Publications by authors named "Julio C Furlan"

93 Publications

A Scoping Review of Registered Clinical Studies on Management of Individuals With Acute Spinal Cord Injury (2000-2020): Trends and Characteristics of the Research Initiatives.

Am J Phys Med Rehabil 2022 Feb;101(2):184-190

From the Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (JCF); KITE-Research Institute, University Health Network, Toronto, Ontario, Canada (JCF, DTF, CM-C); Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (JCF); Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada (JCF); Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada (JCF); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (JCF); and Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada (CM-C).

Abstract: This scoping review examined the current trends and characteristics of the clinical research initiatives on the management of acute spinal cord injury. This review included all clinical studies on the acute treatment of spinal cord injury that were registered in the ClinicalTrials.gov website from February 2000 to December 2020. The search strategy combined the terms "acute spinal cord injury" and "treatment." There has been a gradual increase in the number of registered clinical studies on acute treatment of spinal cord injury over the past two decades. Of the 116 studies, there were 103 interventional studies, 12 observational studies, and 1 registry. While 115 clinical studies recruited male and female participants, most of the registered clinical studies included only adults with an upper age limit after spinal cord injury. Most of the registered clinical studies were interventional studies led by single institutions in North America (n = 70), Europe (n = 29), and Asia (n = 15). Most of the research initiatives were interventional studies on new therapies for management of individuals with spinal cord injury (n = 91). In conclusion, the results of this scoping review suggest that although there has been an increase in the amount and diversity of the research initiatives on treatment of acute spinal cord injury over the past two decades, their generalizability remains relatively limited.
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http://dx.doi.org/10.1097/PHM.0000000000001811DOI Listing
February 2022

Effects of age on survival and neurological recovery of individuals following acute traumatic spinal cord injury.

Authors:
Julio C Furlan

Spinal Cord 2022 Jan 11;60(1):81-89. Epub 2021 Oct 11.

Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.

Study Design: Retrospective cohort study.

Objectives: To evaluate the effects of older age at the time of injury on the individuals' survival and neurological recovery within the first year after acute traumatic spinal cord injury (tSCI).

Setting: United States.

Methods: This study included all participants enrolled into the First National Acute Spinal Cord Injury Study (NASCIS-1). Outcome measures included survival and neurological recovery (as assessed using the NASCIS motor and sensory scores) within the first year after tSCI. Data analyses of neurological recovery were adjusted for major potential confounders.

Results: The study included 39 females and 267 males with overall mean age of 31 years who mostly sustained cervical severe tSCI after motor vehicle accidents or falls. Survival rates among older individuals are significantly lower than among younger individuals within the first year following tSCI (p < 0.0001). Among who survived the first year of tSCI, there were no statistically significant difference between older survivors and younger survivors regarding motor and sensory recovery in the multiple regression analyses adjusted for major potential confounders.

Conclusions: The results of this retrospective study suggest that older age at the injury onset is associated with lower survival rate within the first year following tSCI. However, older individuals have similar potential to recover from their initial neurological impairment to younger individuals after tSCI. The results of this study combined to the recent literature underline the need for multidisciplinary team approach to the management of the elderly with acute SCI is essential to maximize their recovery.
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http://dx.doi.org/10.1038/s41393-021-00719-0DOI Listing
January 2022

Recent advances and new discoveries in the pipeline of the treatment of primary spinal tumors and spinal metastases: a scoping review of registered clinical studies from 2000 to 2020.

Neuro Oncol 2022 Jan;24(1):1-13

Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.

The field of spinal oncology has substantially evolved over the past decades. This review synthesizes and appraises what was learned and what will potentially be discovered from the recently completed and ongoing clinical studies related to the treatment of primary and secondary spinal neoplasms. This scoping review included all clinical studies on the treatment of spinal neoplasms registered in the ClinicalTrials.gov website from February 2000 to December 2020. The terms "spinal cord tumor," "spinal metastasis," and "metastatic spinal cord compression" were used. Of the 174 registered clinical studies on primary spinal tumors and spinal metastasis, most of the clinical studies registered in this American registry were interventional studies led by single institutions in North America (n = 101), Europe (n = 43), Asia (n = 24), or other continents (n = 6). The registered clinical studies mainly focused on treatment strategies for spinal neoplasms (90.2%) that included investigating stereotactic radiosurgery (n = 33), radiotherapy (n = 21), chemotherapy (n = 20), and surgical technique (n = 11). Of the 69 completed studies, the results from 44 studies were published in the literature. In conclusion, this review highlights the key features of the 174 clinical studies on spinal neoplasms that were registered from 2000 to 2020. Clinical trials were heavily skewed toward the metastatic population as opposed to the primary tumors which likely reflects the rarity of the latter condition and associated challenges in undertaking prospective clinical studies in this population. This review serves to emphasize the need for a focused approach to enhancing translational research in spinal neoplasms with a particular emphasis on primary tumors.
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http://dx.doi.org/10.1093/neuonc/noab214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8730766PMC
January 2022

Effects on Outcomes of Hyperglycemia in the Hyperacute Stage after Acute Traumatic Spinal Cord Injury.

Authors:
Julio C Furlan

Neurotrauma Rep 2021 19;2(1):14-24. Epub 2021 Jan 19.

Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada.

