Management of nonpainful supernumerary phantom limbs after incomplete spinal cord injury with visual-tactile feedback therapy: a case report

INTRODUCTION

Supernumerary phantom limb (SPL) is an uncommon phantom sensation where the patient experiences the illusory presence of one or more limbs in addition to their existing limbs. SPL after a spinal cord injury (SCI) is rare with few documented cases. There is minimal treatment guidance available, with some reports of visual-tactile feedback therapy used to manage SPL.

CASE PRESENTATION

A 43-year-old male sustained a C4 ASIA Impairment Scale grade C SCI, developing the sensation of two SPL arms originating from his shoulders 6 days after injury. He developed a self-directed method of visual-tactile feedback as a means to improve the SPL sensations, consisting of shrugging his shoulders repeatedly for 1 min while observing the movement of his actual arms. After completion of this routine, the SPL moved to the same location as his arms, providing relief. Also, an elastic band was placed on a sensate region of his arm, providing additional visual-tactile feedback. The SPL improved and resolved by day 45.

DISCUSSION

SPL after SCI is poorly characterized, usually occurring within 6-7 days of injury after a complete or incomplete cervical SCI. While the mechanism is unclear, the inability to integrate visual, tactile, and proprioceptive information after deafferentation may contribute to development. Similarities between SPL and phantom limb sensation after an amputation have resulted in the use of visual and visual-tactile feedback therapy for painful SPL management. This is the first case documenting successful use of visual-tactile feedback therapy to manage nonpainful SPL.

Surfer's myelopathy: an atypical case presentation

INTRODUCTION

Surfer's myelopathy (SM) is a rare nontraumatic spinal cord injury seen in beginner surfers and people participating in activities involving prolonged lumbar hyperextension. The majority of cases of SM have been reported in younger patients under 40 years of age, with initial magnetic resonance imaging (MRI) showing T2 signal abnormalities. We present a case of SM in a person over 40 years old whose initial MRI did not show the T2 signal abnormalities usually reported in SM.

CASE PRESENTATION

A 43-year-old male in good physical condition went surfing for the first time and developed generalized back pain that progressed to include bilateral lower extremity pain with numbness and weakness. MRI within 11-12 h of symptom onset revealed no acute T2 signal abnormalities. At the time of initial presentation he had classification consistent with a T12 American Spinal Injury Association Impairment Scale (AIS) A and at rehabilitation discharge, 6 weeks later, he had classification of T12 AIS B.

DISCUSSION

Not all cases of SM present similarly. As surfing is a popular sport, education on early identification of warning signs is crucial for instructors and trainees, as well as health care providers. Our case highlights the importance of a comprehensive history and physical examination in developing the diagnosis, especially in presentations that are not classic in nature.

Creation and validation of a new tool for the monitoring efficacy of neurogenic bowel dysfunction treatment on response: the MENTOR tool

STUDY DESIGN

Prospective observational study.

OBJECTIVES

A tool to help decision-making tool for Neurogenic Bowel Dysfunction (NBD) in individuals with SCI is needed. We present a project to create and validate a new tool, the Monitoring Efficacy of NBD Treatment On Response (MENTOR), and to determine its level of concordance with decisions made by experienced clinicians in the field.

SETTING

UK, Denmark, USA, Italy, The Netherlands, Germany.

METHODS

The first phase was creation of the tool through a modified Delphi process. The second phase was the validation, wherein individuals with spinal cord injury with NBD were asked to complete the MENTOR tool immediately prior to clinic consultation. From the responses to the questionnaire of the tool, each participant was allocated into one of three categories reflecting the possible therapeutic recommendations ("recommend change", "further discussion" and "monitoring"). An expert clinician then assessed the participant, blinded to MENTOR results, and made an independent treatment decision.

RESULTS

A total of 248 MENTOR forms were completed. Strong agreement was found when the MENTOR tool recommended monitoring (92%) or treatment change (83%); the lowest concordance when the decision was for the "further discussion" option (59%). Patient acceptability was reported by 97% of individuals.

CONCLUSIONS

MENTOR is an easy to use tool to monitor the treatment of NBD and determinate progression through the clinical pathway. This validation study shows good correspondence between expert clinician opinion and MENTOR result. The tool has potential to be used in other patient groups, following further studies.

Anal reflex versus bulbocavernosus reflex in evaluation of patients with spinal cord injury

The examination of sacral reflexes provides an important method to differentiate an upper motor neuron vs lower motor neuron spinal cord injury (SCI). Two common sacral mediated reflexes used as part of the neurological assessment include the bulbocavernosus reflex (BCR) and anal reflex. As the clinical information from these tests are similar, we suggest that the anal reflex provides a better first option as a non-invasive clinical assessment of sacral reflex status in clinical practice in SCI as the testing for the anal reflex is less intrusive and already being performed as part of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) by pinprick stimulation of the S4-5 dermatome.

