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Sangari S, Perez MA. Prevalence of spasticity in humans with spinal cord injury with different injury severity. J Neurophysiol 2022; 128:470-479. [PMID: 35507475 PMCID: PMC9423778 DOI: 10.1152/jn.00126.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 11/22/2022] Open
Abstract
Spasticity is one of the most common symptoms manifested following spinal cord injury (SCI). The aim of this study was to assess spasticity in individuals with subacute and chronic SCI with different injury severity, standardizing the time and assessments of spasticity. We tested 110 individuals with SCI classified by the American Spinal Injury Association Impairment Scale (AIS) as either motor complete (AIS A and B; subacute, n = 25; chronic, n = 33) or motor incomplete (AIS C and D; subacute, n = 23; chronic, n = 29) at a similar time after injury (subacute, ∼1 mo after injury during inpatient rehabilitation and chronic, ≥1 yr after injury) using clinical (modified Ashworth scale) and kinematic (pendulum test) outcomes to assess spasticity in the quadriceps femoris muscle. Using both methodologies, we found that among individuals with subacute motor complete injuries, only a minority showed spasticity, whereas the majority exhibited no spasticity. This finding stands in contrast to individuals with subacute motor incomplete injury, where both methodologies revealed that a majority exhibited spasticity, whereas a minority exhibited no spasticity. In chronic injuries, most individuals showed spasticity regardless of injury severity. Notably, when spasticity was present, its magnitude was similar across injury severity in both subacute and chronic injuries. Our results suggest that the prevalence, not the magnitude, of spasticity differs between individuals with motor complete and incomplete SCI in the subacute and chronic stages of the injury. We thus argue that considering the "presence of spasticity" might help the stratification of participants with motor complete injuries for clinical trials.NEW & NOTEWORTHY The prevalence of spasticity in humans with SCI remains poorly understood. Using kinematic and clinical outcomes, we examined spasticity in individuals with subacute and chronic injuries of different severity. We found that spasticity in the quadriceps femoris muscle was more prevalent among individuals with subacute motor incomplete than in those with motor complete injuries. However, in a different group of individuals with chronic injuries, no differences were found in the prevalence of spasticity across injury severity.
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Affiliation(s)
| | - Monica A Perez
- Shirley Ryan AbilityLab, Chicago, Illinois
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
- Edward Hines Jr., VA Hospital, Hines, Illinois
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Kaneyama H, Kawano O, Morishita Y, Yamamoto T, Maeda T. Predicting motor function recovery in cervical spinal cord injury-induced complete paralysis with reflex response. Spinal Cord 2022; 60:1020-1022. [PMID: 35662288 DOI: 10.1038/s41393-022-00821-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A retrospective clinical study. OBJECTIVE To elucidate the usefulness of the patellar tendon reflex (PTR), bulbocavernosus reflex (BCR), and plantar response (PR) as factors in the prognostic prediction of motor function in complete paralysis due to cervical spinal cord injuries (CSCIs) at the acute phase. SETTING Department of Orthopedic Surgery, Spinal Injuries Center, Japan. METHODS 99 patients assessed as the American Spinal Injury Association Impairment Scale (AIS) grade A (AIS A) were included in this study. The PTR, BCR, and PR were evaluated respectively as positive or negative at the time of injury. We classified the patients into two groups based on their neurological recovery at 3 months after injury: "recovered" group was defined as AIS C, D, or E; "non-recovered" group was defined as AIS A or B. RESULTS Eight patients demonstrated positive PTR, while 91 demonstrated negative. Three out of eight patients with positive PTR (37.5%) were R group, while 83 out of 91 patients with negative PTR (91.2%) were N group. A significant difference was observed (p = 0.043). For BCR, no significant difference was observed (p > 0.05). Twenty-six patients demonstrated positive PTR, while 73 demonstrated negative. Nine out of twenty-six patients with positive PR (34.6%) were R group, while 71 out of 73 patients with negative PR (97.3%) were N group. A significant difference was observed (p = 0.000068). CONCLUSION The PTR and PR are useful for poor prognostic prediction of motor function in CSCI at the acute phase.
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Affiliation(s)
- Hironari Kaneyama
- Department of Orthopedic Surgery, Fukuoka Sanno Hospital, Fukuoka, Japan. .,Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan.
