, Penumbra and Medtronic. MR declares that he is a Senior Clinician of the National Centre for Stereotactic Radiosurgery., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)
- Published
- 2023
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22. Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial.
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Saadoun S, Grassner L, Belci M, Cook J, Knight R, Davies L, Asif H, Visagan R, Gallagher MJ, Thomé C, Hutchinson PJ, Zoumprouli A, Wade J, Farrar N, and Papadopoulos MC
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- Adult, Humans, Prospective Studies, Quality of Life, Spinal Cord, Lactates, Treatment Outcome, Randomized Controlled Trials as Topic, Multicenter Studies as Topic, Clinical Trials, Phase III as Topic, Cervical Cord, Spinal Cord Injuries diagnosis, Spinal Cord Injuries surgery
- Abstract
Background: Cervical traumatic spinal cord injury is a devastating condition. Current management (bony decompression) may be inadequate as after acute severe TSCI, the swollen spinal cord may become compressed against the surrounding tough membrane, the dura. DISCUS will test the hypothesis that, after acute, severe traumatic cervical spinal cord injury, the addition of dural decompression to bony decompression improves muscle strength in the limbs at 6 months, compared with bony decompression alone., Methods: This is a prospective, phase III, multicenter, randomized controlled superiority trial. We aim to recruit 222 adults with acute, severe, traumatic cervical spinal cord injury with an American Spinal Injury Association Impairment Scale grade A, B, or C who will be randomized 1:1 to undergo bony decompression alone or bony decompression with duroplasty. Patients and outcome assessors are blinded to study arm. The primary outcome is change in the motor score at 6 months vs. admission; secondary outcomes assess function (grasp, walking, urinary + anal sphincters), quality of life, complications, need for further surgery, and mortality, at 6 months and 12 months from randomization. A subgroup of at least 50 patients (25/arm) also has observational monitoring from the injury site using a pressure probe (intraspinal pressure, spinal cord perfusion pressure) and/or microdialysis catheter (cord metabolism: tissue glucose, lactate, pyruvate, lactate to pyruvate ratio, glutamate, glycerol; cord inflammation: tissue chemokines/cytokines). Patients are recruited from the UK and internationally, with UK recruitment supported by an integrated QuinteT recruitment intervention to optimize recruitment and informed consent processes. Estimated study duration is 72 months (6 months set-up, 48 months recruitment, 12 months to complete follow-up, 6 months data analysis and reporting results)., Discussion: We anticipate that the addition of duroplasty to standard of care will improve muscle strength; this has benefits for patients and carers, as well as substantial gains for health services and society including economic implications. If the addition of duroplasty to standard treatment is beneficial, it is anticipated that duroplasty will become standard of care., Trial Registration: IRAS: 292031 (England, Wales, Northern Ireland) - Registration date: 24 May 2021, 296518 (Scotland), ISRCTN: 25573423 (Registration date: 2 June 2021); ClinicalTrials.gov number : NCT04936620 (Registration date: 21 June 2021); NIHR CRN 48627 (Registration date: 24 May 2021)., (© 2023. BioMed Central Ltd., part of Springer Nature.)
- Published
- 2023
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23. Removal or retention of minimally invasive screws in thoracolumbar fractures? Systematic review and case-control study.
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Visagan R, Kearney S, Trifoi S, Kalyal N, Hogg F, Quercetti B, Abdalla M, Danciut M, and Papadopoulos MC
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- Humans, Case-Control Studies, Retrospective Studies, Fracture Fixation, Internal adverse effects, Lumbar Vertebrae diagnostic imaging, Lumbar Vertebrae surgery, Thoracic Vertebrae diagnostic imaging, Thoracic Vertebrae surgery, Thoracic Vertebrae injuries, Treatment Outcome, Spinal Fractures diagnostic imaging, Spinal Fractures surgery, Pedicle Screws adverse effects, Fractures, Bone
- Abstract
Background: There is uncertainty regarding delayed removal versus retention of minimally invasive screws following percutaneous fixation for thoracolumbar fractures. We conducted a systematic review and case-control study to test the hypothesis that delayed metalwork removal following percutaneous fixation for thoracolumbar fractures improves outcome., Methods: A systematic review was performed in accordance with the PRISMA guidelines. Our case-control study retrospectively evaluated 55 consecutive patients with thoracolumbar fractures who underwent percutaneous fixation in a single unit: 19 with metalwork retained (controls) and 36 with metalwork removed. Outcomes were the Oswestry Disability Index (ODI), a supplemental questionnaire, and complications., Results: The systematic review evaluated nine articles. Back pain was reduced in most patients after metalwork removal. One study found no difference in the ODI after versus before metalwork removal, whereas three studies reported significant improvement. Six studies noted no significant alterations in radiological markers of stability after metalwork removal. Mean complication rate was 1.7% (0-6.7). Complications were superficial wound infection, screw breakage at the time of removal, pull-out screw, and a broken rod. In the case-control study, both groups were well matched. For metalwork removal, mean operative time was 69.5 min (range 30-120) and length of stay was 1.3 days (0-4). After metalwork removal, 24 (68.6%) patients felt better, 10 (28.6%) the same and one felt worse. Two patients had superficial hematomas, one had a superficial wound infection, and none required re-operation. Metalwork removal was a significant predictor of return to work or baseline household duties (odds ratio 5.0 [1.4-18.9]). The ODI was not different between groups., Conclusions: The findings of both the systematic review and our case-control study suggest that removal of metalwork following percutaneous fixation of thoracolumbar fractures is safe and is associated with improved outcome in most patients., (© 2023. The Author(s).)
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- 2023
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24. Response to: Very rare incidence of ascending paralysis in a patient of traumatic spinal cord injury: a case report.
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Visagan R and Papadopoulos MC
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- Humans, Incidence, Paralysis epidemiology, Paralysis etiology, Spinal Cord Injuries complications, Spinal Cord Injuries epidemiology, Spinal Injuries complications
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- 2023
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25. Targeting patient recovery priorities in degenerative cervical myelopathy: design and rationale for the RECEDE-Myelopathy trial-study protocol.
