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Ariji Y, Hayashi T, Ideta R, Koga R, Murai S, Naka T, Ifuku R, Towatari F, Sakai H, Kurata H, Maeda T. Identification of a reliable sacral-sparing examination to assess the ASIA impairment scale in patients with traumatic spinal cord injury. J Spinal Cord Med 2024; 47:286-292. [PMID: 35352975 PMCID: PMC10885764 DOI: 10.1080/10790268.2022.2047548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES We evaluated the time course of the American Spinal Cord Injury Association (ASIA) impairment scale (AIS) for up to three months in participants within 72 h after traumatic spinal cord injury (TSCI) with complete paralysis. We aimed to determine the most useful sacral-sparing examination (deep anal pressure [DAP], voluntary anal contraction [VAC], S4-5 light touch [LT], or pin prick [PP] sensation) in determining AIS grades. DESIGN Retrospective cohort study. SETTING Spinal Injuries Center, Fukuoka, Japan. PARTICIPANTS Among 668 TSCI participants registered in the Japan Single Center study for Spinal Cord Injury Database (JSSCI-DB) between January 2012 and May 2020, we extracted the data of 80 patients with AIS grade A within 72 h after injury and neurological level of injury (NLI) at T12 or higher. INTERVENTIONS None. OUTCOME MEASURES The sacral-sparing examination at the time of the change to incomplete paralysis was compared to the AIS determination using a standard algorithm and with each assessment including the VAC, DAP, S4-5LT, and S4-5PP examinations at the time of AIS functional change. Agreement among assessments was evaluated using weighted kappa coefficients. The relationship was evaluated using Spearman's rank correlation coefficients. RESULTS Fifteen participants (18.8%) improved to incomplete paralysis (AIS B to D) within three months after injury. The single assessment among the sacral-sparing examinations with the highest agreement and strongest correlation with AIS determination was the S4-5LT examination (k = 0.89, P < 0.01, r = 0.84, P < 0.01). CONCLUSIONS The S4-5LT examination is key in determining complete or incomplete paralysis due to its high discriminatory power.
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Affiliation(s)
- Yuto Ariji
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Tetsuo Hayashi
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryosuke Ideta
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryuichiro Koga
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Satoshi Murai
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Tomoki Naka
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryusei Ifuku
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Fumihiro Towatari
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Hiroaki Sakai
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Hiroyuki Kurata
- Department of Bioscience and Bioinformatics, Kyushu Institute of Technology - Iizuka Campus, Fukuoka, Japan
| | - Takeshi Maeda
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
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What is the clinical meaning of a negative bulbocavernosus reflex in spinal cord injury patients? Spinal Cord Ser Cases 2022; 8:24. [PMID: 35181651 PMCID: PMC8857246 DOI: 10.1038/s41394-022-00495-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE To highlight some issues about the clinical meaning of a negative bulbocavernosus reflex (BCR) in spinal cord injury (SCI) patients. SETTINGS Research group University Antwerp Belgium. METHODS The study included 170 patients in whom the BCR was examined at a mean of 7 years post SCI. Changes over time were explored in a subset of patients. RESULTS BCR was negative in 45%. There was no influence of age and gender, nor could a relation be found with the American Spinal Injury Association Impairment Scale score. The anal sphincter reflex (ASR) was positive in 13% of patients with negative BCR. With a mean interval of 45 weeks, BCR changed in 32% of a subset of 44 patients (14 became positive, 3 negative), while the neurological condition did not change and no treatments had been given that could influence the outcome. The data show that a negative BCR may not only be due to a disrupted reflex nervous pathway (which in some patients is different from that of ASR), but may also be caused by a difficulty to provoke the reflex. CONCLUSION A negative BCR test indicates interruption of the reflex neurologic pathways, but can also depend on the ease to elicit the reflex. By also doing ASR, this dilemma can be partly solved.
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Hadiji N, Prévinaire JG, Soler JM. Use of the ice water test as an early predictor of recovery of erectile function in patients with spinal cord injury. Spinal Cord Ser Cases 2020; 6:51. [DOI: 10.1038/s41394-020-0300-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 11/10/2022] Open
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Previnaire JG, Alexander M. The sacral exam-what is needed to best care for our patients? Spinal Cord Ser Cases 2020; 6:3. [PMID: 31934355 PMCID: PMC6946808 DOI: 10.1038/s41394-019-0252-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/23/2019] [Indexed: 12/26/2022] Open
Abstract
Sacral reflexes are important to allow the SCI practitioner to gain information about the state of the sacral spinal cord segments. The presence of the bulbocavernosus and/or the anal wink reflex indicate an intact spinal reflex arc and reflex conal autonomic function (as part of the upper motor neuron syndrome); their absence defines a lower motor neuron syndrome. The assessment of sacral reflexes helps predict the type of bladder, bowel and sexual functions and the related therapeutic interventions. We suggest adding the sacral component of the International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) to the International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI) examination so there can be a detailed description of these important functions. As an alternative, the performance of sacral reflexes should be routinely required as part of the neurologic examination after SCI. Whether the sacral motor neuron system is classified as upper or lower motor neuron injury is also quite useful and as such should be present in the ISCNSCI.