Hyperglycemia has adverse effects on neuronal recovery after brain injury, but its effects after spinal cord injury (SCI) are understudied. This retrospective cohort study examined the potential effects on outcomes of hyperglycemia in the hyperacute stage after acute traumatic SCI. This study included all individuals enrolled in the National Acute Spinal Cord Injury Study 3 (NASCIS-3). Glycemic levels at 24 h, at 48 h, and at day 7 after acute SCI were examined as potential determinants of survival, neurological outcomes (using NASCIS motor, sensory, and pain scores), and functional outcome (using the Functional Independence Measure [FIM]) within the first year post-SCI. Hyperglycemia was defined using two thresholds (140 mg/dL and 180 mg/dL). Study subjects were 76 females and 423 males with an overall mean age of 36 years who sustained mostly cervical SCI due to motor vehicle accidents or falls. Hyperglycemia diagnosed at day 7 post-injury was associated with significantly greater mortality rates post-SCI. Among the survivors, hyperglycemia during the hyperacute stage was not significantly correlated with neurological recovery post-SCI. Hyperglycemia persistent until day 7 was significantly correlated with lower functional scores post-SCI. These results suggest that hyperglycemia at day 7 is correlated with greater mortality rates within the first year post-SCI. Although hyperglycemia during the hyperacute stage was not associated with neurological recovery, hyperglycemia at day 7 may adversely affect functional recovery within the first year post-SCI. Future investigations are needed to determine the optimal glycemic target in the management of patients with SCI.
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http://dx.doi.org/10.1089/neur.2020.0042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240828PMC
January 2021

In Reply: A Scoping Review of Registered Clinical Studies on Mild Traumatic Brain Injury and Concussion (2000-2019).

Neurosurgery 2021 08;89(3):E180-E181

Krembil Brain Institute and Division of Neurosurgery and Canadian Concussion Centre Toronto Western Hospital University of Toronto Toronto, ON, Canada.

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http://dx.doi.org/10.1093/neuros/nyab191DOI Listing
August 2021

Clinical Benefits and System Design of FES-Rowing Exercise for Rehabilitation of Individuals with Spinal Cord Injury: A Systematic Review.

Arch Phys Med Rehabil 2021 08 6;102(8):1595-1605. Epub 2021 Feb 6.

Institute of Biomedical Engineering, University of Toronto, Toronto, ON; KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON. Electronic address:

Objective: To comprehensively and critically appraise the clinical benefits and engineering designs of functional electrical stimulation (FES)-rowing for management of individuals with spinal cord injury (SCI).

Data Sources: Electronic database searches were conducted in Cumulative Index to Nursing & Allied Health Literature, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Excerpta Medica database, Emcare, Medline, PubMed, Scopus, and Web of Science databases from inception to May 12, 2020.

Study Selection: Search terms used were synonyms of "spinal cord injury" for Population and "Electric Stimulation (Therapy)/ and rowing" for Intervention. Two reviewers independently assessed articles based on the following inclusion criteria: recruited individuals with SCI; had aerobic FES-rowing exercise as study intervention; reported cardiovascular, muscular, bone mineral density, or metabolic outcomes; and examined engineering design of FES-rowing systems. Of the 256 titles that were retrieved in the primary search, 24 were included in this study.

Data Extraction: Study characteristics, quality, participants' characteristics, test descriptions, and results were independently extracted by 2 reviewers. The quality of studies was assessed with the Downs and Black checklist.

Data Synthesis: Comparison of peak oxygen consumption (V̇) rates showed that V̇ during FES-rowing was significantly higher than arm-only exercise; FES-rowing training improved V̇ by 11.2% on average (95% confidence interval, 7.25-15.1), with a 4.1% (95% confidence interval, 2.23-5.97) increase in V̇ per month of training. FES-rowing training reduced bone density loss with increased time postinjury. The rowing ergometer used in 2 studies provided motor assistance during rowing. Studies preferred manual stimulation control (n=20) over automatic (n=4).

Conclusions: Our results suggest FES-rowing is a viable exercise for individuals with SCI that can improve cardiovascular performance and reduce bone density loss. Further randomized controlled trials are needed to better understand the optimal set-up for FES-rowing that maximizes the rehabilitation outcomes.
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http://dx.doi.org/10.1016/j.apmr.2021.01.075DOI Listing
August 2021

Factors Associated with Recovery in Motor Strength, Walking Ability, and Bowel and Bladder Function after Traumatic Cauda Equina Injury.

J Neurotrauma 2021 02 2;38(3):322-329. Epub 2020 Nov 2.

Physical Medicine and Rehabilitation, Dalhousie University Faculty of Medicine, Stan Cassidy Centre for Rehabilitation, Fredericton, New Brunswick, Canada.

Traumatic cauda equina injury (TCEI) is usually caused by spine injury at or below L1 and can result in motor and/or sensory impairments and/or neurogenic bowel and bladder. We examined factors associated with recovery in motor strength, walking ability, and bowel and bladder function to aid in prognosis and establishing rehabilitation goals. The analysis cohort was comprised of persons with acute TCEI enrolled in the Rick Hansen Spinal Cord Injury Registry. Multi-variable regression analysis was used to determine predictors for lower-extremity motor score (LEMS) at discharge, walking ability at discharge as assessed by the walking subscores of either the Functional Independence Measure (FIM) or Spinal Cord Independence Measure (SCIM), and improvement in bowel and bladder function as assessed by FIM-relevant subscores. Age, sex, neurological level and severity of injury, time from injury to surgery, rehabilitation onset, and length of stay were examined as potential confounders. The cohort included 214 participants. Median improvement in LEMS was 4 points. Fifty-two percent of participants were able to walk, and >20% recovered bowel and bladder function by rehabilitation discharge. Multi-variable analyses revealed that shorter time from injury to rehabilitation admission (onset) was a significant predictor for both improvement in walking ability and bowel function. Longer rehabilitation stay and being an older female were associated with improved bladder function. Our results suggest that persons with TCEI have a reasonable chance of recovery in walking ability and bowel and bladder function. This study provides important information for rehabilitation goals setting and communication with patients and their families regarding prognosis.
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http://dx.doi.org/10.1089/neu.2020.7303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7826419PMC
February 2021

Age as a determinant of inflammatory response and survival of glia and axons after human traumatic spinal cord injury.