| | - Osamu Kawano
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan
| | | | - Takuaki Yamamoto
- Department of Orthopedic Surgery, Fukuoka University, Fukuoka, Japan
| | - Takeshi Maeda
- Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan
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Sharif S, Jazaib Ali MY. Outcome Prediction in Spinal Cord Injury: Myth or Reality. World Neurosurg 2020; 140:574-590. [DOI: 10.1016/j.wneu.2020.05.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/20/2022]
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Yousefifard M, Sarveazad A, Babahajian A, Baikpour M, Shokraneh F, Vaccaro AR, Harrop JS, Fehlings MG, Hosseini M, Rahimi‐Movaghar V. Potential diagnostic and prognostic value of serum and cerebrospinal fluid biomarkers in traumatic spinal cord injury: A systematic review. J Neurochem 2019; 149:317-330. [DOI: 10.1111/jnc.14637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/03/2018] [Accepted: 11/20/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Mahmoud Yousefifard
- Physiology Research Center Faculty of Medicine Iran University of Medical Sciences Tehran Iran
| | - Arash Sarveazad
- Colorectal Research Center Iran University of Medical Sciences Tehran Iran
| | - Asrin Babahajian
- Liver and Digestive Research Center Kurdistan University of Medical Sciences Sanandaj Iran
| | - Masoud Baikpour
- Department of Medicine Tehran University of Medical Sciences Tehran Iran
| | - Farhad Shokraneh
- Cochrane Schizophrenia Group Institute of Mental Health University of Nottingham Nottingham UK
| | - Alexander R. Vaccaro
- Department of Orthopedics and Neurosurgery Rothman Institute Thomas Jefferson University Philadelphia Pennsylvania USA
| | - James S. Harrop
- Department of Neurosurgery Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Michael G. Fehlings
- Division of Genetics and Development Krembil Research Institute University Health Network Toronto Ontario Canada
- Division of Neurosurgery, Toronto Western Hospital University Health Network Toronto Ontario Canada
- Department of Surgery and Spine Program University of Toronto Toronto Ontario Canada
| | - Mostafa Hosseini
- Department of Epidemiology and Biostatistics School of Public Health Tehran University of Medical Sciences Tehran Iran
| | - Vafa Rahimi‐Movaghar
- Sina Trauma and Surgery Research Center Tehran University of Medical Sciences Tehran Iran
- Brain and Spinal Injuries Research Center (BASIR) Neuroscience Institute Imam Khomeini Hospital Tehran University of Medical Sciences Tehran Iran
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Ozdemir RA, Perez MA. Afferent input and sensory function after human spinal cord injury. J Neurophysiol 2017; 119:134-144. [PMID: 28701541 DOI: 10.1152/jn.00354.2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Spinal cord injury (SCI) often disrupts the integrity of afferent (sensory) axons projecting through the spinal cord dorsal columns to the brain. Examinations of ascending sensory tracts, therefore, are critical for monitoring the extent of SCI and recovery processes. In this review, we discuss the most common electrophysiological techniques used to assess transmission of afferent inputs to the primary motor cortex (i.e., afferent input-induced facilitation and inhibition) and the somatosensory cortex [i.e., somatosensory evoked potentials (SSEPs), dermatomal SSEPs, and electrical perceptual thresholds] following human SCI. We discuss how afferent input modulates corticospinal excitability by involving cortical and spinal mechanisms depending on the timing of the effects, which need to be considered separately for upper and lower limb muscles. We argue that the time of arrival of afferent input onto the sensory and motor cortex is critical to consider in plasticity-induced protocols in humans with SCI. We also discuss how current sensory exams have been used to detect differences between control and SCI participants but might be less optimal to characterize the level and severity of injury. There is a need to conduct some of these electrophysiological examinations during functionally relevant behaviors to understand the contribution of impaired afferent inputs to the control, or lack of control, of movement. Thus the effects of transmission of afferent inputs to the brain need to be considered on multiple functions following human SCI.
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Affiliation(s)
- Recep A Ozdemir
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami , Miami, Florida.,Bruce W. Carter Department of Veterans Affairs Medical Center , Miami, Florida
| | - Monica A Perez
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami , Miami, Florida.,Bruce W. Carter Department of Veterans Affairs Medical Center , Miami, Florida
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Classifications In Brief: American Spinal Injury Association (ASIA) Impairment Scale. Clin Orthop Relat Res 2017; 475:1499-1504. [PMID: 27815685 PMCID: PMC5384910 DOI: 10.1007/s11999-016-5133-4] [Citation(s) in RCA: 288] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/17/2016] [Indexed: 01/31/2023]
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Abstract
Traumatic spinal cord injury (SCI) has devastating consequences for the physical, social and vocational well-being of patients. The demographic of SCIs is shifting such that an increasing proportion of older individuals are being affected. Pathophysiologically, the initial mechanical trauma (the primary injury) permeabilizes neurons and glia and initiates a secondary injury cascade that leads to progressive cell death and spinal cord damage over the subsequent weeks. Over time, the lesion remodels and is composed of cystic cavitations and a glial scar, both of which potently inhibit regeneration. Several animal models and complementary behavioural tests of SCI have been developed to mimic this pathological process and form the basis for the development of preclinical and translational neuroprotective and neuroregenerative strategies. Diagnosis requires a thorough patient history, standardized neurological physical examination and radiographic imaging of the spinal cord. Following diagnosis, several interventions need to be rapidly applied, including haemodynamic monitoring in the intensive care unit, early surgical decompression, blood pressure augmentation and, potentially, the administration of methylprednisolone. Managing the complications of SCI, such as bowel and bladder dysfunction, the formation of pressure sores and infections, is key to address all facets of the patient's injury experience.