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Davies B, Mowforth OD, Yordanov S, Alvarez-Berdugo D, Bond S, Nodale M, Kareclas P, Whitehead L, Bishop J, Chandran S, Lamb S, Bacon M, Papadopoulos MC, Starkey M, Sadler I, Smith L, Kalsi-Ryan S, Carpenter A, Trivedi RA, Wilby M, Choi D, Wilkinson IB, Fehlings MG, Hutchinson PJ, and Kotter MRN
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- Adult, Humans, Neck, Adjuvants, Immunologic, Pain, Randomized Controlled Trials as Topic, Multicenter Studies as Topic, Spinal Cord Diseases, Bone Marrow Diseases
- Abstract
Introduction: Degenerative cervical myelopathy (DCM) is a common and disabling condition of symptomatic cervical spinal cord compression secondary to degenerative changes in spinal structures leading to a mechanical stress injury of the spinal cord. RECEDE-Myelopathy aims to test the disease-modulating activity of the phosphodiesterase 3/phosphodiesterase 4 inhibitor Ibudilast as an adjuvant to surgical decompression in DCM., Methods and Analysis: RECEDE-Myelopathy is a multicentre, double-blind, randomised, placebo-controlled trial. Participants will be randomised to receive either 60-100 mg Ibudilast or placebo starting within 10 weeks prior to surgery and continuing for 24 weeks after surgery for a maximum of 34 weeks. Adults with DCM, who have a modified Japanese Orthopaedic Association (mJOA) score 8-14 inclusive and are scheduled for their first decompressive surgery are eligible for inclusion. The coprimary endpoints are pain measured on a visual analogue scale and physical function measured by the mJOA score at 6 months after surgery. Clinical assessments will be undertaken preoperatively, postoperatively and 3, 6 and 12 months after surgery. We hypothesise that adjuvant therapy with Ibudilast leads to a meaningful and additional improvement in either pain or function, as compared with standard routine care., Study Design: Clinical trial protocol V.2.2 October 2020., Ethics and Dissemination: Ethical approval has been obtained from HRA-Wales.The results will be presented at an international and national scientific conferences and in a peer-reviewed journals., Trial Registration Number: ISRCTN Number: ISRCTN16682024., Competing Interests: Competing interests: MRNK holds a research grant from clinical scientist award and has support for the study from Medicinova. MCP holds research grant award with the NIHR. BD holds research grants with NIHR HTA POLYFIX-DCM, Evelyn Trust (DCM-COINs) and award from National Lottary UK for developing a peer-to-peer support community for Degenerative Cervical myelopathy. BD is also a founder of MoveMed Ltd. PJH holds NIHR research grants., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)
- Published
- 2023
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26. Chronic relapsing ascending myelopathy: a treatable progressive neurological syndrome following traumatic spinal cord injury.
- Author
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Visagan R, Bandi S, Robinson L, Gadhok A, Saadoun S, and Papadopoulos MC
- Subjects
- Male, Humans, Middle Aged, Aftercare, Patient Discharge, Laminectomy adverse effects, Chronic Disease, Spinal Cord diagnostic imaging, Spinal Cord surgery, Magnetic Resonance Imaging, Spinal Cord Injuries complications, Spinal Cord Injuries surgery, Syringomyelia diagnostic imaging, Syringomyelia etiology, Syringomyelia surgery
- Abstract
Background: We describe a novel progressive neurological syndrome complicating traumatic spinal cord injury (TSCI). Based on clinical and radiological features, we propose the term 'Chronic Relapsing Ascending Myelopathy' (CRAM). We distinguish between the previously described sub-acute progressive ascending myelopathy (SPAM) and post-traumatic syringomyelia (PTS), which may lie on a spectrum with CRAM., Case Report: A 60-year-old man sustained a T4 ASIA-A complete TSCI. Four months post-injury, he developed a rapidly progressive ascending sensory level to C4. Clinical and radiological evaluation revealed ascending myelopathy with progressive T2 hyper-intense cord signal change. He underwent cord detethering and expansion duroplasty. Following an initial dramatic resolution of symptoms, the patient sustained two relapses, each 1-month post-discharge characterised by recurrence of disabling ascending sensory changes, each correlating with the radiological recurrence of cord signal change. Symptoms and radiological signal change permanently resolved with more extensive detethering and expansion duroplasty. There is radiological and clinical resolution at 1-year follow-up., Conclusion: Acute neurological deterioration post-TSCI may be due to SPAM or may occur after years due to PTS. We propose CRAM as a previously unrecognised phenomenon. The radiological characteristics overlap with SPAM. However, CRAM presents later and, clinically, behaves like PTS, but without cord cystic change. Cord detethering with expansion duroplasty are an effective treatment.
- Published
- 2022
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27. Monitoring Spinal Cord Tissue Oxygen in Patients With Acute, Severe Traumatic Spinal Cord Injuries.
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Visagan R, Hogg FRA, Gallagher MJ, Kearney S, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Glucose, Humans, Oxygen, Spinal Cord, Cerebrospinal Fluid Pressure, Spinal Cord Injuries
- Abstract
Objectives: To determine the feasibility of monitoring tissue oxygen tension from the injury site (pscto2) in patients with acute, severe traumatic spinal cord injuries., Design: We inserted at the injury site a pressure probe, a microdialysis catheter, and an oxygen electrode to monitor for up to a week intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), tissue glucose, lactate/pyruvate ratio (LPR), and pscto2. We analyzed 2,213 hours of such data. Follow-up was 6-28 months postinjury., Setting: Single-center neurosurgical and neurocritical care units., Subjects: Twenty-six patients with traumatic spinal cord injuries, American spinal injury association Impairment Scale A-C. Probes were inserted within 72 hours of injury., Interventions: Insertion of subarachnoid oxygen electrode (Licox; Integra LifeSciences, Sophia-Antipolis, France), pressure probe, and microdialysis catheter., Measurements and Main Results: pscto2 was significantly influenced by ISP (pscto2 26.7 ± 0.3 mm Hg at ISP > 10 mmHg vs pscto2 22.7 ± 0.8 mm Hg at ISP ≤ 10 mm Hg), SCPP (pscto2 26.8 ± 0.3 mm Hg at SCPP < 90 mm Hg vs pscto2 32.1 ± 0.7 mm Hg at SCPP ≥ 90 mm Hg), tissue glucose (pscto2 26.8 ± 0.4 mm Hg at glucose < 6 mM vs 32.9 ± 0.5 mm Hg at glucose ≥ 6 mM), tissue LPR (pscto2 25.3 ± 0.4 mm Hg at LPR > 30 vs pscto2 31.3 ± 0.3 mm Hg at LPR ≤ 30), and fever (pscto2 28.8 ± 0.5 mm Hg at cord temperature 37-38°C vs pscto2 28.7 ± 0.8 mm Hg at cord temperature ≥ 39°C). Tissue hypoxia also occurred independent of these factors. Increasing the Fio2 by 0.48 increases pscto2 by 71.8% above baseline within 8.4 minutes. In patients with motor-incomplete injuries, fluctuations in pscto2 correlated with fluctuations in limb motor score. The injured cord spent 11% (39%) hours at pscto2 less than 5 mm Hg (< 20 mm Hg) in patients with motor-complete outcomes, compared with 1% (30%) hours at pscto2 less than 5 mm Hg (< 20 mm Hg) in patients with motor-incomplete outcomes. Complications were cerebrospinal fluid leak (5/26) and wound infection (1/26)., Conclusions: This study lays the foundation for measuring and altering spinal cord oxygen at the injury site. Future studies are required to investigate whether this is an effective new therapy., Competing Interests: Drs. Papadopoulos’s and Saadoun’s institutions received funding from the Wings for Life and the Neurosciences Research Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)
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- 2022
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28. Spinal Cord Perfusion Pressure Correlates with Anal Sphincter Function in a Cohort of Patients with Acute, Severe Traumatic Spinal Cord Injuries.
