Duroplasty for Injured Cervical Spinal Cord With Uncontrolled Swelling (DISCUS)

QUESTION. Does duroplasty improve outcome after spinal cord injury?

WHAT DO WE STUDY? We will investigate whether performing a surgical procedure called duroplasty improves outcomes after spinal cord injury.

WHY SPINAL CORD INJURY? Spinal cord injury is a devastating condition that causes permanent disability such as paralysis, numbness and loss of bladder and bowel control. Currently, there are no treatments shown to improve outcome after spinal cord injury.

WHAT IS DUROPLASTY? Duroplasty is an operation that involves opening the tough membrane around the cord, called the dura, and stitching a patch of artificial dura to expand the space around the swollen cord.

WHY IS DUROPLASTY BEING STUDIED? Based on our preliminary evidence, we think that the dura causes cord pressure after injury. We have shown in a small study of patients that performing this operation safely and effectively reduces pressure on the injured cord.

WHO IS ELIGIBLE? Adult patients with severe spinal cord injuries in the neck who will have surgery within 72 hours.

WHAT TREATMENT? Those who agree to take part will be allocated by chance (like tossing a coin) to standard treatment or standard treatment plus duroplasty. Some patients will also be asked to take part in a smaller study that involves placing probes at the injury site.

WHERE? We will recruit patients from U.K. Major Trauma Centres. Most assessments will be done in U.K. Spinal Injury Centres. Later on, we may recruit from overseas.

HOW LONG? We aim to recruit 222 - 260 patients over 4 years. Patients will be followed up for a year.

WHAT DO WE ASSESS? Patients will be assessed (using questionnaires and by examination) how well they can use their hands, walk, control their bladder and bowel and their quality of life. Some of these assessments will be repeated at 3, 6 and 12 months after surgery.

WHAT IS THE OPTIONAL MECHANISTIC STUDY? DISCUS includes an optional study for at least 50 patients who will take part in the randomised controlled trial. The aim of the mechanistic study is to determine how duroplasty improves outcome, i.e. whether duroplasty reduces cord compression, improves blood flow to the injured cord perfusion, improves cord metabolism and reduces cord inflammation.

WHAT IS THE OPTIONAL INFORMATION STUDY? For the first two years, a study called QuinteT Recruitment Intervention (QRI) is designed to optimise patient recruitment and informed consent in the trauma setting.

Study Overview

• Status: Recruiting
• Conditions: Spinal Cord Injuries
• Intervention / Treatment: Procedure: Duroplasty; Procedure: Spinal surgery

Detailed Description

RESEARCH QUESTION: After severe traumatic spinal cord injury (TSCI), does the addition of dural decompression to bony decompression (includes laminectomy) improve muscle strength in the limbs at 6 months, compared with bony decompression alone? BACKGROUND: TSCI is a devastating condition that affects about 1,000 people in the UK annually. Most remain disabled, tetraplegic or wheelchair bound and are dependent on carers with significant cost to patients, carers and the NHS. Surgery aims to reduce spinal deformity, stabilise the spine and achieve bony decompression of the cord. To date, no treatments have been shown to improve outcome.

AIMS / OBJECTIVES: The primary aim is to determine if, in patients with acute, severe TSCI, the addition of dural decompression to bony decompression improves muscle strength. We hypothesise that, after TSCI, the cord swells and is compressed against the dura. Secondary objectives are to assess patient impact i.e. functional outcomes, health related quality of life (HRQoL), complication rates and mortality. Mechanistic sub-studies aim to determine if the addition of duroplasty improves cord perfusion, reduces cord ischaemia and cord inflammation.

METHODS: This is a prospective, phase III, multicentre randomised controlled trial (RCT). We aim to recruit 222 adults with acute, severe cervical TSCI (American spinal injuries association Impairment Scale (AIS) grade A, B or C) who will be randomised 1:1 to undergo bony decompression alone versus bony decompression with duroplasty. Patients and assessors will be blinded to study arm. The primary outcome is change in AIS motor score (AMS) at 6 months compared with admission (Delta-AMS); secondary outcomes will assess function (grasp, walking, urinary + anal sphincters), HRQoL, complications, need for further surgery and mortality, assessed at baseline, 3 months, 6 months and 12 months from randomisation. A subgroup of 50 patients (25 per arm) will also have observational monitoring from the injury site using a pressure probe (intraspinal pressure ISP, spinal cord perfusion pressure SCPP) and microdialysis (MD) catheter (cord metabolism: tissue glucose, lactate, pyruvate, lactate-to-pyruvate ratio (LPR), glutamate, glycerol); cord inflammation: tissue chemokines/cytokines. Patients will be recruited from the 26 UK major trauma centres (MTCs).

TIMELINES FOR DELIVERY: The study duration is 72 months and includes 6 months set-up, 48 months recruitment, 12 months to complete follow-up and 6 months for data analysis and final reporting of results. There will be a formal stop/go review at month 15 (after 9 months of recruitment) to ensure a minimum of 4 sites have been opened and 8 patients randomised. If these targets are met, the trial will recruit for a further 36 months. Data from the pilot will be included in the final analysis.

ANTICIPATED IMPACT AND DISSEMINATION: It is anticipated that the addition of duroplasty to standard of care will improve muscle strength in patients; this has obvious benefits for patients and their carers as well as substantial gains for the NHS and society including economic implications. If this RCT shows that the addition of duroplasty to standard treatment is beneficial, it is anticipated that duroplasty will become standard NHS care in all 26 UK MTCs. Participants will be informed of study findings via the Surgical Intervention Trials Unit (SITU) website and the Spinal Injuries Association (SIA).

• Study Type: Interventional
• Enrollment (Anticipated): 222
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Melody Chin; Phone Number: 079 17100953; Email: discus@nds.ox.ac.uk
• Study Contact Backup: Name: Nirusha Pathmanathan; Email: npathman@sgul.ac.uk

Study Locations

• United Kingdom
  • London, United Kingdom, SW17 0QT
    • Recruiting
    • St George's Hospital NHS Foundation Trust
    • Contact: Marios C Papadopoulos, MD; Phone Number: 02087254179; Email: mpapadop@sgul.ac.uk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Age ≥16 years
2. Severe cervical (C2 - T1) traumatic spinal cord injury (AIS grade A-C)
3. Deemed to require and be suitable for surgery that includes laminectomy by local surgeon
4. Surgery within 72 hours of traumatic spinal cord injury
5. Able to provide informed consent or consultee declaration or proxy consent.

Exclusion Criteria:

1. Dural tear due to traumatic spinal cord injury
2. Life-limiting or rehabilitation-restricting co-morbidities
3. Thoracic or lumbar traumatic spinal cord injury
4. Other central nervous system disease

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Duroplasty; Duroplasty (includes Surgery with Laminectomy)	Procedure: Duroplasty; Expansion Duroplasty; Procedure: Spinal surgery; Spinal surgery including laminectomy
Active Comparator: No duroplasty; No duroplasty (but includes surgery with Laminectomy)	Procedure: Spinal surgery; Spinal surgery including laminectomy

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in AIS motor score	Change in American Spinal Injury Association Impairment Scale total limb motor score at 6 months	6 months versus baseline

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in AIS light touch score	Change in American Spinal Injury Association Impairment Scale total light touch sensory score	6 months versus baseline
Change in AIS pin prick score	Change in American Spinal Injury Association Impairment Scale total pin prick sensory score	6 months versus baseline
Change in AIS grade	Change in American Spinal Injury Association grade	6 months versus baseline
CUE-Q	Capabilities of upper extremity-questionnaire (CUE-Q)	6 months
Grip strength	Hand grip strength assessed with dynamometer	6 months
WISCI II	Walking Index for Spinal Cord Injury version ii	6 months
SCIM III	Spinal Cord Independence Measure version III	6 months
SF-36	Short Form survey 36	3 months, 6 months, 12 months
Spinal re-operations	Number of reoperations on spine	12 months
Adverse events	Procedure Specific complications and adverse events	12 months
Mortality	Mortality	12 months
Length of hospital stay	Length of hospital stay	12 months
MRI	Magnetic resonance imaging of cervical spine	2 weeks, 6 months
Injury site physiology and metabolism (optional)	Optional mechanistic study: Mean daily intraspinal pressure, spinal cord perfusion pressure, tissue glucose, lactate, pyruvate, glycerol, glutamate, cytokines measured from the injury site	Up to 5 days after surgery

Collaborators and Investigators

• Sponsor: St George's, University of London
• Collaborators: University of Oxford; Ohio State University; University of Bristol; University of Cambridge; St George's University Hospitals NHS Foundation Trust; Buckinghamshire Healthcare NHS Trust; St. Mary's University, Twickenham
• Investigators: Principal Investigator: Marios C Papadopoulos, St George's, University of London, U.K.; Principal Investigator: Samira Saadoun, St George's, University of London, U.K.

Publications and helpful links

General Publications

• Werndle MC, Saadoun S, Phang I, Czosnyka M, Varsos GV, Czosnyka ZH, Smielewski P, Jamous A, Bell BA, Zoumprouli A, Papadopoulos MC. Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study*. Crit Care Med. 2014 Mar;42(3):646-55. doi: 10.1097/CCM.0000000000000028.
• Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC. Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study. J Neurotrauma. 2015 Jun 15;32(12):865-74. doi: 10.1089/neu.2014.3668. Epub 2015 May 4.
• Phang I, Zoumprouli A, Papadopoulos MC, Saadoun S. Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury. Ann Neurol. 2016 Oct;80(4):522-31. doi: 10.1002/ana.24750. Epub 2016 Aug 19.
• Saadoun S, Papadopoulos MC. Acute, Severe Traumatic Spinal Cord Injury: Monitoring from the Injury Site and Expansion Duraplasty. Neurosurg Clin N Am. 2021 Jul;32(3):365-376. doi: 10.1016/j.nec.2021.03.008. Epub 2021 May 7.

Helpful Links

• DISCUS NIHR Research Award
• DISCUS ISRCTN registry

Study record dates

Study Major Dates

• Study Start (Actual): October 8, 2021
• Primary Completion (Anticipated): January 8, 2026
• Study Completion (Anticipated): October 8, 2026

Study Registration Dates

• First Submitted: June 21, 2021
• First Submitted That Met QC Criteria: June 21, 2021
• First Posted (Actual): June 23, 2021

Study Record Updates

• Last Update Posted (Actual): October 27, 2022
• Last Update Submitted That Met QC Criteria: October 26, 2022
• Last Verified: October 1, 2022

More Information

Terms related to this study

• Keywords: Decompression, surgical; Neurosurgery; Paralysis
• Additional Relevant MeSH Terms: Central Nervous System Diseases; Nervous System Diseases; Wounds and Injuries; Trauma, Nervous System; Spinal Cord Diseases; Spinal Cord Injuries
• Other Study ID Numbers: 2021.0056; 25573423 (Registry Identifier: ISRCTN)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes

IPD Plan Description

Appropriately anonymised datasets from our sponsored research will be made available for further analysis wherever possible under our Research Data Management policy:

https://www.sgul.ac.uk/about/governance/policies/research-data-management

• IPD Sharing Time Frame: Publications on this study will be available form PubMed, Study website and other publicly accessible resources.
• IPD Sharing Access Criteria: Specific requests for data sharing should be directed to sponsor St George's University London.
• IPD Sharing Supporting Information Type: Study Protocol; Clinical Study Report (CSR)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No