Exp Neurol 2020 10 13;332:113401. Epub 2020 Jul 13.

Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.

Despite the shift in the demographics of traumatic spinal cord injury (SCI) with increased proportion of injuries in the elderly, little is known on the potential effects of old age on the pathobiology of SCI. Since there is an assumption that age adversely affects neural response to SCI, this study examines the clinically relevant question on whether age is a key determinant of inflammatory response, oligodendroglial apoptosis and axonal survival after traumatic SCI. This unique study includes post-mortem spinal cord tissue from 64 cases of SCI (at cervical or high-thoracic levels) and 38 control cases without CNS injury. Each group was subdivided into subgroups of younger and elderly individuals (65 years of age or older at the SCI onset). The results of this study indicate that age at the SCI onset does not adversely affect the cellular inflammatory response to, oligodendroglial apoptosis and axonal survival after SCI. These results support the conclusion that elderly individuals have similar neurobiological responses to SCI as younger people and, hence, treatment decisions should be based on an assessment of the individual patient and not an arbitrary assumption that "advanced age" should exclude patients with an acute SCI from access to advanced care and translational therapies.
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http://dx.doi.org/10.1016/j.expneurol.2020.113401DOI Listing
October 2020

Peripheral Neuropathy in the Lower Limbs of Individuals With Spinal Cord Injury or Disease: A Retrospective Study.

Am J Phys Med Rehabil 2021 01;100(1):57-64

From the Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada (JL, JCF); and KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (JCF).

Purpose: This study investigated the frequency and types of peripheral neuropathy in the lower limbs of patients undergoing rehabilitation after traumatic spinal cord injury or spinal cord disease.

Methods: This study included consecutive patients with spinal cord injury/spinal cord disease who had electrophysiological assessments during their admission in a rehabilitation center from October 2015 to July 2019. Patients with traumatic spinal cord injury were compared with patients with nontraumatic spinal cord disease.

Results: There were 67 patients (52 male patients, 15 female patients; mean age = 56.5 yrs) of whom 36 patients had spinal cord injury and 31 patients had spinal cord disease. Most of the patients were middle-aged men with at least one preexisting medical comorbidity, who were mostly admitted for rehabilitation of cervical, incomplete spinal cord injury/spinal cord disease. Most patients (86.6%) had abnormal electrophysiological studies representing 5.57% of all admissions. A length-dependent polyneuropathy was diagnosed in 0.77% of all admissions (n = 8). The group of patients with spinal cord injury was comparable with the group of patients with spinal cord disease regarding the other baseline data, clinical, and electrophysiological findings.

Conclusions: Diseases of the peripheral nervous system were similarly found among patients undergoing rehabilitation for either spinal cord injury or spinal cord disease. A length-dependent polyneuropathy was diagnosed in 0.77% of all admissions. Timely diagnosis and proper treatment of the cause of peripheral neuropathies in the lower limbs in these patients may potentially influence rehabilitation protocols and improve patient outcomes.
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http://dx.doi.org/10.1097/PHM.0000000000001518DOI Listing
January 2021

A Scoping Review of Registered Clinical Studies on Mild Traumatic Brain Injury and Concussion (2000 to 2019).

Neurosurgery 2020 10;87(5):891-899

Krembil Brain Institute and Division of Neurosurgery, and Canadian Concussion Centre, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.

Background: While many patients with mild traumatic brain injury (mTBI) or concussion recover completely, prolonged postconcussion symptoms remain a challenge for patients and an opportunity for clinical research. This has led to numerous research initiatives over the last 2 decades.

Objective: To review the characteristics of clinical studies on management of mTBI/concussion; and to examine their definitions of mTBI/concussion.

Methods: This scoping review included all clinical studies on diagnosis and management of patients with mTBI/concussion registered at www.clinicaltrials.gov from 2000 to June/2019. The terms "mild TBI/concussion" were used for the primary search. Definitions of mTBI/concussion were obtained from the protocols. When a definition was missing in the website, the study's investigators were contacted for clarification.

Results: There were 225 interventional and 95 observational studies. Most of the studies are focused on treatment (54.7%) or diagnosis (37.5%), while 3.4% examined preventive measures, 2.8% evaluated prognostic instruments, and 1.6% developed registries. Most of the studies in this American database were single-center initiatives led by American and Canadian institutions. The definitions of mTBI/concussion differed widely among 109 studies.

Conclusion: The results of this review suggest that most of the clinical studies are focused on diagnosis and non-pharmacological therapies for patients with mTBI/concussion. The large number of differing definitions of mTBI/concussion among the studies creates significant limitations when comparing studies. The requirements for registering research protocols on mTBI/concussion should include the necessity to state the definition being used. There is a need for consensus on a uniform definition of concussion.
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http://dx.doi.org/10.1093/neuros/nyaa151DOI Listing
October 2020

Degenerative cervical myelopathy - update and future directions.

Nat Rev Neurol 2020 02 23;16(2):108-124. Epub 2020 Jan 23.

Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada.

