Spinal cord injury in forty-four patients with cervical spondylosis

Who is going to walk? A review of the factors influencing walking recovery after spinal cord injury

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.

Optimal treatment for spinal cord injury associated with cervical canal stenosis (OSCIS): a study protocol for a randomized controlled trial comparing early versus delayed surgery

Background

The optimal management of acute cervical spinal cord injury (SCI) associated with preexisting canal stenosis remains to be established. The objective of this study is to examine whether early surgical decompression (within 24 hours after admission) would result in greater improvement in motor function compared with delayed surgery (later than two weeks) in cervical SCI patients presenting with canal stenosis, but without bony injury.

Methods/design

OSCIS is a randomized, controlled, parallel-group, assessor-blinded, multicenter trial. We will recruit 100 cervical SCI patients who are admitted within 48 hours of injury (aged 20 to 79 years; without fractures or dislocations; American Spinal Injury Association (ASIA) grade C; preexisting spinal canal stenosis). Patients will be enrolled from 36 participating hospitals across Japan and randomly allocated in a 1:1 ratio to either early surgical decompression (within 24 hours after admission) or delayed surgery following at least two weeks of conservative treatment. The primary outcomes include: 1) the change from baseline to one year in the ASIA motor score; 2) the total score of the Spinal Cord Independence Measure and 3) the proportion of patients who are able to walk without human assistance. The secondary outcomes are: 1) the health-related quality of life as measured by the Medical Outcomes Study Short Form 36 and the EuroQol 5 Dimension; 2) the Neuropathic Pain Symptom Inventory and 3) the walking status as evaluated with the Walking Index for Spinal Cord Injury II. The analysis will be on an intention-to-treat basis. The primary analysis will be a comparison of the primary and secondary outcomes one year after the injury.

Discussion

The results of this study will provide evidence of the potential benefit of early surgical decompression compared to the current ‘watch and wait’ strategy.

Trial registration

UMIN000006780; NCT01485458

Clinical diagnosis and prognosis following spinal cord injury

Spinal cord injury (SCI) is a sudden, life-altering event. Injury severity and accompanying recovery vary considerably from individual to individual. The most important determinant of prognosis is whether an injury is clinically complete or incomplete. While approximately 10-20% of complete injuries convert to incomplete during the first year post-injury, the magnitude of motor recovery following complete SCI is limited or absent. Robust functional motor recovery (e.g., weight-bearing, ambulation) distal to the zone of injury is rare. Recovery following incomplete SCI is particularly variable, and anywhere from 20% to 75% of individuals will recover some degree of walking capacity by 1 year post-injury. This is related to presenting injury severity (American Spinal Injury Association Impairment Scale grade); however, even 20-50% of individuals who present as motor complete, sensory incomplete will walk in some capacity by 1 year post-injury. Regardless, for both complete and incomplete injuries, the majority of recovery is observed during the initial 9-12 months, with a relative plateau reached by 12-18 months post-injury. Magnetic resonance imaging (MRI) provides valuable adjunct information when a bedside clinical assessment cannot be completed. The presence of intramedullary hemorrhage and extended segments of edema have been associated with clinically complete SCI.

Cervical spondylosis with spinal cord encroachment: should preventive surgery be recommended?

Background

It has been stated that individuals who have spondylotic encroachment on the cervical spinal cord without myelopathy are at increased risk of spinal cord injury if they experience minor trauma. Preventive decompression surgery has been recommended for these individuals. The purpose of this paper is to provide the non-surgical spine specialist with information upon which to base advice to patients. The evidence behind claims of increased risk is investigated as well as the evidence regarding the risk of decompression surgery.

Methods

A literature search was conducted on the risk of spinal cord injury in individuals with asymptomatic cord encroachment and the risk and benefit of preventive decompression surgery.

Results

Three studies on the risk of spinal cord injury in this population met the inclusion criteria. All reported increased risk. However, none were prospective cohort studies or case-control studies, so the designs did not allow firm conclusions to be drawn. A number of studies and reviews of the risks and benefits of decompression surgery in patients with cervical myelopathy were found, but no studies were found that addressed surgery in asymptomatic individuals thought to be at risk. The complications of decompression surgery range from transient hoarseness to spinal cord injury, with rates ranging from 0.3% to 60%.

Conclusion

There is insufficient evidence that individuals with spondylotic spinal cord encroachment are at increased risk of spinal cord injury from minor trauma. Prospective cohort or case-control studies are needed to assess this risk. There is no evidence that prophylactic decompression surgery is helpful in this patient population. Decompression surgery appears to be helpful in patients with cervical myelopathy, but the significant risks may outweigh the unknown benefit in asymptomatic individuals. Thus, broad recommendations for decompression surgery in suspected at-risk individuals cannot be made. Recommendations to individual patients must consider possible unique circumstances.

Restoring function after spinal cord injury: promoting spontaneous regeneration with stem cells and activity-based therapies

Although neural regeneration is an active research field today, no current treatments can aid regeneration after spinal cord injury. This article reviews the feasibility of spinal cord repair and provides an overview of the range of strategies scientists are taking toward regeneration. The major focus of this article is the future role of stem cell transplantation and similar rehabilitative restorative approaches designed to optimize spontaneous regeneration by mobilizing endogenous stem cells and facilitating other cellular mechanisms of regeneration, such as axonal growth and myelination.

