Research progress from the SCI Model Systems (SCIMS): An interactive discussion on future directions

CONTEXT/OBJECTIVE

To describe current and future directions in spinal cord injury (SCI) research.

DESIGN

The SCI Model Systems (SCIMS) programs funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) during the 2011 to 2016 cycle provided abstracts describing findings from current research projects. Discussion among session participants generated ideas for research opportunities.

SETTING/PARTICIPANTS

Pre-conference workshop before the 2016 American Spinal Injury Association (ASIA) annual meeting. A steering committee selected by the SCIMS directors that included the moderators of the sessions at the ASIA pre-conference workshop, researchers presenting abstracts during the session, and the audience of over 100 attending participants in the pre-conference workshop.

METHODS/RESULTS

Group discussion followed presentations in 5 thematic areas of (1) Demographics and Measurement; (2) Functional Training; (3) Psychosocial Considerations; (4) Assistive Technology; and (5) Secondary Conditions. The steering committee reviewed and summarized discussion points on future directions for research and made recommendations for research based on the discussion in each of the five areas.

CONCLUSION

Significant areas in need of research in SCI remain, the goal of which is continued improvement in the quality of life of individuals with SCI.

Considerations and recommendations for selection and utilization of upper extremity clinical outcome assessments in human spinal cord injury trials

Study design

This is a focused review article.

Objectives

This review presents important features of clinical outcomes assessments (COAs) in human spinal cord injury research. Considerations for COAs by trial phase and International Classification of Functioning, Disability and Health are presented as well as strengths and recommendations for upper extremity COAs for research. Clinical trial tools and designs to address recruitment challenges are identified.

Methods

The methods include a summary of topics discussed during a two-day workshop, conceptual discussion of upper extremity COAs and additional focused literature review.

Results

COAs must be appropriate to trial phase and particularly in mid-late-phase trials, should reflect recovery vs. compensation, as well as being clinically meaningful. The impact and extent of upper vs. lower motoneuron disease should be considered, as this may affect how an individual may respond to a given therapeutic. For trials with broad inclusion criteria, the content of COAs should cover all severities and levels of SCI. Specific measures to assess upper extremity function as well as more comprehensive COAs are under development. In addition to appropriate use of COAs, methods to increase recruitment, such as adaptive trial designs and prognostic modeling to prospectively stratify heterogeneous populations into appropriate cohorts should be considered.

Conclusions

With an increasing number of clinical trials focusing on improving upper extremity function, it is essential to consider a range of factors when choosing a COA.

Sponsors

Craig H. Neilsen Foundation, Spinal Cord Outcomes Partnership Endeavor.

Patterns of Sacral Sparing Components on Neurologic Recovery in Newly Injured Persons With Traumatic Spinal Cord Injury

OBJECTIVE

To assess the patterns of sacral sparing and recovery in newly injured persons with traumatic spinal cord injury (SCI).

DESIGN

Retrospective analysis of data from the national Spinal Cord Injury Model Systems (SCIMS) database for patients enrolled from January 2011 to February 2015.

SETTING

SCIMS centers.

PARTICIPANTS

Individuals (N=1738; age ≥16y) with traumatic SCI admitted to rehabilitation within 30 days after injury with follow-up at discharge, at 1 year, or both.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

International Standards for Neurological Classification of Spinal Cord Injury examination results at admission and follow-up (discharge or 1y, or both).

RESULTS

Conversion from an initial American Spinal Injury Association Impairment Scale (AIS) grade A to incomplete status was 20% at rehabilitation discharge and 27.8% at 1 year, and was greater in cervical and low paraplegia levels (T10 and below) than in high paraplegia level injuries (T1-9). Conversion from AIS B to motor incomplete was 33.9% at discharge and 53.6% at 1 year, and the initial sparing of all sacral sensory components was correlated with the greatest conversion to motor incomplete status at discharge and at 1 year. For patients with initial AIS C, the presence of voluntary anal contraction (VAC) in association with other sacral sparing was most frequently observed to improve to AIS D status at discharge. However, the presence of VAC alone as the initial sacral sparing component had the poorest prognosis for recovery to AIS D status. At follow-up, regaining sacral sparing components correlated with improvement in conversion for patients with initial AIS B and C.

CONCLUSIONS

The components of initial and follow-up sacral sparing indicated differential patterns of neurologic outcome in persons with traumatic SCI. The more sacral components initially spared, the greater the potential for recovery; and the more sacral components gained, the greater the chance of motor recovery. Consideration of whether VAC should remain a diagnostic criterion sufficient for motor incomplete classification in the absence of other qualifying sublesional motor sparing is recommended.

Toward Inclusive Trial Protocols in Heterogeneous Neurological Disorders

Background. Several novel drug- and cell-based potential therapies for spinal cord injury (SCI) have either been applied or will be considered for future clinical trials. Limitations on the number of eligible patients require trials be undertaken in a highly efficient and effective manner. However, this is particularly challenging when people living with incomplete SCI (iSCI) represent a very heterogeneous population in terms of recovery patterns and can improve spontaneously over the first year after injury. Objective. The current study addresses 2 requirements for designing SCI trials: first, enrollment of as many eligible participants as possible; second, refined stratification of participants into homogeneous cohorts from a heterogeneous iSCI population. Methods. This is a retrospective, longitudinal analysis of prospectively collected SCI data from the European Multicenter study about Spinal Cord Injury (EMSCI). We applied conditional inference trees to provide a prediction-based stratification algorithm that could be used to generate decision rules for the appropriate inclusion of iSCI participants to a trial. Results. Based on baseline clinical assessments and a defined subsequent clinical endpoint, conditional inference trees partitioned iSCI participants into more homogeneous groups with regard to the illustrative endpoint, upper extremity motor score. Assuming a continuous endpoint, the conditional inference tree was validated both internally as well as externally, providing stable and generalizable results. Conclusion. The application of conditional inference trees is feasible for iSCI participants and provides easily implementable, prediction-based decision rules for inclusion and stratification. This algorithm could be utilized to model various trial endpoints and outcome thresholds.

