title: Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study.
abstract: OBJECTIVE A novel technique for monitoring intraspinal pressure and spinal cord perfusion pressure in patients with traumatic spinal cord injury was recently described. This is analogous to monitoring intracranial pressure and cerebral perfusion pressure in patients with traumatic brain injury. Because intraspinal pressure monitoring is a new technique, its safety profile and impact on early patient care and long-term outcome after traumatic spinal cord injury are unknown. The object of this study is to review all patients who had intraspinal pressure monitoring to date at the authors' institution in order to define the accuracy of intraspinal pressure probe placement and the safety of the technique. METHODS At the end of surgery to fix spinal fractures, a pressure probe was inserted intradurally to monitor intraspinal pressure at the injury site. Postoperatively, CT scanning was performed within 48 hours and MRI at 2 weeks and 6 months. Neurointensive care management and complications were reviewed. The American Spinal Injury Association Impairment Scale (AIS) grade was determined on admission and at 2 to 4 weeks and 12 to 18 months postoperation. RESULTS To date, 42 patients with severe traumatic spinal cord injuries (AIS Grades A-C) had undergone intraspinal pressure monitoring. Monitoring started within 72 hours of injury and continued for up to a week. Based on postoperative CT and MRI, the probe position was acceptable in all patients, i.e., the probe was located at the site of maximum spinal cord swelling. Complications were probe displacement in 1 of 42 patients (2.4%), CSF leakage that required wound resuturing in 3 of 42 patients (7.1%), and asymptomatic pseudomeningocele that was diagnosed in 8 of 42 patients (19.0%). Pseudomeningocele was diagnosed on MRI and resolved within 6 months in all patients. Based on the MRI and neurological examination results, there were no serious probe-related complications such as meningitis, wound infection, hematoma, wound breakdown, or neurological deterioration. Within 2 weeks postoperatively, 75% of patients were extubated and 25% underwent tracheostomy. Norepinephrine was used to support blood pressure without complications. Overall, the mean intraspinal pressure was around 20 mm Hg, and the mean spinal cord perfusion pressure was around 70 mm Hg. In laminectomized patients, the intraspinal pressure was significantly higher in the supine than lateral position by up to 18 mm Hg after thoracic laminectomy and 8 mm Hg after cervical laminectomy. At 12 to 18 months, 11.4% of patients had improved by 1 AIS grade and 14.3% by at least 2 AIS grades. CONCLUSIONS These data suggest that after traumatic spinal cord injury intradural placement of the pressure probe is accurate and intraspinal pressure monitoring is safe for up to a week. In patients with spinal cord injury who had laminectomy, the supine position should be avoided in order to prevent rises in intraspinal pressure.
authors.affiliation: Academic Neurosurgery Unit, St. George's, University of London; and.
authors.forename: Isaac
authors.initials: I
authors.lastname: Phang
authors.affiliation: Neurointensive Care Unit, St. George's Hospital, London, United Kingdom.
authors.forename: Argyro
authors.initials: A
authors.lastname: Zoumprouli
authors.affiliation: Academic Neurosurgery Unit, St. George's, University of London; and.
authors.forename: Samira
authors.initials: S
authors.lastname: Saadoun
authors.affiliation: Academic Neurosurgery Unit, St. George's, University of London; and.
authors.forename: Marios C
authors.initials: MC
authors.lastname: Papadopoulos
mesh_terms: D000328:Adult; D065634:Cerebrospinal Fluid Leak / Q000175:diagnosis / Q000209:etiology; D015170:Cerebrospinal Fluid Pressure; D005260:Female; D006801:Humans; D007796:Laminectomy / Q000379:methods; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis; D012720:Severity of Illness Index; D013116:Spinal Cord / Q000000981:diagnostic imaging; D013119:Spinal Cord Injuries / Q000175:diagnosis* / Q000188:drug therapy / Q000601:surgery; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
keywords: AIS = American Spinal Injury Association Impairment Scale; ASIA = American Spinal Injury Association; CPP = cerebral perfusion pressure; CPPopt = optimum cerebral perfusion pressure; ICP = intracranial pressure; ISP = intraspinal pressure; MAP = mean arterial pressure; NBD = Neurogenic Bowel Dysfunction; NICU = neurointensive care unit; SCIM III = Spinal Cord Independence Measure III; SCPP = spinal cord perfusion pressure; SCPPopt = optimum spinal cord perfusion pressure; TBI = traumatic brain injury; TSCI = traumatic spinal cord inury; WISCI II = Walking Index for Spinal Cord Injury; critical care; monitoring; paralysis; perfusion pressure; spinal cord injury; trauma