The Canadian Multicentre CSF Monitoring and Biomarker Study

This research project consists of two complementary yet distinct initiatives:

• First, we will prospectively evaluate spinal cord perfusion pressure(SCPP)in patients with acute spinal cord injuries, to provide scientifically-based guidelines on the management of blood pressure during the acute injury phase.
• Second, we will evaluate cerebrospinal fluid(CSF) samples from these patients with the goal of prospectively validating a series of biochemical markers that correlate with injury severity and predict neurologic outcome. Ultimately, our goals are to enhance the neurologic outcome of individuals with spinal cord injuries by improving upon their acute clinical care, and to establish biological surrogates of injury severity that may be used to facilitate clinical trials of novel therapeutic interventions for acute spinal cord injury.

Specific Aims

This multicenter study will enroll patients with acute traumatic cervical and thoracic SCI within 48 hours of their injury. A lumbar intrathecal catheter will be inserted pre-operatively for the measurement of intrathecal pressure (ITP) and the collection of CSF samples. Spinal cord perfusion pressure will be calculated as the difference between mean arterial pressure (MAP) and the ITP. The objectives of this aspect of the study will be to:

• Document the changes in SCPP over the first 5-7 days post-injury (with an intrathecal catheter that is in place for 5 days).
• Determine the effect of different vasopressor agents on SCPP.

Additionally, CSF samples will be obtained from the intrathecal catheter at 8-hour intervals to analyse the expression of the following biochemical markers: including interleukin (IL)-6, IL-8, monocyte chemo-attractant protein (MCP)-1, glial fibrillary acidic protein (GFAP), S100beta, and tau. The objectives of this aspect of the study will be to:

• Evaluate the accuracy of these inflammatory and neuronal markers at classifying the initial severity of paralysis and at predicting the extent of neurologic recovery.
• Characterize the temporal pattern of expression of these proteins to provide a more complete description of the human pathophysiology of SCI.

Inclusion criteria

• 17 years of age or older
• Complete (AIS A)or incomplete (AIS B, C) acute SCI involving bony spinal levels between C0 and L1
• Non-penetrating injury
• Able to communicate in English and provide informed consent
• Enrolled within 48 hours after injury and able to provide CSF and blood samples within this period

Exclusion criteria

• SCI that involves sensory impairment only (i.e., no impairment in ability to move arms and legs)
• Penetrating spinal cord injury
• Isolated radiculopathy (injury only to the nerve outside of the spinal cord)
• Cauda equina injury (injury to nerve roots at the end of the spinal cord)
• Severe injury to head at the time of the SCI
• Injury to lower back (below the spinal level L1)
• Major injury to legs, arms, pelvis, chest, or abdomen that make it impossible for doctors to tell how severely injured the spinal cord is
• Have a pre-existing neurological disorder such as Parkinson's disease, Alzheimer's disease, Huntington's disease, or multiple sclerosis or amyotrophic lateral sclerosis.
• Pre-existing thromboembolic disease or coagulopathy (disorders related to blood clotting), such as haemophilia or von Willebrand's disease
• Pre-existing and ongoing infection in the body (e.g., pneumonia, urinary tract infection, cellulitis)
• Pre-existing inflammatory or autoimmune disorder such as rheumatoid arthritis, systemic lupus, psoriasis
• Systemic disease that may interfere with safety or evaluation of the condition we're studying (e.g., heart disease, HIV, HTLV-1)
• Any other medical condition that in the investigator's opinion would render the study procedures dangerous or impair ability to receive study therapy
• Pregnancy