Lesión medular traumática en Galicia(1995-2014): estudio de la evolución epidemiológica y resultados clínico-funcionales

Programa Oficial de Doutoramento en Ciencias da Saúde. 5007V01[Resumen] Introducción La incidencia mundial de la lesión medular traumática (LMT) es muy variable. Recientes estudios señalan que estamos asistiendo a un cambio epidemiológico de la LMT. Este cambio puede originar una serie de consecuencias en el modelo de atención. Conocer las características epidemiológicas y demográficas de la LMT es vital para planificar las prioridades, asignar los recursos sanitarios adecuados y también, para identificar las directrices de la prevención. Objetivo Determinar las características epidemiológicas de los pacientes con LMT en Galicia durante el periodo 1995-2014 y analizar la afectación neurológica y los factores determinantes de la evolución clínica y funcional en dicho periodo. Material y método Se realizó un estudio observacional con seguimiento retrospectivo y prospectivo de los pacientes con lesión medular de etiología traumática que ingresaron en la Unidad de Lesionados Medulares (ULM) del Complejo Hospitalario Universitario de A Coruña en el período comprendido entre enero de 1995 y diciembre del 2014. Se estudiaron variables socio-demográficas, comorbilidad según el índice de Charlson, etiología, variables de la exploración neurológica según la clasificación ASIA/ISCOS de la lesión medular, tipo de lesión ósea, lesiones asociadas, manejo terapéutico, ingreso en UCI, funcionalidad según la escala Spinal Cord Independence Measure III (SCIM III), capacidad de marcha y escala de marcha de la LM Walking Index Spinal Cord Injury II (WISCI II), destino y tratamiento rehabilitador al alta hospitalaria, y mortalidad. El análisis estadístico se realizó mediante el programa SPSS 19.0. Se efectuó un estudio descriptivo de las variables, expresando las variables cuantitativas como media ± desviación típica y las cualitativas como valor absoluto y porcentaje, con una estimación de su 95% de intervalo de confianza. La comparación de medias se realizó por medio de la t-Student o el test de Mann-Whitney. La comparación múltiple de media se efectuó mediante el ANOVA o el test de Kruskal-Wallis. La asociación de las variables cualitativas se estimó por medio del estadístico Chi cuadrado y la correlación entre variables cuantitativas por medio del coeficiente de correlación de Pearson o Spearman. Se calcularon las tasas de incidencia cruda para cada tipo de lesión, y las tasas estandarizadas ajustadas por edad por el método directo, siendo expresadas como tasas/100.000 habitantes/año. Para el análisis de tendencias de las tasas se utilizaron modelos de regresión 'joinpoint'. Para determinar qué variables se asocian a los eventos de interés realizamos análisis multivariado de regresión lineal múltiple y logística. Se determinó la supervivencia de los pacientes utilizando la metodología de Kaplan-Meier y un modelo de riesgos proporcionales de Cox.[Resumo] Introducción A incidencia mundial da lesión medular traumática (LMT) é moi variable. Recentes estudos sinalan que estamos a asistir a un cambio epidemiolóxico da LMT. Este cambio pode orixinar unha serie de consecuencias no modelo de atención. Coñecer as características epidemiolóxicas e demográficas da LMT é vital para planificar as prioridades, asignar os recursos sanitarios adecuados e tamén, para identificar as directrices da prevención. Obxectivo Determinar as características epidemiolóxicas dos pacientes con LMT en Galicia durante o período 1995-2014 e analizar a afectación neurolóxica e os factores determinantes da evolución clínica e funcional no devandito período. Material e método Realizouse un estudo observacional con seguimento retrospectivo e prospectivo dos pacientes con lesión medular de etioloxía traumática que ingresaron na Unidade de Lesionados Medulares (ULM) do Complexo Hospitalario Universitario da Coruña no período comprendido entre xaneiro de 1995 e decembro do 2014. Estudáronse variables socio-demográficas, comorbilidade segundo o índice de Charlson, etioloxía, variables da exploración neurolóxica segundo a clasificación ASIA/ISCOS da lesión medular, tipo de lesión ósea, lesións asociadas, manexo terapéutico, ingreso en UCI, funcionalidade segundo a escala Spinal Cord Independence Measure III (SCIM III), capacidade de marcha e escala de marcha da lesión medular Walking Index Spinal Cord Injury II (WISCI II), destino e tratamento rehabilitador ao alta hospitalaria, e mortalidade. A análise estatística realizouse mediante o programa SPSS 19.0. Efectuouse un estudo descritivo das variables, expresando as variables cuantitativas como media ± desviación típica e as cualitativas como valor absoluto e porcentaxe, cunha estimación do seu 95% de intervalo de confianza. A comparación de medias realizouse por medio da t-Student ou o test de Mann-Whitney. A comparación múltiple de media efectuouse mediante o ANOVA ou o test de Kruskal-Wallis. A asociación das variables cualitativas estimouse por medio do estatístico Chi cadrado e a correlación entre variables cuantitativas por medio do coeficiente de correlación de Pearson ou Spearman. Calculáronse as taxas de incidencia crúa para cada tipo de lesión, e as taxas estandarizadas axustadas por idade polo método directo, sendo expresadas como taxas/100.000 habitantes/ano. Para a análise de tendencias das taxas utilizáronse modelos de regresión 'joinpoint'. Para determinar que variables se asociaron aos eventos de interese realizamos análise multivariado de regresión lineal múltiple e loxística. Determinouse a supervivencia dos pacientes utilizando a metodoloxía de Kaplan- Meier e un modelo de riscos proporcionais de Cox...[Abstract] Introduction Existing literature demonstrates large variations in traumatic Spinal Cord Injury (tSCI) incidence globally. Recents studies indicate that we are attending an epidemiological change in tSCI. This change can originate a series of consequences in the attention model. Knowing the epidemiological and demographic characteristics of the tSCI is essential to plan priorities allocate adequate health resources and also, to identify the guidelines for prevention. Objective To determine the epidemiological characteristics of patients with tSCI during the period 1995-2014 and to analyze the neurological involvement and the predictive factors of the clinical and functional outcomes in that period. Material and method An observational study was conducted with retrospective and prospective monitoring of patients with spinal cord injuries of traumatic etiology who were admitted to the Spinal Cord Injury Unit (SCIU) of the Complejo Hospitalario Universitario de A Coruña in the period January 1995 and December 2014. W estudied socio-demographic variables, comorbidity according to the Charlson index, etiology, neurological assessment variables according to the ASIA/ISCOS classification of spinal cord innjury, type of bone injury, associated injuries, therapeutic management, admission to the Intensive Unit Care (IUC), functional outcome according to the Spinal Cord Independence Measure III (SCIM III), ambulation and walking scale of spinal cord injury Walking Index Spinal Cord Injury II (WISCI II), destiantion and rehabilitation treatment at hospital discharge, and mortality. The statistical analysis was conducted using SPSS program versio 19.0. A descriptive study of variables was carried out expressing the quantitative variables as mean±standard deviation and the qualitative ones as absolute value and percentage with an estimate of their 95% confidence interval. X The comparison of means was made by the t-Student or the Mann-Witney test. The multiple comparison of means was made through the ANOVA or the Kruskal-Wallis test. Tha association of qualitative variables was estimated by means of Chi-Square statistic and the correlation between quantitative variables by means of the Pearson or Spearman correlation coefficient The crude incidence rates for each type of injury was calculated and the standardized rates adjusted for age by the direct method being expressed as rates/100.000 inhabitants/year. Fort he trend analysis of the rate “joinpoint” regression models were used. To determine which variables are associated to the events of interest, we perform multivariate analysis of multiple linear regression and logistics. Patient survival was analyzed using the Kaplan-Meier methodology and Cox proportional hazard model..