Relationship Between Motor Recovery and Independence After Sensorimotor-Complete Cervical Spinal Cord Injury

Background. For therapeutics directed to the injured spinal cord, a change in neurological impairment has been proposed as a relevant acute clinical study end point. However, changes in neurological function, even if statistically significant, may not be associated with a functional impact, such as a meaningful improvement in items within the self-care subscore of the Spinal Cord Independence Measure (SCIM). Objective. The authors examined the functional significance associated with spontaneously recovering upper-extremity motor function after sensorimotor-complete cervical spinal cord injury (SCI). Methods. Using the European Multi-center Study about Spinal Cord Injury (EMSCI) data set, a retrospective analysis was undertaken of individuals with cervical sensorimotor-complete SCI (initial motor level, C4-C7). Specifically, changes in upper-extremity motor score (UEMS), motor level, and SCIM (total and self-care subscore) were assessed between approximately 1 and 48 weeks after injury (n = 74). Results. The initial motor level did not significantly influence the total UEMS recovered or number of motor levels recovered. SCIM self-care subscore recovery was significantly greater for those individuals regaining 2 motor levels compared with those recovering only 1 or no motor levels. However, the recovery in the SCIM self-care subscore was not significantly different between individuals recovering only 1 motor level and those individuals who showed no motor-level improvement. Conclusions. A 2 motor-level improvement indicates a clinically meaningful change and might be considered a primary outcome in acute and subacute interventional trials enrolling individuals with cervical sensorimotor-complete SCI.

Sacral sparing in SCI: beyond the S4-S5 and anorectal examination

BACKGROUND CONTEXT

Sensory and/or motor function sparing, including the S4-S5 spinal cord segment, is central to classifying neurologic impairment after spinal cord injury (SCI) using the American Spinal Injury Association Impairment Scale (AIS) grades within the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Within the ISNCSCI protocol, which is essential for both clinical and research purposes, assessing sacral sparing requires an anorectal and S4-S5 examination. However, in situations where these data are incomplete, the relationships between anorectal/S4-S5 examinations and functional preservation at more rostral sacral segments may be useful.

PURPOSE

To evaluate whether slightly more rostral sensory and motor outcomes of the ISNCSCI can accurately predict caudal sacral sparing (S4-S5 dermatome sensation, "deep pressure" anal sensation [AS], and voluntary anal contraction [AC]).

STUDY DESIGN

Retrospective analysis of the European Multicenter Study about Spinal Cord Injury database.

PATIENT SAMPLE

One thousand four hundred sixty-seven AIS-A, AIS-B, and AIS-C subjects.

OUTCOME MEASURES

International Standards for Neurological Classification of Spinal Cord Injury examinations.

METHODS

The value of six factors (sensory preservation at S1, S2, and S3; motor preservation at S1; motor function at more than three segments below the motor level; and sensory function at more than three segments below the neurologic level) for predicting ISNCSCI sacral sparing measures (AS, S4-S5 dermatome sensation, AC) was evaluated. Combinations of the most promising factors were then evaluated for their ability to accurately predict the AIS grade.

RESULTS

Preserved sensation at the first sacral segment (S1S) provided good prediction (90.5%) of caudal sacral sensory sparing (ie, AS or S4-S5 sensation). Voluntary anal contraction was accurately predicted by preserved motor function within the first sacral segment (S1M) in 85.4% of cases. The alternate classification schemes evaluated for accurately predicting the AIS classification grade were S1S+S1M and S1S+motor preservation more than three segments below the motor level. The ability of these schemes to accurately predict AIS grades was stable over time but varied with the rostrocaudal level of spinal injury. For the initial baseline examination, the alternate classification schemes were accurate in ~95% of cases for T2-T9 SCI, with slightly lower accuracy for cervical SCI (~80%).

CONCLUSIONS

There are close relationships between functional sparing at different sacral segments. These relationships can be used to estimate AIS grades when complete information about the anorectal and S4-S5 examination is not available. The accuracy of the classification remains stable over time, while the increased variability in lower levels of SCI, that is, lumbar injuries, emphasizes the importance of careful sacral examinations. The highly reliable predictive values of S1-S3 segments can complement conclusions from anorectal examinations if the latter are considered to be confounded or incomplete.

Outcome Measures for Acute/Subacute Cervical Sensorimotor Complete (AIS-A) Spinal Cord Injury During a Phase 2 Clinical Trial

Effective treatment after cervical spinal cord injury (SCI) is imperative as so many activities of daily living (ADLs) are dependent on functional recovery of arm and hand actions. We focus on defining and comparing neurological and functional endpoints that might be used during acute or subacute Phase 2 clinical trials involving subjects with cervical sensorimotor complete SCI (ASIA Impairment Scale [AIS-A]). For the purposes of this review, the trial would examine the effects of a pharmaceutical small molecule, drug, biologic, or cell transplant on spinal tissue. Thus, neurological improvement is the intended consequence and is most directly measured by assessing neurological impairment (eg, motor aspects of the International Standards Neurological Classification of Spinal Cord Injury [ISNCSCI]). However, changes in neurological function, even if statistically significant, may not be associated with a clear functional impact (ie, a meaningful improvement in individual activity, such as independent self-care ADLs). The challenge is to measure improvement as precisely as possible (change in impairment), but to define a clinically meaningful response in the context of functional improvement (impact on activity limitations). The principal comparisons focused on elements of the ISNCSCI assessment, including upper extremity motor score and motor level. Personal activity capabilities were also examined at various time points. The data suggest that an improvement of 2 or more motor levels after cervical sensorimotor complete SCI may be a clinically meaningful endpoint threshold that could be used for acute and subacute Phase 2 trials with subjects having sensorimotor complete cervical SCI.