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Awai L, Bolliger M, Ferguson AR, Courtine G, Curt A. Influence of Spinal Cord Integrity on Gait Control in Human Spinal Cord Injury. Neurorehabil Neural Repair 2015; 30:562-72. [PMID: 26428035 DOI: 10.1177/1545968315600524] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Clinical trials in spinal cord injury (SCI) primarily rely on simplified outcome metrics (ie, speed, distance) to obtain a global surrogate for the complex alterations of gait control. However, these assessments lack sufficient sensitivity to identify specific patterns of underlying impairment and to target more specific treatment interventions. Objective To disentangle the differential control of gait patterns following SCI beyond measures of time and distance. Methods The gait of 22 individuals with motor-incomplete SCI and 21 healthy controls was assessed using a high-resolution 3-dimensional motion tracking system and complemented by clinical and electrophysiological evaluations applying unbiased multivariate analysis. Results Motor-incomplete SCI patients showed varying degrees of spinal cord integrity (spinal conductivity) with severe limitations in walking speed and altered gait patterns. Principal component (PC) analysis applied on all the collected data uncovered robust coherence between parameters related to walking speed, distortion of intralimb coordination, and spinal cord integrity, explaining 45% of outcome variance (PC 1). Distinct from the first PC, the modulation of gait-cycle variables (step length, gait-cycle phases, cadence; PC 2) remained normal with respect to regained walking speed, whereas hip and knee ranges of motion were distinctly altered with respect to walking speed (PC 3). Conclusions In motor-incomplete SCI, distinct clusters of discretely controlled gait parameters can be discerned that refine the evaluation of gait impairment beyond outcomes of walking speed and distance. These findings are specifically different from that in other neurological disorders (stroke, Parkinson) and are more discrete at targeting and disentangling the complex effects of interventions to improve walking outcome following motor-incomplete SCI.
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Affiliation(s)
- Lea Awai
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Marc Bolliger
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Adam R Ferguson
- Brain and Spinal Injury Center (BASIC), University of California - San Francisco (UCSF), CA, USA
| | - Grégoire Courtine
- Center for Neuroprosthetics and Brain Mind Institute, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
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Lee JK, Oh CH, Kim JY, Park HC, Yoon SH. Brain Activation Evoked by Sensory Stimulation in Patients with Spinal Cord Injury : Functional Magnetic Resonance Imaging Correlations with Clinical Features. J Korean Neurosurg Soc 2015; 58:242-7. [PMID: 26539268 PMCID: PMC4630356 DOI: 10.3340/jkns.2015.58.3.242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 08/05/2015] [Accepted: 08/17/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study is to determine whether the changes of contralateral sensorimotor cortical activation on functional magnetic resonance imaging (fMRI) can predict the neurological outcome among spinal cord injury (SCI) patients when the great toes are stimulated without notice. METHODS This study enrolled a total of 49 patients with SCI and investigated each patient's preoperative fMRI, postoperative fMRI, American Spinal Injury Association (ASIA) score, and neuropathic pain occurrence. Patients were classified into 3 groups according to the change of blood oxygenation level dependent (BOLD) response on perioperative fMRI during proprioceptive stimulation with repetitive passive toe movements : 1) patients with a response of contralateral sensorimotor cortical activation in fMRI were categorized; 2) patients with a response in other regions; and 3) patients with no response. Correlation between the result of fMRI and each parameter was analyzed. RESULTS In fMRI data, ASIA score was likely to show greater improvement in patients in group A compared to those belonging to group B or C (p<0.001). No statistical significance was observed between the result of fMRI and neuropathic pain (p=0.709). However, increase in neuropathic pain in response to the signal change of the ipsilateral frontal lobe on fMRI was statistically significant (p=0.030). CONCLUSION When there was change of BOLD response at the contralateral sensorimotor cortex on perioperative fMRI after surgery, relief of neurological symptoms was highly likely for traumatic SCI patients. In addition, development of neuropathic pain was likely to occur when there was change of BOLD response at ipsilateral frontal lobe.