Late neurologic recovery after traumatic spinal cord injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To present Model Spinal Cord Injury System (MSCIS) data on late neurologic recovery after 1 year after spinal cord injury (SCI).

DESIGN

Longitudinal study of neurologic status as determined by annual evaluations at 1 and 5 years postinjury.

SETTING

MSCIS centers contributing data on people with traumatic SCI to the National Spinal Cord Injury Statistical Center database.

PARTICIPANTS

People with traumatic SCI (N=987) admitted to an MSCIS between 1988 and 1997 with 1- and 5-year follow-up examinations.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification, motor index scores (MIS), motor level, and neurologic level of injury (NLI), measured and compared for changes over time.

RESULTS

The majority of subjects (94.4%) who had a neurologically complete injury at 1 year remained complete at 5 years postinjury, with 3.5% improving to AIS grade B, and up to 1.05% each improving to AIS grades C and D. There was a statistically significant change noted for MIS. There were no significant changes for the motor level and NLI over 4 years; however, approximately 20% of subjects improved their motor level and NLI. People with complete and incomplete injuries had similar improvements in motor level, but subjects with an incomplete injury had a greater chance of improvement in NLI and MIS.

CONCLUSIONS

There was a small degree of neurologic recovery (between 1 and 5 y postinjury) after a traumatic SCI. Late conversion, between 1 and 5 years, from a neurologically complete to an incomplete injury occurred in 5.6% of cases, but in only up to 2.1% was there a conversion from motor complete to motor incomplete status. Limitations of this study included changes in the ASIA classification during the study and in the intra- and interrater reliability typically seen in longitudinal studies of the ASIA standards. Functional changes were not studied. Knowledge of the degree of late recovery may help in analyzing newer interventions to enhance recovery.

Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future directions in rehabilitation management

STUDY DESIGN

Review article.

OBJECTIVES

To review the medical literature and provide a framework for predicting neurorecovery and functional outcomes after spinal cord injury based on injury severity.

SUMMARY OF BACKGROUND DATA

The ability to accurately predict the magnitude of neurorecovery and expected functional outcomes after spinal cord injury is of great importance. This information is needed to justify medical and rehabilitation interventions to third party payers as well as to begin the process of planning for postdischarge care. Over the past several decades, significant progress has been made in accurately predicting neurorecovery and its impact on functional outcomes.

METHODS

Structured review of published reports obtained through MED-LINE search and texts.

RESULTS/CONCLUSION

Within 72 hours to 1 month after a spinal cord injury, it is possible to predict with reasonable accuracy the magnitude of expected recovery based on physical examination. The impact of motor level on long-term functional outcomes is also clear and has remained relatively unchanged for several decades. Functional outcomes are likely to improve in upcoming years as novel interventions, such as drugs and functional neuromuscular stimulation, are developed with the goals of limiting secondary injury and restoring neurologic function. New training methods, such as body weight support, that use activity-dependent neuroplasticity will also have a more prominent role.

Trauma sites and clinical features associated with acute hyperextension spinal cord injury without bone damage--relationship between trauma site and severity

To elucidate whether a relationship exists between the site of trauma and severity of acute hyperextension spinal cord injury without bone damage, we examined the clinical features of 25 male and 10 female patients aged 13 to 88 years. None of the patients had vertebral damage such as fracture and dislocation. The site of impact was classified as the buccal, forehead, or mandibular region. The neurological findings were assessed according to Frankel's classification at admission and at follow up after 3 months or more to assess outcome. Eleven patients suffered trauma in the buccal region, one patient in Frankel's grade B, three in grade C, and seven in grade D at admission. All 11 of these patients showed an improvement of one grade or more to an outcome of C in one patient, D in one, and E in nine. Trauma occurred at the forehead region in 18 patients, four in grade B, 10 in grade C, and four in grade D. Improvement was seen at follow up by one grade or more to C in one patient, D in 10, and E in seven. Trauma occurred at the mandibular region in six patients, four in grade B and two in grade C. Four of these patients showed improvement of one grade or more to grade B in one, grade C in four, and grade E in one. Overall, seven patients had poor outcomes, five of whom suffered trauma to the mandibular region, indicating that impact to the mandibular region tends to have an unfavorable clinical outcome. Our findings indicate that the site of trauma greatly influences the severity of hyperextension spinal cord injury.

Predicting neurologic recovery in traumatic cervical spinal cord injury

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.

Recovery of ambulation in motor-incomplete tetraplegia

OBJECTIVE

To determine the effect of age and initial neurologic status on recovery of ambulation in patients with motor-incomplete tetraplegia.

STUDY DESIGN

Inception cohort study.

SETTING

Urban, tertiary care hospital with Regional Spinal Cord Injury Center.

PATIENTS

One hundred five patients with American Spinal Injury Association (ASIA) C or D tetraplegia at admission or within 72 hours of injury.

MAIN OUTCOME MEASURE

Ambulatory status at time of discharge from inpatient rehabilitation.

RESULTS

Ninety-one percent (30/33) of ASIA C patients younger than 50 years of age became ambulatory by discharge, versus 42% (13/31) ASIA C patients age 50 or older (p < .0001). All (41/41) patients initially classified as ASIA D became ambulatory by discharge.

CONCLUSION

For patients with ASIA D tetraplegia, prognosis for recovery of independent ambulation is excellent. For patients with ASIA C tetraplegia, recovery of ambulation is significantly less likely if age is 50 years or older.