Mechanical ventilation, health, and quality of life following spinal cord injury

OBJECTIVE

To examine differences in perceived quality of life (QOL) at 1 year postinjury between people with tetraplegia who required mechanical ventilation assistance at discharge from rehabilitation and those who did not.

DESIGN

Prospective cross-sectional examination of people with spinal cord injury (SCI) drawn from the SCI Model Systems National Database.

SETTING

Community.

PARTICIPANTS

People with tetraplegia (N=1635) who sustained traumatic SCI between January 1, 1994, and September 30, 2008, who completed a 1-year follow-up interview, including 79 people who required at least some use of a ventilator at discharge from rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Satisfaction With Life Scale (SWLS); Craig Handicap Assessment and Reporting Technique (CHART)-Short Form Physical Independence, Mobility, Social Integration, and Occupation subscales; Patient Health Questionnaire-9 (PHQ-9), Medical Outcomes Study 36-Item Short-Form Health Survey self-perceived health status.

RESULTS

Significant differences were found between the ventilator-user (VU) group and non-ventilator-user (NVU) group for cause of trauma, proportion with complete injury, neurologic impairment level, and number of rehospitalizations. The NVU group had significantly higher SWLS and CHART Social Integration scores than the VU group after controlling for selected covariates. The NVU group also had more positive perceived health status compared with a year previously and a lower incidence of depression assessed by using the PHQ-9 than the VU group. There were no significant differences between groups for perceived current health status.

CONCLUSIONS

People in this study who did not require mechanical ventilation at discharge from rehabilitation post-SCI reported generally better health and improved QOL compared with those who required ventilator assistance at 1 year postinjury. Nonetheless, the literature suggests that perceptions of QOL improve as people live in the community for longer periods.

Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the national spinal cord injury database

OBJECTIVE

To present upper- (UEMS) and lower-extremity motor score (LEMS) recovery, American Spinal Injury Association Impairment Scale (AIS) change, and motor level change in persons with traumatic tetraplegia from the Spinal Cord Injury Model Systems (SCIMS).

DESIGN

Longitudinal cohort; follow-up to 1 year.

SETTING

U.S. SCIMS.

PARTICIPANTS

Subjects (N=1436; age>15y) with tetraplegia with at least 2 examinations, the first within 7 days of injury. Subjects were 80% men injured by vehicular collisions (44%), falls (30%), sports (12%), and violence (11%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Change in AIS, UEMS, LEMS, and motor levels.

RESULTS

From a baseline of 7 days or less, 22% of subjects with AIS grade A converted to AIS grade B or better by rehabilitation discharge; and 30%, by 1 year, with 8% to AIS grade C and 7.1% to grade D. Conversion from complete to motor incomplete was not related to timing of the initial examination (P=.54) or initial neurologic level (P=.96). For AIS grade B, 34% remained motor complete, 30% became AIS grade C, and 37% became grade D by 1 year. Although 82.5% of those with AIS grade C improved to AIS grades D and E, mean 1-year UEMS score was only 35 points. UEMS scores in patients with AIS grade A increased a mean of 9 to 11 points, except for C1 to C3 and C8 to T1 motor levels (gain, 2-3 points). Motor level was unchanged or ascended in 35% and improved 1 level in 42%, 2 levels in 14%, and more than 2 levels in 9%. Motor zone of partial preservation of 2 segments or more was associated with gain of 2 or more motor levels, with a relative risk of 5.0 (95% confidence interval, 3.2-7.8; P<.001).

CONCLUSIONS

More patients with cervical complete spinal cord injury may be converting to AIS grade D compared with earlier reports. Motor level recovery in those with AIS grade A and UEMS recovery in those with AIS grade C injuries are potential outcomes for acute clinical trials.

Characterization of neurological recovery following traumatic sensorimotor complete thoracic spinal cord injury

STUDY DESIGN

Retrospective, longitudinal analysis of sensory, motor and functional outcomes from individuals with thoracic (T2-T12) sensorimotor complete spinal cord injury (SCI).

OBJECTIVES

To characterize neurological changes over the first year after traumatic thoracic sensorimotor complete SCI.

METHODS

A dataset of 399 thoracic complete SCI subjects from the European Multi-center study about SCI (EMSCI) was examined for neurological level, sensory levels and sensory scores (pin-prick and light touch), lower extremity motor score (LEMS), ASIA Impairment Scale (AIS) grade, and Spinal Cord Independence Measure (SCIM) over the first year after SCI.

RESULTS

AIS grade conversions were limited. Sensory scores exhibited minimal mean change, but high variability in both rostral and caudal directions. Pin-prick and light touch sensory levels, as well as neurological level, exhibited minor changes (improvement or deterioration), but most subjects remained within one segment of their initial injury level after 1 year. Recovery of LEMS occurred predominantly in subjects with low thoracic SCI. The sensory zone of partial preservation (ZPP) had no prognostic value for subsequent recovery of sensory levels or LEMS. However, after mid or low thoracic SCI, ≥3 segments of sensory ZPP correlated with an increased likelihood for AIS grade conversion.