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Affiliation(s)
- Jun Ki Lee
- Department of Neurosurgery, College of Medicine, Inha University, Incheon, Korea
| | - Chang Hyun Oh
- Department of Neurosurgery, Guro Cham Teun Teun Hospital, Seoul, Korea
| | - Ji Yong Kim
- Department of Neurosurgery, College of Medicine, Inha University, Incheon, Korea
| | - Hyung-Chun Park
- Department of Neurosurgery, College of Medicine, Inha University, Incheon, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, College of Medicine, Inha University, Incheon, Korea
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Translation of the rat thoracic contusion model; part 1—supraspinally versus spinally mediated pain-like responses and spasticity. Spinal Cord 2014; 52:524-8. [DOI: 10.1038/sc.2014.72] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 04/06/2014] [Accepted: 04/08/2014] [Indexed: 11/08/2022]
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Scivoletto G, Tamburella F, Laurenza L, Torre M, Molinari M. Who is going to walk? A review of the factors influencing walking recovery after spinal cord injury. Front Hum Neurosci 2014; 8:141. [PMID: 24659962 PMCID: PMC3952432 DOI: 10.3389/fnhum.2014.00141] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 02/26/2014] [Indexed: 12/11/2022] Open
Abstract
The recovery of walking function is considered of extreme relevance both by patients and physicians. Consequently, in the recent years, recovery of locomotion become a major objective of new pharmacological and rehabilitative interventions. In the last decade, several pharmacological treatment and rehabilitative approaches have been initiated to enhance locomotion capacity of SCI patients. Basic science advances in regeneration of the central nervous system hold promise of further neurological and functional recovery to be studied in clinical trials. Therefore, a precise knowledge of the natural course of walking recovery after SCI and of the factors affecting the prognosis for recovery has become mandatory. In the present work we reviewed the prognostic factors for walking recovery, with particular attention paid to the clinical ones (neurological examination at admission, age, etiology gender, time course of recovery). The prognostic value of some instrumental examinations has also been reviewed. Based on these factors we suggest that a reliable prognosis for walking recovery is possible. Instrumental examinations, in particular evoked potentials could be useful to improve the prognosis.
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Affiliation(s)
- Giorgio Scivoletto
- Spinal Cord Unit, IRCCS Fondazione S. Lucia Rome, Italy ; Clinical and Research Movement Analysis Lab, Fondazione S. Lucia Rome, Italy
| | - Federica Tamburella
- Spinal Cord Unit, IRCCS Fondazione S. Lucia Rome, Italy ; Clinical and Research Movement Analysis Lab, Fondazione S. Lucia Rome, Italy
| | | | - Monica Torre
- Spinal Cord Unit, IRCCS Fondazione S. Lucia Rome, Italy
| | - Marco Molinari
- Spinal Cord Unit, IRCCS Fondazione S. Lucia Rome, Italy ; Clinical and Research Movement Analysis Lab, Fondazione S. Lucia Rome, Italy
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Eck JC, Martin CJ, Lapinsky A, Connolly PJ, Dipaola C. Does intraoperative neurophysiological monitoring have predictive value for functional recovery following spinal cord injury? A case report. J Clin Monit Comput 2012; 27:93-6. [PMID: 22941585 DOI: 10.1007/s10877-012-9395-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 08/25/2012] [Indexed: 10/27/2022]
Abstract
To present a case report of a patient with an ASIA B spinal cord injury with partially intact baseline IONM who made a complete functional recovery postoperatively. A thirty-three year old male presented after a motor vehicle accident. Imaging studies revealed a C4-C5 bilateral facet dislocation. On presentation the patient had 4/5 strength in bilateral biceps and wrist extensors, 3/5 strength in bilateral triceps, and 0/5 strength in the finger flexors, intrinsics and all lower extremity muscles. Motor level was C7. Sensation was grossly intact to light touch throughout all extremities, intact to pinprick from C2 to T7, and absent to pinprick caudal to T7. Rectal tone and contraction were absent. After attempts at closed reduction failed the patient underwent an open reduction and posterior C4-C5 fusion. Intraoperative neurophysiologic monitoring (IONM) revealed the presence of baseline responses to the posterior tibial nerve using somatosensory evoked potentials and to the right abductor hallucis using transcranial motor evoked potentials. At the 6 weeks postoperative visit the patient had full 5/5 motor strength to all muscles except the left deltoid that was 4/5 due to a rotator cuff injury. This case illustrates a potential prognostic value of IONM. Despite lack of clinical motor function at the time of surgery, IONM was able to illicit a motor response in the right lower extremity. Further prospective studies are needed for further investigation.
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Affiliation(s)
- Jason C Eck
- Department of Orthopedic Surgery, University of Massachusetts, Worcester, MA, USA.
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Clinical neurophysiology in the prognosis and monitoring of traumatic spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2012; 109:63-75. [PMID: 23098706 DOI: 10.1016/b978-0-444-52137-8.00004-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Preclinical studies for the repair of spinal cord injury (SCI) and potential therapies for accessing the inherent plasticity of the central nervous system (CNS) to promote recovery of function are currently moving into the translational stage. These emerging clinical trials of therapeutic interventions for the repair of SCI require improved assessment techniques and quantitative outcome measures to supplement the American Spinal Injuries Association (ASIA) Impairment Scales. This chapter attempts to identify those electrophysiological techniques that show the most promise for provision of objective and quantitative measures of sensory, motor, and autonomic function in SCI. Reviewed are: (1) somatosensory evoked potentials, including dermatomal somatosensory evoked potentials, and the electrical perceptual threshold as tests of the dorsal (posterior) column pathway; (2) laser evoked potentials and contact heat evoked potentials as tests of the anterior spinothalamic tract; (3) motor evoked potentials in limb muscles, in response to transcranial magnetic stimulation of the motor cortex as tests of the corticospinal tract, and the application of the technique to assessment of trunk and sphincter muscles; and (4) the sympathetic skin response as a test of spinal cord access to the sympathetic chain.