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults worldwide. DCM encompasses various acquired (age-related) and congenital pathologies related to degeneration of the cervical spinal column, including hypertrophy and/or calcification of the ligaments, intervertebral discs and osseous tissues. These pathologies narrow the spinal canal, leading to chronic spinal cord compression and disability. Owing to the ageing population, rates of DCM are increasing. Expeditious diagnosis and treatment of DCM are needed to avoid permanent disability. Over the past 10 years, advances in basic science and in translational and clinical research have improved our understanding of the pathophysiology of DCM and helped delineate evidence-based practices for diagnosis and treatment. Surgical decompression is recommended for moderate and severe DCM; the best strategy for mild myelopathy remains unclear. Next-generation quantitative microstructural MRI and neurophysiological recordings promise to enable quantification of spinal cord tissue damage and help predict clinical outcomes. Here, we provide a comprehensive, evidence-based review of DCM, including its definition, epidemiology, pathophysiology, clinical presentation, diagnosis and differential diagnosis, and non-operative and operative management. With this Review, we aim to equip physicians across broad disciplines with the knowledge necessary to make a timely diagnosis of DCM, recognize the clinical features that influence management and identify when urgent surgical intervention is warranted.
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http://dx.doi.org/10.1038/s41582-019-0303-0DOI Listing
February 2020

Development of Cardiometabolic Health indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project.

J Spinal Cord Med 2019 10;42(sup1):166-175

KITE, Toronto Rehab - University Health Network , Toronto , Ontario , Canada.

Spinal cord injury or disease (SCI/D) leads to unchanged low-density lipoprotein and cholesterol, very low high-density lipoprotein a form of dyslipidemia and physical inactivity which combine to increase risk of morbidity and mortality from cardiometabolic disease. Herein, we describe the selection of structure, process and outcome indicators for adults in the first 18 months post-SCI/D rehabilitation admission. A Pan-Canadian Cardiometabolic Health Working Group was formed to develop a construct definition. Cardiometabolic risk factors were summarized in a Driver diagram. Release of the Paralyzed Veterans of America "Identification and Management of Cardiometabolic Risk after Spinal Cord Injury" and the International Scientific Exercise Guidelines: "Evidence-based scientific exercise guidelines for adults with spinal cord injury", informed the group's focus on prevention strategies to advance this Domain of rehabilitation admission. The structure indicator identifies during rehabilitation the presence of appropriate time and resources for physical exercise prescription. Process indicators are lipid profile assessment at rehabilitation admission and documented exercise prescriptions prior to discharge. The outcome indicators track patient's knowledge retention regarding exercise prescription at discharge, current exercise adherence and lipid status 18 months after rehabilitation discharge. Routine national implementation of these indicators at the specified time points will enhance efforts to detect dyslipidemia and assure routine participation in endurance exercise. These indicators align with international initiatives to improve cardiometabolic health through interventions targeting modifiable risk factors specifically endurance exercising and optimal lipid profiles, crucial to augmenting cardiometabolic health after SCI/D.
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http://dx.doi.org/10.1080/10790268.2019.1613322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781462PMC
October 2019

Is there any gender or age-related discrepancy in the waiting time for each step in the surgical management of acute traumatic cervical spinal cord injury?

J Spinal Cord Med 2019 10;42(sup1):233-241

Department of Surgery, Division of Neurosurgery, University of Toronto , Toronto , Canada.

Prior studies indicate that patient's gender and age can influence treatment choices during spine disease management. This study examines whether individual's gender and age at injury onset influence the waiting time for each step in the surgical management of patients with acute traumatic cervical spinal cord injury (atcSCI). Retrospective cohort study. Quaternary spine trauma center. This study included consecutive individuals with atcSCI admitted from August/2002 to October/2008 who were enrolled in the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS). Spinal cord decompression. Data on the periods of time for each step in the surgical management were analyzed to explore the potential effects of gender and age at injury onset. There were 64 individuals with atcSCI (17 women, 47 men; age range: 18-78 years; mean age: 50.5 ± 2.1 years). Older age was associated with longer stay in the acute spine center, but this association was cofounded by major pre-existing medical co-morbidities. Age did not significantly affect the waiting time for each step in the surgical management of these individuals with atcSCI. Women underwent surgical assessment earlier than men. Gender did not influence other key steps in the surgical management. The study results suggest that older age at injury onset was associated with longer stay in the acute spine care center, and women had a shorter waiting time for surgical assessment than men. Nevertheless, no other age or gender bias was identified in the waiting times for the steps in the management of atcSCI.
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http://dx.doi.org/10.1080/10790268.2019.1614291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781466PMC
October 2019

Sex-related discrepancies in the epidemiology, injury characteristics and outcomes after acute spine trauma: A retrospective cohort study.

J Spinal Cord Med 2019 10;42(sup1):10-20

Department of Surgery, Division of Neurosurgery, University of Toronto , Toronto , Ontario , Canada.

The potential effects of sex on injury severity and outcomes after acute spine trauma (AST) have been reported in pre-clinical and clinical studies, even though the data are conflicting. This study compared females and males regarding the epidemiology, injury characteristics, and clinical outcomes of AST. Retrospective cohort study. Acute spine care quaternary center. All consecutive cases of AST admitted from January/1996 to December/2007 were included. None. The potential effects of sex on the epidemiology, injury characteristics, and clinical outcomes of AST were studied. There were 504 individuals with AST (161 females, 343 males; mean age of 49.44 ± 0.92 years). Sex was not associated with age or pre-existing co-morbidities as assessed using the Charlson Co-morbidity Index, however, females had a greater number of International Classifications of Diseases (ICD) codes at admission and higher Cumulative Illness Rating Scale (CIRS) than males. Over the 12-year period, the male-to-female ratio has not significantly changed. Although there were significant sex-related discrepancies regarding injury etiology, level and severity of AST, males and females had similar lengths of stay in the acute spine center, in-hospital survival post-AST, and need for mechanical ventilation and tracheostomy. This study suggests that females with AST present with a greater number of pre-existing co-morbidities, a higher frequency of thoraco-lumbar trauma, less severe neurological impairment and a greater proportion of MVA-related injuries. However, females and males have a similar length of stay in the acute spine center, and comparable in-hospital survival, need for mechanical ventilation, and tracheostomy after AST.
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http://dx.doi.org/10.1080/10790268.2019.1607055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781464PMC
October 2019

Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review.