CONCLUSION

The data suggest that a sustained deterioration of three or more thoracic sensory levels or loss of upper extremity motor function are rare events and may be useful for tracking the safety of a therapeutic intervention in early phase acute SCI clinical trials, if a significant proportion of study subjects exhibit such an ascent.

Posttraumatic spinal cord tethering and syringomyelia: surgical treatment and long-term outcome

Object

Permanent neurological loss after spinal cord injury (SCI) is a well-known phenomenon. There has also been a growing recognition and improved understanding of the pathophysiological mechanisms of late progressive neurological loss, which may occur after SCI as a result of posttraumatic spinal cord tethering (SCT), myelomalacia, and syringomyelia. A clinical study of 404 patients sustaining traumatic SCIs and undergoing surgery to arrest a progressive myelopathy caused by SCT, with or without progressive myelomalacia and cystic cavitation (syringomyelia) was undertaken. Both objective and subjective long-term outcomes were evaluated. To the authors' knowledge, this is the first series of this size correlating long-term patient perception of outcome with long-term objective outcome analyses.

Methods

During the period from January 1993 to November 2003, 404 patients who had previously sustained traumatic SCIs underwent 468 surgeries for progressive myelopathies attributed to tethering of the spinal cord to the surrounding spinal canal, with or without myelomalacia and syrinx formation. Forty-two patients were excluded because of additional pathological entities that were known to contribute to a progressive myelopathy. All surgeries were performed by the same neurosurgeon at a single SCI treatment center and by using a consistent surgical technique of spinal cord detethering, expansion duraplasty, and when indicated, cyst shunting.

Results

Outcome data were collected up to 12 years postoperatively. Comparisons of pre- and postoperative American Spinal Injury Association sensory and motor index scores showed no significant change when only a single surgery was required (86% of patients). An outcome questionnaire and phone interview resulted in > 90% of patients self-assessing arrest of functional loss; > 50% of patients self-assessing improvement of function; 17 and 18% self-assessing improvement of motor and sensory functions to a point greater than that achieved at any time postinjury, respectively; 59% reporting improvement of spasticity; and 77% reporting improvement of hyperhidrosis.

Conclusions

Surgery for spinal cord detethering, expansion duraplasty, and when indicated, cyst shunting, is a successful treatment strategy for arresting a progressive myelopathy related to posttraumatic SCT and syringomyelia. Results suggest that surgery leads to functional return in ~ 50% of patients, and that in some patients posttraumatic SCT limits maximal recovery of spinal cord function postinjury. A patient's perception of surgery's failure to arrest the progressive myelopathy corresponds closely with the need for repeat surgery because of retethering, cyst reexpansion, and pseudomeningocele formation.

Apolipoprotein E epsilon4 allele and outcomes of traumatic spinal cord injury

BACKGROUND/OBJECTIVE

To test the hypothesis that apolipoprotein E (APOE) polymorphisms are associated with outcomes after spinal cord injury (SCI).

METHODS

Retrospective cohort study, from rehabilitation admission to discharge.

PARTICIPANTS

Convenience sample of 89 persons with cervical SCI (C3-C8) treated from 1995 through 2003. Median age was 30 years (range 14-70); 67 were male (75%) and 83 were white (93%).

MAIN OUTCOME MEASURES

American Spinal Injury Association (ASIA) motor and sensory scores, ASIA Impairment Scale (AIS), time from injury to rehabilitation admission, and length of stay (LOS) in rehabilitation.

RESULTS

Subjects with an APOE epsilon4 allele (n = 15; 17%) had significantly less motor recovery during rehabilitation than did individuals without an epsilon4 allele (median 3.0 vs 5.5; P < 0.05) and a longer rehabilitation LOS (median 106 vs 89 days; P = 0.04), but better sensory-pinprick recovery (median 5.0 vs 2.0; P= 0.03). There were no significant differences by APOE epsilon4 allele status in sensory-light touch recovery, likelihood of improving AIS Grade, or time from injury to rehabilitation admission.

CONCLUSIONS

APOE epsilon4 allele was associated with differences in neurological recovery and longer rehabilitation LOS. Genetic factors may be among the determinants of outcome after SCI and warrant further study.

Long-term survival of persons ventilator dependent after spinal cord injury

BACKGROUND/OBJECTIVE

Identify factors related to long-term survival, and quantify their effect on mortality and life expectancy.

SETTING

Model spinal cord injury systems of care across the United States.

STUDY DESIGN

Survival analysis of persons with traumatic spinal cord injury who are ventilator dependent at discharge from inpatient rehabilitation and who survive at least 1 year after injury.

METHODS

Logistic regression analysis on a data set of 1,986 person-years occurring among 319 individuals injured from 1973 through 2003.

RESULTS

The key factors related to long-term survival were age, time since injury, neurologic level, and degree of completeness of injury. The life expectancies were modestly lower than previous estimates. Pneumonia and other respiratory conditions remain the leading cause of death but account for only 31% of deaths of known causes.

CONCLUSIONS

Whereas previous research has suggested a dramatic improvement in survival over the last few decades in this population, this is only the case during the critical first few years after injury. There was no evidence for such a trend in the subsequent period.