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Hogg FRA, Kearney S, Gallagher MJ, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Aged, Anal Canal, Humans, Middle Aged, Perfusion adverse effects, Young Adult, Fecal Incontinence complications, Spinal Cord Injuries
- Abstract
Background: Acute, severe traumatic spinal cord injury often causes fecal incontinence. Currently, there are no treatments to improve anal function after traumatic spinal cord injury. Our study aims to determine whether, after traumatic spinal cord injury, anal function can be improved by interventions in the neuro-intensive care unit to alter the spinal cord perfusion pressure at the injury site., Methods: We recruited a cohort of patients with acute, severe traumatic spinal cord injuries (American Spinal Injury Association Impairment Scale grades A-C). They underwent surgical fixation within 72 h of the injury and insertion of an intrathecal pressure probe at the injury site to monitor intraspinal pressure and compute spinal cord perfusion pressure as mean arterial pressure minus intraspinal pressure. Injury-site monitoring was performed at the neuro-intensive care unit for up to a week after injury. During monitoring, anorectal manometry was also conducted over a range of spinal cord perfusion pressures., Results: Data were collected from 14 patients with consecutive traumatic spinal cord injury aged 22-67 years. The mean resting anal pressure was 44 cmH
2 O, which is considerably lower than the average for healthy patients, previously reported at 99 cmH2 O. Mean resting anal pressure versus spinal cord perfusion pressure had an inverted U-shaped relation (Ȓ2 = 0.82), with the highest resting anal pressures being at a spinal cord perfusion pressure of approximately 100 mmHg. The recto-anal inhibitory reflex (transient relaxation of the internal anal sphincter during rectal distension), which is important for maintaining fecal continence, was present in 90% of attempts at high (90 mmHg) spinal cord perfusion pressure versus 70% of attempts at low (60 mmHg) spinal cord perfusion pressure (P < 0.05). During cough, the rise in anal pressure from baseline was 51 cmH2 O at high (86 mmHg) spinal cord perfusion pressure versus 37 cmH2 O at low (62 mmHg) spinal cord perfusion pressure (P < 0.0001). During anal squeeze, higher spinal cord perfusion pressure was associated with longer endurance time and spinal cord perfusion pressure of 70-90 mmHg was associated with stronger squeeze. There were no complications associated with anorectal manometry., Conclusions: Our data indicate that spinal cord injury causes severe disruption of anal sphincter function. Several key components of anal continence (resting anal pressure, recto-anal inhibitory reflex, and anal pressure during cough and squeeze) markedly improve at higher spinal cord perfusion pressure. Maintaining too high of spinal cord perfusion pressure may worsen anal continence., (© 2021. The Author(s).)- Published
- 2021
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29. Acute, severe traumatic spinal cord injury: improving urinary bladder function by optimizing spinal cord perfusion.
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Hogg FRA, Kearney S, Solomon E, Gallagher MJ, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Aged, Blood Pressure physiology, Cohort Studies, Female, Humans, Male, Middle Aged, Predictive Value of Tests, Risk Factors, Urinary Bladder, Neurogenic physiopathology, Urinary Bladder, Neurogenic prevention & control, Young Adult, Regional Blood Flow physiology, Spinal Cord blood supply, Spinal Cord Injuries complications, Spinal Cord Injuries physiopathology, Urinary Bladder, Neurogenic etiology, Urodynamics physiology
- Abstract
Objective: The authors sought to investigate the effect of acute, severe traumatic spinal cord injury on the urinary bladder and the hypothesis that increasing the spinal cord perfusion pressure improves bladder function., Methods: In 13 adults with traumatic spinal cord injury (American Spinal Injury Association Impairment Scale grades A-C), a pressure probe and a microdialysis catheter were placed intradurally at the injury site. We varied the spinal cord perfusion pressure and performed filling cystometry. Patients were followed up for 12 months on average., Results: The 13 patients had 63 fill cycles; 38 cycles had unfavorable urodynamics, i.e., dangerously low compliance (< 20 mL/cmH2O), detrusor overactivity, or dangerously high end-fill pressure (> 40 cmH2O). Unfavorable urodynamics correlated with periods of injury site hypoperfusion (spinal cord perfusion pressure < 60 mm Hg), hyperperfusion (spinal cord perfusion pressure > 100 mm Hg), tissue glucose < 3 mM, and tissue lactate to pyruvate ratio > 30. Increasing spinal cord perfusion pressure from 67.0 ± 2.3 mm Hg (average ± SE) to 92.1 ± 3.0 mm Hg significantly reduced, from 534 to 365 mL, the median bladder volume at which the desire to void was first experienced. All patients with dangerously low average initial bladder compliance (< 20 mL/cmH2O) maintained low compliance at follow-up, whereas all patients with high average initial bladder compliance (> 100 mL/cmH2O) maintained high compliance at follow-up., Conclusions: We conclude that unfavorable urodynamics develop within days of traumatic spinal cord injury, thus challenging the prevailing notion that the detrusor is initially acontractile. Urodynamic studies performed acutely identify patients with dangerously low bladder compliance likely to benefit from early intervention. At this early stage, bladder function is dynamic and is influenced by fluctuations in the physiology and metabolism at the injury site; therefore, optimizing spinal cord perfusion is likely to improve urological outcome in patients with acute severe traumatic spinal cord injury.
- Published
- 2021
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30. Letter to the Editor. The INSPIRE studies for spinal cord injury.
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Papadopoulos MC and Saadoun S
- Published
- 2021
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31. Acute, Severe Traumatic Spinal Cord Injury: Monitoring from the Injury Site and Expansion Duraplasty.
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Saadoun S and Papadopoulos MC
- Subjects
- Dura Mater surgery, Humans, Spinal Cord, Plastic Surgery Procedures, Spinal Cord Injuries surgery
- Abstract
We discuss 2 evolving management options for acute spinal cord injury that hold promise to further improve outcome: pressure monitoring from the injured cord and expansion duraplasty. Probes surgically implanted at the injury site can transduce intraspinal pressure, spinal cord perfusion pressure, and cord metabolism. Intraspinal pressure is not adequately reduced by bony decompression alone because the swollen, injured cord is compressed against the dura. Expansion duraplasty may be necessary to effectively decompress the injured cord. A randomized controlled trial called DISCUS is investigating expansion duraplasty as a novel treatment for acute, severe traumatic cervical spinal cord injury., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)
- Published
- 2021
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32. Acute Spinal Cord Injury: Correlations and Causal Relations Between Intraspinal Pressure, Spinal Cord Perfusion Pressure, Lactate-to-Pyruvate Ratio, and Limb Power.