Global Spine J 2019 Aug 23;9(5):545-558. Epub 2018 May 23.

Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada.

Study Design: Systematic review.

Objectives: War-related spinal cord injuries (SCIs) are commonly more severe and complex than traumatic SCIs among civilians. This systematic review, for the first time, synthesized and critically appraised the literature on the epidemiology of war-related SCIs. This review aimed to identify distinct features from the civilian SCIs that can have an impact on the management of military and civilian SCIs.

Methods: Medline, EMBASE, and PsycINFO databases were searched for articles on epidemiology of war-related SCI among combatants, published from 1946 to December 20, 2017. This review included only original publications on epidemiological aspects of SCIs that occur during an act of war. The STROBE statement was used to examine the quality of the publications.

Results: The literature search identified 1594 publications, of which 25 articles fulfilled the inclusion and exclusion criteria. The studies were classified into the following topics: 17 articles reported demographics, level and severity of SCI, mechanism of injury and/or associated bodily injuries; 5 articles reported the incidence of war-related SCI; and 6 articles reported the frequency of SCI among other war-related bodily injuries. Overall, military personnel with war-related SCI were typically young, white men, with predominantly thoracic or lumbar level, complete (American Spinal Injury Association [ASIA] Impairment Scale A) SCI due to gunshot or explosion and often associated with other bodily injuries. Marines appear to be at a greater risk of war-related SCI than the military personal in the Army, Navy, and Air Force.

Conclusions: The war-related SCIs among soldiers are distinct from the traumatic SCI in the general population. The majority of the current literature is based on the American experiences in most recent wars.
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http://dx.doi.org/10.1177/2192568218776914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686388PMC
August 2019

Application of electrophysiological measures in spinal cord injury clinical trials: a narrative review.

Spinal Cord 2019 Nov 23;57(11):909-923. Epub 2019 Jul 23.

Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.

Study Design: Narrative review.

Objectives: To discuss how electrophysiology may contribute to future clinical trials in spinal cord injury (SCI) in terms of: (1) improvement of SCI diagnosis, patient stratification and determination of exclusion criteria; (2) the assessment of adverse events; and (3) detection of therapeutic effects following an intervention.

Methods: An international expert panel for electrophysiological measures in SCI searched and discussed the literature focused on the topic.

Results: Electrophysiology represents a valid method to detect, track, and quantify readouts of nerve functions including signal conduction, e.g., evoked potentials testing long spinal tracts, and neural processing, e.g., reflex testing. Furthermore, electrophysiological measures can predict functional outcomes and thereby guide rehabilitation programs and therapeutic interventions for clinical studies.

Conclusion: Objective and quantitative measures of sensory, motor, and autonomic function based on electrophysiological techniques are promising tools to inform and improve future SCI trials. Complementing clinical outcome measures, electrophysiological recordings can improve the SCI diagnosis and patient stratification, as well as the detection of both beneficial and adverse events. Specifically composed electrophysiological measures can be used to characterize the topography and completeness of SCI and reveal neuronal integrity below the lesion, a prerequisite for the success of any interventional trial. Further validation of electrophysiological tools with regard to their validity, reliability, and sensitivity are needed in order to become routinely applied in clinical SCI trials.
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http://dx.doi.org/10.1038/s41393-019-0331-zDOI Listing
November 2019

Traumatic spinal cord injury in military personnel versus civilians: a propensity score-matched cohort study.

BMJ Mil Health 2020 Nov 31;166(E):e57-e62. Epub 2019 May 31.

Division of Physicial Medicine and Rehabilitation, Toronto Rehabilitation Institute - Lyndhurst Centre, Toronto, Ontario, Canada.

Introduction: Military personnel are exposed to mechanisms of bodily injuries that may differ from civilians. A retrospective cohort study (RCS) and a propensity score-matched cohort study (PSMCS) were undertaken to examine the potential differences in injury epidemiology, management and outcomes after spinal cord injury (SCI) between military personnel and civilians.

Methods: Using a Canadian multicentre SCI database, data of all individuals with sufficient data from October 2013 to January 2017 were included in the RCS (n=1043). In the PSMCS, a group of 50 military personnel with SCI was compared with a group of 50 civilians with SCI who were matched regarding sex, age, and level, severity and mechanism of SCI.

Results: In the RCS, military personnel with SCI (n=61) were significantly older and predominantl males when compared with civilians with SCI (n=982). However, the study groups were not statistically different with regards to their: level, severity and mechanisms of SCI; frequency of associated bodily injuries; and need for mechanical ventilation after SCI. In the PSMCS, the group of military individuals with SCI (n=50) was similar to the group of civilians with SCI (n=50) regarding pre-existing medical comorbidities, degree of motor impairment at admission, initial treatment for SCI and clinical and neurological outcomes after SCI.

Conclusions: The results of these studies suggest that military SCI group has disproportionally older men at the time of injury compared with civilians with SCI. However, the military and civilian SCI groups had similar outcomes of alike initial treatment when both groups were matched regarding their demographic profile and injury characteristics.
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http://dx.doi.org/10.1136/jramc-2019-001197DOI Listing
November 2020

Personalized adapted locomotor training for an individual with sequelae of West Nile virus infection: a mixed-method case report.

Physiother Theory Pract 2020 Jul 23;36(7):844-854. Epub 2018 Aug 23.

Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network , Toronto, ON, Canada.

Background: West Nile virus (WNV) can have severe consequences, including encephalitis and paralysis. : To describe the benefits of intensive locomotor training (LT) for an individual with a previous WNV infection resulting in chronic paraplegia. : The patient, who became a wheelchair user following standard rehabilitation, began LT 3 years post infection. Her goals included standing and walking with an assistive device and transferring independently. The intervention consisted of bodyweight-supported treadmill training and overground training, which involved walking, balancing, strengthening, and transferring activities. : Following 5 months of LT, the patient ambulated independently with a walker at a speed = 0.34m/s. She walked 110.1 metres in 6 minutes and increased her Berg Balance Scale score by 17 points. These improvements were either maintained or further increased 3 months post LT. The patient's perspectives on LT were collected through a semi-structured interview. A conventional content analysis, which uses data to drive themes, revealed three themes: (1) recalibrating goals, (2) outcomes (i.e. physical and psychological benefits, such as a sense of accomplishment), and (3) challenges of LT and effective coping strategies. : The patient demonstrated improved balance and walking abilities. Intensive LT was feasible and effective for this individual with chronic paraplegia due to WNV infection.
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http://dx.doi.org/10.1080/09593985.2018.1510450DOI Listing
July 2020

Economic Impact of Aging on the Initial Spine Care of Patients With Acute Spine Trauma: From Bedside to Teller.

Neurosurgery 2019 06;84(6):1251-1260

Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada.

Background: Aging of the population has prompted an escalation of service utilization and costs in many jurisdictions including North America. However, relatively little is known on the economic impact of old age on the management of acute spine trauma (AST).

Objective: To examine the potential effects of age on the service utilization and costs of the management of patients with acute spine trauma.

Methods: This retrospective cohort study included consecutive patients with AST admitted to an acute spine care unit of a Canadian quaternary university hospital between February, 2002 and September, 2007. The study population was grouped into elderly (≥65 yr) and younger individuals. All costing data were converted and updated to US dollars in June/2017.

Results: There were 55 women and 91 men with AST (age range: 16-92 yr, mean age of 49.9 yr) of whom 37 were elderly. The mean total hospital costs for initial admission after AST in the elderly (USD $19 338 ± $4892) were significantly greater than among younger individuals (USD $13 775 ± $1344). However, elderly people had significantly lower per diem total, fixed, direct, and indirect costs for AST than younger individuals. Both groups were comparable regarding the proportion of services utilized in the acute care hospital.

Conclusion: Given the escalating demand for surgical and nonsurgical spine treatment in the age of aging population, the timely results of this study underline key aspects of the economic impact of the spine care of the elderly. Further investigations are needed to fulfill significant knowledge gaps on the economics of caring for elderly with AST.
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http://dx.doi.org/10.1093/neuros/nyy180DOI Listing
June 2019

A scoping review on health economics in neurosurgery for acute spine trauma.

Neurosurg Focus 2018 05;44(5):E15

Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network; and.

OBJECTIVE Acute spine trauma (AST) has a relatively low incidence, but it often results in substantial individual impairments and societal economic burden resulting from the associated disability. Given the key role of neurosurgeons in the decision-making regarding operative management of individuals with AST, the authors performed a systematic search with scoping synthesis of relevant literature to review current knowledge regarding the economic burden of AST. METHODS This systematic review with scoping synthesis included original articles reporting cost-effectiveness, cost-utility, cost-benefit, cost-minimization, cost-comparison, and economic analyses related to surgical management of AST, whereby AST is defined as trauma to the spine that may result in spinal cord injury with motor, sensory, and/or autonomic impairment. The initial literature search was carried out using MEDLINE, EMBASE, CINAHL, CCTR, and PubMed. All original articles captured in the literature search and published from 1946 to September 27, 2017, were included. Search terms used were the following: (cost analysis, cost effectiveness, cost benefit, economic evaluation or economic impact) AND (spine or spinal cord) AND (surgery or surgical). RESULTS The literature search captured 5770 titles, of which 11 original studies met the inclusion/exclusion criteria. These 11 studies included 4 cost-utility analyses, 5 cost analyses that compared the cost of intervention with a comparator, and 2 studies examining direct costs without a comparator. There are a few potentially cost-saving strategies in the neurosurgical management of individuals with AST, including 1) early surgical spinal cord decompression for acute traumatic cervical spinal cord injury (or traumatic thoracolumbar fractures, traumatic cervical fractures); 2) surgical treatment of the elderly with type-II odontoid fractures, which is more costly but more effective than the nonoperative approach among individuals with age at AST between 65 and 84 years; 3) surgical treatment of traumatic thoracolumbar spine fractures, which is implicated in greater direct costs but lower general-practitioner visit costs, private expenditures, and absenteeism costs than nonsurgical management; and 4) removal of pedicle screws 1-2 years after posterior instrumented fusion for individuals with thoracolumbar burst fractures, which is more cost-effective than retaining the pedicle screws. CONCLUSIONS This scoping synthesis underscores a number of potentially cost-saving opportunities for neurosurgeons when managing patients with AST. There are significant knowledge gaps regarding the potential economic impact of therapeutic choices for AST that are commonly used by neurosurgeons.
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http://dx.doi.org/10.3171/2018.2.FOCUS17778DOI Listing
May 2018

Autonomic dysreflexia following acute myelitis due to neuromyelitis optica.

