Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial

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)

PP78. Primary CNS Lymphoma Outcomes in a Single Centre: A 7 Year Study

INTRODUCTION: Primary CNS Lymphoma (PCNSL) in the immunocompetent population is reported as comprising 3–5% of all primary CNS neoplasms. They are considered aggressive tumours and their management remains controversial. We report a single centre experience of PCNSL over 7 years. METHODS: This is a retrospective cohort study of all biopsy confirmed PCNSLs between 2009 and 2016 in a busy London neurosurgical unit. Data was sourced from the lymphoma database, pathology reports, patient notes and radiology. We then reviewed their oncology treatment and outcomes. Primary endpoints were mortality, relapse and treatment complication rates. RESULTS: We had 58 patients (35 males and 23 females). 13 (22.4%) had a previous history of cancer and 10(17.2%) were immunocompromised. The rate of mortality during the seven years was 58.6% (34/58). The mean survival was 1.9 years (11 days to 7.16 years) Biopsies for tissue diagnosis had a low complication rate in our cohort (1 patient with biopsy related intracranial haematoma; 1 patient with wound breakdown). We were able to review treatment plans of 30 patients of whom 19 underwent chemotherapy and 10 had palliative radiotherapy only. 3 patients were not fit for either chemotherapy or radiotherapy. Neutropenic sepsis occurred in 26.1% (6/30) of the treated group with a similar proportion having neurological problems such as short term memory loss, seizures and hydrocephalus. 21.7% (5/30) had relapse despite treatment. CONCLUSIONS: 40% of our cohort had a history of cancer or being immunocompromised which can be attributed to the presence of activated oncogenes and failure of cell cycle repair mechanisms. A significant proportion (21.7% in our cohort) had relapse despite treatment which supports previous studies of PCNSL as an aggressive disease. It remains a disease with a high mortality and significant complications during treatment

OP23. T cell expression in CNS lymphomas: A single centre experience of Primary CNS T-Cell Lymphomas

INTRODUCTION: Primary CNS lymphomas (PCNSLs) are a rare entity and comprise only 5% of brain tumours. Histopathologically they are primarily of B-cell phenotype. Primary CNS T-Cell Lymphomas (PCNSTLs) constitute \u3c5% of all PCNSLs. Such rarity in clinical practice means there is a paucity of robust data on the long term outcomes for patients with PCNSTLs. We report our PCNSTL (or T-Cell rich PCNSLs) experience over 7 years. METHODS: We reviewed our pathology database for all PCNSLs diagnosed between 2009 and 2016. Specifically T-cell expression, Ki67 Proliferative Index (KPI) and CD expression were looked reviewed from histopathological reports. Treatment options, survival and complications were also reviewed. RESULTS: We identified a total of 58 PCNSLs of which 2 were pure T-cell lymphomas and 3 were B cell lymphomas with T cell expression (2 were ‘T-cell rich’; 1 was anaplastic). Mean age was 58.4 (44–66 years). These 5 patients comprised of 4 males and 1 female. One patient was HIV positive; and another had a previous history of lung cancer. On FLAIR MR Imaging, three patients had supratentorial bihemispheric lesions; and one patient (who is still alive) had a left cerebellar lesion. In our small sample, those with bihemispheric lesions had shorter survival times which would correlate with extent of disease dissemination within the white matter tracts. The 2 ‘T-cell rich’ samples had a KPI of 70–80%. (In the PCNSLs with T cell expression, the KPI ranged from 20% - 90% and in our group this correlated with survival).One patient whose cells demonstrated a KPI of 90% survived for only 56 days from diagnostic biopsy. Immunohistochemistry showed variable CD expression (as in previous published literature). All 5 patients had their histology dually reported by a neuropathologist and haemotopathologist. One patient was not fit enough for oncology treatment. The other 4 had chemotherapy and all had relapses or progression on treatment. Mean survival time was 275.2 days (7.56months with a range of 56–571 days). At the time of writing, 1 patient was still alive with ongoing haematology clinic review; 1 was discharged to a palliative care facility and 3 patients had died. SUMMARY: With PCNSTls or PCNSLs with T-cell expression, there seems to be an association between survival and the Ki67 proliferative index in addition to presence of bilateral supratentorial disease on MR imaging. As they are extremely rare presentations, further studies would perhaps benefit from multi-centre involvement. Their histological diagnosis (especially immunohistochemistry) remains challenging due to the heterogeneity of the cells and CD expression, and in our experience has often required multiple histology reviews

Additional file 4 of Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

Additional file 4: Diaphragmatic excursion videos, M-mod

Additional file 5 of Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

Additional file 5: Intercostal muscle ultrasound video

Additional file 1 of Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

Additional file 1: Supplementary method

Additional file 7 of Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

Additional file 7: Plots of relations between individual patient’s breathing function vs SCP

Additional file 8 of Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

Additional file 8: Sample sizes for each grap