Neurorehabilitation of spinal cord injuries following lightning and electrical trauma

While spinal cord injuries caused by lightning strike or electrical shock are rare, their clinical manifestations pose unique challenges to the clinician who must anticipate the interaction of multiple system involvement with the altered physiology of spinal cord injury. Spinal cord damage may be secondary to the direct effects of electrical current passing through neural tissue producing immediate or delayed impairment. Alternatively, lightning strike and electrical shock may lead to spinal cord damage due to the secondary consequences of injury such as spinal fractures sustained after a fall. In addition to effects on the spinal cord, electrical trauma may result in injury to the brain, peripheral nervous system, musculoskeletal system, skin, and cardiovascular system. This article will review the neurorehabilitation approach to this rare and challenging group of patients.

Visceral pain and life quality in persons with spinal cord Injury: a brief report

BACKGROUND/OBJECTIVE

Few studies have examined the prevalence of visceral pain in persons with spinal cord injury (SCI), and virtually no studies have looked at the relationship between visceral pain and self-reported quality of life. We examined the frequency of reported visceral pain at 5, 10, and 15 years after injury to determine whether the presence of visceral pain is related to quality of life, and to determine to what extent visceral pain should be of concern to clinicians treating patients with SCI.

METHODS

Visceral pain and quality of life in persons with SCI were compared from a combined Craig Hospital and National Model SCI Systems database at 5 (N = 33), 10 (N = 132), and 15 (N = 96) years after injury.

RESULTS

The rates of visceral pain increased at each measurement (10% at year 5, 22% at year 10, and 32% at year 15); although these numbers reflect cross-sectional data, they do show a clear statistical change. Only a limited true longitudinal sample was available, but at 10 years after injury, individuals who had reported visceral pain at any time reported a significantly lower quality of life than those never experiencing visceral pain, F1,188 = 3.95, P < 0.05.

CONCLUSIONS

Although visceral pain may not be as prevalent as the more researched neuropathic and musculoskeletal subtypes of pain, it may account for a higher percentage of people with SCI who report pain than previously recognized. More quantitative and longitudinal research is needed to examine the relationship of visceral pain with overall quality of life and to pursue interventions.

Research from the Model Spinal Cord Injury Systems: findings from the current 5-year grant cycle

This issue of the Archives of Physical Medicine and Rehabilitation is dedicated to current research findings of the Model Spinal Cord Injury Systems (MSCIS) program. The MSCIS grants were established by the Rehabilitation Services Administration in the 1970s. Now administered by the National Institute on Disability and Rehabilitation Research within the Office of Special Education and Rehabilitation Services in the US Department of Education, the program has included 27 spinal cord injury centers in the United States over the years. In the current 5-year grant cycle (2000-2005), there are 16 designated regional MSCIS centers. In addition to establishing a comprehensive system of care, the grantees contribute patient data to the National Spinal Cord Injury Database (which now contains data on 30,532 subjects with follow-up of up to 30 y). In addition, the MSCIS grants enable the conduct of site-specific and collaborative research projects. To highlight the research findings of the program, the MSCIS have produced a special dissemination effort during each of the previous 5 grant cycles, with this issue of the Archives representing the latest of these endeavors. This article provides a brief history of the MSCIS program and highlights the important findings of the 17 original research articles contained in this issue.

Update on pharmaceutical trials in acute spinal cord injury

OBJECTIVE

To review the major pharmacological trials in acute spinal cord injury (SCI) that have been conducted over the past 25 years.

METHODS

Review article.

RESULTS

The publication of the first National Acute Spinal Cord Injury (NASCIS) trial in 1984 ushered in the era of pharmacological trials of therapies intended to improve neurologic outcome in acute SCI. Subsequent trials of methylprednisolone sodium succinate (MPSS) and GM-1 have added to the evidence basis that informs the current management practices for acute SCI.

CONCLUSION

The last 50 years have seen a conceptual shift from the pessimism of the past to a cautious optimism that the meager prognosis for neurologic recovery in acute SCI will yield to the progress of medical science. Major advances in the understanding of primary and secondary injury mechanisms have led to the preclinical study of many promising pharmacological therapies, all with the goal of improving neurologic outcome. A few of these drugs have stood the test of animal model experiments and have made it to the forum of human clinical trials. The NASCIS trials of methylprednisolone have been acknowledged widely as the first human studies to claim improved neurologic outcome. Although the results of these trials remain controversial, the MPSS therapy that they reported has been adopted widely by clinicians around the world as the best currently available, even if not a consensus "standard of care." Clearly, the challenge for medical science remains. The search for effective treatment has only begun.

Aging with spinal cord injury: Changes in selected health indices and life satisfaction11No 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

OBJECTIVES

To document the impact of age, age at injury, years postinjury, and injury severity on changes over time in selected physical and psychosocial outcomes of people aging with spinal cord injury (SCI), and to identify the best predictors of these outcomes.

DESIGN

Retrospective cross-sectional and longitudinal examination of people with SCI.

SETTING

Follow-up of people who received initial rehabilitation in a regional Model Spinal Cord Injury System.

PARTICIPANTS

People who meet the inclusion criteria for the National Spinal Cord Injury Database were studied at 5, 10, 15, 20, and 25 years postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Number of pressure ulcers, number of times rehospitalized, number of days rehospitalized, perceived health status, satisfaction with life, and pain during the most recent follow-up year.

RESULTS

The number of days rehospitalized and frequency of rehospitalizations decreased and the number of pressure ulcers increased as time passed. For the variables of pressure ulcers, poor perceived health, the perception of pain and lower life satisfaction, the best predictor of each outcome was the previous existence or poor rating of that same outcome.