Authors:
Julio C Furlan

Mult Scler Relat Disord 2018 Jul 16;23:1-3. Epub 2018 Apr 16.

Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, 520 Sutherland Drive, Toronto, Ontario, M4G 3V9, Canada; Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Canada. Electronic address:

Background: Cardiovascular autonomic dysfunction is a relatively common secondary complication of tetraplegia. In addition to low baseline arterial blood pressure, tetraplegics can develop sudden-onset hypertensive episodes associated with a variety of symptoms and signs (so-called autonomic dysreflexia). Unfortunately, this potentially life-threatening medical entity is often overlooked and mismanaged. With this, a case of typical presentation of autonomic dysreflexia in an individual with acute severe cervical spinal cord impairment due to neuromyelitis optica (NMO) is reported and discussed.

Case Report: A 60-year-old, Asian woman developed a rapidly progressive tetraplegia associated with neurogenic bladder and bowel, and cardiovascular autonomic dysfunction due to NMO. In addition to low baseline blood pressure and orthostatic hypotension, the patient developed episodes of autonomic dysreflexia during the acute stage following C2 motor complete tetraplegia. The episodes of autonomic dysreflexia resolved after fecal disimpaction. Her blood pressure stabilized after fecal disimpaction, even though occasional, milder episodes of autonomic dysreflexia occurred during bowel routines in the acute and subacute stages after tetraplegia. Her cardiovascular function normalized as she also regained motor and sensory function in the chronic stage after initial flare of NMO.

Conclusions: This case report illustrates a clinically relevant, but still under-recognized cardiovascular autonomic complication of severe, cervical or high-thoracic spinal cord impairment due to NMO. In addition to low baseline blood pressure and orthostatic hypotension, the patient developed episodes of autonomic dysreflexia during the acute stage after tetraplegia. Autonomic dysreflexia requires early diagnosis and proper treatment in order to prevent severe complications or death. Greater awareness of this potentially life-threatening cardiovascular emergency of spinal cord impairment is needed among patients, caregivers, and healthcare professionals, including neurologists.
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http://dx.doi.org/10.1016/j.msard.2018.04.007DOI Listing
July 2018

Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist: Is Pregabalin Effective in the Treatment of Radiating Low Back Pain Into the Leg?

Am J Phys Med Rehabil 2018 09;97(9):e78-e80

From the Toronto Rehabilitation Institute, University Health Network, Toronto, Canada (SMA, JCF); and Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada (SLM, DK).

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http://dx.doi.org/10.1097/PHM.0000000000000944DOI Listing
September 2018

A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression.

Global Spine J 2017 Sep 5;7(3 Suppl):70S-83S. Epub 2017 Sep 5.

USC Spine Center, Los Angeles, CA, USA.

Study Design: Guideline development.

Objectives: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy.

Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the management of degenerative cervical myelopathy (DCM).

Results: Our recommendations were as follows: (1) "We recommend surgical intervention for patients with moderate and severe DCM." (2) "We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial nonoperative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve." (3) "We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically." (4) "Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above."

Conclusions: These guidelines will promote standardization of care for patients with DCM, decrease the heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.
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http://dx.doi.org/10.1177/2192568217701914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684840PMC
September 2017

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Rehabilitation.

Global Spine J 2017 Sep 5;7(3 Suppl):231S-238S. Epub 2017 Sep 5.

Thomas Jefferson University, Philadelphia, PA, USA.

Introduction: The objective of this study is to develop guidelines that outline the appropriate type and timing of rehabilitation in patients with acute spinal cord injury (SCI).

Methods: A systematic review of the literature was conducted to address key questions related to rehabilitation in patients with acute SCI. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the type and timing of rehabilitation. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest.

Results: Based on the findings from the systematic review, our recommendations were: (1) We suggest rehabilitation be offered to patients with acute spinal cord injury when they are medically stable and can tolerate required rehabilitation intensity (no included studies; expert opinion); (2) We suggest body weight-supported treadmill training as an option for ambulation training in addition to conventional overground walking, dependent on resource availability, context, and local expertise (low evidence); (3) We suggest that individuals with acute and subacute cervical SCI be offered functional electrical stimulation as an option to improve hand and upper extremity function (low evidence); and (4) Based on the absence of any clear benefit, we suggest not offering additional training in unsupported sitting beyond what is currently incorporated in standard rehabilitation (low evidence).

Conclusions: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions.
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http://dx.doi.org/10.1177/2192568217701910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684839PMC
September 2017

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role of Baseline Magnetic Resonance Imaging in Clinical Decision Making and Outcome Prediction.

Global Spine J 2017 Sep 5;7(3 Suppl):221S-230S. Epub 2017 Sep 5.

Thomas Jefferson University, Philadelphia, PA, USA.

Introduction: The objective of this guideline is to outline the role of magnetic resonance imaging (MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury (SCI).

Methods: A systematic review of the literature was conducted to address key questions related to the use of MRI in patients with traumatic SCI. This review focused on longitudinal studies that controlled for baseline neurologic status. A multidisciplinary Guideline Development Group (GDG) used this information, their clinical expertise, and patient input to develop recommendations on the use of MRI for SCI patients. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest."