- Author
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Hogg FRA, Kearney S, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Humans, Lactates, Perfusion, Pyruvates, Spinal Cord, Spinal Cord Injuries
- Abstract
Background/objective: We have recently developed monitoring from the injury site in patients with acute, severe traumatic spinal cord injuries to facilitate their management in the intensive care unit. This is analogous to monitoring from the brain in patients with traumatic brain injuries. This study aims to determine whether, after traumatic spinal cord injury, fluctuations in the monitored physiological, and metabolic parameters at the injury site are causally linked to changes in limb power., Methods: This is an observational study of a cohort of adult patients with motor-incomplete spinal cord injuries, i.e., grade C American spinal injuries association Impairment Scale. A pressure probe and a microdialysis catheter were placed intradurally at the injury site. For up to a week after surgery, we monitored limb power, intraspinal pressure, spinal cord perfusion pressure, and tissue lactate-to-pyruvate ratio. We established correlations between these variables and performed Granger causality analysis., Results: Nineteen patients, aged 22-70 years, were recruited. Motor score versus intraspinal pressure had exponential decay relation (intraspinal pressure rise to 20 mmHg was associated with drop of 11 motor points, but little drop in motor points as intraspinal pressure rose further, R
2 = 0.98). Motor score versus spinal cord perfusion pressure (up to 110 mmHg) had linear relation (1.4 motor point rise/10 mmHg rise in spinal cord perfusion pressure, R2 = 0.96). Motor score versus lactate-to-pyruvate ratio (greater than 20) also had linear relation (0.8 motor score drop/10-point rise in lactate-to-pyruvate ratio, R2 = 0.92). Increased intraspinal pressure Granger-caused increase in lactate-to-pyruvate ratio, decrease in spinal cord perfusion, and decrease in motor score. Increased spinal cord perfusion Granger-caused decrease in lactate-to-pyruvate ratio and increase in motor score. Increased lactate-to-pyruvate ratio Granger-caused increase in intraspinal pressure, decrease in spinal cord perfusion, and decrease in motor score. Causality analysis also revealed multiple vicious cycles that amplify insults to the cord thus exacerbating cord damage., Conclusion: Monitoring intraspinal pressure, spinal cord perfusion pressure, lactate-to-pyruvate ratio, and intervening to normalize these parameters are likely to improve limb power.- Published
- 2021
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33. Contralateral lumbosacral plexopathy following lumbar microdiscectomy.
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Tulloch I, Ali R, and Papadopoulos MC
- Subjects
- Brachial Plexus Neuropathies diagnosis, Brachial Plexus Neuropathies etiology, Female, Humans, Middle Aged, Spine surgery
- Abstract
We describe the unique case of a 51-year-old lady who developed a contralateral lumbosacral plexopathy two days after a lumbar microdiscectomy. This is the first report to date of this complication occurring following this procedure. We review the literature regarding lumbosacral plexopathy and discuss the evidence base behind investigating and managing this condition and the potential pathophysiological mechanisms which underlie its development. We draw comparisons with the more widely recognised post-operative brachial neuritis, characterised by delayed onset brachial plexopathy developing after cervical decompression, and propose an immune-mediated inflammatory mechanism linking the two conditions.
- Published
- 2020
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34. Effects of local hypothermia-rewarming on physiology, metabolism and inflammation of acutely injured human spinal cord.
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Gallagher MJ, Hogg FRA, Kearney S, Kopp MA, Blex C, Serdani L, Sherwood O, Schwab JM, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adolescent, Adult, Aged, Cerebrospinal Fluid Pressure, Female, Humans, Inflammation etiology, Inflammation pathology, Male, Middle Aged, Monitoring, Physiologic, Prospective Studies, Young Adult, Cytokines metabolism, Hypothermia, Induced methods, Inflammation therapy, Rewarming methods, Spinal Cord Injuries complications
- Abstract
In five patients with acute, severe thoracic traumatic spinal cord injuries (TSCIs), American spinal injuries association Impairment Scale (AIS) grades A-C, we induced cord hypothermia (33 °C) then rewarming (37 °C). A pressure probe and a microdialysis catheter were placed intradurally at the injury site to monitor intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), tissue metabolism and inflammation. Cord hypothermia-rewarming, applied to awake patients, did not cause discomfort or neurological deterioration. Cooling did not affect cord physiology (ISP, SCPP), but markedly altered cord metabolism (increased glucose, lactate, lactate/pyruvate ratio (LPR), glutamate; decreased glycerol) and markedly reduced cord inflammation (reduced IL1β, IL8, MCP, MIP1α, MIP1β). Compared with pre-cooling baseline, rewarming was associated with significantly worse cord physiology (increased ICP, decreased SCPP), cord metabolism (increased lactate, LPR; decreased glucose, glycerol) and cord inflammation (increased IL1β, IL8, IL4, IL10, MCP, MIP1α). The study was terminated because three patients developed delayed wound infections. At 18-months, two patients improved and three stayed the same. We conclude that, after TSCI, hypothermia is potentially beneficial by reducing cord inflammation, though after rewarming these benefits are lost due to increases in cord swelling, ischemia and inflammation. We thus urge caution when using hypothermia-rewarming therapeutically in TSCI.
- Published
- 2020
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35. Acute Spinal Cord Injury: Monitoring Lumbar Cerebrospinal Fluid Provides Limited Information about the Injury Site.