CONCLUSIONS

Common complications of SCI often herald the recurrence of those same complications at a later point in time, highlighting the importance of early intervention to prevent future health and psychosocial difficulties.

Factors associated with survival after bladder cancer in spinal cord injury

OBJECTIVE

The purpose of this study was to evaluate factors influencing survival in individuals with spinal cord injury (SCI) and bladder cancer. We hypothesized that bladder cancer survivors would have undergone more intense genitourinary surveillance and would have had fewer risk factors for bladder cancer.

DESIGN

Case-control study.

PARTICIPANTS/METHODS

Eight participants with SCI who had survived at least 5 years (survivors) with bladder cancer were compared with 12 SCI controls who had died due to bladder cancer. Data was obtained retrospectively through medical record review and were analyzed using a two-tailed Mann-Whitney and Fisher's exact tests.

RESULTS

The survivor and control groups were similar with regard to age at SCI, duration of SCI, age at bladder cancer diagnosis, and time utilizing an indwelling catheter. The proportion that developed squamous cell carcinoma was similar for the survivors and controls, at 37.5% and 44%, respectively. Survivors were more likely to be nonsmokers (P = 0.04), and have a history of squamous metaplasia (P = 0.05) and papillary cystitis (P = 0.03). Examining risk factors together, controls were more likely to have multiple risk factors for bladder cancer. The mean number of cystoscopies for the survivor and control groups, respectively, was 8.6 (range = 1-22, SE = 3.1) vs 18.9 (range = 4-48, SE = 6.6), and the mean number of bladder biopsies was 1.5 (range = 1-5, SE = 0.6) vs 4.2 (range = 1-11, SE = 2.0), respectively.

CONCLUSION

Bladder cancer survivors were less likely to have multiple genitourinary risk factors. Fewer screening cystoscopies and biopsies were performed in survivors of bladder cancer than in those who died of bladder cancer.

A view of the future Model Spinal Cord Injury System through the prism of past achievements and current challenges

OBJECTIVE

To examine the contributions of the Model Spinal Cord Injury System (MSCIS) program to the evaluation and care of individuals with spinal cord injury (SCI) and to acknowledge today's challenges to chart the future course of the MSCIS.

METHODS

Retrospective review of the literature and prospective development of consensus by task force members and consultants. Integration of recent reported findings from panel presentations and publications regarding the MSCIS 2000 through 2005.

FINDINGS

Significant strides have been made toward the improvement of care for individuals with SCI, which can be attributed to the quality of clinical investigation and education. This has been achieved through the leadership of MSCIS directors in partnership with members from national and international voluntary organizations. These efforts include more than 2,000 peer-reviewed publications from the MSCIS, which have served as a basis for practice guidelines in the field. Although much has been accomplished with regard to reducing medical and behavioral complications, mortality, and length of stay in the hospital and increasing successful return to the community, more is needed.

CONCLUSION

The MSCIS has a unique opportunity to provide solutions because of its world-renowned database and center, outcome measures, and infrastructure for trials. To maximize this opportunity, the MSCIS must continue to address the appropriate investigational and service issues by defining the best approach to data collection, rigorous clinical studies, and behavioral strategies in the next decade.

Administration of corticosteroids for acute spinal cord injury: the current practice of trauma medical directors and emergency medical system physician advisors

OBJECTIVE

In 1997, the results from the Third National Acute Spinal Cord Injury Study (NASCIS 3) were published. We undertook the present study to determine the treatment protocols for patients with spinal cord injuries in Colorado and assess whether there were any barriers to the administration of corticosteroids.

STUDY DESIGN

Cross-sectional.

METHODS

In May 1999, surveys were mailed to every trauma facility medical director and emergency medical system physician advisor in the state. Physicians were asked to provide information about their facilities' or agencies' current practice(s) for administering steroids to patients with spinal cord injuries. They were also asked about their opinion on whether the data on corticosteroid treatment for spinal cord injury support its use.

RESULTS

Ninety-eight percent (39 out of 41) of the medical directors who responded and treat patients with spinal cord injuries said that their facilities do administer steroids to those patients. Fourteen percent reported following the NASCIS 3 protocol; 75%, the NASCIS 2 protocol. About half of the medical directors were either uncertain or did not believe that the data regarding the corticosteroid treatment for spinal cord injury supported its use. The majority of physician advisors responded that they do not authorize the administration of corticosteroids to patients with spinal cord injuries in the field, primarily because of short transport times.

CONCLUSIONS

Our study demonstrated relatively poor compliance with the NASCIS 3 protocol, but good compliance with the NASCIS 2 protocol. There was skepticism about the efficacy of corticosteroid treatment among some Colorado physicians that treat patients with spinal cord injuries acutely; however, this does not completely explain the findings.

Predictors of personal care assistance for people with spinal cord injury

OBJECTIVE

To assess the predictors of personal care assistance (PCA) use in people with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Follow-up of individuals crossing their 1st, 5th, 10th, 15th, 20th, or 25th anniversary of injury who underwent their initial rehabilitation at a Spinal Cord Injury Model Systems center.

PARTICIPANTS

A total of 2154 participants (2547 records) who met the inclusion criteria for the National Spinal Cord Injury Database and had valid values for the main outcome measures.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily hours of paid, unpaid, and occasional PCA services.

RESULTS

Differences in an interval version of the motor portion of the FIM trade mark instrument accounted for 26.3% of the variance in total PCA hours, Model Systems differences accounted for 9.3%, and no other predictor accounted for more than 2.1% of the variance.

