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

Isaac Phang, Melissa C Werndle, Samira Saadoun, Georgios Varsos, Marek Czosnyka, Argyro Zoumprouli, Marios C Papadopoulos, Isaac Phang, Melissa C Werndle, Samira Saadoun, Georgios Varsos, Marek Czosnyka, Argyro Zoumprouli, Marios C Papadopoulos

Abstract

We recently showed that, after traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression. This is an open label, prospective trial comparing combined bony and dural decompression versus laminectomy. Twenty-one patients with acute severe TSCI had re-alignment of the fracture and surgical fixation; 11 had laminectomy alone (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy+duroplasty group). Primary outcomes were magnetic resonance imaging evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy+duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group. Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. We conclude that, after TSCI, laminectomy+duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy alone.

Keywords: decompression; duroplasty; perfusion pressure; spinal cord injury.

Figures

FIG. 1.
FIG. 1.
Duroplasty technique and computed tomography (CT)/magnetic resonance imaging (MRI). (A) Left: Exposed dura after laminectomy. Middle: Durotomy held open with forceps showing injured spinal cord and intraspinal pressure (ISP) probe. Right: Sutured dural patch. (B) Pre-operative T2 MRI showing high signal at site of traumatic spinal cord injury. (C) Post-operative (left) CT showing ISP probe and (right) T2 MRI showing duroplasty. Color image is available online at www.liebertpub.com/neu
FIG. 2.
FIG. 2.
Duroplasty increases space round the injured spinal cord. (A) T2 magnetic resonance imaging (MRI; top) before and after laminectomy, and (middle) before and after laminectomy+duroplasty, showing mid-sagittal anteroposterior diameter of the most compressed part of the dura (Di), the anteroposterior diameter of the mid-vertebral dura above the level of injury (Da), and the anteroposterior diameter of the mid-vertebral dura below the level of injury (Db). (Bottom) Percent increase in Di after laminectomy versus laminectomy+duroplasty. Points are patients, lines are means. (B) Top: Post-operative T2 magnetic resonance imaging (MRI) looking for cerebrospinal fluid (CSF) round the injured cord. Bottom: Numbers of patients with and without CSF around the injured cord. (C) Post-operative T2 MRI looking for expansion of the injured cord into the duroplasty. (D) T2 MRI in an American Spinal Injury Association A patient (left) before surgery, (middle) at two weeks after surgery (arrow shows pseudomeningocele), and (right) at six months after surgery (no pseudomeningocele). LAMI, laminectomy; LAMI+DURO, laminectomy+duroplasty. p<0.05*, 0.01**.
FIG. 3.
FIG. 3.
Intraspinal pressure (ISP) and spinal cord perfusion pressure (SCPP). (A) Representative ISP waveform showing percussion (P1), tidal (P2) and dicrotic (P3) peaks. (B) Mean four-hourly ISP of laminectomy, and laminectomy+duroplasty patients. (C) Cumulative frequency curve of ISP. (D) Mean four-hourly SCPP of laminectomy and duroplasty patients. (E) Cumulative frequency curve of SCPP. Laminectomy (open circles, n=11); laminectomy+duroplasty (closed circles, n=9), Mean±standard error. LAM, laminectomy; LAMI+DURO, laminectomy+duroplasty. p<0.05*, 0.01**.
FIG. 4.
FIG. 4.
Vascular pressure reactivity index (sPRx). (A) Representative intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), and sPRx. (a) ISP constant high, SCPP rises, sPRx falls; (b) ISP constant high; SCPP constant low; sPRx constant high; (c) ISP low; SCPP high; sPRx low (for explanation, see text). (B) sPRx after laminectomy+duroplasty and after laminectomy. The SCPP that produces the best spinal cord pressure reactivity (SCPPopt) corresponds to minimum sPRx. Points are patients, lines are means. (C) Mean sPRx vs. SCPP after laminectomy and after laminectomy+duroplasty. (D) sPRx vs. SCPP for two patients (Patient 1 SCPPopt=70 mm Hg; Patient 2 SCPPopt=100 mm Hg). (E) SCPPopt of individual laminectomy (open circles) and laminectomy+duroplasty (closed circles) patients. Laminectomy (open circles, n=11); laminectomy+duroplasty (closed circles, n=7). LAMI, laminectomy; LAMI+DURO, laminectomy+duroplasty. p<0.01**.
FIG. 5.
FIG. 5.
Intraspinal pressure (ISP) and spinal cord perfusion pressure (SCPP) in supine vs. lateral patient position after laminectomy+duroplasty. (A) Representative ISP and corresponding SCPP recorded from a patient lying supine or laterally (i.e., lying on left or right side). Recorded signal (gray line), mean (black line). (B) Mean daily difference between supine and side positions for ISP (ISPsup – ISPlat) and SCPP (SCPPsup – SCPPlat) plotted against days since surgery. n=9; mean±standard error.
FIG. 6.
FIG. 6.
Outcomes after laminectomy vs. laminectomy+duroplasty at follow-up. (A) Change in American Spinal Injury Association grade (at follow-up minus at presentation). (B) Walking Index for Spinal Cord Injury (WISCI II). (C) Spinal Cord Independence Measure (SCIM III) bladder. (D) SCIM III bowel.