Results: Based on the limited available evidence and the clinical expertise of the GDG, our recommendations were: (1) "We suggest that MRI be performed in adult patients with acute SCI prior to surgical intervention, when feasible, to facilitate improved clinical decision-making" (quality of evidence, very low) and (2) "We suggest that MRI should be performed in adult patients in the acute period following SCI, before or after surgical intervention, to improve prediction of neurologic outcome" (quality of evidence, low).

Conclusions: These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI.
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http://dx.doi.org/10.1177/2192568217703089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684845PMC
September 2017

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis.

Global Spine J 2017 Sep 5;7(3 Suppl):212S-220S. Epub 2017 Sep 5.

Thomas Jefferson University, Philadelphia, PA, USA.

Introduction: The objective of this study is to develop evidence-based guidelines that recommend effective, safe and cost-effective thromboprophylaxis strategies in patients with spinal cord injury (SCI).

Methods: A systematic review of the literature was conducted to address key questions relating to thromboprophylaxis in SCI. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest."

Results: Based on conclusions from the systematic review and expert panel opinion, the following recommendations were developed: (1) "We suggest that anticoagulant thromboprophylaxis be offered routinely to reduce the risk of thromboembolic events in the acute period after SCI;" (2) "We suggest that anticoagulant thromboprophylaxis, consisting of either subcutaneous low-molecular-weight heparin or fixed, low-dose unfractionated heparin (UFH) be offered to reduce the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with the use of adjusted-dose UFH, we suggest against this option;" (3) "We suggest commencing anticoagulant thromboprophylaxis within the first 72 hours after injury, if possible, in order to minimize the risk of venous thromboembolic complications during the period of acute hospitalization."

Conclusions: These guidelines should be implemented into clinical practice in patients with SCI to promote standardization of care, decrease heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.
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http://dx.doi.org/10.1177/2192568217702107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684841PMC
September 2017

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Use of Methylprednisolone Sodium Succinate.

Global Spine J 2017 Sep 5;7(3 Suppl):203S-211S. Epub 2017 Sep 5.

Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Introduction: The objective of this guideline is to outline the appropriate use of methylprednisolone sodium succinate (MPSS) in patients with acute spinal cord injury (SCI).

Methods: A systematic review of the literature was conducted to address key questions related to the use of MPSS in acute SCI. A multidisciplinary Guideline Development Group used this information, in combination with their clinical expertise, to develop recommendations for the use of MPSS. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest."

Results: The main conclusions from the systematic review included the following: (1) there were no differences in motor score change at any time point in patients treated with MPSS compared to those not receiving steroids; (2) when MPSS was administered within 8 hours of injury, pooled results at 6- and 12-months indicated modest improvements in mean motor scores in the MPSS group compared with the control group; and (3) there was no statistical difference between treatment groups in the risk of complications. Our recommendations were: (1) "We suggest not offering a 24-hour infusion of high-dose MPSS to adult patients who present after 8 hours with acute SCI"; (2) "We suggest a 24-hour infusion of high-dose MPSS be offered to adult patients within 8 hours of acute SCI as a treatment option"; and (3) "We suggest not offering a 48-hour infusion of high-dose MPSS to adult patients with acute SCI."

Conclusions: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in SCI patients.
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http://dx.doi.org/10.1177/2192568217703085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686915PMC
September 2017

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery.

Global Spine J 2017 Sep 5;7(3 Suppl):195S-202S. Epub 2017 Sep 5.

Department of Orthopedic Surgery, Jefferson Health, Thomas Jefferson University, Philadelphia, PA, USA.

Objective: To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome.

Methods: A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as "we recommend," whereas a weak recommendation is presented as "we suggest."

Results: Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at 6 and 12 months in patients managed with early versus late surgery; and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations were: "We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome" and "We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level." Quality of evidence for both recommendations was considered low.

Conclusions: These guidelines should be implemented into clinical practice to improve outcomes in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies, and encouraging clinicians to make evidence-informed decisions.
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http://dx.doi.org/10.1177/2192568217706367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684850PMC
September 2017

The Health Economics of the spinal cord injury or disease among veterans of war: A systematic review.

J Spinal Cord Med 2017 11 6;40(6):649-664. Epub 2017 Sep 6.

a Department of Medicine, Division of Physical Medicine and Rehabilitation , University of Toronto , Toronto , ON , Canada.

Context: Information on health-care utilization and the economic burden of disease are essential to understanding service demands, service accessibility, and practice patterns. This information may also be used to enhance the quality of care through altered resource allocation. Thus, a systematic review of literature on the economic impact of caring for SCI/D veterans would be of great value.

Objective: To systematically review and critically appraise the literature on the economics of the management of veterans with SCI/D.

Methods: Medline, EMBASE and PsycINFO databases were searched for articles on economic impact of management of SCI/D veterans, published from 1946 to September/2016. The STROBE statement was used to determine publication quality.

Results: The search identified 1,573 publications of which 13 articles fulfilled the inclusion/exclusion criteria with 12 articles focused on costs of management of SCI/D veterans; and, one cost-effectiveness analysis. Overall, the health care costs for the management of SCI/D veterans are substantial ($30,770 to $62,563 in 2016 USD per year) and, generally, greater than the costs of caring for patients with other chronic diseases. The most significant determinants of the higher total health-care costs are cervical level injury, complete injury, time period (i.e. first year post-injury and end-of-life year), and presence of pressure ulcers.

Conclusions: There is growing evidence for the economic burden of SCI/D and its determinants among veterans, whereas there is a paucity of comparative studies on interventions including cost-effectiveness analyses. Further investigations are needed to fulfill significant knowledge gaps on the economics of caring for veterans with SCI/D.
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http://dx.doi.org/10.1080/10790268.2017.1368267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778929PMC
November 2017
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