Traumatic and non-traumatic spinal cord injury: Demographic characteristics, neurological and functional outcomes. A 7-year single centre experience

Factors influencing on functional independence outcomes after hospitalization and rehabilitation in children with spinal cord injury

OBJECTIVE

This study is to investigate the factors that influence functional autonomy outcomes in children who have undergone rehabilitation for spinal cord injury. The aim is to enhance the clinical guidance provided to inpatients at the China Rehabilitation Research Center, Beijing Bo-ai Hospital. Furthermore, the objective is to optimize rehabilitation interventions and establish a scientific basis.

METHODS

This study employed a retrospective survey method for data collection and analysis. Descriptive analysis, one-way ANOVA analysis, and Multiple logistic regression analysis were utilized to examine the influencing factors associated with the prognosis of functional independence outcomes in children with SCI. The degree of influence of each independent variable on functional independence outcomes was ultimately determined.

RESULTS

The total score of SCIM-III at admission was 41.48 ± 4.089, and the total score of SCIM-III at discharge was 50.05 ± 25.028, resulting in a significant difference in the total score of SCIM-III was (8.57 ± 7.000, p < 0.001).In one-way ANOVA analysis, Self-care: injury segments, damage plane, ASIA, assistive devices, complications, rehabilitation duration treatment, WISCI-II, UEMS and LEMS, BI, and 6WMD groups were statistically significant (p < 0.001). Respiratory and sphincter management: injury segments, ASIA, complications, injury to recovery time interval, rehabilitation duration treatment, WISCI-II, UEMS and LEMS, BI, and 6WMD groups were statistically significant (p < 0.05). Move: age, injury segments, damage plane, rehabilitation duration treatment, WISCI-II, UEMS and LEMS groups were statistically significant (p < 0.05). SCIM-III total score: age, AISA, assistive devices, injury to recovery time interval, rehabilitation duration treatment were statistically significant (p < 0.05). Multiple logistic regression analysis, revealed that the injury to recovery time interval had a negative correlation with the total difference in SCIM-III scale (t = -9.893, p < 0.001; 95%CI-12.006~-7.780), while the duration of rehabilitation treatment (t = 4.245, p < 0.001, 95%CI 2.636 ~ 5.854) had a positive correlation with different age groups (t = 4.002, p < 0.001, 95%CI 2.421 ~ 5.583).

CONCLUSION

The shorter the interval between the time of spinal cord injury and the time of intervention for rehabilitation, the more favorable the functional recovery of the children. Children with SCI who were hospitalized for rehabilitation and achieved 3-month daily functional independence scores were more successful. It is recommended that rehabilitation interventions for children with SCI in this institution should be initiated as early as possible and maintained over time. Among the subjects, the prognosis of functional independence was more favorable in the school-age group (6-18y) than in the preschool group (3-6 y).

Optimizing length of hospital stay among inpatients with spinal cord injury: An observational study

INTRODUCTION AND OBJECTIVES

Despite the importance of length of stay (LOS) following spinal cord injury, it remains underexplored in the literature. This study aims to bridge this gap by investigating the association between rehabilitation LOS and functional gains among patients with traumatic (TSCI) or non-traumatic (NTSCI) spinal cord injuries.

METHODS

We conducted a retrospective observational cohort study assessing functional gains using the motor Functional Independence Measure (mFIM) and the Spinal Cord Independence Measure (SCIM III) from rehabilitation admission to discharge. Outcomes were analyzed across four neurological categories based on the American Spinal Injury Association Impairment Scale (AIS): C1-C4 AIS A-C; C5-8 AIS A-C; T1-S5 AIS A-C; and AIS D. Linear regression models estimated changes across rehabilitation LOS quarters (Q1-Q4), adjusting for covariates.

RESULTS

We included 1036 patients admitted for rehabilitation between 2007 and 2023 (46.3% TSCI, 53.7% NTSCI). TSCI: age 42.7, 80.2% male, 41.8% AIS A, LOS 90.5. NTSCI: age 55.7, 54.2% male, 14.2% AIS A, LOS 69.6. For TSCI, mFIM and SCIM III gains increased significantly from Q1 to Q2 (T1-S5-ABC, n=214) and Q2 to Q3 (AIS D, n=129). For NTSCI, gains increased from Q2 to Q3 (T1-S5-ABC, n=195) and from Q1 to Q2 as well as from Q2 to Q3 (AIS D, n=304). Adjusted models showed decreasing gains for Q2 and Q3 vs. Q1 (TSCI) but increasing gains for Q2-Q4 vs. Q1 (NTSCI) for both measures. No significant gains were observed from Q3 to Q4.

