Rehabilitation outcome of individuals with nontraumatic myelopathy resulting from spinal stenosis

Characteristics and Postoperative Outcomes for High Cervical versus Subaxial Cervical Intradural Extramedullary Tumors: A Multicenter Study

BACKGROUND

High cervical intradural extramedullary tumors are uncommon. Their relationship to surrounding neural structures and vertebral arteries makes surgical excision challenging. No previous studies have compared high cervical to subaxial cervical intradural extramedullary spinal tumors to elucidate their unique characteristics and surgical outcomes.

METHODS

We performed a retrospective study in which patients who underwent excision of a cervical intradural extramedullary tumor were divided into a high cervical group and a subaxial cervical group. Variables included sex, age, Charlson Comorbidity Index, volume, laterality, preoperative weakness, use of neuromonitoring and drains, instrumented fusion, complications, length of stay, histology, discharge location, recurrence, and duration of follow-up. Variables were compared between the 2 groups. Limb power and Nurick classification were charted preoperatively, at discharge, and at 6 months to plot their recovery trajectory.

RESULTS

Eighty-four patients with a total of 90 tumors were enrolled, including 40 patients in the high cervical group and 44 patients in the subaxial spine group. More patients with neurofibromas (P = 0.011) and bilateral tumors (P = 0.044) were in the high cervical group. A greater prevalence of neurofibromatosis type 1 was significant for bilateral high cervical tumors (P = 0.033). More patients in the subaxial group had instrumented fusion (P = 0.045). More patients in the high cervical group had improvement in limb power (P = 0.025) and Nurick classification (P = 0.0001) postoperatively before discharge. By 6 months, both groups had similar recovery. No mortality was attributable to surgery in either group.

CONCLUSION

High cervical intradural extramedullary spine tumors have more bilateral tumors associated with neurofibromatosis type 1. Despite the challenging anatomy, surgical resection is safe with good outcomes in this group.

Developing Peri-Operative Rehabilitation in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 6]: An Unexplored Opportunity?

STUDY DESIGN

Narrative review.

OBJECTIVE

Degenerative cervical myelopathy is one of the most frequent impairments of the spinal cord encountered internationally in adults. Currently, surgical decompression is the recommended treatment for people with DCM (PwCM) presenting with moderate to severe symptoms or neurological deficits. However, despite surgical intervention, not all patients make a complete recovery due to the irreversible tissue damage within the spinal cord. The objective of this review is to describe the state and gaps in the current literature on rehabilitation for PwCM and possible innovative rehabilitation strategies.

METHODS

Literature search.

RESULTS

In other neurological disorders such as stroke and acute traumatic spinal cord injury (SCI), timely and strategic rehabilitation has been shown to be indispensable for maximizing functional outcomes, and it is imperative that appropriate perioperative rehabilitative interventions accompany surgical approaches in order to enable the best outcomes. In this review, the current state of knowledge regarding rehabilitation for PwCM is described. Additionally, various therapies that have shown to improve outcomes in comparable neurological conditions such as stroke and SCI which may be translated to DCM will be reviewed.

CONCLUSIONS

We conclude that locomotor training and arm/hand therapy may benefit PwCM. Further, we conclude that body weight support, robotic assistance, and virtual/augmented reality therapies may be beneficial therapeutic analogs to locomotor and hand therapies.

Analysis of Gait Motion Changes by Intervention Using Robot Suit Hybrid Assistive Limb (HAL) in Myelopathy Patients After Decompression Surgery for Ossification of Posterior Longitudinal Ligament