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van Middendorp JJ, Goss B, Urquhart S, Atresh S, Williams RP, Schuetz M. Diagnosis and prognosis of traumatic spinal cord injury. Global Spine J 2011; 1:1-8. [PMID: 24353930 PMCID: PMC3864437 DOI: 10.1055/s-0031-1296049] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Accepted: 10/13/2011] [Indexed: 11/19/2022] Open
Abstract
Despite promising advances in basic spinal cord repair research, no effective therapy resulting in major neurological or functional recovery after traumatic spinal cord injury (tSCI) is available to date. The neurological examination according to the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients (International Standards) has become the cornerstone in the assessment of the severity and level of the injury. Based on parameters from the International Standards, physicians are able to inform patients about the predicted long-term outcomes, including the ability to walk, with high accuracy. In those patients who cannot participate in a reliable physical neurological examination, magnetic resonance imaging and electrophysiological examinations may provide useful diagnostic and prognostic information. As clinical research on this topic continues, the prognostic value of the reviewed diagnostic assessments will become more accurate in the near future. These advances will provide useful information for physicians to counsel tSCI patients and their families during the catastrophic initial phase after the injury.
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Affiliation(s)
- Joost J. van Middendorp
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia,Trauma Service, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ben Goss
- AOSpine Reference Centre, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Susan Urquhart
- Spinal Injuries Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Sridhar Atresh
- Spinal Injuries Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Richard P. Williams
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia,AOSpine Reference Centre, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Michael Schuetz
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia,Trauma Service, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Jung JK, Oh CH, Yoon SH, Ha Y, Park S, Choi B. Outcome evaluation with signal activation of functional MRI in spinal cord injury. J Korean Neurosurg Soc 2011; 50:209-15. [PMID: 22102951 PMCID: PMC3218180 DOI: 10.3340/jkns.2011.50.3.209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 07/05/2011] [Accepted: 09/14/2011] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The authors investigated the changes of cortical sensorimotor activity in functional MRI (fMRI) and functional recovery in spinal cord injury (SCI) patients who had been treated by bone marrow cell transplantation. METHODS Nineteen patients with SCI were included in this study; ten patients with clinical improvement and nine without. The cortical sensorimotor activations were studied using the proprioceptive stimulation during the fMRI. RESULTS Diagnostic accuracy of fMRI with neurological improvement was 70.0% and 44.4% for sensitivity and specificity, respectively. Signal activation in the ipsilateral motor cortex in fMRI was commonly observed in the clinically neurological improved group (p-value=0.002). Signal activation in the contralateral temporal lobe and basal ganglia was more commonly found in the neurological unimproved group (p-value<0.001). Signal activation in other locations was not statistically different. CONCLUSION In patients with SCI, activation patterns of fMRI between patients with neurologic recovery and those without varied. Such plasticity should be considered in evaluating SCI interventions based on behavioral and neurological measurements.
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Affiliation(s)
- Jong Kwon Jung
- Department of Anesthesiology, Inha University Hospital, Incheon, Korea
| | - Chang Hyun Oh
- Seoul Regional Military Manpower Administration, Seoul, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Inha Neural Repair Center, Inha University Hospital, Incheon, Korea
| | - Yoon Ha
- Department of Neurosurgery, Yonsei Severance Hospital University, Seoul, Korea
| | - Sora Park
- Inha Neural Repair Center, Inha University Hospital, Incheon, Korea
- Department of Physiology, Inha University College of Medicine, Incheon, Korea
| | - Byunghyune Choi
- Inha Neural Repair Center, Inha University Hospital, Incheon, Korea
- Inha Research Institute for Medical Sciences, Inha University Hospital, Incheon, Korea
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Zörner B, Blanckenhorn WU, Dietz V, Curt A. Clinical algorithm for improved prediction of ambulation and patient stratification after incomplete spinal cord injury. J Neurotrauma 2010; 27:241-52. [PMID: 19645527 DOI: 10.1089/neu.2009.0901] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The extent of ambulatory recovery after motor incomplete spinal cord injury (miSCI) differs considerably amongst affected persons. This makes individual outcome prediction difficult and leads to increased within-group variation in clinical trials. The aims of this study on subjects with miSCI were: (1) to rank the strongest single predictors and predictor combinations of later walking capacity; (2) to develop a reliable algorithm for clinical prediction; and (3) to identify subgroups with only limited recovery of walking function. Correlation and logistic regression analyses were performed on a dataset of 90 subjects with tetra- or paraparesis, recruited in a prospective European multicenter study. Eleven measures obtained in the subacute injury period, including clinical examination, tibial somatosensory evoked potentials (tSSEP), and demographic factors, were related to ambulatory outcome (WISCI II, 6minWT) 6 months after injury. The lower extremity motor score (LEMS) alone and in combination was identified as most predictive for later walking capacity in miSCI. Ambulatory outcome of subjects with tetraparesis was correctly predicted for 92% (WISCI II) or 100% (6minWT) of the cases when LEMS was combined with either tSSEP or the ASIA Impairment Scale, respectively. For individuals with paraparesis, prediction was less distinct, mainly due to low prediction rates for individuals with poor walking outcome. A clinical algorithm was generated that allowed for the identification of a subgroup composed of individuals with tetraparesis and poor ambulatory recovery. These data provide evidence that a combination of predictors enables a reliable prediction of walking function and early patient stratification for clinical trials in miSCI.