CONCLUSIONS

We identified specific neurological categories and LOS quarters yielding to significant functional gains.

Vasopressor Use in Acute Spinal Cord Injury: Current Evidence and Clinical Implications

Acute spinal cord injury (SCI) often results in severe neurologic deficits, with hemodynamic instability contributing to secondary ischemic damage. Beyond surgical decompression, maintaining adequate mean arterial pressure (MAP) is key to enhancing spinal cord perfusion and oxygenation. Vasopressor therapy is frequently used to achieve hemodynamic stability, but optimal MAP targets and vasopressor selection remain controversial. This review explores updated guidelines and current evidence regarding MAP management and the use of vasopressors in SCI, focusing on their impact on spinal cord perfusion and neurologic outcomes. Recent studies highlight the role of durotomy in directly improving spinal cord perfusion pressure (SCPP) by reducing intraspinal pressure (ISP), offering a complementary mechanical intervention as part of pharmacologic therapies. Recent guidelines suggest an MAP range of 75-80 mmHg as a lower limit and 90-95 mmHg as an upper limit for 3-7 days post-injury, highlighting the need for personalized hemodynamic management. Norepinephrine is commonly preferred due to its balanced effects on peripheral vascular resistance and spinal cord perfusion pressure (SCPP), though dopamine, phenylephrine, and dobutamine each offer unique hemodynamic profiles suited to specific clinical scenarios. Despite their benefits, vasopressors carry significant risks, including arrhythmias and potential myocardial strain, necessitating careful selection based on individual patient factors. Further research is needed to refine vasopressor use and establish evidence-based protocols that optimize neurologic recovery, alongside continued exploration of SCPP as a potential therapeutic target.

Unveiling the mosaic: comparing demographics and outcomes in traumatic vs. non-traumatic spinal cord injuries

BACKGROUND

This study analyzed the percentage of patients with nontraumatic spinal cord injury (SCI) which is increasing with the increase of population age. However, little is known about the effect of the etiology of SCI on the outcome of these subjects.

AIM

The aim of this study was to investigate functional and neurological outcomes in patients with traumatic and nontraumatic spinal cord lesions, with a focus on factors influencing rehabilitation outcomes.

DESIGN

The design of this study was that of a retrospective analysis of prospectively recorded data.

SETTING

The setting of this analysis was a single Spinal Unit in Italy.

POPULATION

The population included 1080 subjects, of which 599 (55%) had injuries of traumatic origin and 481 (45%) had nontraumatic injuries.

METHODS

International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI) were utilized as measurement tools. Multivariate (backwards selection, P=0.20) logistic regression was used to assess the associations of "complication during hospitalization," "bowel management autonomy," "spontaneous micturition," "home destination" and "neurological improvement" with the following variables: etiology, age, sex, lesion level and severity and length of stay. Multivariate (backwards selection, P=0.20) negative binomial regression was used to assess the relative risks of higher SCIM and WISCI Scores at discharge after adjusting for the abovementioned variables.

RESULTS

Our work highlighted several significant differences between the traumatic and nontraumatic groups (including age, sex, lesion severity, and time from lesion onset to admission). Both groups exhibited comparable improvements in neurological and functional status, although some data were in favor of subjects with traumatic lesions. However, the regression analyses demonstrated that the main factors impacting the neurological and functional status at discharge were age, lesion level and severity, rather than the etiology of the lesion.

CONCLUSIONS

Our study provides valuable insights into the rehabilitation trajectories of traumatic and nontraumatic spinal cord injuries and demonstrates that the cause of SCI has no impact on rehabilitation outcomes.

CLINICAL REHABILITATION IMPACT

An understanding of neurological and functional recovery after spinal cord lesions is essential for answering patients' questions about their potential functional capabilities. It also assists in determining the necessary resources for inpatient rehabilitation and post discharge care. Moreover, the possession of a thorough grasp of the course and factors influencing the natural recovery of a spinal cord lesion is now a scientific necessity and is crucial for assessing the efficacy of new pharmacological and rehabilitative methods.