Mesenchymal stem cell therapy in traumatic spinal cord injury: a systematic review

Review[Abstract] Recovery from a traumatic spinal cord injury (TSCI) is challenging due to the limited regenerative capacity of the central nervous system to restore cells, myelin, and neural connections. Cell therapy, particularly with mesenchymal stem cells (MSCs), holds significant promise for TSCI treatment. This systematic review aims to analyze the efficacy, safety, and therapeutic potential of MSC-based cell therapies in TSCI. A comprehensive search of PUBMED and COCHRANE databases until February 2023 was conducted, combining terms such as "spinal cord injury," "stem cells," "stem cell therapy," "mesenchymal stem cells," and "traumatic spinal cord injury". Among the 53 studies initially identified, 22 (21 clinical trials and 1 case series) were included. Findings from these studies consistently demonstrate improvements in AIS (ASIA Impairment Scale) grades, sensory scores, and, to a lesser extent, motor scores. Meta-analyses further support these positive outcomes. MSC-based therapies have shown short- and medium-term safety, as indicated by the absence of significant adverse events within the studied timeframe. However, caution is required when drawing generalized recommendations due to the limited scientific evidence available. Further research is needed to elucidate the long-term safety and clinical implications of these advancements. Although significant progress has been made, particularly with MSC-based therapies, additional studies exploring other potential future therapies such as gene therapies, neurostimulation techniques, and tissue engineering approaches are essential for a comprehensive understanding of the evolving TSCI treatment landscape.Instituto de Salud Carlos III; PI20/0093