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Affiliation(s)
- Björn Zörner
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.
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Abstract
Electrophysiological measures can provide information that complements clinical assessments such as the American Spinal Injury Association sensory and motor scores in the evaluation of outcomes after spinal cord injury (SCI). The authors review and summarize the literature regarding tests that are most relevant to the study of SCI recovery--in particular, motor evoked potentials and somatosensory evoked potentials (SSEPs). In addition, they discuss the role of other tests, including F-wave nerve conductance tests and electromyography, sympathetic skin response, and the Hoffman reflex (H-reflex) test as well as the promise of dermatomal SSEPs and the electrical perceptual threshold test, newer quantitative tests of sensory function. It has been shown that motor evoked potential amplitudes improve with SCI recovery but latencies do not. Somatosensory evoked potentials are predictive of ambulatory capacity and hand function. Hoffman reflexes are present during spinal shock despite the loss of tendon reflexes, but their amplitudes increase with time after injury. Further, H-reflex modulation is reflective of changes in spinal excitability. While these tests have produced data that is congruent with clinical evaluations, they have yet to surpass clinical evaluations in predicting outcomes. Continuing research using these methodologies should yield a better understanding of the mechanisms behind SCI recovery and thus provide potentially greater predictive and evaluative power.
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Affiliation(s)
- James Xie
- Neural Plasticity and Outcomes Research Laboratories, Veterans' Affairs Palo Alto Health Care System, Stanford, California, USA
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Morishita K, Kasai Y, Ueta T, Shiba K, Akeda K, Uchida A. Patellar tendon reflex as a predictor of improving motor paralysis in complete paralysis due to cervical cord injury. Spinal Cord 2009; 47:640-2. [PMID: 19223860 DOI: 10.1038/sc.2009.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE We have encountered several cases of complete sensorimotor paralysis in which patellar tendon reflex (PTR) was demonstrated approximately 3 days after injury and improvement of motor paralysis was subsequently achieved. We considered that PTR apparent in the early stage after injury may offer an index to predict improvements in motor paralysis. MATERIALS AND METHODS A total of 142 patients assessed as ASIA Impairment Scale A on admission from 1979 to 1998 were included in the study. The patients who demonstrated PTR within 72 h after injury were classified as the PTR(+) group and those who did not constituted the PTR(-) group. With regard to the method of motor paralysis assessment at about 6 months after injury, patients assessed as ASIA Impairment Scale A or B (that is, complete motor paralysis) were classified as 'Non-recovered', whereas those assessed as ASIA Impairment Scale C, D or E (that is, showing obvious improvement of motor paralysis) were considered as 'Recovered'. RESULTS A significant difference was noted between groups, with the Recovered group including 16 of the 17 PTR(+) patients (94.1%) and 11 of the 115 PTR(-) patients (9.6%) (P<0.0001). CONCLUSION The results obtained indicate that motor paralysis recovery could be expected at a very high rate among patients demonstrating PTR within 72 h of injury. As all physicians should be familiar with the PTR, this seems to represent a simple and highly useful sign to predict improvements in motor paralysis during the acute stage of cervical cord injury.
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Affiliation(s)
- K Morishita
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Mie Prefecture, Japan
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Scivoletto G, Di Donna V. Prediction of walking recovery after spinal cord injury. Brain Res Bull 2009; 78:43-51. [PMID: 18639616 DOI: 10.1016/j.brainresbull.2008.06.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Revised: 05/28/2008] [Accepted: 06/04/2008] [Indexed: 12/11/2022]
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Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med 2008; 31:403-79. [PMID: 18959359 PMCID: PMC2582434 DOI: 10.1043/1079-0268-31.4.408] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Kirshblum SC, O’Connor KC. Levels of Spinal Cord Injury and Predictors of Neurologic Recovery. Phys Med Rehabil Clin N Am 2000. [DOI: 10.1016/s1047-9651(18)30144-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Iseli E, Cavigelli A, Dietz V, Curt A. Prognosis and recovery in ischaemic and traumatic spinal cord injury: clinical and electrophysiological evaluation. J Neurol Neurosurg Psychiatry 1999; 67:567-71. [PMID: 10519858 PMCID: PMC1736605 DOI: 10.1136/jnnp.67.5.567] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compare prognostic factors and functional recovery between paraplegic patients with either ischaemic (28 patients) or traumatic (39 patients) spinal cord injury (SCI). METHODS On admission to the spinal injury centre and 6 months later the patients underwent clinical (following the guidelines set down by the American Spinal Injury Association) and electrophysiological (tibial and pudendal somatosensory evoked potentials) examinations in parallel. The degree of ambulatory capacity was assessed after discharge from the rehabilitation programme or at least 6 months after trauma. RESULTS At the acute stage of either ischaemic or traumatic SCI similar motor and sensory deficits and pathological SSEP recordings were present. Both patient groups recovered to similar degrees with respect to motor, sensory, and ambulatory capacity. The clinical examination in both patient groups was the most sensitive prognostic factor of functional recovery irrespective of the aetiology of the SCI. In the ischaemic patients only the tibial SSEP whereas in the traumatic patients both the pudendal and tibial SSEP were of value in predicting recovery. CONCLUSIONS Although the two patient groups are pathophysiologically different, the severity and extent of neurological deficits and rate of recovery are quite similar. In both ischaemic and traumatic SCI clinical and electrophysiological examinations are of prognostic value for the functional recovery.