Traumatic and Non-traumatic Radiculomedullary Compressions: A Comparative Analysis

Background Radiculomedullary lesions represent a significant public health issue, with their epidemiological, clinical, and therapeutic characteristics varying depending on whether they are of traumatic or non-traumatic origin. The aim of this study was to compare clinical, therapeutic, and postoperative aspects between traumatic radiculomedullary lesions (TRML) and non-traumatic radiculomedullary lesions (NTRML). Methods This was a prospective cohort study conducted from 2020 to 2023 involving patients suffering from radiculomedullary lesions operated at the Department of Neurosurgery, University Teaching Hospital of Kinshasa. In addition to socio-demographic characteristics, the two patient groups - traumatic and non-traumatic - were compared based on clinical, therapeutic, and postoperative aspects using the American Spinal Injury Association (ASIA) and Spinal Cord Independence Measures (SCIM III) scores.  Results We included 153 patients, with 73 traumatic cases (47.7%) and 80 non-traumatic cases (52.3%). TRMLs were predominantly caused by road traffic accidents (34%) and falls (11%), while NTRMLs were mainly due to disc herniations (22.2%) and tuberculosis (13.7%). The mean age for TRMLs was 35.4 ±12.8 years with a sex ratio of 3.5, compared to 50.7±15.9 years and a sex ratio of 1.1 for NTRMLs. TRMLs were more frequently located in the cervical region (32.8%) and the thoracolumbar junction (40%), whereas NTRMLs predominantly affected the thoracic (22.5%) and lumbar (63.7%) regions. Patients with NTRMLs had more incomplete lesions (98.7%) and better SCIM III scores at admission compared to TRMLs (p ˂ 0.001). TRMLs had more complete deficits 42 (57.3%) vs 1 (1.3%). Both groups significantly improved their ASIA and SCIM III scores postoperatively (p ˂ 0.001) but in a similar manner (Diff-in-diff: ASIA, p=0.955; SCIM, p=0.967). TRMLs developed more complications than NTRMLs (p˂0,001). Only five patients (11.6%) with ASIA A progressed to higher grades, and all remained dependent (SCIM III score ˂50). The average hospital stay was 89.2 ±74.2 days for TRMLs and 57.5±52.9 days for NTRMLs (p˂0.001). Conclusion This study revealed that TRMLs frequently affect young male individuals and are often located in the cervical region and thoracolumbar junction. In contrast, NTRMLs affect older individuals without gender preference and are usually found in the thoracic and lumbar regions. TRMLs often lead to complete deficits, pressure sores, urinary infections, and longer hospital stays compared to NTRMLs. Both patient groups showed significant postoperative improvement with no significant difference between them. However, patients with complete deficits showed less improvement in both groups.

Community integration after spinal cord injury rehabilitation: Predictors and causal mediators

CONTEXT/OBJECTIVE

Community integration (CI) is a crucial rehabilitation goal after spinal cord injury (SCI). There is a pressing need to enhance our understanding of the factors associated with CI for individuals with traumatic or non-traumatic etiologies, with the latter being notably understudied. Accordingly, our research explores the associations and potential mediators influencing CI across these populations.

SETTING

Specialized neurological rehabilitation center.

PARTICIPANTS

Community-dwelling individuals who were admitted as inpatients within 3 months post-injury (n = 431, 51.9% traumatic, 48.1% non-traumatic), assessed in relation to community integration within 1-3 years after discharge.

OUTCOME MEASURE

Community Integration Questionnaire (CIQ). Covariates: American Spinal Injury Association Impairment Scale (AIS), Functional Independence Measure (FIM) and Hospital Anxiety and Depression Scale (HADS).

RESULTS

Multiple linear regression yielded age, B AIS grade, educational level (< 6 years and <12 years), time since injury to admission, length of stay, HADS-depression at discharge, total FIM at discharge and three social work interventions (support in financial, legal and transportation services) as significant predictors of total CIQ score (Adjusted R2 = 41.4). Multiple logistic regression identified age, traumatic etiology, educational level (< 6 years and <12 years), length of stay, HADS depression at discharge, total FIM at discharge and one social work intervention (transportation support) as significant predictors of good community integration, AUC (95% CI): 0.82 (0.75-0.89), Sensitivity:0.76, Specificity:0.73. We identified motor FIM at discharge and motor FIM efficiency as causal mediators of total CIQ.