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Affiliation(s)
| | - Marcalee Alexander
- Department of PMR, University of Alabama at Birmingham School of Medicine, Birmingham, AL USA
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Kirshblum S, Eren F. Anal reflex versus bulbocavernosus reflex in evaluation of patients with spinal cord injury. Spinal Cord Ser Cases 2020; 6:2. [PMID: 31934354 PMCID: PMC6946655 DOI: 10.1038/s41394-019-0251-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/30/2019] [Accepted: 10/27/2019] [Indexed: 12/14/2022] Open
Abstract
The examination of sacral reflexes provides an important method to differentiate an upper motor neuron vs lower motor neuron spinal cord injury (SCI). Two common sacral mediated reflexes used as part of the neurological assessment include the bulbocavernosus reflex (BCR) and anal reflex. As the clinical information from these tests are similar, we suggest that the anal reflex provides a better first option as a non-invasive clinical assessment of sacral reflex status in clinical practice in SCI as the testing for the anal reflex is less intrusive and already being performed as part of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) by pinprick stimulation of the S4-5 dermatome.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institution for Rehabilitation, West Orange, NJ USA
- 2Department of PM&R, Rutgers New Jersey Medical School, Newark, NJ USA
- 3Kessler Foundation, West Orange, NJ USA
| | - Fatma Eren
- 2Department of PM&R, Rutgers New Jersey Medical School, Newark, NJ USA
- 3Kessler Foundation, West Orange, NJ USA
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Chun A, Delgado AD, Tsai CY, Spielman L, Taylor K, Ramirez A, Huang V, Kolakowsky-Hayner SA, Escalon MX, Bryce TN. An interview based approach to the anorectal portion of the International Standards of Neurological Classification of Spinal Cord Injury Exam (I-A-ISNCSCI): a pilot study. Spinal Cord 2019; 58:553-559. [PMID: 31822807 DOI: 10.1038/s41393-019-0399-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/28/2019] [Accepted: 11/28/2019] [Indexed: 12/12/2022]
Abstract
STUDY DESIGN Prospective, single-blinded study. OBJECTIVE To design and evaluate the use of an interview based version of the anorectal portion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam in the acute inpatient rehabilitation (AIR) setting. SETTING AIR unit. METHODS Participants admitted to AIR underwent standard ISNCSCI exams (S-ISNCSCI) as part of routine inpatient care within 3 days of being administered an interview version of the anorectal portion of the ISNCSCI (I-A-ISNCSCI). Agreement between the anorectal portion of the S-ISNCSCI (S-A-ISNCSCI) and the I-A-ISNCSCI was evaluated. RESULTS Forty of forty-five enrolled participants completed the assessments. Agreement between the I-A-ISNCSCI and S-A-ISNCSCI was substantial for anorectal sensation to light touch (k = 0.71, 95% CI 0.52-0.90, N = 36), pin prick (k = 0.68, 95% CI 0.48-0.87, N = 38), deep anal pressure (k = 0.77, 95% CI 0.53-1.00, N = 37), and completeness of injury based on combined sacral sensory criteria (k = 0.72, 95% CI 0.47-0.97, N = 40); and fair for voluntary anal contraction (k = 0.29, 95% CI -0.01 to 0.59, N = 36). Responses of "I don't know" were excluded from agreement analyses. CONCLUSIONS This pilot study was a first step in developing interview based tools such as the I-A-ISNCSCI in an AIR setting providing convenient access to individuals with SCI and their direct feedback. The study design introduces potential recall bias and may not match true clinical situations such as remote follow-up of neurological changes for chronic patients. The use of interview based tools for assessing individuals with SCI remains worthy of further study.