CONCLUSION

Activities of daily living functioning, as measured by the motor portion of the FIM, was the strongest predictor of PCA use among people with SCI.

Excess risk of bladder cancer in spinal cord injury: evidence for an association between indwelling catheter use and bladder cancer

OBJECTIVES

To evaluate whether the risk of bladder cancer is greater in individuals with spinal cord injury (SCI) than in the general population and whether indwelling catheter (IDC) use is a significant independent risk factor for bladder cancer.

DESIGN

Historical cohort study in which subjects with SCI were stratified according to bladder management method and followed for the development of bladder cancer.

SETTING

A large rehabilitation hospital in the Spinal Cord Injury Model Systems.

PARTICIPANTS

A total of 3670 patients with SCI who were evaluated for bladder cancer on at least 1 occasion by cystoscopy over a period of 1 to 47 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Bladder cancer occurring after SCI determined by diagnosis at our facility, by subject report, or by report of next of kin.

RESULTS

Twenty-one cases of bladder cancer were found in the 3670 study participants. The risk of bladder cancer for subjects with SCI using IDC is 77 per 100,000 person-years, corresponding to an age- and gender-adjusted standardized morbidity ratio (SMR) of 25.4 (95% confidence interval [CI], 14.0--41.9) when compared with the general population. After controlling for age at injury, gender, level and completeness of SCI, history of bladder calculi, and smoking, those using solely IDC had a significantly greater risk of bladder cancer (relative risk [RR] = 4.9; 95% CI, 1.3--13.8) than those using nonindwelling methods. Mortality caused by bladder cancer in individuals with SCI was significantly greater than that of the US population (SMR = 70.6; 95% CI, 36.9--123.3).

CONCLUSIONS

Bladder cancer risk and mortality are heightened in SCI compared with the general population. IDC is a significant independent risk factor for the increased risk of and mortality caused by bladder cancer in the SCI population.

Surgical treatment of posttraumatic cystic and tethered spinal cords

Posttraumatic syringomyelia as a cause of progressive neurologic deterioration has been well described. More recently, the noncystic posttraumatic tethered cord has been associated with identical progressive neurologic deterioration. A retrospective analysis of patients treated surgically with spinal cord untethering and/or cyst shunting to arrest a progressive myelopathy from a posttraumatic tethered and/or cystic cord was performed. Emphasis was on outcome using the American Spinal Injury Association (ASIA) sensory and motor scoring systems. During an 18-month period from May 1993 to December 1994, 70 patients with spinal cord injury were operated upon for tethered and/or cystic spinal cords because of a progressive myelopathy and deteriorating ASIA sensory/motor scores. Fifty-nine patients had follow-up data 1 year postoperatively. At the 1 year follow-up, there was small improvement in light touch sensory scores (0.67 points), pinprick scores (1.3 points), and motor scores (0.41 points) demonstrating that the progression of the myelopathic process was arrested. Thirty-four of these 59 patients had no previous surgery to their spinal cords. At 1 year follow-up, light touch scores improved on average 2.38 points, pinprick scores 3.88 points (p < 0.05), and motor scores 1.47 points, suggesting better outcome with first-time surgery. Of this latter group, 64.3% regained a lost function, 62.5% saw improvement in spasticity, 55.6% had substantial improvement in neurogenic pain, and 95.8% felt that surgery prevented further neurologic deterioration.

Recent trends in mortality and causes of death among persons with spinal cord injury

OBJECTIVE

To identify and quantify trends in mortality and causes of death among persons with spinal cord injury.

DESIGN

Cohort study.

SETTING

Model spinal cord injury care systems and Shriner's Hospitals spinal cord injury units throughout the United States.

PATIENTS

A total of 28,239 consecutive persons admitted to the model system or to a Shriner's Hospital within 1 year of injury.

MAIN OUTCOME MEASURE

Length of survival and cause of death.

RESULTS

Among persons who were admitted to the model system within 1 day of injury, the odds of dying during the first postinjury year were reduced by 67% for persons injured between 1993 and 1998 relative to persons injured between 1973 and 1977 after adjusting for trends in age, gender, race, neurologic level of injury, Frankel grade, ventilator status, etiology of injury, sponsor of care, and model system where treatment occurred. However, mortality rates after the first anniversary of injury, which had also been declining from 1973 to 1992, increased 33% for persons injured between 1993 and 1998 relative to persons injured between 1988 and 1992. Respiratory disease was the only cause of death after the first anniversary of injury for which the relative odds increased meaningfully during the latest time period (76% increase over 1988-1992 compared to all other causes).

CONCLUSION

While great improvements in life expectancy have been achieved since the Model SCI Systems program began, current data support the need for renewed efforts to improve the prevention and treatment of the complications of spinal cord injury.

Technetium-99m-MAG3 renal studies in spinal cord injury patients: normal range, reproducibility, and change as a function of duration and level of injury

The normal range, reproducibility, and change as a function of duration and level of injury for Tc-99m-MAG3 renal studies were quantitated in spinal cord injury (SCI) patients.

METHODS

Five SCI patients without evidence of renal disease in each of four groups: less than 2 months, 2-12 months, 1-2 years, and greater than 2 years from time of injury, were each studied twice. There were at least two patients with paraplegia and two with tetraplegia in each group. Renal clearance (camera based method), percent function in each kidney, time of peak renal parenchymal activity, and half time of parenchymal activity following the peak were evaluated. The peak and half times were determined with regions of interest (ROIs) over the entire kidney and over just the cortex. All results were compared to normal ranges previously established in normal subjects of the same age range using the same methodology.