References

    1. Cripps R.A., Lee B.B., Wing P., Weerts E., Mackay J., and Brown D. (2011). A global map for traumatic spinal cord injury epidemiology: towards a living data repository for injury prevention. Spinal Cord 49, 493–501
    1. Curt A., Van Hedel H.J., Klaus D., and Dietz V. (2008). Recovery from a spinal cord injury: significance of compensation, neural plasticity, and repair. J. Neurotrauma 25, 677–685
    1. Kornblith L.Z., Kutcher M.E., Callcut R.A., Redick B.J., Hu C.K., Cogbill T.H., Baker C.C., Shapiro M.L., Burlew C.C., Kaups K.L., DeMoya M.A., Haan J.M., Koontz C.H., Zolin S.J., Gordy S.D., Shatz D.V., Paul D.B., and Cohen M.J; Western Trauma Association Study Group. (2013). Mechanical ventilation weaning and extubation after spinal cord injury: a Western Trauma Association multicenter study. J. Trauma Acute Care Surg. 75, 1060–1069
    1. Cao Y., Chen Y., and DeVivo M. (2011). Lifetime direct costs after spinal cord injury. Topics Spinal Cord Inj. Rehabil. 16, 10–16
    1. Werndle M.C., Zoumprouli A., Sedgwick P., and Papadopoulos M.C. (2012). Variability in the treatment of acute spinal cord injury in the United Kingdom: results of a national survey. J. Neurotrauma 29, 880–888
    1. Fehlings M.G., Rabin D., Sears W., Cadotte D.W., and Aarabi B. (2010). Current practice in the timing of surgical intervention in spinal cord injury. Spine (Phila Pa 1976) 35(21 Suppl), S166–S173
    1. Walters B.C., Hadley M.N., Hurlbert R.J., Aarabi B., Dhall S.S., Gelb D.E., Harrigan M.R., Rozelle C.J., Ryken T.C., and Theodore N.; American Association of Neurological Surgeons; Congress of Neurological Surgeons. (2013). Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery 60 Suppl 1, 82–91
    1. Werndle M.C., Saadoun S., Phang I., Czosnyka M., Varsos G.V., Czosnyka Z.H., Smielewski P., Jamous A., Bell B.A., Zoumprouli A., and Papadopoulos M.C. (2014). Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study*. Crit. Care Med. 42, 646–655
    1. Ropper A.H. (2014). Management of raised intracranial pressure and hyperosmolar therapy. Pract. Neurol. 14, 152–158
    1. van Middendorp J.J., Hosman A.J.F., and Doi S.A.R. (2013). The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J. Neurotrauma 30, 1781–1794
    1. Fehlings M.G., Vaccaro A., Wilson J.R., Singh A.W., Cadotte D., Harrop J.S., Aarabi B., Shaffrey C., Dvorak M., Fisher C., Arnold P., Massicotte E.M., Lewis S., and Rampersaud R. (2012). Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One 7(2): e32037.
    1. Huang X. and Wen L. (2010). Technical considerations in decompressive craniectomy in the treatment of traumatic brain injury. Int. J. Med. Sci. 7, 385–390
    1. Kirshblum S.C., Waring W., Biering-Sorensen F., Burns S.P., Johansen M., Schmidt-Read M., Donovan W., Graves D., Jha A., Jones L., Mulcahey M.J., and Krassioukov A. (2011). Reference for the 2011 revision of the International Standards for Neurological Classification of Spinal Cord Injury. J. Spinal Cord Med. 34, 547–554