Ossification of the posterior longitudinal ligament (OPLL) is a hyperostonic condition in which the posterior longitudinal ligament becomes thick and loses its flexibility, resulting in ectopic ossification and severe neurologic deficit (Matsunaga and Sakou, 2012). It commonly presents with myelopathy and radiculopathy and with myelopathy progression motor disorders and balance disorders can appear. Even after appropriate surgical decompression, some motor impairments often remain. The Hybrid Assistive Limb (HAL) is a wearable powered suit designed to assist and support the user's voluntary control of hip and knee joint motion by detecting bioelectric signals from the skin surface and force/pressure sensors in the shoes during movement. In the current study, the HAL intervention was applied to 15 patients diagnosed with OPLL who presented with myelopathy after decompression surgery (6 acute and 9 chronic stage). Following the HAL intervention, there were significant improvements in gait speed, cadence, stride length, in both acute and chronic groups. Joint angle analysis of the lower limbs showed that range of motion (ROM) of hip and knee joints in acute group, and also ROM of hip joint and toe-lift during swing in chronic group increased significantly. ROM of knee joint became closer to healthy gait in both groups. Electromyography analysis showed that hamstrings activity in the late swing phase increased significantly for acute patients. Immidiate effect from HAL session was also observed. EMG of vastus medialis were decreased except chronic 7th session and EMG of gastrocnemius were decreased except acute 7th session, which suggests the patients were learning to walk with lesser knee-hypertension during the sessions. After all, double knee action appeared in both acute and chronic groups after the HAL intervention, rather than knee hyper-extension which is a common gait impairment in OPLL. We consider that these improvements lead to a smoother and healthier gait motion.

Posterior cord syndrome: Demographics and rehabilitation outcomes

Context/Objectives: To describe demographics, clinical characteristics, and functional outcomes of patients with incomplete spinal cord injuries and posterior cord syndrome (PCS).Design: Five-year retrospective case series.Setting: Spinal cord injury (SCI) rehabilitation unit at a Level 1 tertiary university medical center.Participants: 9 patients with incomplete cord injuries diagnosed with PCS admitted to rehabilitation within the past 5 years.Outcome measures: Functional Independence Measure (FIM) motor scores, length of stay (LOS), discharge disposition.Results: Incidence of PCS was 2% with an average age of 62.0 years. The most common etiology for PCS was spinal cord compression from localized tumors (78%). Seven (78%) patients had paraparesis. All patients had an American Spinal Injury Association impairment scale (AIS) classification of AIS D. SCI-related complications most commonly included: neuropathic pain (78%), spasticity (44%), and neurogenic bladder (78%). Average LOS on the rehabilitation unit was 28 days. Average admission and discharge FIM motor scores were significantly improved (P = 0.001) from 41 to 65, respectively. Two-thirds (67%) of patients were able to walk at least 150 feet with a rolling walker prior to discharge. Most (78%) patients were discharged to home. Continence improved from admission to discharge from 22% vs 56% (bladder) and 67% vs 78% (bowel).Conclusions: We can conclude that PCS most often results in paraparesis due to tumor compression. Typical SCI-related medical complications are encountered. These patients often experience significant functional improvements during SCI rehabilitation with the majority also having bladder and bowel continence allowing them to return home at discharge.

Psychological morbidity and chronic disease among adults with nontraumatic spinal cord injuries: a cohort study of privately insured beneficiaries

BACKGROUND

Individuals living with a spinal cord injury (SCI) are at heightened risk for a number of chronic health conditions such as secondary comorbidities that may develop or be influenced by the injury, the presence of impairment, and/or the process of aging. However, very little is known about the development of secondary comorbidities among individuals living with nontraumatic SCIs (NTSCIs).

PURPOSE

The objective of this study was to compare the prevalence of psychological morbidities and chronic diseases among adults with and without NTSCIs.

DESIGN

Cross-sectional cohort from a nationwide insurance claims database.

METHODS

Privately insured beneficiaries were included if they had an ICD-9-CM diagnostic code for a NTSCI and accompanying diagnosis of paraplegia, tetraplegia, quadriplegia, or unspecified paralysis (n=10,006). Adults without SCIs were also included (n=779,545). Prevalence estimates of common psychological morbidities, chronic diseases, and multimorbidity (≥2 conditions) were compared.