RESULTS

Renal clearance in the less than 2 month SCI patients was not significantly different from normal subjects in either paraplegic or in tetraplegic individuals. However, clearance in tetraplegics was increased by 28.5% at 2-12 month, increased by 50.6% at 1-2 years, and decreased by 25.9% at greater than 2 years compared to normal subjects (all P < 0.02). Clearance in those with paraplegia showed a similar, but less marked, trend (P = NS). The time of peak parenchymal activity when measured with cortical ROIs did not vary among patient groups or level of injury, but was increased compared to normal subjects (P < 0.05). The percent function in each kidney and half time following the peak were symmetrical, did not differ among patient groups or with level of injury, and did not differ from normal subjects. The parenchymal peak time was significantly shorter with cortical rather than renal ROIs in all patient groups (P < 0.05). In serial studies in the same patient the percent standard deviation in total renal clearance was less than between single studies in different patients, but the decrease was significant for only the right kidney (P < 0.03), and the decrease was not as great as in normal subjects. In addition, the percent standard deviation for percent function in each kidney was significantly less than the percent standard deviations in single studies (P < 0.02). There were no significant differences between intra- and interpatient studies for any other parameter.

CONCLUSION

We conclude that: (1) renal clearance measured with Tc-99m-MAG3 in tetraplegic patients increases significantly during the first 2 years following injury and decreases significantly thereafter; there is a similar, but much less marked, trend in paraplegics, (2) parenchymal peak times with cortical ROIs occur later for SCI patients than for normal subjects, and (3) there is more intrapatient variation in total renal clearance and percent renal clearance on a side in SCI patients than in normal subjects suggesting that it may be harder to study SCI patients reproducibly. These findings should be taken into account when performing and interpreting Tc-99m-MAG3 renal studies in SCI patients.

Neurorehabilitation of lightning and electrical injuries

Lightning and electrical (L/E) injuries can be among the most dramatic of all events that damage the nervous system. The three major classes of neurologic sequelae that require the expertise of the neurorehabilitationist are: (1) cerebral disorders, either global or focal; (2) neuropsychologic sequelae; and (3) spinal cord injury. Neurorehabilitation management necessary for each of these three areas will be discussed. From the viewpoint of the neurorehabilitationist, therapy principles are the same for L/E trauma as for other more common forms of injury. The goal is to maximize the functional return given the specific impairment.

Utilization and effectiveness of methylprednisolone in a population-based sample of spinal cord injured persons

The announcement and publication of the second National Acute Spinal Cord Injury Study (NASCIS II) project's findings regarding the role of high dose methylprednisolone in improving neurological outcomes following acute traumatic spinal cord injury generated widespread excitement and interest. To determine the association between this interest and actual use and implementation of the protocol, Colorado's comprehensive population-based spinal cord injury surveillance data were examined. The medical records of 218 SCI survivors injured between May 1, 1990 and December 31, 1991, and of 145 persons spinal cord injured 2 years later, during 1993, were reviewed to determine the rapidity and extent of NASCIS II implementation by Colorado's hospitals, factors associated with use and non-use of the protocol, changing usage trends over time, and the short term neurological outcomes of patients who received the protocol. Clear documentation of the protocol's usage was present for only 46% of the reported patients' medical records in 1990-91, and 61% in 1993. Small, emergency triage facilities were significantly more likely to use the protocol than larger acute care hospitals, and patients with initially incomplete injuries were less likely to receive the drug. There were no significant differences in neurological outcomes, using the Frankel classification system, between those who received the protocol and those who did not. The limitations and implications of these findings are discussed.

Rehabilitation in spinal cord disorders. 4. Outcomes and issues of aging after spinal cord injury

This self-directed learning module highlights current concepts in outcomes and issues of aging in spinal cord injury. It is part of the chapter on rehabilitation in spinal cord disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This article includes discussion of the measurement of impairment, disability, and handicap, and outcomes with respect to employment, long-term adjustment, aging, life expectancy, and causes of death in spinal cord injury.

Rehabilitation in spinal cord disorders. 2. Anatomy, pathogenesis, and research for neurologic recovery

This self-directed learning module highlights advances in this topic area. It is part of the chapter on rehabilitation in spinal cord disorders in the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This article contains learning objectives on the anatomy of the spine and spinal cord, pathogenesis of spinal cord trauma, mechanisms of spinal fractures and dislocations, causes of nontraumatic spinal cord disorders, and research on neurologic recovery. Advances that are covered in this section include various experimental animal models for producing spinal cord injury and new approaches to limit damage in acute injury and to promote recovery in chronic injury.

Rehabilitation in spinal cord disorders. 3. Comprehensive management of spinal cord injury

This self-directed learning module highlights advances in the management of the person with a spinal cord deficit. Traumatic spinal cord injury is being used as the model, but the principles apply to all patients with spinal cord deficits. This article is part of the chapter on rehabilitation of spinal cord disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. Specifically, this section contains information regarding prehospital care, acute assessment and management, primary rehabilitation by systems, sexuality and psychosocial issues, management of pain and spasticity, functional goals, the role of functional electrical stimulation, and long-term follow-up.

Rehabilitation in spinal cord disorders. 1. Epidemiology, prevention, and system of care of spinal cord disorders

This self-directed learning module highlights current concepts of the epidemiology, prevention, and systematic treatment of spinal cord disorders. It is part of the chapter on rehabilitation of spinal cord disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This article contains information regarding the incidence, prevalence, and causes of spinal cord injury, methods of prevention, and the components of a comprehensive system of care for spinal cord injury.