With this, we're going to start our abstract presentation. I would like to ask Dr. DiGiorgio to the podium. He will present aggressive surgical treatment and critical care associated with improving neurological recovery in spinal cord injury. Hi, my name is Anthony DiGiorgio. I'm a PGY-6 here at LSU New Orleans. Pretty humbling to be following Dr. Benzel on such an incredible talk. I hope my little study can do this podium some justice. So this was a project that was undertaken during my research here. I spent some time at UCSF. I was fortunate enough to be allowed to participate in their TRAC-SCI study. So this is some of their early data from that. And I'll get into the TRAC-SCI further shortly. This is partially funded by a DoD grant and the Craig Nielsen Foundation. So I have no personal disclosures, though. I don't need to belabor the point about how devastating complete spinal cord injury is. We just heard Dr. Benzel eloquently describe that. Historically, the rates of conversion for ASIA-A or complete spinal cord injury have been about 5% to 30%. And it really depends on what literature you look at. The conversion rates are actually kind of all over the map if you look at some of them. And this study was from the JNS Spine a few months ago, a meta-review or meta-analysis of 1,100 patients and showed that, overall, they found about a 28.1% conversion rate. They also did find that early surgery, less than 24 hours from injury, had a higher conversion rate or higher improvement rate among the complete spinal cord injuries. And that's a point I'll kind of touch on as well. However, they were comparing both observational and randomized control trials, and they were going as far back as 1997 with the VCARO trial, including trials up until the present. And again, the rates of conversion were sort of all over the map. And a lot of the observational studies had a lot higher conversion rates, some as high as even 70%. So, that other point, does early surgery improve outcomes? This has been sort of looked at in a number of different ways, a number of different trials, and the results are still inconclusive. And I think if you talk to enough people, you'll get plenty of differing opinions, as Dr. Benzel also showed. Some studies that show that early surgery improves outcomes and some studies that don't. And then the definition of early surgery kind of varies as well. Some people consider 24 hours, 72 hours, et cetera. So, what is TRACK-SCI? Many of you may be familiar with the TRACK-TBI program, which also came out of UCSF's trauma hospital. TRACK-SCI is simply the spinal cord injury equivalent of that, transforming research and clinical knowledge in spinal cord injury. It's a treatment protocol and a prospective database or registry based out of the UCSF Brain and Spinal Injury Center. So, the standard protocol involves CT and MRI imaging. They actually have a basic score that they use for their MRI imaging of the spinal cord. They do pressure support in all these patients, elevating the MAPs greater than 85. Mechanical ventilation, ICU management, intensive ICU management by a dedicated intensivist. Prompt surgery, they like to do it within 12 hours, if possible. Early DVT prophylaxis within 24 hours with Lovenox or Noxaparin. They do biomarker collection. They collect blood biomarkers as well as intraoperative motor evoked potentials which they use as a biomarker for potential recovery as well. And then they do standardized INSCE exams on all the patients at set time points. These patients are, again, prospectively collected, consent informed. Right now it is at two sites, at UCSF Fresno and at UCSF. Briefly, this has been a point that I think has been touched on a lot in this meeting versus randomized control trials. Randomized control trials, we all know, are the gold standard, but registries have a lot of real-world applicability as well. They cover all patients. They're not typically exclusionary and they reflect real-life practice patterns. I mentioned about 50 different things that they do in the TRACK-SCI protocol. It would be tough to tease out any single one of those in a randomized control trial. A trial to test any one of those treatments to patients, whereas a registry, you can do all these things and see the overall improvement in patients. For the preliminary data presented here, we simply mined the database and looked at all patients presenting with ASIA-A or complete spinal cord injury. I wanted to look specifically at the admission and discharge ASIA scores as well as their time to intervention, keeping it simple. Here are the overall totals. There are 27 ASIA-A patients. Wide variety in the age, 19 to 87 years old. Large amount of variability in injury or severity score. The time to operating room, 12 to 96 hours. Injury level, cervical and thoracolumbar. You can see just with their standard SCI protocol, they had about a 55% conversion rate from ASIA-A, which is better than most of the reported rates in the literature. If you dig deeper, again, that time to OR, the patients that are operated on within 12 hours from injury, actually had almost a 90% improvement rate in their ASIA scores. Again, this subgroup analysis is a pretty small total number, but this did reach statistical significance. The injury severity scores and the ASIAs among the two groups were pretty well matched. There were a few more thoracolumbar patients in the greater than 12-hour group and none in the less than 12-hour group. There's a potential for some bias there. Again, there's also, of course, potential for selection bias in this. This is a retrospective look at this data. Even though it's prospectively collected, it is retrospective data in that there may be a reason why these patients are operated on later, if they're sick or what have you, although the injury severity score did not necessarily point to that. As I said, there are significant limitations. This is just some of the early data out of the TRAC-SCI. It is a pretty small sample size. It is a retrospective review. It is prospectively gathered, but it is retrospectively reviewed. There are some significant limitations. In conclusion, I think that applying all these protocols and having aggressive SCI management can actually lead to better rates. Maybe we should start looking at more and more literature on what we can expect from these patients when they arrive with complete spinal cord injuries. Regardless, if it's devastating, I think there is more chance for the recovery than we generally give credit for for these patients. Surgical intervention within 12 hours, not within 24, but actually within 12 hours, may actually improve your rates of AJA recovery even further than previously reported. I have to acknowledge, of course, the UCSF folks that were kind enough to host me. In my own program, of course, my chairman was Dr. Clicky. It was wonderful enough to let me go spend some time there. Thank you very much for your time. Applause Applause Are there any questions from the audience? I have a question for you because when I think about intensive ICU management, the first thing that comes to me is MAP. Can I ask the audience who has a MAP goal for his spinal cord injury patients? Can I see the hands? Who keeps it on for three days? And are there people who keep it on for a week? So the majority for a week. What is the standard in a track spinal cord injury? For a week, yes. Thank you. Question. So you said the recovery is one level. What does that mean from the practical, functional point of view? Right, so you're right. An AJA to AJA B is really not that meaningful for the patient. So you're right. That needs to be teased down more because you really want to be looking at at least an AJA C improvement or D to make a difference in the patient's life. So we can sort of focus more on the avoidance of complications and early recovery, early discharge, early transfer which are, I think, potentially real points that we can prove, make real changes to the patients and also help hospitals actually deal with the trauma load. Yeah, absolutely. I agree. Thanks. These weren't randomized, right? These were just prospectively collected. So, I mean, I think all of us have seen people who are AJA initially within 12 hours and if they don't get operated on convert spontaneously to AJA B's or C's and so, you know, when you see somebody at less than 24 hours how do you know that they're really AJA A's and they aren't going to be like an AJA B within 24 hours kind of thing? How do you tease apart those particular patients to really differentiate and understand whether or not your decompression is improving or whether they would have spontaneously improved anyway? Ideally, you would have some idea about spinal shock usually with the bulbocavernosis reflex but these were standardized INSCE exams performed by, I think, two or three specialists that were trained in performing the INSCE exam on arrival and then at multiple time points along the way. But I think that point is a good one because the difference between AJA A and AJA B on arrival may be a rectal exam that was completed by a trauma intern or it may be a patient was in spinal shock and a bulbocavernosis wasn't checked and I think that may explain why some of the data from the historical studies are kind of all over the place is that we may not be categorizing AJA A's correctly. So are you, in your studies, were you assessing bulbocavernosis? I didn't take part in the actual studies but I do believe that as part of the INSCE exam that they did but I would have to double check on that to get back to you. Thank you.

spinal cord injury

TRAC-SCI study

early surgery

neurological recovery

aggressive management