RESULTS

Adults with NTSCIs had a higher prevalence of adjustment reaction (11.4% vs 5.1%), anxiety disorders (23.7% vs 14.5%), depressive disorders (31.6% vs 9.6%), drug dependence (3.4% vs 0.8%), episodic mood disorders (15.9% vs 5.4%), central pain syndrome (1% vs 0%), psychogenic pain (1.9% vs 0.2%), dementia (5.2% vs 1.5%), and psychological multimorbidity (29.3% vs 11.6%), as compared to adults without SCIs. The adjusted odds of psychological multimorbidity were 1.86 (95% confidence interval: 1.76-2.00). Adults with NTSCIs also had a significantly higher prevalence of all chronic diseases and chronic disease multimorbidity (73.5% vs 18%), except HIV/AIDS. After propensity matching for age, education, race, sex, and the chronic diseases (n=7,419 matched pairs), there was still a higher prevalence of adjustment reaction (9.2% vs 5.4%), depressive symptoms (23.5% vs 16.0%), central pain syndrome (1% vs 0%), psychogenic pain (1.5% vs 0.3%), and psychological multimorbidity (20.2% vs 17.4%) among adults with NTSCIs.

CONCLUSIONS

Adults with NTSCIs have a significantly increased prevalence of psychological morbidities, chronic disease, and multimorbidity, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of disease onset/progression in this higher risk population.

Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review

STUDY DESIGN

This is a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

OBJECTIVE

To assess the outcomes reported in trials and observational studies of surgery for cauda equina syndrome (CES), and to inform the development of a core outcome set.

SUMMARY OF BACKGROUND DATA

Scoping searches revealed that there were inconsistencies in which outcomes were reported and how they were measured in research studies for patients who had undergone surgery for CES.

METHODS

Ovid Medline, Embase, CINAHL Plus, and trial registries were searched from January 1, 1990 to September 30, 2016 with the term "cauda equina syndrome." Inclusion and exclusion criteria were applied according to study design, diagnosis, procedure, publication date, language, and patient age. Data extracted included demographics, study design, the outcomes reported, and their definition. We also assessed variation in the use of terminology for each outcome domain.

RESULTS

A total of 1873 articles were identified, of which 61 met the inclusion criteria. Of these, 737 outcomes reported verbatim were categorized into 20 core outcome domains and 12 subdomains with a range of 1 to 141 outcomes per outcome domain or subdomain. The most commonly reported outcomes were bladder function (70.5%), motor function (63.9%), and sensation (50.8%). Significant variation in the terms used for each outcome was documented, for example, bladder function outcome domain had 141 different terms.

CONCLUSION

There is significant heterogeneity in outcomes reported for studies after surgery for CES patients. This indicates a clear need for the development of a core outcome set, which has been registered as number 824 on the COMET (Core Outcome Measure in Effectiveness Trials) database.

LEVEL OF EVIDENCE

1.

Effects of etiology on inpatient rehabilitation outcomes in 65- to 74-year-old patients with incomplete paraplegia from a nontraumatic spinal cord injury

OBJECTIVE

To examine differences in rehabilitation outcomes for older patients with a nontraumatic spinal cord injury (NT-SCI) for 5 etiologic diagnoses: degenerative spinal disease (DSD), malignant spinal tumor, benign spinal tumor, vascular ischemia, and spinal abscess.

DESIGN

Retrospective cohort study that used Medicare claims and assessment data.

SETTING

A total of 479 inpatient rehabilitation hospitals and units.

PATIENTS

A total of 1780 Medicare beneficiaries (65-74 years old) with incomplete paraplegia attributable to NT-SCI who were discharged from inpatient rehabilitation facilities from 2002 through 2005.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Length of stay, discharge Functional Independence Measure (FIM) instrument motor item and subscale scores, and discharge destination.