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Affiliation(s)
- E Iseli
- Swiss Paraplegic Centre, University Hospital Balgrist, Zürich, Switzerland
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Bajd T, Kralj A, Stefancic M, Lavrac N. Use of functional electrical stimulation in the lower extremities of incomplete spinal cord injured patients. Artif Organs 1999; 23:403-9. [PMID: 10378929 DOI: 10.1046/j.1525-1594.1999.06360.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
After a program of therapeutic electrical stimulation, 3 groups of incomplete spinal cord injured (SCI) patients were identified, those in whom an improvement of both voluntary and stimulated muscle force was observed, those with an increase in stimulation response only, and patients in whom no effect of electrical stimulation training could be recorded. As it is difficult to predict the outcome of the electrical stimulation rehabilitation process, a diagnostic procedure was developed to predict soon after accidents which incomplete SCI patients are candidates for permanent use of a functional electrical stimulation (FES) orthotic aid. The candidates for chronic use of FES are patients with weak ankle dorsiflexors and sufficiently strong knee extensors. These patients are equipped with a single channel peroneal stimulator augmenting dorsiflexion and knee and hip flexion in a total lower limb flexion response. By applying FES to the ankle plantar flexors, the swing phase of walking can be significantly shortened and faster walking obtained.
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Affiliation(s)
- T Bajd
- Faculty of Electrical Engineering, University of Ljubljana, Slovenia
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Kirshblum SC, O'Connor KC. Predicting neurologic recovery in traumatic cervical spinal cord injury. Arch Phys Med Rehabil 1998; 79:1456-66. [PMID: 9821910 DOI: 10.1016/s0003-9993(98)90244-1] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Traumatic spinal cord injury (SCI) affects 8,000 to 10,000 individuals per year in the United States. One of the most difficult tasks confronting the clinician is the discussion of neurologic recovery and prognosis with the patient and/or family. Our objective is to provide a guide for practitioners to accurately predict neurologic outcome in acute traumatic cervical SCI (tetraplegia). DATA SOURCE Published reports obtained through MEDLINE search, texts, and studies presented at national conferences. STUDY SELECTION Peer reviewed studies, in English language, that discussed prognosis after traumatic SCI. CONCLUSION A comprehensive physical examination of the acute SCI patient is essential in determining the initial level and classification of the injury and is the most accurate method to predict neurologic recovery. Other diagnostic tests, including somatosensory evoked potentials, magnetic resonance imaging, and transcranial magnetic stimulation, may be helpful in further determining outcome when used in association with the clinical examination. The understanding of neurologic recovery should help predict ultimate functional capability and potential needs.
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Affiliation(s)
- S C Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
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Dickstein R, Zaslanski R, Heffes Y, Mizrachi E, Shabtai EL, Abulaffio N. Somatosensory evoked potentials of the posterior tibial nerve in hemiparetic patients: relation to stance balance and walking ability. Arch Phys Med Rehabil 1997; 78:1125-8. [PMID: 9339164 DOI: 10.1016/s0003-9993(97)90139-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To examine the association between stance ability and walking performance of poststroke hemiplegic patients and their posterior tibial nerve somatosensory evoked potentials (SEPs). DESIGN AND SETTING Fifteen patients, residents of a geriatric rehabilitation hospital, were evaluated twice, with a 2-week interval between sessions. In each session, clinical tests of stance balance and walking ability were performed, and bilateral SEPs to stimulation of the posterior tibial nerve were recorded. Eight healthy, age-matched control subjects underwent the same tests in a single session, but SEPs were recorded unilaterally. Correlation analysis and analysis of variance (ANOVA) were used for studying the prognostic value of the initial posterior tibial nerve SEP measurements as well as the within- and between-sessions relationships between the clinical-functional tests and the SEP data. RESULTS No significant correlations between the initial SEP values and functional improvement were established. Within each session, positive significant correlations existed between decreased latencies of several of the medium-latency SEP waves and the performance of stance and gait tasks. However, the between-sessions improvement in stance balance was not correlated with a decrease in latency of the SEP peaks or with an increase in their amplitudes. As to walking ability, in those patients whose gait significantly improved, a significant shortening of P37 and P54 latencies took place. CONCLUSIONS The association between the initial and/or the 2-week changes in SEP of the posterior tibial nerve and improvement in stance and walking abilities is equivocal. In addition, the applicability of SEP measurements is limited by patients' physical status and cooperation. The clinical significance of posterior tibial nerve SEP testing in poststroke hemiparetic patients is therefore debatable.