CONCLUSIONS

We identified modifiable factors during rehabilitation-functional independence, depression, and social work interventions-that are associated with CI.

Harnessing Artificial Neural Networks for Spinal Cord Injury Prognosis

Background: Prediction of neurorehabilitation outcomes after a Spinal Cord Injury (SCI) is crucial for healthcare resource management and improving prognosis and rehabilitation strategies. Artificial neural networks (ANNs) have emerged as a promising alternative to conventional statistical approaches for identifying complex prognostic factors in SCI patients. Materials: a database of 1256 SCI patients admitted for rehabilitation was analyzed. Clinical and demographic data and SCI characteristics were used to predict functional outcomes using both ANN and linear regression models. The former was structured with input, hidden, and output layers, while the linear regression identified significant variables affecting outcomes. Both approaches aimed to evaluate and compare their accuracy for rehabilitation outcomes measured by the Spinal Cord Independence Measure (SCIM) score. Results: Both ANN and linear regression models identified key predictors of functional outcomes, such as age, injury level, and initial SCIM scores (correlation with actual outcome: R = 0.75 and 0.73, respectively). When also alimented with parameters recorded during hospitalization, the ANN highlighted the importance of these additional factors, like motor completeness and complications during hospitalization, showing an improvement in its accuracy (R = 0.87). Conclusions: ANN seemed to be not widely superior to classical statistics in general, but, taking into account complex and non-linear relationships among variables, emphasized the impact of complications during the hospitalization on recovery, particularly respiratory issues, deep vein thrombosis, and urological complications. These results suggested that the management of complications is crucial for improving functional recovery in SCI patients.

The role of apoptosis in spinal cord injury: a bibliometric analysis from 1994 to 2023

Background

Apoptosis after spinal cord injury (SCI) plays a pivotal role in the secondary injury mechanisms, which cause the ultimate neurologic insults. A better understanding of the molecular and cellular basis of apoptosis in SCI allows for improved glial and neuronal survival via the administrations of anti-apoptotic biomarkers. The knowledge structure, development trends, and research hotspots of apoptosis and SCI have not yet been systematically investigated.

Methods

Articles and reviews on apoptosis and SCI, published from 1st January 1994 to 1st Oct 2023, were retrieved from the Web of Science™. Bibliometrix in R was used to evaluate annual publications, countries, affiliations, authors, sources, documents, key words, and hot topics.

Results

A total of 3,359 publications in accordance with the criterions were obtained, which exhibited an ascending trend in annual publications. The most productive countries were the USA and China. Journal of Neurotrauma was the most impactive journal; Wenzhou Medical University was the most prolific affiliation; Cuzzocrea S was the most productive and influential author. "Apoptosis," "spinal-cord-injury," "expression," "activation," and "functional recovery" were the most frequent key words. Additionally, "transplantation," "mesenchymal stemness-cells," "therapies," "activation," "regeneration," "repair," "autophagy," "exosomes," "nlrp3 inflammasome," "neuroinflammation," and "knockdown" were the latest emerging key words, which may inform the hottest themes.

Conclusions

Apoptosis after SCI may cause the ultimate neurological damages. Development of novel treatments for secondary SCI mainly depends on a better understanding of apoptosis-related mechanisms in molecular and cellular levels. Such therapeutic interventions involve the application of anti-apoptotic agents, free radical scavengers, as well as anti-inflammatory drugs, which can be targeted to inhibit core events in cellular and molecular injury cascades pathway.

Decision Tree Analysis Accurately Predicts Discharge Destination After Spinal Cord Injury Rehabilitation

OBJECTIVES

To predict discharge destination after spinal cord injury (SCI) rehabilitation.

STUDY DESIGN

A retrospective, single-center study. We collected the following data from medical charts: age, sex, living arrangement before injury, acute length of stay (LOS), level of injury on admission, American Spinal Injury Association Impairment Scale (AIS) on admission, Upper Extremity Motor Score (UEMS) on admission, Lower Extremity Motor Score on admission (LEMS), Spinal Cord Independence Measure (SCIM) scores on admission and discharge, and discharge destination. A decision tree algorithm was used to establish prediction models in a train-test split manner using features on admission or discharge.