- Author
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Hogg FRA, Gallagher MJ, Kearney S, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Aged, Female, Humans, Male, Middle Aged, Spinal Cord Injuries therapy, Cerebrospinal Fluid Pressure physiology, Drainage methods, Monitoring, Physiologic methods, Spinal Cord Injuries cerebrospinal fluid, Spinal Cord Injuries diagnostic imaging, Spinal Puncture methods
- Abstract
In some centers, monitoring lumbar cerebrospinal fluid (CSF) is used to guide management of patients with acute traumatic spinal cord injuries (TSCI) and draining lumbar CSF to improve spinal cord perfusion. Here, we investigate whether the lumbar CSF provides accurate information about the injury site and the effect of draining lumbar CSF on injury site perfusion. In 13 TSCI patients, we simultaneously monitored lumbar CSF pressure (CSFP) and intraspinal pressure (ISP) from the injury site. Using CSFP or ISP, we computed spinal cord perfusion pressure (SCPP), vascular pressure reactivity index (sPRx) and optimum SCPP (SCPP
opt ). We also assessed the effect on ISP of draining 10 mL CSF. Metabolites at the injury site were compared with metabolites in the lumbar CSF. We found that ISP was pulsatile, but CSFP had low pulse pressure and was non-pulsatile 21% of the time. There was weak or no correlation between CSFP versus ISP ( R = -0.11), SCPP(csf) versus SCPP(ISP) ( R = 0.39), and sPRx(csf) versus sPRx(ISP) ( R = 0.45). CSF drainage caused no significant change in ISP in 7/12 patients and a significant drop of <5 mm Hg in 4/12 patients and of ∼8 mm Hg in 1/12 patients. Metabolite concentrations in the CSF versus the injury site did not correlate for lactate ( R = 0.00), pyruvate ( R = -0.12) or lactate-to-pyruvate ratio ( R = -0.05) with weak correlations noted for glucose ( R = 0.31), glutamate ( R = 0.61), and glycerol ( R = 0.56). We conclude that, after a severe TSCI, monitoring from the lumbar CSF provides only limited information about the injury site and that lumbar CSF drainage does not effectively reduce ISP in most patients.- Published
- 2020
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36. Heterogeneous effect of increasing spinal cord perfusion pressure on sensory evoked potentials recorded from acutely injured human spinal cord.
- Author
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Gallagher MJ, López DM, Sheen HV, Hogg FRA, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Blood Pressure, Catheterization, Electric Stimulation Therapy, Electrophysiology, Female, Humans, Lactic Acid blood, Magnetic Resonance Imaging, Male, Microdialysis, Middle Aged, Monitoring, Physiologic, Perfusion, Pressure, Pyruvic Acid blood, Tibial Nerve, Tomography, X-Ray Computed, Young Adult, Cerebrospinal Fluid Pressure, Evoked Potentials, Somatosensory, Spinal Cord physiopathology, Spinal Cord Injuries diagnosis, Spinal Cord Injuries physiopathology
- Abstract
Purpose: To investigate the effect of increasing spinal cord perfusion pressure (SCPP) on sensory evoked potentials (SEPs) and injury site metabolism in patients with severe traumatic spinal cord injury TSCI., Materials and Methods: In 12 TSCI patients we placed a pressure probe, a microdialysis catheter and a strip electrode with 8 contacts on the surface of the injured cord. We monitored SCPP, lactate-to-pyruvate ratio (LPR) and SEPs (after median or posterior tibial nerve stimulation)., Results: Increase in SCPP by ~20 mmHg produced a heterogeneous response in SEPs and injury site metabolism. In some patients, SEP amplitudes increased and the LPR decreased indicating improved tissue metab olism. In others, SEP amplitudes decreased and the LPR increased indicating more impaired metabolism. Compared with patients who did not improve at follow-up, those who improved had significantly more electrode contacts with SEP amplitude increase in response to increasing SCPP., Conclusions: Increasing SCPP after acute, severe TSCI may be beneficial (if associated with increase in SEP amplitude) or detrimental (if associated with decrease in SEP amplitude). Our findings support individualized management of patients with acute, severe TSCI guided by monitoring from the injury site rather than applying universal blood pressure targets as is current clinical practice., Competing Interests: Declaration of Competing Interest There are no conflicts of interest., (Copyright © 2019 Elsevier Inc. All rights reserved.)
- Published
- 2020
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37. Targeted Perfusion Therapy in Spinal Cord Trauma.
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Saadoun S and Papadopoulos MC
- Subjects
- Humans, Perfusion methods, Cerebrospinal Fluid Pressure physiology, Spinal Cord Injuries physiopathology, Spinal Cord Injuries therapy
- Abstract
We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets. Key concepts are discussed such as intraspinal pressure and spinal cord perfusion pressure (SCPP) at the injury site, respectively, analogous to intracranial pressure and cerebral perfusion pressure for traumatic brain injury. The concept of spinal cord autoregulation is introduced and quantified using spinal pressure reactivity index (sPRx), which is analogous to pressure reactivity index for traumatic brain injury. The U-shaped relationship between sPRx and SCPP defines the optimum SCPP as the SCPP that minimizes sPRx (i.e., maximizes autoregulation), and suggests that not only ischemia but also hyperemia at the injury site may be detrimental. The observation that optimum SCPP varies between patients and temporally in each patient supports individualized management. We discuss multimodality monitoring, which revealed strong correlations between SCPP and injury site metabolism (tissue glucose, lactate, pyruvate, glutamate, glycerol), monitored by surface microdialysis. Evidence is presented that the dura is a major, but unappreciated, cause of spinal cord compression after TSCI; we thus propose expansion duroplasty as a novel treatment. Monitoring spinal cord blood flow at the injury site has revealed novel phenomena, e.g., 3 distinct blood flow patterns, local steal, and diastolic ischemia. We conclude that monitoring from the injured spinal cord in the intensive care unit is a safe technique that appears to enable optimized and individualized spinal cord perfusion.
- Published
- 2020
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38. Predictors of Intraspinal Pressure and Optimal Cord Perfusion Pressure After Traumatic Spinal Cord Injury.
- Author
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Hogg FRA, Gallagher MJ, Chen S, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Aged, Female, Humans, Male, Middle Aged, Spinal Cord Injuries surgery, Young Adult, Blood Circulation physiology, Cerebrospinal Fluid Pressure physiology, Neurophysiological Monitoring methods, Spinal Cord blood supply, Spinal Cord Injuries diagnosis, Spinal Cord Injuries physiopathology
- Abstract
Background/objectives: We recently developed techniques to monitor intraspinal pressure (ISP) and spinal cord perfusion pressure (SCPP) from the injury site to compute the optimum SCPP (SCPP
opt ) in patients with acute traumatic spinal cord injury (TSCI). We hypothesized that ISP and SCPPopt can be predicted using clinical factors instead of ISP monitoring., Methods: Sixty-four TSCI patients, grades A-C (American spinal injuries association Impairment Scale, AIS), were analyzed. For 24 h after surgery, we monitored ISP and SCPP and computed SCPPopt (SCPP that optimizes pressure reactivity). We studied how well 28 factors correlate with mean ISP or SCPPopt including 7 patient-related, 3 injury-related, 6 management-related, and 12 preoperative MRI-related factors., Results: All patients underwent surgery to restore normal spinal alignment within 72 h of injury. Fifty-one percentage had U-shaped sPRx versus SCPP curves, thus allowing SCPPopt to be computed. Thirteen percentage, all AIS grade A or B, had no U-shaped sPRx versus SCPP curves. Thirty-six percentage (22/64) had U-shaped sPRx versus SCPP curves, but the SCPP did not reach the minimum of the curve, and thus, an exact SCPPopt could not be calculated. In total 5/28 factors were associated with lower ISP: older age, excess alcohol consumption, nonconus medullaris injury, expansion duroplasty, and less intraoperative bleeding. In a multivariate logistic regression model, these 5 factors predicted ISP as normal or high with 73% accuracy. Only 2/28 factors correlated with lower SCPPopt : higher mean ISP and conus medullaris injury. In an ordinal multivariate logistic regression model, these 2 factors predicted SCPPopt as low, medium-low, medium-high, or high with only 42% accuracy. No MRI factors correlated with ISP or SCPPopt ., Conclusions: Elevated ISP can be predicted by clinical factors. Modifiable factors that may lower ISP are: reducing surgical bleeding and performing expansion duroplasty. No factors accurately predict SCPPopt ; thus, invasive monitoring remains the only way to estimate SCPPopt .- Published
- 2019
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39. Spinal Cord Blood Flow in Patients with Acute Spinal Cord Injuries.