    1. Czosnyka M. and Pickard J.D. (2004). Monitoring and interpretation of intracranial pressure. J. Neurol. Neurosurg. Psychiatry 75, 813–821
    1. Ditunno J.F, Jr., Ditunno P.L., Graziani V., Scivoletto G., Bernardi M., Castellano V., Marchetti M., Barbeau H., Frankel H.L., D'Andrea Greve J.M., Ko H.Y., Marshall R., and Nance P. (2001). Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study. Spinal Cord 38, 234–243
    1. Ackerman P., Morrison S.A., McDowell S., and Vazquez L. (2010). Using the Spinal Cord Independence Measure III to measure functional recovery in a post-acute spinal cord injury program. Spinal Cord 48, 380–387
    1. Rowland J.W., Hawryluk G.W., Kwon B., and Fehlings M.G. (2008). Current status of acute spinal cord injury pathophysiology and emerging therapies: promise on the horizon. Neurosurg. Focus 25, E2.
    1. Martirosyan N.L., Feuerstein J.S., Theodore N., Cavalcanti D.D., Spetzler R.F., and Preul M.C. (2011). Blood supply and vascular reactivity of the spinal cord under normal and pathological conditions. J. Neurosurg. Spine 15, 238–251
    1. Steiner L.A., Czosnyka M., Piechnik S.K., Smielewski P., Chatfield D., Menon D.K., and Pickard J.D. (2002). Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit. Care Med. 30, 733–738
    1. Timofeev I., Czosnyka M., Nortje J., Smielewski P., Kirkpatrick P., Gupta A., and Hutchinson P. (2008). Effect of decompressive craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury. J. Neurosurg. 108, 66–73
    1. Papadopoulos M.C. and Verkman A.S. (2012). Aquaporin 4 and neuromyelitis optica. Lancet Neurol. 11, 535–44
    1. Perkins P. and Deane R. (1998). Long-term follow-up of six patients with acute spinal injury following dural decompression. Injury 19, 397–401
    1. Jone C.F., Newell R.S., Lee J.H., Cripton P.A., and Kwon B.K. (2012). The pressure distribution of cerebrospinal fluid responds to residual compression and decompression in an animal model of acute spinal cord injury. Spine (Phila Pa 1976) 37, E1422–E431
    1. Awwad W., Bassi M., Shrier I., Al-Ahaideb A., Steele R.J., and Jarzem P.F. (2014). Mitigating spinal cord distraction injuries: the effect of durotomy in decreasing cord interstitial pressure in vitro. Eur. J. Orthop. Surg. Traumatol. 24 Suppl 1, S261–S267
    1. Smith J.S., Anderson R., Pham T., Bhatia N., Steward O., and Gupta R. (2010). Role of early surgical decompression of the intradural space after cervical spinal cord injury in an animal model. J. Bone Joint Surg. Am. 92, 1206–1214
    1. Iannotti C., Zhang Y.P., Shields L.B., Han Y., Burke D.A., Xu X.M., and Shields C.B. (2006). Dural repair reduces connective tissue scar invasion and cystic cavity formation after acute spinal cord laceration injury in adult rats. J. Neurotrauma 23, 853–865
    1. Fernandez E. and Pallini R. (1985). Connective tissue scarring in experimental spinal cord lesions: significance of dural continuity and role of epidural tissues. Acta Neurochir. (Wien) 76, 145–148

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner