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Tsai CY, Weinrauch WJ, Manente N, Huang V, Bryce TN, Spungen AM. Exoskeletal-Assisted Walking During Acute Inpatient Rehabilitation Enhances Recovery for Persons with Spinal Cord Injury-A Pilot Randomized Controlled Trial. J Neurotrauma 2024; 41:2089-2100. [PMID: 38661533 DOI: 10.1089/neu.2023.0667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Spinal cord injury (SCI) negatively impacts individuals' functional independence, and motor and sensory function. Intense walking training has been shown to facilitate recovery for individuals with chronic SCI. Powered robotic exoskeletons provide therapists with a tool that allows them to conduct walking training with less therapist effort as compared to conventional walking training. Exoskeletal-assisted walking (EAW) has been studied in the chronic SCI population with preliminary reports showing benefits in mobility, health, and quality-of-life outcomes. However, few reports have studied EAW's benefits in the acute (<90 days post) SCI population at a time when neural plasticity is most dynamic and modifiable. The purpose of the study was to conduct a pilot randomized controlled trial (RCT) to understand the effects of incorporated EAW in acute inpatient rehabilitation (AIR) for individuals with SCI on functional, motor, and sensory recovery. The study outcomes included the Spinal Cord Independence Measure (SCIM) III and International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor and sensory scores that were assessed by unblinded assessors. We also recorded EAW session data, including adverse events, walking and up time, step counts, Borg Rating of Perceived Exertion (RPE), and compliance with scheduled EAW training. From August 2019 to July 2022, 16 participants completed the AIR with incorporated EAW, and 12 completed the standard AIR, all with SCI and preserved leg function within 90 days post-injury. During each session, the AIR with incorporated EAW group averaged 34.3 (±9.4) min of up time, 25.4 (±7.7) min of walk time, and 536 (±157) steps. Analysis via two-by-two mixed-effects models showed significant increases in the SCIM total score and ISNCSCI total motor and sensory scores over time for the AIR with incorporated EAW group [SCIM total score: F(1, 26) = 5.59, p = 0.03; total motor score: F(1, 26) = 8.06, p < 0.01; total sensory score: F(1, 19.2) = 5.08, p = 0.04], outperforming the standard AIR group. The AIR with incorporated EAW group showed 13, 14, and 22 points higher changes in the SCIM total score, total motor score, and total sensory score (respectively) by discharge compared with the standard AIR group. Incorporating EAW into AIR may facilitate functional, motor, and sensory recovery for individuals with SCI during AIR better than standard AIR. However, the study had a limited sample size. Further studies are needed to clarify the effects of EAW in AIR.
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Affiliation(s)
- Chung-Ying Tsai
- Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Spinal Cord Damage Research Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - William J Weinrauch
- Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicholas Manente
- Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vincent Huang
- Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas N Bryce
- Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ann M Spungen
- Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Spinal Cord Damage Research Center, James J. Peters VA Medical Center, Bronx, New York, USA
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Wang Y, Zhang J, Yuan J, Li Q, Zhang S, Wang C, Wang H, Wang L, Zhang B, Wang C, Sun Y, Lu X. Application of a novel nested ensemble algorithm in predicting motor function recovery in patients with traumatic cervical spinal cord injury. Sci Rep 2024; 14:17403. [PMID: 39075134 PMCID: PMC11286788 DOI: 10.1038/s41598-024-65755-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/24/2024] [Indexed: 07/31/2024] Open
Abstract
Traumatic cervical spinal cord injury (TCSCI) often causes varying degrees of motor dysfunction, common assessed by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale. Accurate prediction of motor function recovery is extremely important for formulating effective diagnosis, therapeutic and rehabilitation programs. The aim of this study is to investigate the validity of a novel nested ensemble algorithm that uses the very early ASIA motor score (AMS) of ISNCSCI examination to predict motor function recovery 6 months after injury in TCSCI patients. This retrospective study included complete data of 315 TCSCI patients. The dataset consisting of the first AMS at ≤ 24 h post-injury and follow-up AMS at 6 months post-injury was divided into a training set (80%) and a test set (20%). The nested ensemble algorithm was established in a two-stage manner. Support Vector Classification (SVC), Adaboost, Weak-learner and Dummy were used in the first stage, and Adaboost was selected as second-stage model. The prediction results of the first stage models were uploaded into second-stage model to obtain the final prediction results. The model performance was evaluated using precision, recall, accuracy, F1 score, and confusion matrix. The nested ensemble algorithm was applied to predict motor function recovery of TCSCI, achieving an accuracy of 80.6%, a F1 score of 80.6%, and balancing sensitivity and specificity. The confusion matrix showed few false-negative rate, which has crucial practical implications for prognostic prediction of TCSCI. This novel nested ensemble algorithm, simply based on very early AMS, provides a useful tool for predicting motor function recovery 6 months after TCSCI, which is graded in gradients that progressively improve the accuracy and reliability of the prediction, demonstrating a strong potential of ensemble learning to personalize and optimize the rehabilitation and care of TCSCI patients.
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Affiliation(s)
- Yijin Wang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jianjun Zhang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jincan Yuan
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Qingyuan Li
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
| | - Shiyu Zhang
- UCSI University, No. 1, Jalan UCSI, UCSI Heights, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Chenfeng Wang
- Zhejiang University, No. 866 Yuhangtang Road, Xihu District, Hangzhou, 310058, Zhejiang, People's Republic of China
| | - Haibing Wang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Liang Wang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Bangke Zhang
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Can Wang
- North Sichuan Medical College, No. 234 Fuljiang Road, Shunqing District, Nanchong, 637100, Sichuan, People's Republic of China
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Yuling Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
| | - Xuhua Lu
- Department of Orthopedic Surgery, Changzheng Hospital, Naval Medical University, No. 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
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Mputu PM, Beauséjour M, Richard-Denis A, Dionne A, Mac-Thiong JM. Does Improvement in American Spinal Injury Association Impairment Scale Grade Correlate With Functional Recovery in All Patients With a Traumatic Spinal Cord Injury? Am J Phys Med Rehabil 2024; 103:117-123. [PMID: 37408130 DOI: 10.1097/phm.0000000000002313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The aim of the study is to determine what improvement on the American Spinal Injury Impairment Scale correlates with functional status after a traumatic spinal cord injury. DESIGN We performed an observational cohort study, analyzing prospective data from 168 patients with traumatic spinal cord injury admitted to a single level 1 trauma center. A multivariable analysis was performed to assess the relationship between functional status (from the Spinal Cord Independence Measure) at 1-year follow-up and American Spinal Injury Impairment Scale grade (baseline and 1-yr follow-up), while taking into account covariables describing the sociodemographic status, trauma severity, and level of neurological injury. RESULTS Individuals improving to at least American Spinal Injury Impairment Scale grade D had significantly higher Spinal Cord Independence Measure score compared with those not reaching American Spinal Injury Impairment Scale D (89.3 ± 15.2 vs. 52.1 ± 20.4) and were more likely to reach functional independence (68.5% vs. 3.6%), regardless of the baseline American Spinal Injury Impairment Scale grade. Higher final Spinal Cord Independence Measure was more likely with an initial American Spinal Injury Impairment Scale grade D (β = 1.504; 95% confidence interval = 0.46-2.55), and a final American Spinal Injury Impairment Scale grade D (β = 3.716; 95% CI = 2.77-4.66) or E (β = 4.422; 95% CI = 2.91-5.93). CONCLUSIONS Our results suggest that reaching American Spinal Injury Impairment Scale grade D or better 1 yr after traumatic spinal cord injury is highly predictive of significant functional recovery, more so than the actual improvement in American Spinal Injury Impairment Scale grade from the injury to the 1-yr follow-up.
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Affiliation(s)
- Pascal Mputu Mputu
- From the Hôpital du Sacré-Cœur de Montréal, Montreal, Canada (PMM, AR-D, AD, J-MM-T); Department of Biomedical Sciences, Faculty of Medicine, University of Montreal, Montreal, Canada (PMM, AD); Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, Canada (MB, J-MM-T); Department of Community Health Sciences, University of Sherbrooke, Longueuil, Canada (MB); Sainte-Justine University Hospital Research Center, Montréal, Canada (MB, J-MM-T); and Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Canada (AR-D)
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Morooka Y, Kunisawa Y, Okubo Y, Araki S, Takakura Y. Effects of early mobilization within 48 hours of injury in patients with incomplete cervical spinal cord injury. J Spinal Cord Med 2024:1-9. [PMID: 38265416 DOI: 10.1080/10790268.2024.2304919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE To investigate the effects of early mobilization within 48 h of injury on motor function and walking ability in patients with incomplete cervical spinal cord injury (SCI). DESIGN A retrospective observational study. SETTING Intensive care unit or high care unit of a university hospital emergency center. PARTICIPANTS Of 224 patients with SCI having American Spinal Injury Association impairment scale grades C and D, 158 consecutive patients hospitalized for at least 3 weeks after injury were included. INTERVENTIONS Patients were categorized into two groups: an early mobilization group in which patients were mobilized within 48 h of injury and a delayed mobilization group in which they were mobilized after 48 h of injury. OUTCOME MEASURES The upper extremity motor score (UEMS), lower extremity motor score (LEMS), and Walking Index for Spinal Cord Injury II (WISCI II) were compared using propensity score matching analysis. RESULTS Of the 158 patients who met the eligibility criteria, 32 were matched between the groups. There was a significant difference in the change in LEMS from the initial assessment to the assessment 2 weeks postoperatively in the early mobilization group (median 9 points vs. 3 points, p < 0.05). There were no significant differences in UEMS or WISCI II. CONCLUSION Early mobilization within 48 h may improve lower extremity motor function in patients with acute incomplete cervical SCI.
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Affiliation(s)
- Yusuke Morooka
- Faculty of Health, Department of Physical Therapy, Saitama Medical University, Saitama, Japan
| | - Yosuke Kunisawa
- Faculty of Health, Department of Physical Therapy, Saitama Medical University, Saitama, Japan
| | - Yuya Okubo
- Saitama Medical Center, Department of Rehabilitation, Kawagoe, Japan
| | - Shinta Araki
- Saitama Medical Center, Department of Rehabilitation, Kawagoe, Japan
| | - Yasuyuki Takakura
- Faculty of Health, Department of Physical Therapy, Saitama Medical University, Saitama, Japan
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Fallah N, Noonan VK, Waheed Z, Charest-Morin R, Dandurand C, Cheng C, Ailon T, Dea N, Paquette S, Street JT, Fisher C, Dvorak MF, Kwon BK. Pattern of neurological recovery in persons with an acute cervical spinal cord injury over the first 14 days post injury. Front Neurol 2023; 14:1278826. [PMID: 38169683 PMCID: PMC10758406 DOI: 10.3389/fneur.2023.1278826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/31/2023] [Indexed: 01/05/2024] Open
Abstract
Introduction Following a traumatic spinal cord injury (SCI) it is critical to document the level and severity of injury. Neurological recovery occurs dynamically after injury and a baseline neurological exam offers a snapshot of the patient's impairment at that time. Understanding when this exam occurs in the recovery process is crucial for discussing prognosis and acute clinical trial enrollment. The objectives of this study were to: (1) describe the trajectory of motor recovery in persons with acute cervical SCI in the first 14 days post-injury; and (2) evaluate if the timing of the baseline neurological assessment in the first 14 days impacts the amount of motor recovery observed. Methods Data were obtained from the Rick Hansen Spinal Cord Injury Registry (RHSCIR) site in Vancouver and additional neurological data was extracted from medical charts. Participants with a cervical injury (C1-T1) who had a minimum of three exams (including a baseline and discharge exam) were included. Data on the upper-extremity motor score (UEMS), total motor score (TMS) and American Spinal Injury Association (ASIA) Impairment Scale (AIS) were included. A linear mixed-effect model with additional variables (AIS, level of injury, UEMS, time, time2, and TMS) was used to explore the pattern and amount of motor recovery over time. Results Trajectories of motor recovery in the first 14 days post-injury showed significant improvements in both TMS and UEMS for participants with AIS B, C, and D injuries, but was not different for high (C1-4) vs. low (C5-T1) cervical injuries or AIS A injuries. The timing of the baseline neurological examination significantly impacted the amount of motor recovery in participants with AIS B, C, and D injuries. Discussion Timing of baseline neurological exams was significantly associated with the amount of motor recovery in cervical AIS B, C, and D injuries. Studies examining changes in neurological recovery should consider stratifying by severity and timing of the baseline exam to reduce bias amongst study cohorts. Future studies should validate these estimates for cervical AIS B, C, and D injuries to see if they can serve as an "adjustment factor" to control for differences in the timing of the baseline neurological exam.
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Affiliation(s)
- Nader Fallah
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Zeina Waheed
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Raphaele Charest-Morin
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
| | - Charlotte Dandurand
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
| | | | - Tamir Ailon
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
| | - Nicolas Dea
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
| | - Scott Paquette
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
| | - John T. Street
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
| | - Charles Fisher
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
| | - Marcel F. Dvorak
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Brian K. Kwon
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
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Oae K, Kamei N, Sawano M, Yahata T, Morii H, Adachi N, Inokuchi K. Immediate Closed Reduction Technique for Cervical Spine Dislocations. Asian Spine J 2023; 17:835-841. [PMID: 37408488 PMCID: PMC10622818 DOI: 10.31616/asj.2022.0409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/24/2023] [Accepted: 02/13/2023] [Indexed: 07/07/2023] Open
Abstract
STUDY DESIGN Retrospective study. PURPOSE This research aimed to assess the clinical outcomes of patients with traumatic cervical spine dislocation who underwent closed reduction employing our approach. OVERVIEW OF LITERATURE Bedside closed reduction is the quickest procedure for repairing traumatic cervical spine dislocations; nevertheless, it also possesses the risk of neurological deterioration. METHODS For closed reduction, the patient's head was elevated on a motorized bed, the cervical spine was placed at the midline, traction of 10 kg was applied, the motorized bed was gradually returned to a flat position, the head was lifted off the bed, and the cervical spine was slowly adjusted to a flexed position. The weight of traction was elevated by 5-kg increments until the positional shift was attained. Subsequently, the bed was gradually tilted while traction was applied again to return the cervical spine to the midline position. RESULTS Of the 43 cases of cervical spine dislocation, closed reduction was carried out in 40 cases, of which 36 were successful. During repositioning, three patients experienced a temporary worsening of their neck pain and neurological symptoms that enhanced when the cervical spine was flexed. Closed reduction was conducted while the patient was awake; nevertheless, sedation was needed in three cases. Among the 24 patients whose pretreatment paralysis had been characterized by American Spinal Injury Association Impairment Scale (AIS) grades A-C, seven patients (29.2%) demonstrated an enhancement of two or more AIS grades at the last observation. CONCLUSIONS Our closed reduction approach safely repaired traumatic cervical spine dislocations.
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Affiliation(s)
- Kazunori Oae
- Emergency and Critical Care Medicine Center, Saitama Medical Center, Saitama Medical University, Kawagoe,
Japan
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima,
Japan
| | - Naosuke Kamei
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima,
Japan
| | - Makoto Sawano
- Emergency and Critical Care Medicine Center, Saitama Medical Center, Saitama Medical University, Kawagoe,
Japan
| | - Tadashi Yahata
- Emergency and Critical Care Medicine Center, Saitama Medical Center, Saitama Medical University, Kawagoe,
Japan
| | - Hokuto Morii
- Emergency and Critical Care Medicine Center, Saitama Medical Center, Saitama Medical University, Kawagoe,
Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima,
Japan
| | - Koichi Inokuchi
- Emergency and Critical Care Medicine Center, Saitama Medical Center, Saitama Medical University, Kawagoe,
Japan
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Altahla R, Alshorman J, Tao X. The Impact of COVID-19 on Epidemiological Features of Spinal Cord Injury in Wuhan, China: A Comparative Study in Different Time Periods. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1699. [PMID: 37893418 PMCID: PMC10608034 DOI: 10.3390/medicina59101699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/30/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: Spinal cord injury (SCI) is a severe affliction that can have a profound impact on a person's ability to move and feel, affecting a significant number of individuals. However, rehabilitation after SCI treatment remains a critical method to improve motor-sensory functions, which improves the patient's quality of life. This study aims to describe the epidemiological profile of SCI during the COVID-19 pandemic ("COVID-19 period") and before and after the COVID-19 pandemic ("non-COVID-19 period") in Wuhan City, Hubei Province, China. Materials and Methods: Medical records of 93 patients diagnosed with SCI admitted to the rehabilitation department of Wuhan Tongji Hospital from January 2019 to May 2023 were retrospectively reviewed. Basic demographics and clinical characteristics such as level of injury, American Spinal Injury Association (ASIA) Impairment Scale, treatment method, and concomitant injuries were analyzed. Results: Forty patients with SCI from the non-COVID-19 period and fifty-three patients from the COVID-19 period were identified. The mean ages were 38.80 ± 17.71 and 44.53 ± 13.27 years, respectively, with a consistent male-to-female ratio of 2:1 across both periods. Notably, falls accounted for the most prevalent mechanism of injury, constituting 50% of cases during the non-COVID-19 period and 37.74% during the COVID-19 period. The most common initial ASIA grade was B in the non-COVID-19 period and grade C in the COVID-19 period. In addition, the final ASIA grade after treatment was grade C in the non-COVID-19 period and grade D in the COVID-19 period. Conclusions: A greater proportion of males suffer from SCI, and the primary causes are falls and traffic accidents. Workers are the most vulnerable group to SCI among all patients. Prevention strategies should be customized based on the unique characteristics of SCI patients. This study highlights the importance of SCI rehabilitation.
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Affiliation(s)
- Ruba Altahla
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Jamal Alshorman
- Department of Orthopedics, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Xu Tao
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China;
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D’hondt N, Marcial KM, Mittal N, Costanzi M, Hoydonckx Y, Kumar P, Englesakis MF, Burns A, Bhatia A. A Scoping Review of Epidural Spinal Cord Stimulation for Improving Motor and Voiding Function Following Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2023; 29:12-30. [PMID: 37235192 PMCID: PMC10208259 DOI: 10.46292/sci22-00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Objectives To identify and synthesize the existing evidence on the effectiveness and safety of epidural spinal cord stimulation (SCS) for improving motor and voiding function and reducing spasticity following spinal cord injury (SCI). Methods This scoping review was performed according to the framework of Arksey and O'Malley. Comprehensive serial searches in multiple databases (MEDLINE, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, LILACS, PubMed, Web of Science, and Scopus) were performed to identify relevant publications that focused on epidural SCS for improving motor function, including spasticity, and voiding deficits in individuals with SCI. Results Data from 13 case series including 88 individuals with complete or incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] grade A to D) were included. In 12 studies of individuals with SCI, the majority (83 out of 88) demonstrated a variable degree of improvement in volitional motor function with epidural SCS. Two studies, incorporating 27 participants, demonstrated a significant reduction in spasticity with SCS. Two small studies consisting of five and two participants, respectively, demonstrated improved supraspinal control of volitional micturition with SCS. Conclusion Epidural SCS can enhance central pattern generator activity and lower motor neuron excitability in individuals with SCI. The observed effects of epidural SCS following SCI suggest that the preservation of supraspinal transmission is sufficient for the recovery of volitional motor and voiding function, even in patients with complete SCI. Further research is warranted to evaluate and optimize the parameters for epidural SCS and their impact on individuals with differing degrees of severity of SCI.
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Affiliation(s)
- Nina D’hondt
- Department of Pain Medicine, Multidisciplinary Pain Center, VITAZ, Sint-Niklaas, Belgium
| | - Karmi Margaret Marcial
- Department of Anesthesiology, Philippine General Hospital, University of Philippines, Philippines
| | - Nimish Mittal
- Department of Physical Medicine and Rehabilitation, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Matteo Costanzi
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Yasmine Hoydonckx
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Pranab Kumar
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marina F. Englesakis
- MLIS Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Anthony Burns
- Department of Physical Medicine and Rehabilitation, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Anuj Bhatia
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Kamal R, Verma H, Narasimhaiah S, Chopra S. Predicting the Role of Preoperative Intramedullary Lesion Length and Early Decompressive Surgery in ASIA Impairment Scale Grade Improvement Following Subaxial Traumatic Cervical Spinal Cord Injury. J Neurol Surg A Cent Eur Neurosurg 2023; 84:144-156. [PMID: 35668673 PMCID: PMC9977512 DOI: 10.1055/s-0041-1740379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/15/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Traumatic cervical spinal cord injury (TCSCI) is a disabling condition with uncertain neurologic recovery. Clinical and preclinical studies have suggested early surgical decompression and other measures of neuroprotection improve neurologic outcome. We investigated the role of intramedullary lesion length (IMLL) on preoperative magnetic resonance imaging (MRI) and the effect of early cervical decompressive surgery on ASIA impairment scale (AIS) grade improvement following TCSCI. METHODS In this retrospective study, we investigated 34 TCSCI patients who were admitted over a 12-year period, from January 1, 2008 to January 31, 2020. We studied the patient demographics, mode of injury, IMLL and timing of surgical decompression. The IMLL is defined as the total length of edema and contusion/hemorrhage within the cord. Short tau inversion recovery (STIR) sequences or T2-weighted MR imaging with fat saturation increases the clarity of edema and depicts abnormalities in the spinal cord. All patients included had confirmed adequate spinal cord decompression with cervical fixation and a follow-up of at least 6 months. RESULTS Of the 34 patients, 16 patients were operated on within 24 hours (early surgery group) and 18 patients were operated on more than 24 hours after trauma (delayed surgery group). In the early surgery group, 13 (81.3%) patients had improvement of at least one AIS grade, whereas in the delayed surgery group, AIS grade improvement was seen in only in 8 (44.5%) patients (early vs. late surgery; odds ratio [OR] = 1.828; 95% confidence interval [CI]: 1.036-3.225). In multivariate regression analysis coefficients, the timing of surgery and intramedullary edema length on MRI were the most significant factors in improving the AIS grade following cervical SCI. Timing of surgery as a unique variance predicted AIS grade improvement significantly (p < 0.001). The mean IMLL was 41.47 mm (standard deviation [SD]: 18.35; range: 20-87 mm). IMLL was a predictor of AIS grade improvement on long-term outcome in bivariate analysis (p < 0.001). This study suggests that patients who had IMLL of less than 30 mm had a better chance of grade conversion irrespective of the timing of surgery. Patients with an IMLL of 31 to 60 mm had chances of better grade conversion after early surgery. A longer IMLL predicts lack of improvement (p < 0.05). If the IMLL is greater than 61 mm, the probability of nonconversion of AIS grade is higher, even if the patient is operated on within 24 hours of trauma. CONCLUSION Surgical decompression within 24 hours of trauma and shorter preoperative IMLL are significantly associated with improved neurologic outcome, reflected by better AIS grade improvement at 6 months' follow-up. The IMLL on preoperative MRI can reliably predict outcome after 6 months. The present study suggests that patients have lesser chances of AIS grade improvement when the IMLL is ≥61 mm.
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Affiliation(s)
- Raj Kamal
- Department of Neurosurgery, Escorts Hospital, Amritsar, Punjab, India
| | - Himanshu Verma
- Department of Neurosurgery, Escorts Hospital, Amritsar, Punjab, India
| | | | - Suruchi Chopra
- Department of Radiology, Escorts Hospital, Amritsar, Punjab, India
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10
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Najafali D, Pozin M, Naik A, MacInnis B, Subbarao N, Zuckerman SL, Arnold PM. Early Predictors and Outcomes of American Spinal Injury Association Conversion at Discharge in Surgical and Nonsurgical Management of Sports-Related Spinal Cord Injury. World Neurosurg 2023; 171:e93-e107. [PMID: 36436773 DOI: 10.1016/j.wneu.2022.11.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aims to evaluate the rate of improvement in neurologic recovery of patients with sports-related spinal cord injury (SRSCI) who had surgical intervention (SS) and those who did not (NSS). We aimed to 1) evaluate the rate of American Spinal Injury Association (ASIA) conversion in patients with and without surgery, and 2) assess predictors of conversion in ASIA grade. METHODS The National Spinal Cord Injury Model Systems Database (SCIMS) was used from 1973 to 2016. Patients with SRSCI were included. The primary outcome was rate of conversion in ASIA grade. Multivariate logistic regression was performed with separate subgroup analysis on patients with cervical injury (represented by odds ratio [OR]; 95% confidence interval [CI]). RESULTS A total of 1647 patients had SRSCI with 1502 (91%) SSs. Most patients (88%) were male, white (87%), and between the ages of 15 and 29 years (63%). Patients undergoing SS had significantly longer inpatient rehabilitation length of stay (LOS) (P < 0.001) and a more patients undergoing SS had complete motor or sensory loss compared with the NSS group. Multivariate logistic regression showed that injury at the thoracic level (OR, 0.41; 95% CI, 0.21-0.78), age 15-29 years (OR, 0.44; 95% CI, 0.20-0.97]), water-based injury (OR, 0.45; 95% CI, 0.21-0.95), and ASIA impairment grades of B, C, and D at admission were significantly associated with ASIA SCORE conversion. CONCLUSIONS We found that patients undergoing SS had longer LOS and a higher prevalence of complete injuries. Surgical intervention was not associated with conversion in ASIA grade to an improved status at time of discharge in a large cohort of patients with SRSCI and in a subcohort of patients with cervical SRSCI.
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Affiliation(s)
- Daniel Najafali
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Michael Pozin
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Bailey MacInnis
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Natasha Subbarao
- Kansas City University College of Medicine, Joplin, Missouri, USA
| | - Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paul M Arnold
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois, USA.
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Cui Z, Lin J, Fu X, Zhang S, Li P, Wu X, Wang X, Chen W, Zhu S, Li Y. Construction of the dynamic model of SCI rehabilitation using bidirectional stimulation and its application in rehabilitating with BCI. Cogn Neurodyn 2023; 17:169-181. [PMID: 36704625 PMCID: PMC9871133 DOI: 10.1007/s11571-022-09804-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/04/2022] [Accepted: 03/26/2022] [Indexed: 01/29/2023] Open
Abstract
Patients with complete spinal cord injury have a complete loss of motor and sensory functions below the injury plane, leading to a complete loss of function of the nerve pathway in the injured area. Improving the microenvironment in the injured area of patients with spinal cord injury, promoting axon regeneration of the nerve cells is challenging research fields. The brain-computer interface rehabilitation system is different from the other rehabilitation techniques. It can exert bidirectional stimulation on the spinal cord injury area, and can make positively rehabilitation effects of the patient with complete spinal cord injury. A dynamic model was constructed for the patient with spinal cord injury under-stimulation therapy, and the mechanism of the brain-computer interface in rehabilitation training was explored. The effects of the three current rehabilitation treatment methods on the microenvironment in a microscopic nonlinear model were innovatively unified and a complex system mapping relationship from the microscopic axon growth to macroscopic motor functions was constructed. The basic structure of the model was determined by simulating and fitting the data of the open rat experiments. A clinical rehabilitation experiment of spinal cord injury based on brain-computer interface was built, recruiting a patient with complete spinal cord injury, and the rehabilitation training and follow-up were conducted. The changes in the motor function of the patient was simulated and predicted through the constructed model, and the trend in the motor function improvement was successfully predicted over time. This proposed model explores the mechanism of brain-computer interface in rehabilitating patients with complete spinal cord injury, and it is also an application of complex system theory in rehabilitation medicine. Supplementary Information The online version contains supplementary material available at 10.1007/s11571-022-09804-3.
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Affiliation(s)
- Zhengzhe Cui
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Juan Lin
- Rehabilitation Medicine Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangxiang Fu
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | | | - Peng Li
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Xixi Wu
- Rehabilitation Medicine Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xue Wang
- Rehabilitation Medicine Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weidong Chen
- Qiushi Academy for Advanced Studies, Zhejiang University, Hangzhou, China
| | - Shiqiang Zhu
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Yongqiang Li
- Rehabilitation Medicine Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Wuxi Tongren Rehabilitation Hospital, Wuxi, China
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12
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Javeed S, Greenberg JK, Zhang JK, Dibble CF, Khalifeh JM, Liu Y, Wilson TJ, Yang LJ, Park Y, Ray WZ. Derivation and Validation of a Clinical Prediction Rule for Upper Limb Functional Outcomes After Traumatic Cervical Spinal Cord Injury. JAMA Netw Open 2022; 5:e2247949. [PMID: 36542381 PMCID: PMC9857030 DOI: 10.1001/jamanetworkopen.2022.47949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Traumatic cervical spinal cord injury (SCI) can result in debilitating paralysis. Following cervical SCI, accurate early prediction of upper limb recovery can serve an important role in guiding the appropriateness and timing of reconstructive therapies. OBJECTIVE To develop a clinical prediction rule to prognosticate upper limb functional recovery after cervical SCI. DESIGN, SETTING, AND PARTICIPANTS This prognostic study was a retrospective review of a longitudinal cohort study including patients enrolled in the National SCI model systems (SCIMS) database in US. Eligible patients were 15 years or older with tetraplegia (neurological level of injury C1-C8, American Spinal Cord Injury Association [ASIA] impairment scale [AIS] A-D), with early (within 1 month of SCI) and late (1-year follow-up) clinical examinations from 2011 to 2016. The data analysis was conducted from September 2021 to June 2022. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of dependency in eating, bladder management, transfers, and locomotion domains of functional independence measure at 1-year follow-up. Each domain ranges from 1 to 7 with a lower score indicating greater functional dependence. Composite dependency was defined as a score of 4 or higher in at least 3 chosen domains. Multivariable logistic regression was used to predict the outcome based on early neurological variables. Discrimination was quantified using C statistics, and model performance was internally validated with bootstrapping and 10-fold cross-validation. The performance of the prediction score was compared with AIS grading. Data were split into derivation (2011-2014) and temporal-validation (2015-2016) cohorts. RESULTS Among 2373 patients with traumatic cervical SCI, 940 had complete 1-year outcome data (237 patients [25%] aged 60 years or older; 753 men [80%]). The primary outcome was present in 118 patients (13%), which included 92 men (78%), 83 (70%) patients who were younger than 60 years, and 73 (62%) patients experiencing AIS grade A SCI. The variables significantly associated with the outcome were age (age 60 years or older: OR, 2.31; 95% CI, 1.26-4.19), sex (men: OR, 0.60; 95% CI, 0.31-1.17), light-touch sensation at C5 (OR, 0.44; 95% CI, 0.44-1.01) and C8 (OR, 036; 95% CI, 0.24-0.53) dermatomes, and motor scores of the elbow flexors (C5) (OR, 0.74; 95% CI, 0.60-0.89) and wrist extensors (C6) (OR, 0.61; 95% CI, 0.49-0.75). A multivariable model including these variables had excellent discrimination in distinguishing dependent from independent patients in the temporal-validation cohort (C statistic, 0.90; 95% CI, 0.88-0.93). A clinical prediction score (range, 0 to 45 points) was developed based on these measures, with higher scores increasing the probability of dependency. The discrimination of the prediction score was significantly higher than from AIS grading (change in AUC, 0.14; 95% CI, 0.10-0.18; P < .001). CONCLUSIONS AND RELEVANCE The findings of this study suggest that this prediction rule may help prognosticate upper limb function following cervical SCI. This tool can be used to set patient expectations, rehabilitation goals, and aid decision-making regarding the appropriateness and timing for upper limb reconstructive surgeries.
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Affiliation(s)
- Saad Javeed
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | - Justin K. Zhang
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | | | - Jawad M. Khalifeh
- Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Ying Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Thomas J. Wilson
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Lynda J. Yang
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor
| | - Yikyung Park
- Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Wilson Z. Ray
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
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Cui Z, Li Y, Huang S, Wu X, Fu X, Liu F, Wan X, Wang X, Zhang Y, Qiu H, Chen F, Yang P, Zhu S, Li J, Chen W. BCI system with lower-limb robot improves rehabilitation in spinal cord injury patients through short-term training: a pilot study. Cogn Neurodyn 2022; 16:1283-1301. [PMID: 36408074 PMCID: PMC9666612 DOI: 10.1007/s11571-022-09801-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/27/2021] [Accepted: 11/04/2021] [Indexed: 12/27/2022] Open
Abstract
In the recent years, the increasing applications of brain-computer interface (BCI) in rehabilitation programs have enhanced the chances of functional recovery for patients with neurological disorders. We presented and validated a BCI system with a lower-limb robot for short-term training of patients with spinal cord injury (SCI). The cores of this system included: (1) electroencephalogram (EEG) features related to motor intention reported through experiments and used to drive the robot; (2) a decision tree to determine the training mode provided for patients with different degrees of injuries. Seven SCI patients (one American Spinal Injury Association Impairment Scale (AIS) A, three AIS B, and three AIS C) participated in the short-term training with this system. All patients could learn to use the system rapidly and maintained a high intensity during the training program. The strength of the lower limb key muscles of the patients was improved. Four AIS A/B patients were elevated to AIS C. The cumulative results indicate that clinical application of the BCI system with lower-limb robot is feasible and safe, and has potentially positive effects on SCI patients. Supplementary Information The online version contains supplementary material available at 10.1007/s11571-022-09801-6.
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Affiliation(s)
- Zhengzhe Cui
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Yongqiang Li
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sisi Huang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xixi Wu
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangxiang Fu
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Fei Liu
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaojiao Wan
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Xue Wang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuting Zhang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huaide Qiu
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fang Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Peijin Yang
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Shiqiang Zhu
- School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Jianan Li
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weidong Chen
- Qiushi Academy for Advanced Studies, Zhejiang University, Hangzhou, China
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14
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Moon TJ, Furdock R, Ahn N. Do Patients With Chronic Diabetes Have Worse Motor Outcomes After Cervical ASIA C Traumatic Spinal Cord Injury? Clin Spine Surg 2022; 35:E731-E736. [PMID: 35778753 DOI: 10.1097/bsd.0000000000001362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/18/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN This was a level IV retrospective prognostic study. OBJECTIVE The objective of this study was to determine if patients with chronic diabetes have worse functional outcomes and motor recovery after cervical traumatic spinal cord injury (TSCI). SUMMARY OF BACKGROUND DATA Diabetes mellitus has multiple deleterious neurological effects and has been shown to worsen elective cervical spine surgery outcomes. Prior literature has scarcely characterized the impact of chronic diabetes on motor and functional outcomes after TSCI. METHODS The National Spinal Cord Injury Statistical Center (NSCISC) database was utilized to retrospectively collect data on cervical American Spinal Injury Association (ASIA) C TSCI between 2011 and 2016. Patients were divided into diabetes and nondiabetes groups. Primary outcomes included wheelchair requirement and ambulatory status 1 year after injury. Secondary outcomes were motor score collected at the time of rehab admission, rehab discharge, and 1-year follow-up. All outcome variables were analyzed using univariate and multivariate regression to assess for differences between diabetes and nondiabetes groups and possible confounders. RESULTS A total of 219 patients met the inclusion criteria for the study: 193 without diabetes and 26 with diabetes (12.0%). After controlling for confounders, patients with diabetes had had significantly increased wheelchair requirement (83.3% vs. 51.8%, relative risk=1.63, 95% confidence interval: 1.20-1.83, P =0.009 multivariate) and decreased ambulatory rates (50% vs. 67.9%, relative risk=0.55, 95% confidence interval: 0.25-0.98, P =0.042 multivariate) at 1 year. They also had no difference in average total motor scores at rehab admission but significantly worse total motor scores at rehab discharge (50.6±23.3 vs. 60.3±21.4, P =0.033 univariate, P =0.002 multivariate). CONCLUSIONS Patients with diabetes have increased wheelchair requirement and decreased ambulatory ability at 1 year after the injury as well as diminished recovery in motor scores after motor-incomplete cervical TSCI. These patients may be targets for aggressive diabetic screening and intervention to minimize negative outcomes.
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Affiliation(s)
- Tyler J Moon
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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15
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Intraoperative Sensory Signals Predict Prognosis for Patients with Traumatic Cervical Spinal Cord Injury. World Neurosurg 2022; 168:e393-e398. [DOI: 10.1016/j.wneu.2022.10.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
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Anderson KD, Korupolu R, Musselman KE, Pierce J, Wilson JR, Yozbatiran N, Desai N, Popovic MR, Thabane L. Multi-center, single-blind randomized controlled trial comparing functional electrical stimulation therapy to conventional therapy in incomplete tetraplegia. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:995244. [PMID: 36188946 PMCID: PMC9500231 DOI: 10.3389/fresc.2022.995244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022]
Abstract
Background Loss of upper extremity function after tetraplegia results in significant disability. Emerging evidence from pilot studies suggests that functional electrical stimulation (FES) therapy may enhance recovery of upper extremity function after tetraplegia. The aim of this trial was to determine the effectiveness of FES therapy delivered by the Myndmove stimulator in people with tetraplegia. Methods A multi-center, single-blind, parallel-group, two-arm, randomized controlled trial was conducted comparing FES to conventional therapy in adults (≥18 years) with C4–C7 traumatic incomplete tetraplegia between 4 and 96 months post-injury, and with a baseline spinal cord injury independence measure III -self-care (SCIM III-SC) score of ≤10. Participants were enrolled at four SCI-specialized neurorehabilitation centers in the U.S. and Canada. Participants were stratified by center and randomized in a 1:1 ratio to receive either 40 sessions of FES or conventional therapy targeting upper extremities over a 14-week period. Blinded assessors measured SCIM III, Toronto Rehabilitation Institute Hand Function Test, and Graded Redefined Assessment of Strength, Sensibility, and Prehension at baseline, after 20th session, after 40th session or 14 weeks after 1st session, and at 24 weeks after 1st session. The primary outcome measure was change in SCIM III-SC from baseline to end of the treatment. Based on the primary outcome measure, a sample size of 60 was calculated. Seventeen participants' progress in the study was interrupted due to the COVID-19 lockdown. The protocol was modified for these participants to allow them to complete the study. Results Between June 2019 to August 2021, 51 participants were randomized to FES (n = 27) and conventional therapy (n = 24). Both groups gained a mean of 2 points in SCIM-SC scores at the end of treatment, which was a clinically meaningful change. However, there was no statistically significant difference between the groups on any outcomes. Conclusion Forty sessions of FES therapy delivered by the MyndMove stimulator are as effective as conventional therapy in producing meaningful functional improvements that persist after therapy is completed. Limitations of this study include the impact of COVID-19 limiting the ability to recruit the target sample size and per-protocol execution of the study in one-third of the participants. Registration This trial is registered at www.ClinicalTrials.gov, NCT03439319.
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Affiliation(s)
- Kim D. Anderson
- MetroHealth Rehabilitation Institute, MetroHealth System, Cleveland, OH, United States
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Correspondence: Kim D. Anderson
| | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
- The Institute of Rehabilitation / Research (TIRR) Memorial Hermann, Houston, TX, United States
| | - Kristin E. Musselman
- The KITE Research Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Jacqueline Pierce
- HealthTech Connex Centre for Neurology Studies/Neuromotion Physiotherapy, Vancouver, BC, Canada
| | - James R. Wilson
- MetroHealth Rehabilitation Institute, MetroHealth System, Cleveland, OH, United States
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Nuray Yozbatiran
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
- The Institute of Rehabilitation / Research (TIRR) Memorial Hermann, Houston, TX, United States
| | - Naaz Desai
- Krembil Research Institute-University Health Network, Toronto, ON, Canada
| | - Milos R. Popovic
- The KITE Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- CRANIA, University Health Network, Toronto, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton ON, Canada
- Biostatistics Unit, St. Joseph’s Healthcare, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, Gauteng, South Africa
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Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury. J Pers Med 2022; 12:jpm12071126. [PMID: 35887623 PMCID: PMC9323191 DOI: 10.3390/jpm12071126] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 12/25/2022] Open
Abstract
The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a spinal cord injury (SCI), supraspinal influences on the spinal segmental control system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, pain and dysesthesia, sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of traumatic SCI, current and emerging methods of classification, and its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue.
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18
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Validity and responsiveness of the Standing and Walking Assessment Tool for sub-acute traumatic spinal cord injury. Spinal Cord 2022; 60:1108-1114. [PMID: 35789193 DOI: 10.1038/s41393-022-00830-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN This is a retrospective longitudinal study. OBJECTIVE The Standing and Walking Assessment Tool (SWAT) combines stages of standing and walking recovery (SWAT stages) with established measures (Berg Balance Scale (BBS), 10-m walk test (10MWT), 6-min walk test (6MWT), and modified Timed Up-and-Go (mTUG)). We evaluated the SWAT's validity (known-groups and convergent) and responsiveness among inpatients with sub-acute, traumatic spinal cord injury (SCI). SETTING Ten Canadian rehabilitation hospitals. METHODS Upon admission, SWAT stage and core measures (BBS, 10MWT, 6MWT, and mTUG), International Standards for Neurological Classification of SCI sensory and motor scores, and Spinal Cord Independence Measure III (SCIM) were collected from 618 adults with SCI. Known-groups validity was evaluated by comparing SWAT stage distributions across American Spinal Injury Association Impairment Scale (AIS) classification. Convergent validity was evaluated by correlating SWAT stages with scores on other measures using Spearman's rho. The SWAT (stage and core measures) was re-administered at discharge. To evaluate responsiveness, SWAT stages at admission and discharge were compared. The standardized response mean (SRM) was used to evaluate the responsiveness of core SWAT measures. RESULTS The SWAT stage distribution of participants with AIS D injuries differed from those of participants with AIS A-C injuries (p ≤ 0.002). SWAT stages correlated strongly with BBS and motor scores (ρ = 0.778-0.836), and moderately with SCIM, mTUG, 10MWT, 6MWT, and sensory scores (ρ = 0.409-0.692). Discharge SWAT stage was greater than the admission stage (p < 0.0001). The BBS was the most responsive core SWAT measure (SRM = 1.26). CONCLUSIONS The SWAT is a valid and responsive approach to the measurement of standing and walking ability during sub-acute SCI.
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19
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Ter Wengel PV, de Gendt EEA, Martin E, Adegeest CY, Stolwijk-Swüste J, Fehlings MG, Oner FC, Vandertop WP. The impact of surgical timing on motor level lowering in motor complete traumatic spinal cord injury patients. J Neurotrauma 2022; 39:651-657. [PMID: 35019765 DOI: 10.1089/neu.2021.0428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Patients with motor complete traumatic spinal cord injury (tSCI) have a low potential to recover ambulation. Motor level recovery, adjacent to the level of injury, could influence functional independency. This study addresses whether surgical timing influences motor level recovery in patients with sensorimotor complete (AIS A) and motor complete sensory incomplete (AIS B) tSCI. A retrospective cohort study was performed in the Netherlands in patients with motor complete tSCI (C2-L2), who consecutively underwent surgery between January 2010 and April 2020. Neurological examination was performed directly at presentation to the ER and at discharge from the rehabilitation facility. Motor level lowering, AIS grade and Upper and Lower Extremity Motor Score (UEMS and LEMS) recovery were calculated for patients who underwent early (<24h) and late (24h+) surgery. A total of 96 patients met the inclusion criteria. In the multivariate analysis late surgical decompression (24h+) was negatively associated with ≥1 motor level lowering and ≥2 AIS grade improvement (Odds Ratio (OR) 0.11 (95% CI: 0.01, 0.67) p=0.046, OR 0.06 (95% CI: 0.00, 047) p=0.030). The presence of sacral sparing (AIS B) at initial examination, and cervical level of the tSCI were associated with ≥1 motor level lowering. In addition, AOSpine C-type injuries were negatively associated with any type of neurological recovery, except motor level lowering. Although sensorimotor complete injuries as well as thoracolumbar injuries negatively influence neurological recovery, early surgical decompression (<24h) appears independently associated with enhanced neurological recovery in patients with traumatic spinal cord injury despite level and severity of injury.
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Affiliation(s)
- Paula Valerie Ter Wengel
- Amsterdam UMC Locatie VUmc, 1209, Neurosurgery, Amsterdam, Noord-Holland, Netherlands.,Medisch Centrum Haaglanden Westeinde, 2901, Neurosurgery, Den Haag, Zuid-Holland, Netherlands;
| | | | - Enrico Martin
- UMC Utrecht, 8124, Plastic and reconstructive surgery, Utrecht, Utrecht, Netherlands;
| | - Charlotte Y Adegeest
- Medisch Centrum Haaglanden Westeinde, 2901, Den Haag, Zuid-Holland, Netherlands.,Leiden Universitair Medisch Centrum, 4501, Leiden, Zuid-Holland, Netherlands;
| | - Janneke Stolwijk-Swüste
- UMC Utrecht Brain Center Rudolf Magnus, 36512, Center of Excellence for Rehabilitation Medicine, Heidelberglaan 100, Utrecht, Utrecht, Netherlands, 3584 CX.,Revalidation Centre De Hoogstraat, 84896, Center of Excellence for Rehabilitation Medicine, Rembrandtkade 10, Utrecht, Utrecht, Netherlands, 3583 TM;
| | - Michael G Fehlings
- Toronto Western Hospital, 26625, Neurosurgery, Toronto, Ontario, Canada;
| | - F Cumhur Oner
- Universitair Medisch Centrum Utrecht, 8124, Utrecht, Utrecht, Netherlands;
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20
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Characterizing Natural Recovery of People With Initial Motor Complete Tetraplegia. Arch Phys Med Rehabil 2021; 103:649-656. [PMID: 34800476 DOI: 10.1016/j.apmr.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/02/2021] [Accepted: 09/17/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the differences in neurologic recovery in persons with initial cervical American Spinal Cord Injury Association Impairment Scale (AIS) grades A and B over time. DESIGN Retrospective analysis of data from people with traumatic cervical spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Model Systems (SCIMS) database from 2011-2019. SETTING SCIMS centers. PARTICIPANTS Individuals (N=187) with traumatic cervical (C1-C7 motor level) SCI admitted with initial AIS grade A and B injuries within 30 days of injury, age 16 years or older, upper extremity motor score (UEMS) ≤20 on both sides, and complete neurologic data at admission and follow-up between 6 months and 2 years. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Conversion in AIS grades, UEMS and lower extremity motor scores (LEMS), and sensory scores. RESULTS Mean time to initial and follow-up examinations were 16.1±7.3 days and 377.5±93.4 days, respectively. Conversion from an initial cervical AIS grades A and B to motor incomplete status was 13.4% and 50.0%, respectively. The mean UEMS change for people with initial AIS grades A and B did not differ (7.8±6.5 and 8.8±6.1; P=.307), but people with AIS grade B experienced significantly higher means of LEMS change (2.3±7.4 and 8.8±13.9 (P≤.001). The increased rate of conversion to motor incomplete status from initial AIS grade B appears to be the primary driving factor of increased overall motor recovery. Individuals with initial AIS grade B had greater improvement in sensory scores. CONCLUSIONS While UEMS recovery is similar in persons with initial AIS grades A and B, the rate of conversion to motor incomplete status, LEMS, and sensory recovery are significantly different. This information is important for clinical as well as research considerations.
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Lena E, Baroncini I, Pavese C, Musumeci G, Volini S, Masciullo M, Aiachini B, Fizzotti G, Puci MV, Scivoletto G. Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions. Spinal Cord 2021; 60:30-36. [PMID: 34326462 DOI: 10.1038/s41393-021-00675-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective, observational study. OBJECTIVES The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) represent the gold standard for the assessment of patients with spinal cord injury (SCI) and their measurement properties have been evaluated in patients with traumatic lesions. Albeit the ISNCSCI are widely used also for the assessment and prognosis of patients with non-traumatic SCI, a validation of this grading system in this sample has never been performed. Therefore, the aim of this study is to evaluate the measurement properties of the ISNCSCI in a population of persons with non-traumatic SCI. SETTING Three Italian rehabilitation hospitals. METHODS The sample included 140 patients with non-traumatic SCI of different etiology, level and grade, for a total of 169 evaluations performed by two examiners. Cronbach's Alpha was used to evaluate the internal consistency of the ISNCSCI various components. The agreement between two examiners of each center in the definition of different components was used to assess the inter-rater reliability. The construct validity was evaluated through the correlation of the ISNCSCI with the Spinal Cord Independence Measure (SCIM). RESULTS The ISNCSCI showed substantial internal consistency, and substantial inter-rater agreement for AIS grade, cumulative motor and sensory scores. The motor scores for upper and lower extremity showed fair to moderate correlation with SCIM self-care and motility subscores, respectively. The ISNCSCI total motor score correlated with the total SCIM score. CONCLUSIONS Our study demonstrates that the ISNCSCI are a valid and reliable tool for the assessment of patients with non-traumatic SCI.
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Affiliation(s)
| | | | - Chiara Pavese
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Neurorehabilitation and Spinal Unit, Institute of Pavia, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | | | | | - Marcella Masciullo
- Spinal Cord Unit, IRCCS Fondazione Santa Lucia, Rome, Italy.,Spinal Rehabilitation SpiRe lab, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Beatrice Aiachini
- Neurorehabilitation and Spinal Unit, Institute of Pavia, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Gabriella Fizzotti
- Neurorehabilitation and Spinal Unit, Institute of Pavia, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Mariangela V Puci
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Giorgio Scivoletto
- Spinal Cord Unit, IRCCS Fondazione Santa Lucia, Rome, Italy. .,Spinal Rehabilitation SpiRe lab, IRCCS Fondazione Santa Lucia, Rome, Italy.
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22
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Abstract
Neuroprotection after acute spinal cord injury is an important strategy to limit secondary injury. Animal studies have shown that systemic hypothermia is an effective neuroprotective strategy that can be combined with other therapies. Systemic hypothermia affects several processes at the cellular level to reduce metabolic activity, oxidative stress, and apoptotic neuronal cell death. Modest systemic hypothermia has been shown to be safe and feasible in the acute phase after cervical spinal cord injury. These data have provided the impetus for an active multicenter randomized controlled trial for modest systemic hypothermia in acute cervical spinal cord injury.
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Jaja BNR, Badhiwala J, Guest J, Harrop J, Shaffrey C, Boakye M, Kurpad S, Grossman R, Toups E, Geisler F, Kwon B, Aarabi B, Kotter M, Fehlings MG, Wilson JR. Trajectory-Based Classification of Recovery in Sensorimotor Complete Traumatic Cervical Spinal Cord Injury. Neurology 2021; 96:e2736-e2748. [PMID: 33849991 DOI: 10.1212/wnl.0000000000012028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 03/01/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that sensorimotor complete traumatic cervical spinal cord injury (SCI) is a heterogenous clinical entity comprising several subpopulations that follow fundamentally different trajectories of neurologic recovery. METHODS We analyzed demographic and injury data from 655 patients who were pooled from 4 prospective longitudinal multicenter studies. Group-based trajectory modeling was applied to model neurologic recovery trajectories over the initial 12 months postinjury and to identify predictors of recovery trajectories. Neurologic outcomes included upper extremity motor score, total motor scores, and American Spinal Injury Association Impairment Scale (AIS) grade improvement. RESULTS The analysis identified 3 distinct trajectories of neurologic recovery. These clinical courses included (1) marginal recovery trajectory, characterized by minimal or no improvement in motor strength or change in AIS grade status (remained grade A); (2) moderate recovery trajectory, characterized by low baseline motor scores that improved approximately 13 points or AIS conversion of 1 grade point; (3) good recovery trajectory, characterized by baseline motor scores in the upper quartile that improved to near maximum values within 3 months of injury. Patients following the moderate or good recovery trajectories were younger, had more caudally located injuries, had a higher degree of preserved motor and sensory function at baseline examination, and exhibited a greater extent of motor and sensory function in the zone of partial preservation. CONCLUSION Cervical complete SCI can be classified into one of 3 distinct subpopulations with fundamentally different trajectories of neurologic recovery. This study defines unique clinical phenotypes based on potential for recovery, rather than baseline severity of injury alone. This approach may prove beneficial in clinical prognostication and in the design and interpretation of clinical trials in SCI.
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Affiliation(s)
- Blessing N R Jaja
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Jetan Badhiwala
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - James Guest
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - James Harrop
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Chris Shaffrey
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Max Boakye
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Shekar Kurpad
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Robert Grossman
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Elizabeth Toups
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Fred Geisler
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Brian Kwon
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Bizhan Aarabi
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Mark Kotter
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Michael G Fehlings
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK
| | - Jefferson R Wilson
- From the Division of Neurosurgery and Spine Program (B.N.R.J., M.G.F.), Toronto Western Hospital, Division of Neurosurgery and Spine Program (J.B.), and Division of Neurosurgery and Spine Program, St. Michael's Hospital (J.R.W.), University of Toronto, Canada; Division of Neurosurgery (J.G.), University of Miami, FL; Division of Neurosurgery (J.H.), Thomas Jefferson University Hospital, Philadelphia, PA; Duke Spine Division (C.S.), Duke University School of Medicine, Durham, NC; Division of Neurosurgery (M.B.), University of Louisville, KY; Division of Neurosurgery (S.K.), Medical College of Wisconsin, Milwaukee; Division of Neurosurgery (R.G., E.T.), Methodist Hospital, Houston, TX; Chicago Institute of Neurosurgery and Neuroresearch (F.G.), Rush University, IL; Division of Spine Surgery (B.K.), Vancouver General Hospital, University of British Columbia, Canada; Division of Neurosurgery, Shock Trauma (B.A.), University of Maryland, Baltimore; and Division of Neurosurgery, Department of Clinical Neurosciences (M.K.), University of Cambridge, UK.
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Kirshblum S, Snider B, Eren F, Guest J. Characterizing Natural Recovery after Traumatic Spinal Cord Injury. J Neurotrauma 2021; 38:1267-1284. [PMID: 33339474 PMCID: PMC8080912 DOI: 10.1089/neu.2020.7473] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6-9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersy, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Brittany Snider
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Fatma Eren
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - James Guest
- Neurological Surgery, Miller School of Medicine, Miami, Florida, USA
- The Miami Project to Cure Paralysis, Miami, Florida, USA
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Perrouin-Verbe B, Lefevre C, Kieny P, Gross R, Reiss B, Le Fort M. Spinal cord injury: A multisystem physiological impairment/dysfunction. Rev Neurol (Paris) 2021; 177:594-605. [PMID: 33931244 DOI: 10.1016/j.neurol.2021.02.385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 12/24/2022]
Abstract
Spinal cord injury (SCI) is a complex disease that affects not only sensory and motor pathways below the neurological level of injury (NLI) but also all the organs and systems situated below this NLI. This multisystem impairment implies comprehensive management in dedicated SCI specialized centers, by interdisciplinary and multidisciplinary teams, able to treat not only the neurological impairment, but also all the systems and organs affected. After a brief history of the Spinal Cord Medicine, the author describes how to determine the level and severity of a SCI based on the International Standards for Neurological Classification of Spinal Cord Injury and the prognosis factors of recovery. This article provides also a review of the numerous SCI-related impairments (except for urinary, sexual problems and pain treated separately in this issue), their principles of management and related complications.
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Affiliation(s)
- B Perrouin-Verbe
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France.
| | - C Lefevre
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - P Kieny
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - R Gross
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - B Reiss
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
| | - M Le Fort
- Department of Neurological Physical Medicine and Rehabilitation, St Jacques Hospital, University Hospital of Nantes, 85, rue st Jacques, 44093 Nantes cedex 01, France
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Pfyffer D, Vallotton K, Curt A, Freund P. Predictive Value of Midsagittal Tissue Bridges on Functional Recovery After Spinal Cord Injury. Neurorehabil Neural Repair 2020; 35:33-43. [PMID: 33190619 PMCID: PMC8350965 DOI: 10.1177/1545968320971787] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The majority of patients with spinal cord injury (SCI) have anatomically incomplete lesions and present with preserved tissue bridges, yet their outcomes vary. Objective To assess the predictive value of the anatomical location (ventral/dorsal) and width of preserved midsagittal tissue bridges for American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion and SCI patient stratification into recovery-specific subgroups. Methods This retrospective longitudinal study includes 70 patients (56 men, age: 52.36 ± 18.58 years) with subacute (ie, 1 month) SCI (45 tetraplegics, 25 paraplegics), 1-month neuroimaging data, and 1-month and 12-month clinical data. One-month midsagittal T2-weighted scans were used to determine the location and width of tissue bridges. Their associations with functional outcomes were assessed using partial correlation and unbiased recursive partitioning conditional inference tree (URP-CTREE). Results Fifty-seven (81.4%) of 70 patients had tissue bridges (2.53 ± 2.04 mm) at 1-month post-SCI. Larger ventral (P = .001, r = 0.511) and dorsal (P < .001, r = 0.546) tissue bridges were associated with higher AIS conversion rates 12 months post-SCI (n = 39). URP-CTREE analysis identified 1-month ventral tissue bridges as predictors of 12-month total motor scores (0.4 mm cutoff, P = .008), recovery of upper extremity motor scores at 12 months (1.82 mm cutoff, P = .002), 12-month pin-prick scores (1.4 mm cutoff, P = .018), and dorsal tissue bridges at 1 month as predictors of 12-month Spinal Cord Independence Measure scores (0.5 mm cutoff, P = .003). Conclusions Midsagittal tissue bridges add predictive value to baseline clinical measures for post-SCI recovery. Based on tissue bridges’ width, patients can be classified into subgroups of clinical recovery profiles. Midsagittal tissue bridges provide means to optimize patient stratification in clinical trials.
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Affiliation(s)
- Dario Pfyffer
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Kevin Vallotton
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick Freund
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Wellcome Trust Center for Neuroimaging, UCL Institute of Neurology, University College London, London, UK.,Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
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Marino RJ, Leff M, Cardenas DD, Donovan J, Chen D, Kirshblum S, Leiby BE. Trends in Rates of ASIA Impairment Scale Conversion in Traumatic Complete Spinal Cord Injury. Neurotrauma Rep 2020; 1:192-200. [PMID: 34223541 PMCID: PMC8240895 DOI: 10.1089/neur.2020.0038] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Recent studies of persons with spinal cord injury (SCI) report higher conversion rates of the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades, especially for complete injuries. We examined the rate of conversion over time after complete SCI, accounting for demographic and injury characteristics. Subjects were 16 years of age and older with a complete SCI injury between 1995 and 2015, enrolled in the National SCI Database as day-1 admissions. We grouped subjects into 3-year intervals and assessed trends in conversion for the total sample and by tetraplegia (Tetra), high paraplegia (levels T1–9, HPara), and low paraplegia (levels T10–12, LPara).We used logistic regression to identify factors related to conversion such as age, sex, etiology, and level of injury. Of 2036 subjects, 1876 subjects had a follow-up examination between 30 and 730 days post-injury. Average age at injury was 34.2 ± 14.6 years; 79.8% were male, 44.6% Tetra, 35.3% HPara, and 20.1% LPara. There was a strong trend toward increased rates of conversion over time (p < 0.01 for all groups), especially for Tetra (to incomplete from 17.6% in 1995–1997 to 50% in 2013–2015, and to motor incomplete from 9.4% to 28.1%). Conversion rates for Para were less dramatic. There were increased odds of converting to incomplete for year of injury, level of injury (Tetra >LPara >HPara), non-violent etiology, and age (older is better). We found similar factors for conversion to motor incomplete, except sex was significant and etiology was not. Conversion rates from complete to incomplete and motor incomplete injury have been increasing, particularly for persons with tetraplegia. This has implications for acute clinical trials and for prognostication early after SCI.
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Affiliation(s)
- Ralph J Marino
- Department of Rehabilitation Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Leff
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Diana D Cardenas
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jayne Donovan
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - David Chen
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steve Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA.,Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Benjamin E Leiby
- Biostatistics Division, Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Yoo J. Evaluation and prognosis of spinal cord injury. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.10.596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
It is important to perform an accurate neurological assessment using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to judge the prognosis of spinal cord injury patients. We can gauge the prognosis for upper extremity function or gait ability according to the ISNCSCI results. ISNCSCI involves both sensory and motor examination, and it is performed with the patient in the supine position to enable a comparison between the initial and follow-up exams. The sensory exam is performed on the 28 key sensory points of dermatomes for light touch and pinprick. The motor exam is performed on 10 key muscles on each side. The sensory and motor levels for the right and left sides are determined according to the sensory and motor exam results. The neurological level of injury is the most caudal level of the cord at which both the motor and sensory functions are intact. Finally, the American Spinal Injury Association Impairment Scale (AIS) is determined. AIS A indicates complete injury, and AIS B, C, and D indicate incomplete injuries. Once the sensory and motor levels, neurological level of injury, and AIS scale of a spinal cord injury patient are determined through ISNCSCI, the patient's prognosis can be predicted based on those results. Furthermore, ISNCSCI performed at 72 hours after an injury yields the most significant prognostic factors.
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Engel-Haber E, Zeilig G, Haber S, Worobey L, Kirshblum S. The effect of age and injury severity on clinical prediction rules for ambulation among individuals with spinal cord injury. Spine J 2020; 20:1666-1675. [PMID: 32502654 DOI: 10.1016/j.spinee.2020.05.551] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT While several models for predicting independent ambulation early after traumatic spinal cord injury (SCI) based upon age and specific motor and sensory level findings have been published and validated, their accuracy, especially in individual American Spinal Injury Association [ASIA] Impairment Scale (AIS) classifications, has been questioned. Further, although age is widely used in prediction rules, its role and possible modifications have not been adequately evaluated until now. PURPOSE To evaluate the predictive accuracy of existing clinical prediction rules for independent ambulation among individuals at spinal cord injury model systems (SCIMS) Centers as well as the effect of modifying the age parameter from a cutoff of 65 years to 50 years. STUDY DESIGN Retrospective analysis of a longitudinal database. PATIENT SAMPLE Adult individuals with traumatic SCI. OUTCOME MEASURES The FIM locomotor score was used to assess independent walking ability at the 1-year follow-up. METHODS In all, 639 patients were enrolled in the SCIMS database between 2011 and 2015, with complete neurological examination data within 15 days following the injury and a follow-up assessment with functional independence measure (FIM) at 1-year post injury. Two previously validated logistic regression models were evaluated for their ability to predict independent walking at 1-year post injury with participants in the SCIMS database. Area under the receiver operating curve (AUC) was calculated for the individual AIS categories and for different age groups. Prediction accuracy was also calculated for a new modified LR model (with cut-off age of 50). RESULTS Overall AUC for each of the previous prediction models was found to be consistent with previous reports (0.919 and 0.904). AUCs for grouped AIS levels (A+D, B+C) were consistent with prior reports, moreover, prediction for individual AIS grades continued to reveal lower values. AUCs by different age categories showed a decline in prognostication accuracy with an increase in age, with statistically significant improvement of AUC when age-cut off was reduced to 50. CONCLUSIONS We confirmed previous results that former prediction models achieve strong prognostic accuracy by combining AIS subgroups, yet prognostication of the separate AIS groups is less accurate. Further, prognostication of persons with AIS B+C, for whom a clinical prediction model has arguably greater clinical utility, is less accurate than those with AIS A+D. Our findings emphasize that age is an important factor in prognosticating ambulation following SCI. Prediction accuracy declines for older individuals compared with younger ones. To improve prediction of independent ambulation, the age of 50 years may be a better cutoff instead of age of 65.
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Affiliation(s)
- Einat Engel-Haber
- Department of Neurological Rehabilitation, The Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Gabi Zeilig
- Department of Neurological Rehabilitation, The Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Simi Haber
- Department of Mathematics, Bar-Ilan University, Ramat-Gan, Israel
| | - Lynn Worobey
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange NJ, USA; Rutgers New Jersey Medical School, Newark, NJ, USA
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Kirshblum S, Botticello A, Benedetto J, Donovan J, Marino R, Hsieh S, Wagaman N. A Comparison of Diagnostic Stability of the ASIA Impairment Scale Versus Frankel Classification Systems for Traumatic Spinal Cord Injury. Arch Phys Med Rehabil 2020; 101:1556-1562. [DOI: 10.1016/j.apmr.2020.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/20/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
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Buri M, Curt A, Steeves J, Hothorn T. Baseline-adjusted proportional odds models for the quantification of treatment effects in trials with ordinal sum score outcomes. BMC Med Res Methodol 2020; 20:104. [PMID: 32375705 PMCID: PMC7204322 DOI: 10.1186/s12874-020-00984-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/20/2020] [Indexed: 11/10/2022] Open
Abstract
Background Sum scores of ordinal outcomes are common in randomized clinical trials. The approaches routinely employed for assessing treatment effects, such as t-tests or Wilcoxon tests, are not particularly powerful in detecting changes in relevant parameters or lack the ability to incorporate baseline information. Hence, tailored statistical methods are needed for the analysis of ordinal outcomes in clinical research. Methods We propose baseline-adjusted proportional odds logistic regression models to overcome previous limitations in the analysis of ordinal outcomes in randomized clinical trials. For the validation of our method, we focus on common ordinal sum score outcomes of neurological clinical trials such as the upper extremity motor score, the spinal cord independence measure, and the self-care subscore of the latter. We compare the statistical power of our models to other conventional approaches in a large simulation study of two-arm randomized clinical trials based on data from the European Multicenter Study about Spinal Cord Injury (EMSCI, ClinicalTrials.gov Identifier: NCT01571531). We also use the new method as an alternative analysis of the historical Sygen®clinical trial. Results The simulation study of all postulated trial settings demonstrated that the statistical power of the novel method was greater than that of conventional methods. Baseline adjustments were more suited for the analysis of the upper extremity motor score compared to the spinal cord independence measure and its self-care subscore. Conclusions The proposed baseline-adjusted proportional odds models allow the global treatment effect to be directly interpreted. This clear interpretation, the superior statistical power compared to the conventional analysis approaches, and the availability of open-source software support the application of this novel method for the analysis of ordinal outcomes of future clinical trials.
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Affiliation(s)
- Muriel Buri
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, Zurich, CH-8001, Switzerland
| | - Armin Curt
- University Hospital Balgrist, Spinal Cord Injury Center, Forchstrasse 340, Zurich, CH-8008, Switzerland
| | - John Steeves
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver/Kelowna, Canada
| | - Torsten Hothorn
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, Zurich, CH-8001, Switzerland.
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ter Wengel PV, De Haan Y, Feller RE, Oner FC, Vandertop WP. Complete Traumatic Spinal Cord Injury: Current Insights Regarding Timing of Surgery and Level of Injury. Global Spine J 2020; 10:324-331. [PMID: 32313798 PMCID: PMC7160809 DOI: 10.1177/2192568219844990] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
STUDY DESIGN A narrative literature review. OBJECTIVES To review the neurological recovery patterns in traumatic spinal cord injury (tSCI) patients with a complete lack of motor and sensory function below the level of injury (ie, ASIA A [American Spinal Injury Association scale]), as well as the impact of level of injury and timing of surgical intervention. RESULTS Spontaneous neurological recovery in patients with complete tSCI differs per level of injury: patients with cervical and thoracolumbar tSCI recover ≥1 ASIA grade in 17.3% to 34.0% 1 year after injury, compared with 10.7% to 18.6% in thoracic tSCI. Surgical decompression within 24 hours has a beneficial effect on neurological recovery in patients with complete cervical tSCI, whereas this effect is less clear for thoracic and thoracolumbar tSCI. A 1- or 2-grade improvement in the ASIA scale does not necessarily result in functional recovery. CONCLUSION In complete tSCI, the level of injury as well as surgical timing affect neurological recovery. There appears to be a beneficial effect of early surgical decompression in patients with complete cervical tSCI, more so than for thoracic and thoracolumbar tSCI. Frequently, the effect of surgical intervention is evaluated by an improvement in ASIA grade, but it is unclear whether this scale is sensitive enough to evaluate meaningful effectiveness of the intervention and desired outcome for patients with tSCI.
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Affiliation(s)
- Paula Valerie ter Wengel
- VU University Medical Center, Amsterdam, Netherlands,Leiden University Medical Center, Leiden, Netherlands,Paula Valerie ter Wengel, De Boelelaan 1117,
Amsterdam 1081 HV, Netherlands.
| | | | | | | | - William Peter Vandertop
- VU University Medical Center, Amsterdam, Netherlands,Academic Medical Center, Amsterdam, Netherlands
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Shanmuganathan K, Zhuo J, Bodanapally UK, Kuladeep S, Aarabi B, Adams J, Miller C, Gullapallie RP, Menakar J. Comparison of Acute Diffusion Tensor Imaging and Conventional Magnetic Resonance Parameters in Predicting Long-Term Outcome after Blunt Cervical Spinal Cord Injury. J Neurotrauma 2020; 37:458-465. [DOI: 10.1089/neu.2019.6394] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
| | - Jiachen Zhuo
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Uttam K. Bodanapally
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sudini Kuladeep
- Department of Environmental Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jason Adams
- Department of Rehabilitation Services, University of Maryland School of Medicine, Baltimore, Maryland
| | - Catriona Miller
- Aeromedical Research Department, U.S. Air Force School of Aerospace Medicine, Center for the Sustainment of Trauma and Readiness Skills, Baltimore, Maryland
| | - Rao P. Gullapallie
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jay Menakar
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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Evaniew N, Sharifi B, Waheed Z, Fallah N, Ailon T, Dea N, Paquette S, Charest-Morin R, Street J, Fisher CG, Dvorak MF, Noonan VK, Rivers CS, Kwon BK. The influence of neurological examination timing within hours after acute traumatic spinal cord injuries: an observational study. Spinal Cord 2019; 58:247-254. [DOI: 10.1038/s41393-019-0359-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 11/09/2022]
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Shamsi M, Vaisi-Raygani A, Rostami A, Mirzaei M. The effect of adding TENS to stretch on improvement of ankle range of motion in inactive patients in intensive care units: a pilot trial. BMC Sports Sci Med Rehabil 2019; 11:15. [PMID: 31428432 PMCID: PMC6694557 DOI: 10.1186/s13102-019-0129-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 07/24/2019] [Indexed: 12/04/2022]
Abstract
Background Patients hospitalized in intensive care units (ICUs) are susceptible to joint contracture and diminished range of motion. This is due to immobility as well as other underlying factors such as brain damage. Joint contracture causes functional disorders thereby diminishing the quality of life of patients following the intensive care period. Recent studies have introduced transcutaneous electrical nerve stimulation (TENS) as a new method for preventing and treating joint contracture. This study was performed to determine the effect of adding TENS to stretch on the range of ankle motion in patients hospitalized in ICUs. Methods Thirty-six patients admitted to the ICU ward of the hospital who were not able to move their legs voluntarily were assigned randomly into experimental (n = 18) and control (n = 18) groups. The intervention group received TENS along with manual stretch in the ankle three times a week for 2 weeks. The control group only received stretch in the ankle for the same time. The extent of dorsiflexion and plantar flexion of the ankle was measured using a standard goniometer. Both groups were evaluated before and one and 2 weeks after the intervention. The obtained data were analyzed by SPSS 21 through analysis of covariance and repeated measures ANOVA tests. Results In both groups, the increase in the ankle range of motion parameters was significant over time (means ranged over 44–48 for plantar flexion and means ranged over 5–11 for dorsiflexion, P < 0.001 for all of time points). The increase in ankle plantar and dorsiflexion in experimental group was significantly more than control group (mean between-group differences ranged over 1.35–3.57 within 95% CI of 1.04 to 4.01, P < 0.001). Conclusion Adding TENS to stretch may provide more improvement in ankle dorsiflexion and plantar flexion. Trial registration Trial registration: This study was registered in the Iranian Clinical Trial Center with the code IRCT2017010814333N64, registered 20 January 2017.
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Affiliation(s)
- MohammadBagher Shamsi
- 1School of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Aliakbar Vaisi-Raygani
- 2Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Asghar Rostami
- 2Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran.,3Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Maryam Mirzaei
- 1School of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Merritt CH, Taylor MA, Yelton CJ, Ray SK. Economic impact of traumatic spinal cord injuries in the United States. ACTA ACUST UNITED AC 2019; 6. [PMID: 33869674 PMCID: PMC8052100 DOI: 10.20517/2347-8659.2019.15] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Individuals having sustained traumatic spinal cord injury (TSCI) in the United States are living longer as compared to historical trends, thanks to an ever-evolving understanding of the nature of this injury. Despite this, multiple barriers to care for TSCI patients remain including variations in government-issued veteran insurance, privatized insurance, and among uninsured individuals. The United States alone experiences 12,000 new TSCI cases every year, many of these are found to occur in a growing proportion of elderly individuals. It is crucial to understand both the short-term direct costs as wells as the long-term rehabilitation costs required by these TSCI patients. The lifetime financial burden for those having sustained a TSCI can be immense for patients, insurance companies, and hospital systems alike. Among those with TSCI, re-hospitalization rates are high, leading to increased healthcare resource utilization within this specific patient population. Costs can quickly balloon into hundreds of thousands of dollars and cause a profound financial burden for these patients. This review article seeks to communicate an understanding of the current financial landscape surrounding TSCI patients. The authors will also examine the costs of acute emergency room surgical care such as American spinal injury association grade, hospital length of stay, as well as the timing delay between injury and surgical decompression. Long-term costs associated with TSCI such as rehabilitation, care of secondary comorbidities, and post-injury employment prospects will be examined as well. These costs will be framed from the patient’s perspective as well as from both the hospital and insurance company’s perspectives. It is hoped a complete understanding as to what makes TSCI such a medically and financially burdensome injury will allow for improved healthcare resource utilization in this population.
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Affiliation(s)
- Christopher H Merritt
- Department of Pathology, Microbiology, and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Matthew A Taylor
- Department of Pathology, Microbiology, and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Caleb J Yelton
- Department of Pathology, Microbiology, and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Swapan K Ray
- Department of Pathology, Microbiology, and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
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Khorasanizadeh M, Yousefifard M, Eskian M, Lu Y, Chalangari M, Harrop JS, Jazayeri SB, Seyedpour S, Khodaei B, Hosseini M, Rahimi-Movaghar V. Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis. J Neurosurg Spine 2019; 30:683-699. [PMID: 30771786 DOI: 10.3171/2018.10.spine18802] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/11/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
| | - Mahmoud Yousefifard
- 2Physiology Research Center and Department of Physiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahsa Eskian
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Yi Lu
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maryam Chalangari
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - James S Harrop
- 4Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia
- 5Neurosurgery, Delaware Valley Regional Spinal Cord Injury Center, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | | | - Simin Seyedpour
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Behzad Khodaei
- 1Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences
| | - Mostafa Hosseini
- 6Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Evaniew N, Fallah N, Rivers CS, Noonan VK, Fisher CG, Dvorak MF, Wilson JR, Kwon BK. Unbiased Recursive Partitioning to Stratify Patients with Acute Traumatic Spinal Cord Injuries: External Validity in an Observational Cohort Study. J Neurotrauma 2019; 36:2732-2742. [PMID: 30864876 PMCID: PMC6727480 DOI: 10.1089/neu.2018.6335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Clinical trials of novel therapies for acute spinal cord injury (SCI) are challenging because variability in spontaneous neurologic recovery can make discerning actual treatment effects difficult. Unbiased Recursive Partitioning regression with Conditional Inference Trees (URP-CTREE) is a novel approach developed through analyses of a large European SCI database (European Multicenter Study about Spinal Cord Injury). URP-CTREE uses early neurologic impairment to predict achieved motor recovery, with potential to optimize clinical trial design by optimizing patient stratification and decreasing sample sizes. We performed external validation to determine how well a previously reported URP-CTREE model stratified patients into distinct homogeneous subgroups and predicted subsequent neurologic recovery in an independent cohort. We included patients with acute cervical SCI level C4-C6 from a prospective registry at a quaternary care center from 2004-2018 (n = 101) and applied the URP-CTREE model and evaluated Upper Extremity Motor Score (UEMS) recovery, considered correctly predicted when final UEMS scores were within a pre-specified threshold of 9 points from median; sensitivity analyses evaluated the effect of timing of baseline neurological examination. We included 101 patients, whose mean times from injury baseline and follow-up examinations were 6.1 days (standard deviation [SD] 17) and 235.0 days (SD 71), respectively. Median UEMS recovery was 7 points (interquartile range 2-12). One of the predictor variables was not statistically significant in our sample; one group did not fit progressively improving UEMS scores, and three of five groups had medians that were not significantly different from adjacent groups. Overall accuracy was 75%, but varied from 82% among participants whose examinations occurred at <12 h, to 64% at 12-24 h, and 58% at >24 h. A previous URP-CTREE model had limited ability to stratify an independent into homogeneous subgroups. Overall accuracy was promising, but may be sensitive to timing of baseline neurological examinations. Further evaluation of external validity in incomplete injuries, influence of timing of baseline examinations, and investigation of additional stratification strategies is warranted.
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Affiliation(s)
- Nathan Evaniew
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Spine Surgery Institute, Vancouver, British Columbia, Canada
| | - Nader Fallah
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Carly S Rivers
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | | | - Charles G Fisher
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Spine Surgery Institute, Vancouver, British Columbia, Canada
| | - Marcel F Dvorak
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Spine Surgery Institute, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Brian K Kwon
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Spine Surgery Institute, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
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Marino RJ, Sinko R, Bryden A, Backus D, Chen D, Nemunaitis GA, Leiby BE. Comparison of Responsiveness and Minimal Clinically Important Difference of the Capabilities of Upper Extremity Test (CUE-T) and the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP). Top Spinal Cord Inj Rehabil 2018; 24:227-238. [PMID: 29997426 DOI: 10.1310/sci2403-227] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: The Capabilities of Upper Extremity Test (CUE-T) and the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) were both developed to detect change in upper extremity (UE) function in persons with tetraplegia. Objective: To compare the responsiveness and minimal clinically important difference (MCID) of the CUE-T and the quantitative prehension (QtP) scale of the GRASSP. Methods: Subjects included 69 persons with tetraplegia: 60 with acute and 9 with chronic injuries. Subjects were assessed twice 3 months apart using the CUE-T, QtP-GRASSP, and upper extremity motor scores (UEMS). Subjects rated their impression of change in overall and right/left UE function from -7 to +7. The standardized response mean (SRM) was determined for acute subjects. MCID was estimated using a small subjective change (2-3 points) and change in UEMS. Results: Subjects were 41.9 ± 18.1 years old, neurological levels C1-C7; 25 were motor complete. For acute subjects, the SRMs for total/side CUE-T scores were 1.07/0.96, and for the QtP-GRASSP they were 0.88/0.78. MCIDs based on subjective change for total/side CUE-T scores were 11.7/6.1 points and for QtP-GRASSP were 6.4/3.0 points. Based on change in UEMS, MCIDs for total/side were 11.9/6.3 points for CUE-T and 6.0/3.3 points for QtP-GRASSP. Some subjects had changes in the CUE-T due to its arm items that were not seen with the QtP-GRASSP. Conclusion: Both the CUE-T and QtP-GRASSP are responsive to change in persons with acute cervical spinal cord injury with large SRMs. The CUE-T detects some changes in UE function not seen with the QtP-GRASSP.
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Affiliation(s)
- Ralph J Marino
- Department of Rehabilitation Medicine, Sidney Kimmel Medical College, Jefferson (Philadelphia University + Thomas Jefferson University), Philadelphia, Pennsylvania
| | - Rebecca Sinko
- Department of Occupational Therapy, Jefferson College of Health Professions, Jefferson (Philadelphia University + Thomas Jefferson University), Philadelphia, Pennsylvania
| | - Anne Bryden
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Deborah Backus
- Crawford Research Institute, Shepherd Center Hospital, Atlanta, Georgia
| | - David Chen
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, Chicago, Illinois
| | - Gregory A Nemunaitis
- MetroHealth Medical Center/MetroHealth Rehabilitation Institute of Ohio, Cleveland, Ohio.,Department of Physical Medicine & Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Benjamin E Leiby
- Division of Biostatics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College at, Jefferson (Philadelphia University + Thomas Jefferson University), Philadelphia, Pennsylvania
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Freyvert Y, Yong NA, Morikawa E, Zdunowski S, Sarino ME, Gerasimenko Y, Edgerton VR, Lu DC. Engaging cervical spinal circuitry with non-invasive spinal stimulation and buspirone to restore hand function in chronic motor complete patients. Sci Rep 2018; 8:15546. [PMID: 30341390 PMCID: PMC6195617 DOI: 10.1038/s41598-018-33123-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/17/2018] [Indexed: 01/01/2023] Open
Abstract
The combined effects of cervical electrical stimulation alone or in combination with the monoaminergic agonist buspirone on upper limb motor function were determined in six subjects with motor complete (AIS B) injury at C5 or above and more than one year from time of injury. Voluntary upper limb function was evaluated through measures of controlled hand contraction, handgrip force production, dexterity measures, and validated clinical assessment batteries. Repeated measure analysis of variance was used to evaluate functional metrics, EMG amplitude, and changes in mean grip strength. In aggregate, mean hand strength increased by greater than 300% with transcutaneous electrical stimulation and buspirone while a corresponding clinically significant improvement was observed in upper extremity motor scores and the action research arm test. Some functional improvements persisted for an extended period after the study interventions were discontinued. We demonstrate that, with these novel interventions, cervical spinal circuitry can be neuromodulated to improve volitional control of hand function in tetraplegic subjects. The potential impact of these findings on individuals with upper limb paralysis could be dramatic functionally, psychologically, and economically.
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Affiliation(s)
- Yevgeniy Freyvert
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Nicholas Au Yong
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Erika Morikawa
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Sharon Zdunowski
- Departments of Integrative Biology and Physiology, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Melanie E Sarino
- Rancho Los Amigos National Rehabilitation Center, Downey, California, 90242, USA
| | - Yury Gerasimenko
- Departments of Integrative Biology and Physiology, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Pavlov Institute of Physiology, St. Petersburg, Russia
| | - V Reggie Edgerton
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Departments of Integrative Biology and Physiology, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Neurobiology, University of California, Los Angeles, Los Angeles, California, 90095, USA
- Brain Research Institute, University of California, Los Angeles, Los Angeles, California, 90095, USA
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, 90095, USA.
- Neuromotor Recovery and Rehabilitation Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, 90095, USA.
- Brain Research Institute, University of California, Los Angeles, Los Angeles, California, 90095, USA.
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Chi B, Chau B, Yeo E, Ta P. Virtual reality for spinal cord injury-associated neuropathic pain: Systematic review. Ann Phys Rehabil Med 2018; 62:49-57. [PMID: 30312665 DOI: 10.1016/j.rehab.2018.09.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/02/2018] [Accepted: 09/15/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Treatment of spinal cord injury (SCI)-associated neuropathic pain is challenging, with limited efficacy and no definitive options, and SCI patients often show resistance to pharmacologic treatment. Virtual reality (VR) therapy is a non-invasive, non-pharmacologic alternative with minimal adverse effects. OBJECTIVE To investigate the effect of VR therapy on SCI-associated neuropathic pain in a systematic review. METHODS Articles needed to 1) be written in English; 2) include adult subjects, with at least half the study population with a SCI diagnosis; 3) involve any form of VR therapy; and 4) assess neuropathic pain by quantitative outcome measures. Articles were searched in MEDLINE/PubMed, CINAHL®, EMBASE, and PsycINFO up to April 2018. Reference lists of retrieved articles were hand-searched. Methodologic quality was assessed by the Physiotherapy Evidence Database Score (PEDro) for randomized controlled trials and Modified Downs and Black Tool (D&B) for all other studies. Level of evidence was determined by using a modified Sackett scale. RESULTS Among 333 studies identified, 9 included in this review (n=150 participants) evaluated 4 methods of VR therapy (virtual walking, VR-augmented training, virtual illusion, and VR hypnosis) for treating neuropathic pain in SCI patients. Each VR method reduced neuropathic pain: 4 studies supported virtual walking, and the other 3 VR methods were each supported by a different study. Combined treatment with virtual walking and transcranial direct current stimulation was the most effective. The quality of studies was a major limitation. CONCLUSION VR therapy could reduce SCI-associated neuropathic pain, although the clinical significance of this analgesic effect is unclear. Clinical trials evaluating VR therapy as standalone and/or adjunct therapy for neuropathic pain in SCI patients are warranted.
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Affiliation(s)
- B Chi
- Department of Physical Medicine and Rehabilitation, Loma Linda University Health, 11406 Loma Linda Drive, Suite 516, 92354 Loma Linda, CA, USA; Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, 11549 Hempstead, NY, USA.
| | - B Chau
- Department of Physical Medicine and Rehabilitation, Loma Linda University Health, 11406 Loma Linda Drive, Suite 516, 92354 Loma Linda, CA, USA; VA Loma Linda Healthcare System, 11201 Benton Street, 92357 Loma Linda, CA, USA
| | - E Yeo
- Loma Linda University School of Medicine, 11175 Campus Street, 92350 Loma Linda, CA, USA
| | - P Ta
- Department of Physical Medicine and Rehabilitation, Loma Linda University Health, 11406 Loma Linda Drive, Suite 516, 92354 Loma Linda, CA, USA
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Cowan RE, Anderson KD. Replication and novel analysis of age and sex effects on the neurologic and functional value of each spinal segment in the US healthcare setting. Spinal Cord 2018; 57:156-164. [DOI: 10.1038/s41393-018-0206-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/17/2018] [Accepted: 09/10/2018] [Indexed: 11/09/2022]
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Evaluation of a ketogenic diet for improvement of neurological recovery in individuals with acute spinal cord injury: a pilot, randomized safety and feasibility trial. Spinal Cord Ser Cases 2018; 4:88. [PMID: 30275980 DOI: 10.1038/s41394-018-0121-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 01/26/2023] Open
Abstract
Study design Longitudinal, randomized study. Objectives (1) Test the safety and feasibility of a ketogenic diet (KD) intervention in the acute stages of spinal cord injury (SCI), (2) assess the effects of a KD on neurological recovery, and (3) identify potential serum biomarkers associated with KD-induced changes in neurological recovery. Setting Acute care and rehabilitation facility. Methods The KD is a high-fat, low-carbohydrate diet that includes ≈70-80% total energy as fat. Seven participants with acute complete and incomplete SCI (AIS A-D) were randomly assigned to KD (n = 4) or standard diet (SD, n = 3). Neurological examinations, resting energy expenditure analysis, and collection of blood for evaluation of circulating ketone levels were performed within 72 h of injury and before discharge. Untargeted metabolomics analysis was performed on serum samples to identify potential serum biomarkers that may explain differential responses between groups. Results Our pilot findings primarily demonstrated that KD is safe and feasible to be administered in acute SCI. Furthermore, upper extremity motor scores were higher (p < 0.05) in the KD vs. SD group and an anti-inflammatory lysophospholipid, lysoPC 16:0, was present at higher levels, and an inflammatory blood protein, fibrinogen, was present at lower levels in the KD serum samples vs. SD serum samples. Conclusion Taken together, these preliminary results suggest that a KD may have anti-inflammatory effects that may promote neuroprotection, resulting in improved neurological recovery in SCI. Future studies with larger sample size are warranted for demonstrating efficacy of KD for improving neurological recovery.
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Aarabi B, Sansur CA, Ibrahimi DM, Simard JM, Hersh DS, Le E, Diaz C, Massetti J, Akhtar-Danesh N. Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury. Neurosurgery 2017; 80:610-620. [PMID: 28362913 DOI: 10.1093/neuros/nyw053] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/14/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Evidence indicates that, over time, patients with spinal cord injury (SCI) improve neurologically in various degrees. We sought to further investigate indicators of grade conversion in cervical SCI. OBJECTIVE To detect predictors of ASIA impairment scale (AIS) grade conversion in SCI following surgical decompression. METHODS In a retrospective study, demographics, clinical, imaging, and surgical data from 100 consecutive patients were assessed for predictors of AIS grade conversion. RESULTS American Spinal Injury Association motor score was 17.1. AIS grade was A in 52%, B in 29%, and C in 19% of patients. Surgical decompression took place on an average of 17.6 h following trauma (≤12 h in 51 and >12 h in 49). Complete decompression was verified by magnetic resonance imaging (MRI) in 73 patients. Intramedullary lesion length (IMLL) on postoperative MRI measured 72.8 mm, and hemorrhage at the injury epicenter was noted in 71 patients. Grade conversion took place in 26.9% of AIS grade A patients, 65.5% of AIS grade B, and 78.9% of AIS grade C. AIS grade conversion had statistical relationship with injury severity score, admission AIS grade, extent of decompression, presence of intramedullary hemorrhage, American Spinal Injury Association motor score, and IMLL. A stepwise multiple logistic regression analysis indicated IMLL was the sole and strongest indicator of AIS grade conversion (odds ratio 0.950, 95% CI 0.931-0.969). For 1- and 10-mm increases in IMLL, the model indicates 4% and 40% decreases, respectively, in the odds of AIS grade conversion. CONCLUSION Compared with other surrogates, IMLL remained as the only predictor of AIS grade conversion.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.,R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles A Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David M Ibrahimi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David S Hersh
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth Le
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cara Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Massetti
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Noori Akhtar-Danesh
- School of Nursing and Depart-ment of Clinical Epidemiology and Bio-statistics, McMaster University, Hamilton, Ontario, Canada
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Computer-Assessed Preference-Based Quality of Life in Patients with Spinal Cord Injury. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4543610. [PMID: 28948166 PMCID: PMC5602611 DOI: 10.1155/2017/4543610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/27/2017] [Accepted: 07/16/2017] [Indexed: 12/03/2022]
Abstract
Objectives Our aims were to (1) measure quality of life (QoL) in spinal cord injury (SCI) patients using different methods and analyze differences; (2) enable targeted treatments by identifying variables that affect QoL; and (3) provide decision-makers with useful data for cost-utility analyses in SCI population. Methods Seventy-one participants were enrolled. The computer-based tool UceWeb was used to elicit QoL in terms of utility coefficients, through the standard gamble, time trade-off, and rating scale methods. The SF36 questionnaire was also administered. Statistical analyses were performed to find predictors of QoL among collected variables. Results Median values for rating scale, time trade-off, and standard gamble were 0.60, 0.82, and 0.85, respectively. All scales were significantly correlated. Rating scale and SF36 provided similar values, significantly lower than the other methods. Impairment level, male gender, older age, living alone, and higher education were correlated with lower QoL but accounted for only 20% of the variation in utility coefficients. Conclusions Demographic and clinical variables are useful to predict QoL but do not completely capture utility coefficients variability. Therefore, direct preference-based utility elicitation should be strengthened. Finally, this is the first study providing data that can be used as a reference for cost-utility analyses in the Italian SCI population.
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Motor exam of patients with spinal cord injury: a terminological imbroglio. Neurol Sci 2017; 38:1159-1165. [PMID: 28357583 DOI: 10.1007/s10072-017-2931-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
The description of the motor deficit of patients with spinal cord injury (SCI) varies significantly, leading to confusion within the neurological terminology. This paper proposes a concise and easy to use terminology to describe the motor deficit of patients with SCI. A broad review of the origin of the nomenclature used to describe the motor deficit of patients with SCI was performed and discussed. The prefix: "hemi" should be used to describe paralysis of one half of the body; "mono" for one limb; "para" for lower limbs, di" for two symmetrical segments and/or parts in both sides of the body; "tri" for three limbs, or two limbs and one side of the face; and "tetra" for four limbs. The suffix: "plegia" should be used for total paralysis of a limb or part of the body, and "paresis" for partial paralysis. The term "brachial" refers to the upper limbs; and "podal" to the lower limbs. According to the spinal cord origin of the main key muscles for the limbs, patients with complete injury affecting spinal cord segments C1-5 usually presents with "tetraplegia"; C6-T1 presents with "paraplegia and brachial diparesis"; T2-L2 with "paraplegia"; and L3-S1 with "paraparesis".
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49
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Lu DC, Edgerton VR, Modaber M, AuYong N, Morikawa E, Zdunowski S, Sarino ME, Sarrafzadeh M, Nuwer MR, Roy RR, Gerasimenko Y. Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients. Neurorehabil Neural Repair 2016; 30:951-962. [PMID: 27198185 PMCID: PMC5374120 DOI: 10.1177/1545968316644344] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Paralysis of the upper limbs from spinal cord injury results in an enormous loss of independence in an individual's daily life. Meaningful improvement in hand function is rare after 1 year of tetraparesis. Therapeutic developments that result in even modest gains in hand volitional function will significantly affect the quality of life for patients afflicted with high cervical injury. The ability to neuromodulate the lumbosacral spinal circuitry via epidural stimulation in regaining postural function and volitional control of the legs has been recently shown. A key question is whether a similar neuromodulatory strategy can be used to improve volitional motor control of the upper limbs, that is, performance of motor tasks considered to be less "automatic" than posture and locomotion. In this study, the effects of cervical epidural stimulation on hand function are characterized in subjects with chronic cervical cord injury. OBJECTIVE Herein we show that epidural stimulation can be applied to the chronic injured human cervical spinal cord to promote volitional hand function. METHODS AND RESULTS Two subjects implanted with a cervical epidural electrode array demonstrated improved hand strength (approximately 3-fold) and volitional hand control in the presence of epidural stimulation. CONCLUSIONS The present data are sufficient to suggest that hand motor function in individuals with chronic tetraplegia can be improved with cervical cord neuromodulation and thus should be comprehensively explored as a possible clinical intervention.
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Affiliation(s)
- Daniel C Lu
- University of California, Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Erika Morikawa
- University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Melanie E Sarino
- Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | | | - Marc R Nuwer
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Roland R Roy
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Yury Gerasimenko
- University of California, Los Angeles, Los Angeles, CA, USA Pavlov Institute of Physiology, St. Petersburg, Russia
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Kirshblum SC, Botticello AL, Dyson-Hudson TA, Byrne R, Marino RJ, Lammertse DP. Patterns of Sacral Sparing Components on Neurologic Recovery in Newly Injured Persons With Traumatic Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:1647-55. [PMID: 26971670 DOI: 10.1016/j.apmr.2016.02.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/15/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the patterns of sacral sparing and recovery in newly injured persons with traumatic spinal cord injury (SCI). DESIGN Retrospective analysis of data from the national Spinal Cord Injury Model Systems (SCIMS) database for patients enrolled from January 2011 to February 2015. SETTING SCIMS centers. PARTICIPANTS Individuals (N=1738; age ≥16y) with traumatic SCI admitted to rehabilitation within 30 days after injury with follow-up at discharge, at 1 year, or both. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES International Standards for Neurological Classification of Spinal Cord Injury examination results at admission and follow-up (discharge or 1y, or both). RESULTS Conversion from an initial American Spinal Injury Association Impairment Scale (AIS) grade A to incomplete status was 20% at rehabilitation discharge and 27.8% at 1 year, and was greater in cervical and low paraplegia levels (T10 and below) than in high paraplegia level injuries (T1-9). Conversion from AIS B to motor incomplete was 33.9% at discharge and 53.6% at 1 year, and the initial sparing of all sacral sensory components was correlated with the greatest conversion to motor incomplete status at discharge and at 1 year. For patients with initial AIS C, the presence of voluntary anal contraction (VAC) in association with other sacral sparing was most frequently observed to improve to AIS D status at discharge. However, the presence of VAC alone as the initial sacral sparing component had the poorest prognosis for recovery to AIS D status. At follow-up, regaining sacral sparing components correlated with improvement in conversion for patients with initial AIS B and C. CONCLUSIONS The components of initial and follow-up sacral sparing indicated differential patterns of neurologic outcome in persons with traumatic SCI. The more sacral components initially spared, the greater the potential for recovery; and the more sacral components gained, the greater the chance of motor recovery. Consideration of whether VAC should remain a diagnostic criterion sufficient for motor incomplete classification in the absence of other qualifying sublesional motor sparing is recommended.
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Affiliation(s)
- Steven C Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Kessler Foundation, West Orange, NJ.
| | - Amanda L Botticello
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Kessler Foundation, West Orange, NJ
| | - Trevor A Dyson-Hudson
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Kessler Foundation, West Orange, NJ
| | | | - Ralph J Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Daniel P Lammertse
- Craig Hospital, Englewood, CO; Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO
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