SETTING

A spinal center in Tokyo, Japan.

PARTICIPANTS

Participants were individuals with SCI admitted to our hospital from March 2016 to October 2021 for the first rehabilitation after the injury. The study included 210 participants divided into 2 groups: training (n=140) and testing (n=70). Random sampling without replacement was used.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prediction accuracy was evaluated with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating curve (AUC).

RESULTS

AIS was significantly different between the groups. The prediction model using total SCIM scores on discharge (D-Classification and Regression Tree [CART]) revealed that a cut-off value of 40 accurately predicted the discharge destination. In contrast, the prediction model using features on admission (A-CART) revealed that subtotal SCIM mobility scores of 5, age of 74 years, and UEMS of 23 were significant predictors. Sensitivity, specificity, PPV, NPV, and AUC of D-CART and A-CART were 0.837, 0.810, 0.911, 0.680, and 0.832 and 0.857, 0.810, 0.913, 0.708, and 0.869, respectively.

CONCLUSIONS

D-CART and A-CART showed comparable prediction accuracies. This suggests that, even during the early stages of rehabilitation, it is possible to predict the discharge destination.

Pressure Ulcers-A Longstanding Problem: A 7-Year Neurorehabilitation Unit Experience of Management, Care, and Clinical Outcomes

BACKGROUND

Neurological disease patients present an increased risk of developing pressure ulcers. The primary aim of this study is to evaluate the incidence and prevalence of pressure ulcers and their impact on length of stay and functional recovery.

METHODS

A retrospective study was conducted in a neurorehabilitation unit over a seven-year period. Data collected include demographic data, length of stay, functional evaluation, risk of pressure ulcers development, nutritional status, and skin. Pressure ulcers were classified according to the European Pressure Ulcer Advisory Panel System.

RESULTS

Data from 816 patients were analyzed. On admission, the authors found 236 pressure ulcers in 131 patients (about 16%), divided into stage I (25%), stage II (50%), and stage III-IV (25%). The most common sites were the heel (36%) and sacrum (29%). Among the risk factors for the development of pressure ulcers, malnutrition played a significant role, with approximately 76% of patients with pressure ulcers having mild to moderate malnutrition.

CONCLUSION

The presence of pressure ulcers seems to have a negative impact on the functional recovery of patients, as shown by the outcome scales and the average length of stay: 51 days versus 36 days (p < 0.01).

METTL3 Affects Spinal Cord Neuronal Apoptosis by Regulating Bcl-2 m6A Modifications After Spinal Cord Injury

OBJECTIVE

Spinal cord injury (SCI) is a severe type of neurological trauma. N6-methyladenosine (m6A) modification is one of the most common internal modifications of RNA. The role of METTL3, the predominant methylation enzyme of m6A modification, in SCI remains unclear. This study aimed to investigate the role of methyltransferase METTL3 in SCI.

METHODS

After establishing the oxygen-glucose deprivation (OGD) model of PC12 cells and rat spinal cord hemisection model, we found that the expression of METTL3 and the overall m6A modification level were significantly increased in neurons. The m6A modification was identified on B-cell lymphoma 2 (Bcl-2) messenger RNA (mRNA) by bioinformatics analysis, and m6A-RNA immunoprecipitation and RNA immunoprecipitation. In addition, METTL3 was blocked by the specific inhibitor STM2457 and gene knockdown, and then apoptosis levels were measured.

RESULTS

In different models, we found that the expression of METTL3 and the overall m6A modification level were significantly increased in neurons. After inducing OGD, inhibition of METTL3 activity or expression increased the mRNA and protein levels of Bcl-2, inhibited neuronal apoptosis, and improved neuronal viability in the spinal cord.

CONCLUSION

Inhibition of METTL3 activity or expression can inhibit the apoptosis of spinal cord neurons after SCI through the m6A/Bcl-2 signaling pathway.

Nontraumatic Spinal Cord Injury: Epidemiology, Etiology and Management

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 traumatic spinal cord injury (SCI), supraspinal influences on the peripheral nervous system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, 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 the less reported nontraumatic SCI (NTSCI), its classification, 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. Finally, management strategies for NTSCI will be provided.