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Affiliation(s)
- R Dickstein
- Flieman Geriatric Rehabilitation Hospital, Haifa, Israel
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Saboe LA, Darrah JM, Pain KS, Guthrie J. Early predictors of functional independence 2 years after spinal cord injury. Arch Phys Med Rehabil 1997; 78:644-50. [PMID: 9196473 DOI: 10.1016/s0003-9993(97)90431-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine: (1) how well factors measured at admission to an acute care facility predict functional independence measure (FIM) scores, use of personal care assistance, and wheelchair ownership 2 years after traumatic spinal cord injury (SCI); (2) the extent that factors measured during inpatient stay add to these predictions; and (3) if FIM scores differ through use of assistance and wheelchair ownership 2 years after SCI. DESIGN Prospective, longitudinal. SETTING Tertiary care acute, rehabilitation hospitals and home settings. PATIENTS One hundred sixty SCI admissions. MAIN OUTCOME MEASURES FIM, use of personal care assistance (yes/no), and wheelchair ownership (manual/electric/none) 2 years after SCI. RESULTS Year 2 FIM scores were highly correlated (> or = .68) to the ASIA admission and discharge light touch, pin prick, and motor scores. Admission neurological status and age accounted for 65% of year 2 FIM score variance. Adding hospital events and the discharge ASIA motor score increased prediction to 76% of the variance. A separate regression model using only year 2 neurological scores and age accounted for 73% of the total FIM variance. Discriminant function analysis indicated 86% correct classification regarding use of personal care assistance and 88% correct classification of wheelchair ownership. Using a separate cross-validation sample, overall classification accuracy for assistance was 80% and wheelchair ownership 67%. FIM scores were significantly lower in assistance users (78 +/- 24) than nonusers (120 +/- 8) and were significantly different between wheelchair ownership groups: manual (103 +/- 21), electric (61 +/- 15), and none (125 +/- 2). CONCLUSIONS Late disability can be predicted using early impairment measures. The FIM prediction from variables measured during the early treatment phase was as good as prediction based on concurrent measures.
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Affiliation(s)
- L A Saboe
- Physical Therapy Services, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
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Curt A, Dietz V. Ambulatory capacity in spinal cord injury: significance of somatosensory evoked potentials and ASIA protocol in predicting outcome. Arch Phys Med Rehabil 1997; 78:39-43. [PMID: 9014955 DOI: 10.1016/s0003-9993(97)90007-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Prediction of outcome of ambulatory capacity in patients with acute spinal cord injury (SCI) by the American Spinal Injury Association (ASIA) protocol and somatosensory evoked potentials (SSEP). DESIGN Correlational study on a prospective cohort. SETTING Spinal cord injury center, university hospital. PATIENTS Consecutively sampled, 70 acute and 34 chronic SCI patients. MAIN OUTCOME MEASURES (1) ASIA motor and sensory scores; (2) tibial and pudendal SSEP graded in 5 categories, from normal to absent; (3) ambulatory capacity rated as no, therapeutic, functional, or full. The outcome of the ambulatory capacity was assessed after discharge from the rehabilitation program, at least 6 months after trauma. RESULTS In acute SCI both the initial ASIA scores and the SSEP recordings are related (p < .001) to the outcome of ambulatory capacity. In acute tetraplegia the pudendal SSEP (spearman corr. coeff. .92; p < .001) and in acute paraplegia the ASIA motor score (spearman corr. coeff. .90; p < .001) were best related to the outcome of ambulatory capacity. In the early stage of acute SCI, ASIA scores and SSEP recordings can help to assess the outcome of ambulatory capacity and, therefore, can contribute to the selection of the appropriate therapeutic approaches during the rehabilitation program. In patients with acute SCI the ASIA motor score significantly increased (p < .05) in the 6 months after trauma, whereas the ASIA sensory scores and SSEP recordings did not change significantly during this same period. CONCLUSION ASIA scores and SSEP are related to the outcome of ambulatory capacity in patients with acute spinal cord injury; in noncomprehensive or uncooperative patients the SSEP are of supplemental value to the clinical examination. Therefore, the combination of clinical and electrophysiological examinations can be of additional diagnostic value in the assessment of acute spinal cord injury.
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Affiliation(s)
- A Curt
- Swiss Paraplegic Centre, University Hospital Balgrist, Zürich, Switzerland
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Spielholz NI. Lower extremity SEPs. Arch Phys Med Rehabil 1995; 76:978. [PMID: 7487444 DOI: 10.1016/s0003-9993(95)80082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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