MirHojjat Khorasanizadeh, Mahmoud Yousefifard, Mahsa Eskian, Yi Lu, Maryam Chalangari, James S. Harrop, Seyed Behnam Jazayeri, Simin Seyedpour, Behzad Khodaei, Mostafa Hosseini and Vafa Rahimi-Movaghar
Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance.
A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis.
A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2–22.6) for patients with grade A, 73.8% (95% CI 69.0–78.4) for those with grade B, 87.3% (95% CI 77.9–94.8) for those with grade C, and 46.5% (95% CI 38.2–54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62–0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3–5 years) follow-ups.
The authors’ meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.
Mahmoud Yousefifard, Solmaz Nasseri Maleki, Shaghayegh Askarian-Amiri, Alexander R. Vaccaro, Jens R. Chapman, Michael G. Fehlings, Mostafa Hosseini and Vafa Rahimi-Movaghar
There is controversy about the role of scaffolds as an adjunctive therapy to mesenchymal stem cell (MSC) transplantation in spinal cord injury (SCI). Thus, the authors aimed to design a meta-analysis on preclinical evidence to evaluate the effectiveness of combination therapy of scaffold + MSC transplantation in comparison with scaffolds alone and MSCs alone in improving motor dysfunction in SCI.
Electronic databases including Medline, Embase, Scopus, and Web of Science were searched from inception until the end of August 2018. Two independent reviewers screened related experimental studies. Animal studies that evaluated the effectiveness of scaffolds and/or MSCs on motor function recovery following experimental SCI were included. The findings were reported as standardized mean difference (SMD) and 95% confidence interval (CI).
A total of 34 articles were included in the meta-analysis. Analyses show that combination therapy in comparison with the scaffold group alone (SMD 2.00, 95% CI 1.53–2.46, p < 0.0001), the MSCs alone (SMD 1.58, 95% CI 0.84–2.31, p < 0.0001), and the nontreated group (SMD 3.52, 95% CI 2.84–4.20, p < 0.0001) significantly improved motor function recovery. Co-administration of MSCs + scaffolds only in the acute phase of injury (during the first 3 days after injury) leads to a significant recovery compared to scaffold alone (SMD 2.18, p < 0.0001). In addition, the cotransplantation of scaffolds with bone marrow–derived MSCs (SMD 1.99, p < 0.0001) and umbilical cord–derived MSCs (SMD 1.50, p = 0.001) also improved motor function following SCI.
The findings showed that scaffolds + MSCs is more effective than scaffolds and MSCs alone in improving motor function following SCI in animal models, when used in the acute phase of injury.
Soheil Saadat, Seyed Mohammad Ghodsi, Kourosh Holakouie Naieni, Kavous Firouznia, Mostafa Hosseini, Hamid Reza Kadkhodaie and Hossein Saidi
The aim of this study was to develop a decision rule for physicians in developing countries to identify patients with minor head injury who will benefit from emergency brain CT scanning.
Three hundred eighteen patients with a history of blunt head trauma and a Glasgow Coma Scale (GCS) score ≥ 13 who had presented within 12 hours of trauma underwent nonenhanced brain CT and were included in this prospective study. Computed tomography findings that necessitated neurosurgical care (either observation or intervention) were considered as positive findings. Logistic regression was used to develop the decision rule.
Computed tomography scans were always normal in patients < 65 years old who did not have an obvious head wound, a raccoon sign, vomiting, memory deficit, or a decrease in their GCS score. Patients with 1 major criterion (GCS score < 14, raccoon sign, failure to remember the impact, age > 65 years, or vomiting) or 2 minor criteria (wound at the scalp or GCS score < 15) had an abnormal CT scan in 13% of the cases.
The decision rule developed by the authors appears to be 100% sensitive and 46% specific for positive findings on brain CT and will, in developing countries, help clarify the decision to obtain scans.