- Author
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Gallagher MJ, Hogg FRA, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Female, Humans, Male, Middle Aged, Neuroimaging methods, Norepinephrine pharmacology, Regional Blood Flow drug effects, Regional Blood Flow physiology, Spinal Cord pathology, Spinal Cord physiopathology, Spinal Cord Injuries metabolism, Spinal Cord Injuries pathology, Vasoconstrictor Agents pharmacology, Blood Pressure drug effects, Spinal Cord blood supply, Spinal Cord Injuries physiopathology
- Abstract
The effect of traumatic spinal cord injury (TSCI) on spinal cord blood flow (SCBF) in humans is unknown. Whether intervention to achieve the recommended mean arterial pressure (MAP) guideline of 85-90 mm Hg improves SCBF is also unclear. Here, we use laser speckle contrast imaging intraoperatively to visualize blood flow at the injury site in 22 patients with acute, severe spinal cord injuries (American Spinal Injuries Association Impairment Scale, grades A-C). In 17 of 22 patients, injury-site metabolism was also monitored with a microdialysis catheter placed intradurally on the surface of the injured cord. We observed three different SCBF patterns, characterized by distinct injury-site metabolic signatures, which we term necrosis-penumbra, hyperperfusion, and patchy-perfusion. The necrosis-penumbra pattern, only observed in thoracic injuries, had a core of low blood flow (necrosis) with regions of intermediate blood flow on either side (penumbra). The hyperperfusion pattern, only observed in cervical injuries, had very high blood flow throughout the injury site. The patchy-perfusion pattern, found in cervical and thoracic injuries, had irregular regions of low, intermediate, and high blood flow. Though intervention to increase MAP by 20 mm Hg increased overall blood flow at the injury site, in 5 of 22 patients, blood flow increased in some regions, but, surprisingly, decreased in other regions. We term this phenomenon blood pressure-induced local steal. In 7 of 19 patients with MAP 85-90 mm Hg, parts of the injury site were only perfused in systole, but not in diastole, which we term diastolic ischemia. We conclude that acute, severe TSCI produces three pathological blood flow patterns at the injury site. Intervention to increase blood pressure may elicit potentially detrimental SCBF responses in some patients.
- Published
- 2019
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40. Visibility Graph Analysis of Intraspinal Pressure Signal Predicts Functional Outcome in Spinal Cord Injured Patients.
- Author
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Chen S, Gallagher MJ, Hogg F, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Female, Humans, Male, Middle Aged, Cerebrospinal Fluid Pressure physiology, Monitoring, Physiologic methods, Recovery of Function physiology, Spinal Cord Injuries physiopathology
- Abstract
To guide management of patients with acute spinal cord injuries, we developed intraspinal pressure monitoring from the injury site. Here, we examine the complex fluctuations in the intraspinal pressure signal using network theory. We analyzed 7097 h of intraspinal pressure data from 58 patients with severe cord injuries. Intraspinal pressure signals were split into hourly windows. Each window was mapped into a visibility graph as follows. Vertical bars were drawn at 0.1 Hz representing signal amplitudes. Each bar produced a node, thus totalling 360 nodes per graph. Two nodes were linked with an edge if the straight line through the nodes did not intersect a bar. We computed several topological metrics for each graph including diameter, modularity, eccentricity, and small-worldness. Patients were followed up for 20 months on average. Our data show that the topological structure of intraspinal pressure visibility graphs is highly sensitive to pathological events at the injury site, including cord compression (high intraspinal pressure), ischemia (low spinal cord perfusion pressure), and deranged autoregulation (high spinal pressure reactivity index). These pathological changes correlate with long graph diameter, high modularity, high eccentricity and reduced small-worldness. In a multivariate logistic regression model, age, neurological status on admission, and average node eccentricity were independent predictors of neurological improvement. We conclude that analysis of intraspinal pressure fluctuations after spinal cord injury as graphs, rather than as time series, captures clinically important information. Our novel technique may be applied to other signals recorded from injured central nervous system (CNS); for example, intracranial pressure, tissue metabolite, and oxygen levels.
- Published
- 2018
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41. Markedly Deranged Injury Site Metabolism and Impaired Functional Recovery in Acute Spinal Cord Injury Patients With Fever.
- Author
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Gallagher MJ, Zoumprouli A, Phang I, Schwab JM, Kopp MA, Liebscher T, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Body Temperature, Fever metabolism, Glucose metabolism, Humans, Intensive Care Units, Longitudinal Studies, Male, Microdialysis, Spinal Cord metabolism, Spinal Cord Injuries complications, Fever complications, Recovery of Function, Spinal Cord Injuries metabolism
- Abstract
Objectives: To characterize the effect of fever after acute, traumatic spinal cord injury on injury site metabolism and patient outcome., Design: Longitudinal cohort study. In 44 patients (London cohort), we determined the effect of fever on intrathecal injury site metabolism by analyzing 1,767 hours of intraspinal pressure and 759 hours of microdialysis data. We also determined the effect of fever burden, computed for the first 2 weeks in hospital, on neurologic outcome. A distinct cohort of 33 patients (Berlin cohort) was used to independently validate the effect of fever burden on outcome., Setting: ICUs in London and Berlin., Patients: Seventy-seven patients with acute, traumatic spinal cord injuries., Interventions: In the London patients, a pressure probe and a microdialysis catheter were placed intradurally on the surface of the injured cord for up to a week., Measurements and Main Results: Fever (> 37.5°C) occurs frequently (37% of the time) after spinal cord injury. High-grade fever (≥ 38°C) was associated with significantly more deranged metabolite levels than normothermia (36.5-37.5°C), that is, lower tissue glucose (median 2.0 vs 3.3 mM), higher lactate (7.8 vs 5.4 mM), higher glutamate (7.8 vs 6.4 µM), and higher lactate-to-pyruvate ratio (38.9 vs 29.3). High-grade fever was particularly detrimental on injury site metabolism when the peripheral leukocyte count was high. In the London and Berlin cohorts, high fever burden correlated with less neurologic improvement., Conclusions: Early after spinal cord injury, fever is associated with more deranged injury site metabolism than normothermia and worse prognosis.
