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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.

Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC - J. Neurotrauma (2015)

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom .

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.

No MeSH data available.


Related in: MedlinePlus

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**.
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f4: 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**.

Mentions: Representative ISP, SCPP, and sPRx signals recorded simultaneously from one patient are shown in Figure 4A. The signals are divided into three intervals: a, b and c. In a, there is a sudden increase in SCPP without any change in ISP (indicating increased spinal cord perfusion due to a rise in MAP), which is accompanied by a decrease in sPRx (i.e., improved spinal cord pressure reactivity). In b, there is a progressive increase in ISP and decrease in SCPP (probably indicating increasing compression of the injured, swollen spinal cord against the surrounding dura), which is associated with a rise in sPRx (i.e., impaired pressure reactivity). In c, ISP falls and SCPP rises (i.e., reduced spinal cord swelling and improved spinal cord perfusion) associated with a fall in sPRx (i.e., improvement in spinal cord pressure reactivity). For each patient, we averaged sPRx over the entire monitoring period. Compared with the laminectomy group, the laminectomy+duroplasty group had significantly lower average sPRx (i.e., improved spinal cord vascular pressure reactivity; Fig. 4B). There was a U-shaped relationship between sPRx and SCPP for the laminectomy+duroplasty group, as well as the laminectomy group (Fig. 4C). The SCPP at the minimum sPRx (i.e., the SCPP that produces the best spinal cord pressure reactivity) is termed SCPPopt. Figure 4D shows that SCPPopt=∼90 mm Hg for the laminectomy as well as the laminectomy+duroplasty groups. For SCPP 50-110 mm Hg, the sPRx of the laminectomy+duroplasty group is lower than the corresponding sPRx of the laminectomy group. At high SCPP (>110 mm Hg), the sPRx of the laminectomy+duroplasty group is higher than the corresponding sPRx of the laminectomy group. Figure 4D shows the relationship between sPRx versus SCPP for two laminectomy patients (Patient 1, Patient 2). The large difference in SCPPopt between Patient 1 and Patient 2 (70 and 100 mm Hg) suggests high inter-patient variability in SCPPopt. We, therefore, plotted SCPPopt for individual laminectomy as well as laminectomy+duroplasty patients. Two laminectomy+duroplasty patients who did not have a U-shaped relationship between sPRx versus SCPP were excluded. SCPPopt varied between 60-120 mm Hg between patients, with the group average at ∼90 mm Hg.


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.

Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC - J. Neurotrauma (2015)

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**.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4492612&req=5

f4: 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**.
Mentions: Representative ISP, SCPP, and sPRx signals recorded simultaneously from one patient are shown in Figure 4A. The signals are divided into three intervals: a, b and c. In a, there is a sudden increase in SCPP without any change in ISP (indicating increased spinal cord perfusion due to a rise in MAP), which is accompanied by a decrease in sPRx (i.e., improved spinal cord pressure reactivity). In b, there is a progressive increase in ISP and decrease in SCPP (probably indicating increasing compression of the injured, swollen spinal cord against the surrounding dura), which is associated with a rise in sPRx (i.e., impaired pressure reactivity). In c, ISP falls and SCPP rises (i.e., reduced spinal cord swelling and improved spinal cord perfusion) associated with a fall in sPRx (i.e., improvement in spinal cord pressure reactivity). For each patient, we averaged sPRx over the entire monitoring period. Compared with the laminectomy group, the laminectomy+duroplasty group had significantly lower average sPRx (i.e., improved spinal cord vascular pressure reactivity; Fig. 4B). There was a U-shaped relationship between sPRx and SCPP for the laminectomy+duroplasty group, as well as the laminectomy group (Fig. 4C). The SCPP at the minimum sPRx (i.e., the SCPP that produces the best spinal cord pressure reactivity) is termed SCPPopt. Figure 4D shows that SCPPopt=∼90 mm Hg for the laminectomy as well as the laminectomy+duroplasty groups. For SCPP 50-110 mm Hg, the sPRx of the laminectomy+duroplasty group is lower than the corresponding sPRx of the laminectomy group. At high SCPP (>110 mm Hg), the sPRx of the laminectomy+duroplasty group is higher than the corresponding sPRx of the laminectomy group. Figure 4D shows the relationship between sPRx versus SCPP for two laminectomy patients (Patient 1, Patient 2). The large difference in SCPPopt between Patient 1 and Patient 2 (70 and 100 mm Hg) suggests high inter-patient variability in SCPPopt. We, therefore, plotted SCPPopt for individual laminectomy as well as laminectomy+duroplasty patients. Two laminectomy+duroplasty patients who did not have a U-shaped relationship between sPRx versus SCPP were excluded. SCPPopt varied between 60-120 mm Hg between patients, with the group average at ∼90 mm Hg.

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom .

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.

No MeSH data available.


Related in: MedlinePlus