Organ dysfunction as determined by the SOFA score is associated with prognosis in patients with acute traumatic spinal cord injury above T6

Observational study[Abstract] Study design: This is a retrospective, observational study. Objectives: To evaluate organ dysfunction in patients with an acute traumatic spinal cord injury (ATSCI) above T6 using the Sequential Organ Failure Assessment (SOFA) score to determine its association with mortality. Setting: The study was performed at the intensive care unit (ICU) of a tertiary hospital in the northwest of Spain. Methods: The study included 241 patients with an ATSCI above T6 who had been admitted to the ICU between 1998 and 2017. A descriptive analysis of all variables collected was performed to compare the survivors with the non-survivors. In addition, a logistic regression model was used in the multivariate analysis to identify variables that were independently associated with mortality. Results: The results revealed significant differences between the survivors and non-survivors in terms of their age, Charlson Comorbidity Index, Glasgow Coma Scale score on admission, APACHE II score, SOFA score on day 0 and day 4, and delta SOFA 4-0 (ΔSOFA 4-0). The results of this multivariate analysis identified the following variables as independent predictors of intra-ICU mortality: age (OR = 1.05; 95% CI: 1. 01-1.08), SOFA score on day 0 (OR = 1.42; 95% CI: 1.13-1.78), ΔSOFA 4-0 (OR = 1.53; 95% CI: 1.25-1.87), and fluid balance on day 4 (OR = 1.16; 95% CI: 1.00-1.35). Conclusions: The SOFA score is useful for evaluating organ dysfunction in patients with an ATSCI above T6. After adjusting the analysis for conventional variables, organ dysfunction on admission, changes in organ function between day 4 and day 0 (ΔSOFA 4-0), and fluid balance on day 4 were seen to be independently associated with mortality in our study

Rhabdomyolysis and acute kidney injury in patients with traumatic spinal cord injury

[Abstract] Background: Patients with acute traumatic spinal cord injuries (SCIs) exhibit factors that, in other populations, have been associated with rhabdomyolysis. Purpose: The aim of the study is to determine the incidence of rhabdomyolysis in patients with acute traumatic SCI admitted to the Intensive Care Unit (ICU), as well as the development of secondary acute kidney injury and associated factors. Study design and setting: This was an observational, retrospective study. Patient sample: All adult patients admitted to the ICU with acute traumatic SCI who presented rhabdomyolysis, diagnosed through creatine phosphokinase (CPK) levels >500 IU/L. Outcome measures: Incidence of rhabdomyolysis and subsequent renal dysfunction was calculated. Materials and methods: Data about demographic variables, comorbidity, rhabdomyolysis risk factors, and variables involving SCI, severity scores, and laboratory parameters were obtained from clinical records. Multivariate logistic regression was used to identify renal injury risk factors. Results: In 2006-2014, 200 patients with acute SCI were admitted to ICU. Of these, 103 had rhabdomyolysis (incidence = 51.5%; 95% confidence interval [CI]: 44.3%-58.7%). The most typical American Spinal Injury Association classification was A (70.3%). The injury severity score was 30.3 ± 12.1 and sequential organ failure assessment (SOFA) score was 5.6 ± 3.3 points. During their stay, 57 patients (55.3%; 95% CI: 45.2%-65.4%) presented renal dysfunction (creatinine ≥1.2 mg/dL). In the multivariate analysis, variables associated with renal dysfunction were creatinine at admission (odds ratio [OR] = 9.20; P = 0.006) and hemodynamic SOFA score the day following admission (OR = 1.33; P = 0.024). Creatinine was a better predictor of renal dysfunction than the peak CPK value during the rhabdomyolysis (area under the receiver operating characteristic curve: 0.91 vs. 0.63, respectively). Conclusions: Rhabdomyolysis is a frequent condition in patients with acute traumatic SCI admitted to the ICU, and renal dysfunction occurs in half of the cases. Creatinine values should be requested starting at the admission while neither the peak CPK values nor the hemodynamic SOFA scores could be used to properly discriminate between patients with and without renal dysfunction

Neurological recovery after traumatic spinal cord injury: prognostic value of magnetic resonance