- Published
- 2018
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42. Non-linear Dynamical Analysis of Intraspinal Pressure Signal Predicts Outcome After Spinal Cord Injury.
- Author
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Chen S, Gallagher MJ, Papadopoulos MC, and Saadoun S
- Abstract
The injured spinal cord is a complex system influenced by many local and systemic factors that interact over many timescales. To help guide clinical management, we developed a technique that monitors intraspinal pressure from the injury site in patients with acute, severe traumatic spinal cord injuries. Here, we hypothesize that spinal cord injury alters the complex dynamics of the intraspinal pressure signal quantified by computing hourly the detrended fluctuation exponent alpha, multiscale entropy, and maximal Lyapunov exponent lambda. 49 patients with severe traumatic spinal cord injuries were monitored within 72 h of injury for 5 days on average to produce 5,941 h of intraspinal pressure data. We computed the spinal cord perfusion pressure as mean arterial pressure minus intraspinal pressure and the vascular pressure reactivity index as the running correlation coefficient between intraspinal pressure and arterial blood pressure. Mean patient follow-up was 17 months. We show that alpha values are greater than 0.5, which indicates that the intraspinal pressure signal is fractal. As alpha increases, intraspinal pressure decreases and spinal cord perfusion pressure increases with negative correlation between the vascular pressure reactivity index vs. alpha. Thus, secondary insults to the injured cord disrupt intraspinal pressure fractality. Our analysis shows that high intraspinal pressure, low spinal cord perfusion pressure, and impaired pressure reactivity strongly correlate with reduced multi-scale entropy, supporting the notion that secondary insults to the injured cord cause de-complexification of the intraspinal pressure signal, which may render the cord less adaptable to external changes. Healthy physiological systems are characterized by edge of chaos dynamics. We found negative correlations between the percentage of hours with edge of chaos dynamics (-0.01 ≤ lambda ≤ 0.01) vs. high intraspinal pressure and vs. low spinal cord perfusion pressure; these findings suggest that secondary insults render the intraspinal pressure more regular or chaotic. In a multivariate logistic regression model, better neurological status on admission, higher intraspinal pressure multi-scale entropy and more frequent edge of chaos intraspinal pressure dynamics predict long-term functional improvement. We conclude that spinal cord injury is associated with marked changes in non-linear intraspinal pressure metrics that carry prognostic information.
- Published
- 2018
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- View/download PDF
43. An unusual cause of sciatica.
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Tulloch I and Papadopoulos MC
- Published
- 2018
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44. Continuous Monitoring and Visualization of Optimum Spinal Cord Perfusion Pressure in Patients with Acute Cord Injury.
- Author
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Chen S, Smielewski P, Czosnyka M, Papadopoulos MC, and Saadoun S
- Subjects
- Adolescent, Adult, Aged, Child, Female, Humans, Male, Middle Aged, Young Adult, Neurophysiological Monitoring methods, Spinal Cord Injuries physiopathology
- Abstract
The optimum spinal cord perfusion pressure (SCPP) after traumatic spinal cord injury (TSCI) is unknown. Here, we describe techniques to compute and display the optimum SCPP in real time. We recruited adults within 72 h of severe TSCI (American Spinal Injuries Association [ASIA] grades A-C). A pressure probe and a microdialysis catheter were placed on the injured cord. SCPP was computed as mean arterial pressure (MAP) minus intraspinal pressure (ISP), spinal pressure reactivity index (sPRx) as the running ISP/MAP correlation coefficient, and continuous optimum SCPP (cSCPP
opt ) as the SCPP that minimizes sPRx in a moving 4-h window. In 45 patients, we monitored ISP and blood pressure. In 14 patients, we also monitored injury site metabolism. cSCPPopt could be computed 45% of the time. Mean cSCPPopt varied by up to 60 mm Hg between patients. Each patient's cSCPPopt varied with time (standard deviation 10-20 mm Hg). Color-coded maps showing the sPRx/SCPP curve evolution enhanced visualization of cSCPPopt . Periods when SCPP ≈ cSCPPopt were associated with low injury site glucose, high pyruvate, and high lactate. Mean SCPP deviation from cSCPPopt correlated with worse neurological outcome at 9-12 months: ASIA grade improved in 30% of patients with <5 mm Hg deviation, 10% of patients with 5-15 mm Hg deviation, and no one with >15 mm Hg deviation. We conclude that real-time computation and visualization of cSCPPopt after TSCI are feasible. cSCPPopt appears to enhance glucose utilization at the injury site and varies widely between and within patients. Our data suggest that targeting cSCPPopt after TSCI might improve neurological outcome.- Published
- 2017
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45. Intraspinal pressure and spinal cord perfusion pressure predict neurological outcome after traumatic spinal cord injury.
- Author
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Saadoun S, Chen S, and Papadopoulos MC
- Subjects
- Adult, Aged, Blood Pressure physiology, Cohort Studies, Disease Management, Humans, Middle Aged, Monitoring, Physiologic, Multivariate Analysis, Prognosis, Recovery of Function, Spinal Cord Injuries complications, Spinal Injuries complications, United Kingdom, Young Adult, Arterial Pressure physiology, Pressure, Regional Blood Flow physiology, Spinal Cord blood supply, Spinal Cord Injuries physiopathology, Spinal Injuries surgery
- Abstract
Competing Interests: Competing interests: None declared.
- Published
- 2017
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46. Surgical Neurostimulation for Spinal Cord Injury.
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Chari A, Hentall ID, Papadopoulos MC, and Pereira EA
- Abstract
Traumatic spinal cord injury (SCI) is a devastating neurological condition characterized by a constellation of symptoms including paralysis, paraesthesia, pain, cardiovascular, bladder, bowel and sexual dysfunction. Current treatment for SCI involves acute resuscitation, aggressive rehabilitation and symptomatic treatment for complications. Despite the progress in scientific understanding, regenerative therapies are lacking. In this review, we outline the current state and future potential of invasive and non-invasive neuromodulation strategies including deep brain stimulation (DBS), spinal cord stimulation (SCS), motor cortex stimulation (MCS), transcutaneous direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in the context of SCI. We consider the ability of these therapies to address pain, sensorimotor symptoms and autonomic dysregulation associated with SCI. In addition to the potential to make important contributions to SCI treatment, neuromodulation has the added ability to contribute to our understanding of spinal cord neurobiology and the pathophysiology of SCI.