RESULTS

Demographic characteristics varied by etiology group. Mean +/- SD rehabilitation stays ranged from 13.3 +/- 7.7 days for DSD to 26.4 +/- 13.4 days for vascular ischemia. Adjusted data showed stays differed (P < .001) across etiology groups. Adjusted discharge mean self-care and mobility subscores revealed that patients with DSD and benign tumor were more independent (P < .001) than patients with a malignant tumor or spinal abscess. Patients with vascular ischemia were more dependent (P < .01) in mobility than the DSD and benign tumor groups. Etiologic differences (P < .01) in independence in discharge FIM modifiers for walking (FIM > or = 4), bladder (FIM > or = 6) and bowel management (FIM > or = 6) and bowel accidents/continence (FIM > or = 6), but not bladder accidents (FIM > or = 6), were present. The percent of patients discharged to a community residence ranged from 59.3% to 92.6%. Adjusted data showed that significantly larger percentages (P < .01) of patients in the DSD and malignant tumor groups than in the spinal abscess group were discharged to a community residence (versus nursing home).

CONCLUSION

There are etiologic differences in demographics, rehabilitation length of stay, functional outcomes, and discharge destination in elderly patients with NT-SCI.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

PURPOSE

To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 at Loewenstein Rehabilitation Hospital, Israel.

METHOD

This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA.

RESULTS

Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay.

CONCLUSIONS

Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Traumatic vs non-traumatic spinal cord lesions: comparison of neurological and functional outcome after in-patient rehabilitation

STUDY DESIGN

Retrospective comparative study of 2 years duration.

OBJECTIVES

To compare neurological and functional outcome and length of stay of persons with traumatic vs non-traumatic spinal cord lesion (SCL) after in-patient rehabilitation.

SETTING

Neurological rehabilitation department of a tertiary research center in Bangalore, Karnataka, India.

METHODS

Seventy-six in-patients with spinal cord lesion: traumatic (38 patients, M/F=34:4) and non-traumatic (38 patients, M/F=16:22) were admitted for in-patient multidisciplinary neurorehabilitation. ASIA impairment scale, duration of stay (DOS), and admission and discharge--Barthel Index scores in both the groups were recorded, compared and analyzed.

RESULTS

ASIA impairment scale scores were significantly higher in non-traumatic group both at admission and discharge (P=0.020 and 0.017), respectively, showing lesser impairment in non-traumatic group. DOS for rehabilitation was higher for traumatic group as compared to non-traumatic group (65.97+/-47.66 vs 60.68+/-45.69 days), although statistically not significant (P>0.05). Barthel Index scores were 28.68+/-17.15 vs 27.63+/-14.96 at admission and 54.21+/-25.10 vs 51.44+/-19.86 at discharge in traumatic and non-traumatic groups, respectively. All patients (n=76) showed significant improvement in Barthel Index (P=0.000), but no statistically significant difference (P>0.05) was recorded between the two groups, both at admission and at discharge. Orthoses was required significantly more frequently (P=0.043) in traumatic SCL group.

CONCLUSIONS

The study showed that despite more impairment in persons with traumatic spinal cord lesion, there was statistically no significant difference in the length of stay and the functional outcome between persons with traumatic and non-traumatic spinal cord lesion after in-patient rehabilitation.

Comparison of functional results in non-traumatic and traumatic spinal cord injury

PURPOSE

This study was conducted primarily to be a descriptive study about non-traumatic (NT) spinal cord injury (SCI) patients, in terms of their demographic and neurological features, and to investigate the complications and efficient results of rehabilitation in this group. The second aim of the study was to conduct a comparison between non-traumatic SCI patients and traumatic SCI patients.

MATERIALS AND METHODS

The design was a retrospective study at a Physical Medicine and Rehabilitation Training and Research center. The study was carried out with 194 patients, of whom 63 had non-traumatic SCI and 131 had traumatic SCI. Main outcome measures were: Demographics, etiology, Functional Independent Measure score, and level of injury.

RESULTS

A total of 32.47% (n = 63) of the patients in the study had a non-traumatic SCI. In traumatic SCI group, the proportion of male patients were significantly more than the proportion of female patients (p = 0.002). Admission FIM score of non-traumatic SCI group was better than the traumatic SCI group (p = 0.004). The comparison of discharge FIM scores between traumatic SCI and non-traumatic SCI groups did not yield any significant results (p = 0.303). However, the comparison of FIM gain between the two groups showed a significant difference (p = 0.03). The most common complication in non-traumatic SCI group was urinary tract infection and this was observed in 25 patients (39.68%).

CONCLUSIONS

The present study showed that there are certain differences between NT and traumatic SCI patients. Therefore, not all SCI patients should be considered to be falling under a single category, and should be divided into groups on the basis of the etiology of the injury. It is important to consider this information while developing the targets and planning of the rehabilitation program.

Spinal cord injury medicine. 1. Epidemiology and classification

This self-directed learning module reviews the demographics of traumatic and nontraumatic spinal cord injuries (SCIs). It is part of the study guide on SCI medicine in the Self-Directed Physiatric Educational Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the changing demographics of traumatic SCI, the classification of SCI, the common causes of nontraumatic SCI, and the incidence and prevalence of myelomeningocele.

OVERALL ARTICLE OBJECTIVE

To summarize the demographics and classification of traumatic and nontraumatic spinal cord injuries in adults and children.

Incidence and outcomes of spinal cord injury clinical syndromes

BACKGROUND/OBJECTIVE

To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS).

DESIGN

Retrospective review.

SETTING

Tertiary care, level 1 trauma center inpatient rehabilitation unit.

PARTICIPANTS

Eight hundred thirty-nine consecutive admissions with acute SCIs.

MAIN OUTCOMES MEASURES

Functional independence measure (FIM), FIM subgroups (motor, self-care, sphincter control), length of stay (LOS), and discharge disposition.

RESULTS

One hundred seventy-five patients (20.9%) were diagnosed with SCI clinical syndromes. CCS was the most common (44.0%), followed by CES (25.1%) and BSS (17.1%). Significant differences (P < or = 0.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant differences (P < or = 0.01) with respect to age (39.7 vs 53.2 years) and a trend toward significance (P < or = 0.05) with regard to self-care admission and discharge FIM. No significant differences (P < or = 0.01) were found when comparing CMS to CES.

CONCLUSIONS

SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation, with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Patients with cervical BSS seem to achieve higher functional improvement by discharge compared with patients with CCS. Patients with CMS and CES exhibit similar functional outcomes. Patients with ACS and PCS show functional gains with inpatient rehabilitation, with patients with ACS displaying the longest LOS of the SCI clinical syndromes. These findings have important implications for the overall management and outcome of patients with SCI.

Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation

OBJECTIVE

To compare outcomes, complications, and therapy intensity of inpatient rehabilitation in patients with paraplegia caused by spinal cord injury associated with aortic aneurysm repair (SCI-AA) versus patients with traumatic spinal cord injury (SCI).

DESIGN

Case-controlled study.

SETTING

SCI unit in a rehabilitation center.

PARTICIPANTS

Seventeen patients with SCI-AA and 17 patients with traumatic SCI.

INTERVENTION

Standard rehabilitation therapy for SCI.

MAIN OUTCOME MEASURES

Length of stay (LOS) in acute and rehabilitation hospitals; FIM instrument scores; FIM change; FIM efficiency; complications; therapy intensity; and ambulatory state and return to community at discharge.

RESULTS

No significant differences were noted in acute and rehabilitation LOS and admission FIM scores. Discharge FIM scores, FIM change, and FIM efficiencies were significantly lower in the SCI-AA group, which had many complications related to AA and SCI. Intensity of rehabilitation sports therapy in the SCI-AA group was significantly lower than that of the traumatic SCI group, but total therapy intensity did not differ significantly. Both had similar rates of return to ambulatory state and discharge to the community.

CONCLUSIONS

SCI-AA patients had many complications that interfered with rehabilitation therapy, and could not achieve functional gains comparable to those with traumatic SCI. However, both groups achieved comparable success with return to ambulatory state and discharge to the community.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

PURPOSE

To evaluate outcome measures and the factors affecting them in patients treated between 1,962 and 2,000 at Loewenstein Rehabilitation Hospital, Israel.

METHOD

This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA.

RESULTS

Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay.

CONCLUSIONS

Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Functional outcomes and disability after nontraumatic spinal cord injury rehabilitation: Results from a retrospective study 1,211No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.22Reprints are not available from the author

OBJECTIVE

To describe, in a group of patients undergoing initial inpatient rehabilitation after nontraumatic spinal cord injury (SCI), the demographic characteristics, clinical features, and outcomes, with a focus on the functional status and disability.

DESIGN

Retrospective data analysis, 3-year case series.

SETTING

Tertiary medical unit specializing in nontraumatic SCI rehabilitation.

PARTICIPANTS

Consecutive sample of 70 adult inpatient referrals with nontraumatic SCI undergoing initial inpatient rehabilitation.

INTERVENTION

Chart review.

MAIN OUTCOME MEASURES

Primary outcomes were demographic characteristics, clinical features, mortality, length of stay (LOS), neurologic classification, accommodation setting, support services, mobility, bladder and bowel continence, and FIM instrument scores.

RESULTS

Forty-one patients (58.6%) were paraplegic incomplete, 23 (32.9%) were tetraplegic incomplete, and 6 (8.6%) were paraplegic complete. Eight patients (11.4%) died before hospital discharge. Of those who survived, 47 (75.8%) were discharged home, 11 (17.7%) were transferred to a nursing home, and 4 (6.4%) went elsewhere in the community. The geometric mean LOS was 55.8 days. Nine patients (14.5%) were discharged walking unaided, 27 (43.5%) were walking at least 10 m with a gait aid, and 26 (41.9%) were wheelchair dependent for mobility. Thirty patients (48.4%) were voiding on sensation, 7 (11.1%) used intermittent catheterization, 23 (37.2%) had an indwelling catheter, and 2 (2.8%) used reflex voiding. Eleven patients (17.7%) were fecally continent on sensation and 47 (75.8%) were fecally continent with a bowel program, 1 patient (1.6%) had a colostomy, and 3 patients (4.8%) were discharged fecally incontinent. The mean Rasch FIM motor score was 39.6 on admission and 58.7 at discharge (paired t test, t=-11.2; P<.000).

CONCLUSIONS

Most nontraumatic SCI patients returned home with a good level of functioning regarding mobility, bladder, and bowel status, in comparison to other studies of patients with SCI. Patients' disability was usually significantly reduced during rehabilitation.

Recovery of neurologic function following nontraumatic spinal cord lesions in Israel

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess neurologic recovery and the manner in which it is affected by various factors following nontraumatic spinal cord lesions (NTSCLs).

SUMMARY OF BACKGROUND DATA

NTSCLs comprise a considerable portion of spinal cord lesions. However, information about neurologic recovery in these lesions is scarce.

METHOD

The study sample included 1,085 patients with NTSCL treated between 1962 and 2000 at the premier referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from hospital charts. The degree of neurologic recovery was determined by comparing each patient's Frankel grades of neurologic deficit at first admission to rehabilitation and at discharge from the same hospitalization. The study population was also compared with previously studied 250 patients with traumatic spinal cord lesions (TSCLs).

RESULTS

Complete or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred during rehabilitation in 51% of patients who were Grade A, B, or C on admission, and in 57% of those who were Grade C. Neurologic recovery in NTSCL during rehabilitation was significantly affected by initial Frankel grade and by NTSCL etiology. Age had a borderline effect. Gender, lesion level, and the decade of rehabilitation did not affect recovery. Recovery rate was usually higher in NTSCLs than in TSCLs.

CONCLUSIONS

The prognosis for neurologic recovery is affected mainly by SCL severity and etiology, and is usually better in NTSCLs than in TSCLs.

Concurrent (Tandem) Cervical and Lumbar Spinal Stenosis

OBJECTIVE

To determine the frequency of concurrent cervical and lumbar spinal stenosis (i.e., "tandem spinal stenosis" [TSS]) in a 10-yr review of hospital admissions.

DESIGN

In a retrospective study of 460,964 hospital admissions to our 1,000-bed academic community hospital, we identified a base population of 54 patients with TSS. These patients presented with multiple complaints, including neurogenic claudication, progressive gait disturbances, and neurologic signs of both upper and lower motor neuron dysfunction, among others. Since 1964 when TSS was first described, estimates of its frequency have varied widely, ranging from a low of 5% to a high of 28%.

RESULTS

Of the 54 cases of TSS identified among the 460,964 patient admissions during a 10-yr period, 36 were men and 18 were women. A total of 51 were >51 yrs of age. For all ages, the frequency rate of TSS in this series was 12 per 100,000 admissions.

CONCLUSION

With TSS, the symptoms of either the cervical or the lumbar type initially predominate. Often, only after the primary pathology is treated does the secondary problem become evident. Although TSS occurred relatively infrequently in this series, its potential presence should not be overlooked.

Nontraumatic spinal cord injury: demographic characteristics and complications

OBJECTIVES

To investigate the demographic characteristics and complications of nontraumatic spinal cord injury (NT/SCI), to compare patients who were admitted for initial rehabilitation with readmission rehabilitation patients, to compare our findings with those of other studies, and to develop a model to predict the length of stay (LOS).

DESIGN

Retrospective, 3-year, case series.

SETTING

Tertiary medical unit specializing in SCI rehabilitation in Australia.

PARTICIPANTS

Consecutive sample of 134 adult referred inpatients with NT/SCI (58% women; median age, 61y). Patients requiring initial rehabilitation or readmission were included.

INTERVENTION

Chart review.

MAIN OUTCOMES MEASURES

Demographic characteristics, neurologic injury, etiology, comorbidities, and complications of NT/SCI.

RESULTS

The most common cause of NT/SCI was tumor (20.1%), but there were many different etiologies. Tetraplegia occurred in 32.8% of patients, and 56% had motor incomplete injuries. Most patients (63%) had at least 1 complication, including urinary tract infection (32.8%), pressure ulcer (31.5%), and pain (18.7%). Initial rehabilitation patients were significantly older (initial median, 69y vs readmission median, 54y; P=.0001). A multivariate model for LOS was able to predict 52% of the variance.

CONCLUSIONS

NT/SCI rehabilitation patients have a different demographic profile compared with traumatic SCI (T/SCI) patients and a lower prevalence of many of the complications that affect T/SCI patients. There are differences between initial and readmission patients.

Spinal cord injury medicine. 1. Etiology, classification, and acute medical management

This self-directed learning module highlights basic management and approaches to intervention-both established and experimental. The revised American Spinal Injury Association classification (2000) of spinal cord injury (SCI) further defines the examination and classification guidelines. The incidence of traumatic SCI remains at approximately 10,000 cases per year, with 32 years the average age at injury. Initial management includes establishment of oxygenation, circulation (mean blood pressure >85 mm Hg), radiographic evaluations for spine instability, intravenous methylprednisolone, and establishment of spinal alignment. Prevention measures for medical complications include pressure relief for skin, thromboembolism prophylaxis, prevention of gastric ulcers, Foley catheter drainage to prevent urine retention, and bowel care to prevent colonic impaction. Nontraumatic SCI from spinal stenosis, neoplastic compression, abscess, or multiple sclerosis becomes more common with aging. Experimental treatments for SCI include antibodies to block axonal growth inhibitors, gangliosides to augment neurite growth, 4-aminopyridine to enhance axonal conduction through demyelinated nerve fibers, and fetal tissue to fill voids in cystic spinal cord cavities. Early comprehensive rehabilitation at a SCI center prevents complications and enhances functional gains.

OVERALL ARTICLE OBJECTIVE

To summarize the comprehensive evaluation and management of a newly injured individual.

Nontraumatic vs. traumatic spinal cord injury: a rehabilitation outcome comparison

OBJECTIVE

Nontraumatic spinal cord injury (SCI) represents a significant proportion of individuals admitted for SCI rehabilitation; however, there is limited literature regarding their outcomes. As our society continues to age and nontraumatic injuries present with greater frequency, further studies in this area will become increasingly relevant. The objective of this study was to compare outcomes of patients with nontraumatic SCI with those with traumatic SCI after inpatient rehabilitation.

DESIGN

A longitudinal study with matched block design was used comparing 86 patients with nontraumatic SCI admitted to a SCI rehabilitation unit and 86 patients with traumatic SCI admitted to regional model SCI centers, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification. Main outcome measures included acute and rehabilitation hospital length of stay, FIM scores, FIM change, FIM efficiency, rehabilitation charges, and discharge-to-home rates.

RESULTS

Results indicate that when compared with traumatic SCI, patients with nontraumatic SCI had a significantly (P < 0.01) shorter rehabilitation length of stay (22.38 vs. 41.35 days) and lower discharge FIM scores (57.3 vs. 65.6), FIM change (18.6 vs. 31.0), and rehabilitation charges ($25,050 vs. $64,570). No statistical differences were found in acute care length of stay, admission FIM scores, FIM efficiency, and community discharge rates.

CONCLUSIONS

The findings indicate that patients with nontraumatic SCI can achieve rates of functional gains and community discharge comparable with traumatic SCI. Whereas patients with traumatic SCI achieved greater overall functional improvement, patients with nontraumatic SCI had shorter rehabilitation length of stay and lower rehabilitation charges. These findings have important implications for the interdisciplinary rehabilitation process in the overall management and outcome of individuals with nontraumatic SCI.

Nontraumatic spinal cord injury: incidence, epidemiology, and functional outcome

OBJECTIVES

To identify and compare the incidence, demographics, neurologic presentation, and functional outcome of individuals with nontraumatic spinal cord injury (SCI) to individuals with traumatic SCI.

DESIGN

A 5-year prospective study.

SETTING

Level I trauma center of a Regional SCI Model System.

PATIENTS

Two hundred twenty adult SCI admissions.

MAIN OUTCOME MEASURES

Demographics, etiology, level and completeness of injury, Functional Independent Measure (FIM) scores.

RESULTS

Of SCI admissions, 39% were nontraumatic in etiology (spinal stenosis, 54%; tumor, 26%). Compared to subjects with traumatic SCI, those individuals with nontraumatic SCI were significantly (p < .01) older and were more likely married, female, and retired. Injury characteristics revealed significantly more paraplegia and incomplete SCI within the nontraumatic SCI group (p < .01). Both nontraumatic and traumatic SCI individuals had significant FIM changes from rehabilitation admission to discharge (p < .01). Those with tetraplegia-incomplete nontraumatic SCI had significantly higher admission motor FIM scores and shorter rehabilitation length of stay than in the traumatic group (p < .05). Paraplegic-complete and paraplegic-incomplete nontraumatic SCI subjects had lower discharge motor FIM scores, FIM change, and FIM efficiency than those with traumatic SCI. Similar discharge-to-home rates were noted in both nontraumatic and traumatic SCI groups.

CONCLUSIONS

These data suggest that individuals with nontraumatic SCI represent a significant proportion of SCI rehabilitation admissions and, although differing from those with traumatic SCI in demographic and injury patterns, can achieve similar functional outcomes.