[Abstract] Study design: Retrospective observational study. Objectives: Assess the relationship between Magnetic Resonance (MR) image patterns and neurological recovery in patients with Traumatic Spinal Cord Injury (TSCI). Setting: Spinal cord injury unit in Spain. Methods: Patients admitted for acute TSCI between January 2010 and December 2018 with a MR exam performed in the acute phase were selected. Five patterns were established: normal, single-level edema, multilevel edema, hemorrhage, and spinal cord transection. Comparisons between the ASIA Injury Severity (AIS) score and Motor Index (MI) at admission and at discharge were made. Results: Collected 296 patients. Normal and cord transection patterns were excluded due to the low number of cases. Single-level edema pattern was primarily observed in cases with incomplete injuries, hemorrhage pattern in complete injuries, and multilevel edema pattern at similar percentages in complete and incomplete lesions. Improvement of the AIS score was found in 40.9% of single-level edema, 20.2% of multilevel edema, and 19.0% of hemorrhage (p = 0.042) patterns. By excluding the AIS grade D from the analyses, the figures increased to 70.3%, 52.2%, and 19.4% respectively (p < 0.001). This significant relationship was confirmed by multivariate analysis, although it was not as relevant as the examination according to ASIA-ISCoS performed at admission (p = 0.005 vs p < 0.001). Mean variation of the MI was also significantly different (p < 0.001) between the three groups: 22.6 ± 21.4 for single-level edema, 16.9 ± 21.1 for multilevel edema, and 4.5 ± 8.4 for hemorrhage. Conclusion: MR injury patterns observed at the acute phase are associated with the possibility of improvement of the AIS score and MI

Lesión cerebral hipóxico-isquémica secundaria a parada cardiaca en un lesionado medular agudo

Spinal cord injury is a strong risk factor for venous thromboembolism, entity that encludes deep vein thrombosis and pulmonary embolism, this being a potentially reversible cause of cardiac arrest. We report the case of a young male with complete spinal cord injury (ASIA grade A) level C6 suffering cardiac arrest by massive pulmonary embolism secondary to deep vein thrombosis in the left lower limb in the 6th week of admission. We report the incidence of both entities in acute spinal cord injury and their pathophysiology, prevention and treatment; We emphasize the importance of identifying cardiac arrest and early initiation of cardiopulmonary resuscitation by health workers and analyze the consequences of hypoxic-ischemic brain injury resulting from cardiac arrest recoveredLa lesión medular es un factor de riesgo importante para la enfermedad tromboembólica venosa, entidad que engloba la trombosis venosa profunda y el tromboembolismo pulmonar, siendo este una causa potencialmente reversible de parada cardíaca. Presentamos el caso de un varón joven con lesión medular completa (grado ASIA A) con nivel C6 que sufre una parada cardíaca por tromboembolismo pulmonar masivo secundario a trombosis venosa profunda en extremidad inferior izquierda en la 6ª semana de ingreso. Exponemos la incidencia de ambas entidades en la lesión medular aguda así como su fisiopatología, profilaxis y tratamiento; destacamos la importancia de la identificación de la parada cardíaca e inicio precoz de las maniobras de reanimación cardiopulmonar por el personal sanitario y analizamos las consecuencias de la lesión cerebral hipóxico-isquémica derivada de una parada cardíaca recuperada

Respiratory Management in the Patient with Spinal Cord Injury

Spinal cord injuries (SCIs) often lead to impairment of the respiratory system and, consequently, restrictive respiratory changes. Paresis or paralysis of the respiratory muscles can lead to respiratory insufficiency, which is dependent on the level and completeness of the injury. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Vital capacity (VC) is an indicator of overall pulmonary function; patients with severely impaired VC may require assisted ventilation. It is best to proceed with intubation under controlled circumstances rather than waiting until the condition becomes an emergency. Mechanical ventilation can adversely affect the structure and function of the diaphragm. Early tracheostomy following short orotracheal intubation is probably beneficial in selected patients. Weaning should start as soon as possible, and the best modality is progressive ventilator-free breathing (PVFB). Appropriate candidates can sometimes be freed from mechanical ventilation by electrical stimulation. Respiratory muscle training regimens may improve patients’ inspiratory function following a SCI

Lesión cerebral hipóxico-isquémica secundaria a parada cardiaca en un lesionado medular agudo