- Published
- 2017
- Full Text
- View/download PDF
47. Metabolic profile of injured human spinal cord determined using surface microdialysis.
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Chen S, Phang I, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Aged, Cervical Vertebrae, Female, Follow-Up Studies, Humans, Intensive Care Units, Lumbar Vertebrae, Male, Middle Aged, Thoracic Vertebrae, Young Adult, Metabolome physiology, Microdialysis methods, Spinal Cord Injuries diagnosis, Spinal Cord Injuries metabolism
- Abstract
The management of patients having traumatic spinal cord injury would benefit from understanding and monitoring of spinal cord metabolic states. We hypothesized that the metabolism of the injured spinal cord could be visualized using Kohonen self-organizing maps. Sixteen patients with acute, severe spinal cord injuries were studied. Starting within 72 h of the injury, and for up to a week, we monitored the injury site hourly for tissue glucose, lactate, pyruvate, glutamate, and glycerol using microdialysis as well as intraspinal pressure and spinal cord perfusion pressure. A Kohonen map, which is an unsupervised, self-organizing topology-preserving neural network, was used to analyze 3366 h of monitoring data. We first visualized the different spinal cord metabolic states. Our data show that the injured cord assumes one or more of four metabolic states. On the basis of their metabolite profiles, we termed these states near-normal, ischemic, hypermetabolic, and distal. We then visualized how patients' intraspinal pressure and spinal cord perfusion pressure affect spinal cord metabolism. This revealed that for more than 60% of the time, spinal cord metabolism is patient-specific; periods of high intraspinal pressure or low perfusion pressure are not associated with specific spinal cord metabolic patterns. Finally, we determined relationships between spinal cord metabolism and neurological status. Patients with complete deficits have shorter periods of near-normal spinal cord metabolic states (7 ± 4% vs. 58 ± 12%, p < 0.01, mean ± standard error) and more variable injury site metabolic responses (metabolism spread in 70 ± 11 vs. 40 ± 6 hexagons, p < 0.05), compared with patients who have incomplete neurological deficits. We conclude that Kohonen maps allow us to visualize the metabolic responses of the injured spinal cord and may thus aid us in treating patients with acute spinal cord injuries., (© 2016 International Society for Neurochemistry.)
- Published
- 2016
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48. Spinal cord injury: is monitoring from the injury site the future?
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Saadoun S and Papadopoulos MC
- Subjects
- Animals, Blood Pressure physiology, Dura Mater physiopathology, Humans, Intensive Care Units organization & administration, Intensive Care Units standards, Magnetic Resonance Imaging, Methylprednisolone pharmacology, Methylprednisolone therapeutic use, Mice, Monitoring, Physiologic methods, Patient-Centered Care methods, Spinal Cord Injuries surgery, Steroids pharmacology, Steroids therapeutic use, Swine, Wounds and Injuries therapy, Arterial Pressure physiology, Perfusion methods, Spinal Cord Injuries therapy
- Abstract
This paper challenges the current management of acute traumatic spinal cord injury based on our experience with monitoring from the injury site in the neurointensive care unit. We argue that the concept of bony decompression is inadequate. The concept of optimum spinal cord perfusion pressure, which differs between patients, is introduced. Such variability suggests individualized patient treatment. Failing to optimize spinal cord perfusion limits the entry of systemically administered drugs into the injured cord. We conclude that monitoring from the injury site helps optimize management and should be subjected to a trial to determine whether it improves outcome.
- Published
- 2016
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- View/download PDF
49. The dura causes spinal cord compression after spinal cord injury.
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Saadoun S, Werndle MC, Lopez de Heredia L, and Papadopoulos MC
- Subjects
- Adolescent, Adult, Aged, Decompression, Surgical, Dura Mater diagnostic imaging, Female, Humans, Magnetic Resonance Imaging, Male, Middle Aged, Neck Pain diagnostic imaging, Neck Pain etiology, Nervous System Diseases etiology, Spinal Cord Compression diagnostic imaging, Spinal Cord Compression etiology, Spinal Cord Injuries complications, Spinal Cord Injuries diagnostic imaging, Young Adult, Dura Mater pathology, Spinal Cord Compression pathology, Spinal Cord Injuries pathology
- Abstract
MR scans from 65 patients with traumatic spinal cord injury were analysed; on admission 95% had evidence of cord compression - in 26% due to the dura, and in the remaining 74% due to extradural factors. Compression due to dural factors resolved with a half-life of 8.7 days. These findings suggest that bony decompression alone may not relieve spinal cord compression in the quarter of patients in whom dural factors are significant.
- Published
- 2016
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- View/download PDF
50. Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury.
- Author
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Phang I, Zoumprouli A, Papadopoulos MC, and Saadoun S
- Subjects
- Adult, Aged, Anti-Inflammatory Agents administration & dosage, Dexamethasone administration & dosage, Female, Humans, Male, Middle Aged, Young Adult, Anti-Inflammatory Agents pharmacokinetics, Blood Pressure physiology, Dexamethasone pharmacokinetics, Glucose metabolism, Microdialysis methods, Monitoring, Physiologic methods, Practice Guidelines as Topic, Spinal Cord Injuries drug therapy, Spinal Cord Injuries metabolism, Spinal Cord Injuries physiopathology
- Abstract
Objective: There is lack of monitoring from the injury site to guide management of patients with acute traumatic spinal cord injury. Here, we describe a bedside microdialysis monitoring technique for optimizing spinal cord perfusion and drug delivery at the injury site., Methods: Fourteen patients were recruited within 72 hours of severe spinal cord injury. We inserted intradurally at the injury site a pressure probe, to monitor continuously spinal cord perfusion pressure, and a microdialysis catheter, to monitor hourly glycerol, glutamate, glucose, lactate, and pyruvate. The pressure probe and microdialysis catheter were placed on the surface of the injured cord., Results: Microdialysis monitoring did not cause serious complications. Spinal cord perfusion pressure 90 to 100mm Hg and tissue glucose >4.5mM minimized metabolic derangement at the injury site. Increasing spinal cord perfusion pressure by ∼10mm Hg increased the entry of intravenously administered dexamethasone at the injury site 3-fold., Interpretation: This study determined the optimum spinal cord perfusion pressure and optimum tissue glucose concentration at the injury site. We also identified spinal cord perfusion pressure as a key determinant of drug entry into the injured spinal cord. Our findings challenge current guidelines, which recommend maintaining mean arterial pressure at 85 to 90mm Hg for a week after spinal cord injury. We propose that future drug trials for spinal cord injury include pressure and microdialysis monitoring to optimize spinal cord perfusion and maximize drug delivery at the injury site. Ann Neurol 2016;80:522-531., (© 2016 American Neurological Association.)
- Published
- 2016
- Full Text
- View/download PDF
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