Spontaneous spinal cord infarction: a systematic review

Background and objectives Spontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes. Methods The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords ‘spontaneous’, ‘spinal cord’, ‘infarction’ and ‘ischaemic’. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed. Results 440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids. Conclusion The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research to establish diagnostic criteria and treatment guidelines.

In the "databases and search strategy" section of methods Search strategy 7 Present the full search strategies for all databases, registers and websites, including any filters and limits used.
"Supplementary file 2" and in the "databases and search strategy" section of methods

Selection process
8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.
In the "study selection" section of methods

Data collection process
9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.
In the "data extraction" section of methods

Data items 10a
List and define all outcomes for which data were sought.Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.
In the "data extraction" section of methods

Section and Topic
Item # Checklist item Location where item is reported 10b List and define all other variables for which data were sought (e.g.participant and intervention characteristics, funding sources).Describe any assumptions made about any missing or unclear information.
In the "data extraction" section of methods

Study risk of bias assessment
11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.
In the "data synthesis and risk of bias assessment" section of methods

Effect measures
12 Specify for each outcome the effect measure(s) (e.g.risk ratio, mean difference) used in the synthesis or presentation of results.
In the "data synthesis and risk of bias assessment" section of methods

Synthesis methods
13a Describe the processes used to decide which studies were eligible for each synthesis (e.g.tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).
In the "eligibility criteria" section of methods 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.
n/a 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses.
n/a 13d Describe any methods used to synthesize results and provide a rationale for the choice(s).
If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.
n/a 13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g.subgroup analysis, meta-regression).
n/a 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results.
n/a Reporting bias assessment 14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).
In the "data synthesis and risk of bias assessment" section of methods

Certainty assessment
15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome. n/a

Study 16a
Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow In the "characteristics of the included studies" In the "characteristics of the included studies" section of the results

Risk of bias in studies
18 Present assessments of risk of bias for each included study.
In the "characteristics of the included studies" section of the results

Results of individual studies
19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g.confidence/credible interval), ideally using structured tables or plots. n/a

Results of syntheses 20a
For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.
n/a 20b Present results of all statistical syntheses conducted.If meta-analysis was done, present for each the summary estimate and its precision (e.g.confidence/credible interval) and measures of statistical heterogeneity.If comparing groups, describe the direction of the effect.
n/a 20c Present results of all investigations of possible causes of heterogeneity among study results.
n/a 20d Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.

n/a
Reporting biases 21 Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.
In the "characteristics of the included studies" section of the results

Certainty of evidence
22 Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.
n/a DISCUSSION Discussion 23a Provide a general interpretation of the results in the context of other evidence.
In the first paragraph of the discussion 23b Discuss any limitations of the evidence included in the review.
In the "limitation" section of the discussion 23c Discuss any limitations of the review processes used.
In the "limitation" section of the discussion

#
Checklist item Location where item is reported 23d Discuss implications of the results for practice, policy, and future research.
In the "future perspectives" section of the discussion OTHER INFORMATION Registration and protocol 24a Provide registration information for the review, including register name and registration number, or state that the review was not registered.
In the first paragraph of the methods 24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared.
In the first paragraph of the methods 24c Describe and explain any amendments to information provided at registration or in the protocol.
In the first paragraph of the methods Support 25 Describe sources of financial or non-financial for the review, and the role of the funders or sponsors in the review.
In the "funding" section at the end of the review BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)