Resumen. La lesión medular es un factor de riesgo importante para la enfermedad tromboembólica venosa, entidad que engloba la trombosis venosa profunda y el tromboembolismo pulmonar, siendo este una causa potencialmente reversible de parada cardíaca. Presentamos el caso de un varón joven con lesión medular completa (grado ASIA A) con nivel C6 que sufre una parada cardíaca por tromboembolismo pulmonar masivo secundario a trombosis venosa profunda en extremidad inferior izquierda en la 6ª semana de ingreso. Exponemos la incidencia de ambas entidades en la lesión medular aguda así como su fisiopatología, profilaxis y tratamiento; destacamos la importancia de la identificación de la parada cardíaca e inicio precoz de las maniobras de reanimación cardiopulmonar por el personal sanitario y analizamos las consecuencias de la lesión cerebral hipóxico-isquémica derivada de una parada cardíaca recuperada. Abstract. Spinal cord injury is a strong risk factor for venous thromboembolism, entity that encludes deep vein thrombosis and pulmonary embolism, this being a potentially reversible cause of cardiac arrest. We report the case of a young male with complete spinal cord injury (ASIA grade A) level C6 suffering cardiac arrest by massive pulmonary embolism secondary to deep vein thrombosis in the left lower limb in the 6th week of admission. We report the incidence of both entities in acute spinal cord injury and their pathophysiology, prevention and treatment; We emphasize the importance of identifying cardiac arrest and early initiation of cardiopulmonary resuscitation by health workers and analyze the consequences of hypoxic-ischemic brain injury resulting from cardiac arrest recovered

Prognostic value of early magnetic resonance imaging in the morbidity and mortality of traumatic spinal cord injury

[Resumen] Objetivo. Valorar en individuos con lesión medular traumática (LMT) la relación entre la mortalidad y la necesidad de UCI y las alteraciones objetivadas mediante resonancia magnética (RM) precoz, analizando alteraciones parenquimatosas, disrupción de ligamentos vertebrales (DLV) y compresión del cordón medular (CCM). Diseño. Estudio retrospectivo. Ámbito. Hospital de tercer nivel, unidad de lesionados medulares y UCI. Pacientes. Individuos con LMT aguda entre los años 2010 y 2019. Intervenciones. Análisis de RM realizada en las primeras 72 horas. Variables de interés. Ingreso en UCI y mortalidad. Resultados. Recogidos 269 casos. El patrón que se asoció a una mayor mortalidad fue la hemorragia (16,7%) por 12,5% de los edemas a un nivel y 6,5% de los edemas a múltiples niveles (p = 0,125). Lo mismo aconteció con los ingresos en UCI: 69,0% en hemorragia por 60,2% en edema múltiple y 46,3% en edemas cortos (p = 0,018). Con respecto a la CCM, la mortalidad fue del 13,4% con 59,2% de ingresos en UCI por 2,2% y 42,2% de quienes no presentaban compresión (p = 0,020 y p = 0,003). Las cifras de éxitus e ingreso en UCI en los individuos con DLV fueron del 15,0% y el 67,3%, respectivamente, por un 6,2% y 44,4% de los individuos sin DLV (p < 0,001 y p = 0,013). Conclusiones. La presencia de hemorragia medular, CCM y DLV se asoció a una mayor necesidad de UCI. Existe un significativo aumento de la mortalidad en los casos con CCM y DLV.[Abstract] Objective. To assess in individuals with traumatic spinal cord injury (TSCI) the relationship between mortality and need for ICU and early magnetic resonance imaging (MRI), analyzing spinal parenchymal alterations, disruption of vertebral ligaments (DVL) and spinal cord compression (SCC). Design. Retrospective study. Setting. Third-level hospital, Spinal Cord Injury Unit and ICU. Patients. Individuals with acute TSCI between 2010 and 2019. Intervention. Analysis of MRI performed in the first 72 h. Variables of interest. Admission to ICU and mortality. Results. 269 cases collected. The pattern that demonstrated higher mortality was cord hemorrhage (16.7%) for 12.5% of single-level edema and 6.5% of multilevel edema (p = 0.125). The same happened with ICU admissions: 69.0% in hemorrhage, 60.2% in multilevel edema and 46.3% in short edema (p = 0.018). Analyzing CCM, mortality was 13.4% with 59.2% of ICU admissions, for 2.2% and 42.2% of individuals without cord compression (p = 0.020 and p = 0.003). The figures of death and ICU admission among cord injuries with DVL were 15.0% and 67.3%, for 6.2% and 44.4% of the individuals without DLV (p < 0.001 and p = 0.013). Conclusions. The presence of spinal cord hemorrhage, SCC and DVL was associated with a higher admission in ICU. A significant increase in mortality was observed in cases with SCC and DVL