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Affiliation(s)
- Audrey Chun
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA.
| | - Andrew D Delgado
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA.,The Graduate School of Biomedical Sciences, ISMMS, New York, NY, USA
| | - Chung-Ying Tsai
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Lisa Spielman
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Kristell Taylor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA.,The Graduate School of Biomedical Sciences, ISMMS, New York, NY, USA
| | - Arianny Ramirez
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Vincent Huang
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Stephanie A Kolakowsky-Hayner
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Miguel X Escalon
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Thomas N Bryce
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
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Wang J, Guo S, Cai X, Xu JW, Li HP. Establishment and verification of a surgical prognostic model for cervical spinal cord injury without radiological abnormality. Neural Regen Res 2019; 14:713-720. [PMID: 30632513 PMCID: PMC6352577 DOI: 10.4103/1673-5374.247480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Some studies have suggested that early surgical treatment can effectively improve the prognosis of cervical spinal cord injury without radiological abnormality, but no research has focused on the development of a prognostic model of cervical spinal cord injury without radiological abnormality. This retrospective analysis included 43 patients with cervical spinal cord injury without radiological abnormality. Seven potential factors were assessed: age, sex, external force strength causing damage, duration of disease, degree of cervical spinal stenosis, Japanese Orthopaedic Association score, and physiological cervical curvature. A model was established using multiple binary logistic regression analysis. The model was evaluated by concordant profiling and the area under the receiver operating characteristic curve. Bootstrapping was used for internal validation. The prognostic model was as follows: logit(P) = -25.4545 + 21.2576VALUE + 1.2160SCORE - 3.4224TIME, where VALUE refers to the Pavlov ratio indicating the extent of cervical spinal stenosis, SCORE refers to the Japanese Orthopaedic Association score (0-17) after the operation, and TIME refers to the disease duration (from injury to operation). The area under the receiver operating characteristic curve for all patients was 0.8941 (95% confidence interval, 0.7930-0.9952). Three factors assessed in the predictive model were associated with patient outcomes: a great extent of cervical stenosis, a poor preoperative neurological status, and a long disease duration. These three factors could worsen patient outcomes. Moreover, the disease prognosis was considered good when logit(P) ≥ -2.5105. Overall, the model displayed a certain clinical value. This study was approved by the Biomedical Ethics Committee of the Second Affiliated Hospital of Xi'an Jiaotong University, China (approval number: 2018063) on May 8, 2018.
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Affiliation(s)
- Jie Wang
- Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Shuai Guo
- Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Xuan Cai
- Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Jia-Wei Xu
- Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Hao-Peng Li
- Second Affiliated Hospital of Xi'an Jiaotong University; Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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Awards and updates. Spinal Cord Ser Cases 2018; 4:53. [DOI: 10.1038/s41394-018-0080-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 04/15/2018] [Indexed: 11/09/2022] Open
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Goetz LL, Emmanuel A, Krogh K. International standards to document remaining autonomic Function in persons with SCI and neurogenic bowel dysfunction: Illustrative cases. Spinal Cord Ser Cases 2018; 4:1. [PMID: 29423306 PMCID: PMC5802388 DOI: 10.1038/s41394-017-0030-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Neurogenic bowel dysfunction (NBD) is a highly prevalent problem after spinal cord injury, with potential for significant impact on health and quality of life. The international standards to document remaining autonomic function after SCI were developed to standardize communication between professionals regarding neurogenic bowel and other autonomic function after SCI. To improve understanding of the bowel subsection, illustrative cases are presented. CASE PRESENTATION Three cases are presented which illustrate differences in presentation and scoring of the elements in the data set based upon varying injury severity and location. DISCUSSION Determination of neurologic level of injury is insufficient for assessment of autonomic function and there is no direct method of assessment. Hence, surrogate makers are needed. The bowel subsection of the International standards to document remaining autonomic function in persons with SCI is an easy-to-use tool for this purpose.
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Affiliation(s)
- Lance L. Goetz
- Spinal Cord Injury and Disorders Service, Hunter Holmes McGuire VA Medical Center and Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA USA
| | - Anton Emmanuel
- GI Physiology Unit, University College Hospital, London, UK
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Donovan WH. The importance of the anal exam in neurologic classification of spinal cord injury. Spinal Cord Ser Cases 2018; 4:4. [PMID: 29423309 PMCID: PMC5798752 DOI: 10.1038/s41394-017-0014-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 09/27/2017] [Accepted: 09/27/2017] [Indexed: 11/09/2022] Open
Abstract
The examination of the sensation of the anal orifice and the contraction of the external anal sphincter, either voluntarily or reflexly, has always been an integral part of the International Standards for Neurologic Classification of Spinal Cord Injury (ISNCSCI). Yet the importance of this component has been defended and challenged. This paper compares these two points of view as expressed by Previnaire and Marino, respectively. Both authors make important points but as the papers do not address the same aspect of the anal exam, room for further refinement of ISNCSCI both regarding the details of the exam and the use of components of the exam for prognostication of neurologic recovery is apparent.
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Affiliation(s)
- William H. Donovan
- The Institute for Rehabilitation and Research (TIRR), TIRR 1333 Moursund St., Houston, TX 77030 USA
- Department of PM&R McGovern UT Medical School, Houston, TX USA
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