Patient preferences for order of the sensory portion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination

Objective: The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) includes testing light touch (LT) and sharp/dull discrimination, also known as pinprick (PP) testing. The order these tests are performed varies by clinician and no true standard exists. The objective of this study was to determine patients' perceptions of discomfort from each modality and their preferences for the order of the sensory exam.Design: A questionnaire was administered following the exam regarding the degree of pain/discomfort experienced from each modality and patients' preferences for testing order.Participants: 91 adults with traumatic SCI, 55% with neurologically complete injuries and 34% first-time examinees/those who did not recall a previous sensory examination.Main Outcome Measures: Level of pain/discomfort from both sensory modalities and preference on order of sensory testing.Results: All subjects reported that LT was not painful. 57% reported the PP testing as not painful, 24% as moderately painful, and 18.7% as very painful. The majority (66%) reported no preference for testing order, however, first-time examinees and those who did not recall previous sensory testing, were more likely to describe PP testing as "very painful" and report more "very painful" experiences when PP testing was completed first.Conclusions: First-time examinees including those who did not recall previous sensory testing, may experience more pain/discomfort from PP testing especially when PP is tested first. Therefore, testing LT first, especially for the first-time examinee and those who do not recall a previous exam, may allow for a more comfortable experience.

Relationship of American Spinal Injury Association Impairment Scale Grade to Post-injury Hospitalization and Costs in Thoracic Spinal Cord Injury

BACKGROUND

The lifetime economic burden of thoracic spinal cord injury (SCI) is known to be high, but evidence of variability of costs in relation to the American Spinal Injury Association Impairment Scale (AIS) grade is limited.

OBJECTIVE

To estimate lifetime economic costs of hospitalization by AIS grade in thoracic SCI.

METHODS

Using SCI Model Systems data from January 2000 to March 2016 from the National Spinal Cord Injury Statistical Center, we estimated mean total annual days of all-cause hospitalization by AIS grade among persons with thoracic SCI, based on assessments 1, 5, and 10 yr post-injury. We combined this information with secondary cost data and projections of life expectancy to estimate lifetime economic costs of hospitalization by AIS grade in persons aged 35 yr at time of thoracic SCI. Future costs were discounted to present value at 3% annually.

RESULTS

One year post-injury, mean total annual days of hospitalization ranged from 2.1 for persons with AIS-D injuries to 5.9 for those who were AIS-A. Similar differences were noted 5 and 10 yr post-SCI. The estimated net present value of expected lifetime costs of hospitalization following thoracic SCI at age 35 yr was $321 534, $249 514, $188 989, and $68 120 (2015 US$) for AIS-A, AIS-B, AIS-C, and AIS-D injuries, respectively.

CONCLUSION

Persons with less severe thoracic SCI, as reflected in AIS grade, spend fewer days in hospital over their lifetimes, leading to lower costs of inpatient care. Therapies improving AIS grade following thoracic SCI may provide cost savings in addition to addressing substantial unmet need.

Natural history of neurological improvement following complete (AIS A) thoracic spinal cord injury across three registries to guide acute clinical trial design and interpretation

STUDY DESIGN

Retrospective, longitudinal analysis of motor and sensory outcomes following thoracic (T2-T12) sensorimotor complete spinal cord injury (SCI) in selected patients enrolled into three SCI) registries.

OBJECTIVES

To establish a modern-day international benchmark for neurological recovery following traumatic complete thoracic sensorimotor SCI in a population similar to those enrolled in acute clinical trials.

SETTING

Affiliates of the North American Clinical Trial Network (NACTN), European Multicenter Study about Spinal Cord Injury (EMSCI), and the Spinal Cord Injury Model Systems (SCIMS).

METHODS

Only traumatic thoracic injured patients between 2006 and 2016 meeting commonly used clinical trial inclusion/exclusion criteria such as: age 16-70, T2-T12 neurological level of injury (NLI), ASIA Impairment Scale (AIS) A, non-penetrating injury, acute neurological exam within 7 days of injury, and follow-up neurological exam at least ~ 6 months post injury, were included in this analysis. International Standards for Neurological Classification of Spinal Cord injury outcomes including AIS conversion rate, NLI, and sensory and motor scores/levels were compiled.

RESULTS

A total of 170 patients were included from the three registries: 12 from NACTN, 64 from EMSCI, and 94 from SCIMS. AIS conversion rates at approximately 6 months post injury varied from 16.7% to 23.4% (21.1% weighted average). Improved conversion rates were observed in all registries for low thoracic (T10-T12) injuries when compared with high/mid thoracic (T2-T9) injuries. The NLI was generally stable and lower extremity motor score (LEMS) improvement was uncommon and usually limited to low thoracic injuries only.

CONCLUSIONS

This study presents the aggregation of selected multinational natural history recovery data in thoracic AIS A patients from three SCI registries and demonstrates comparable minimal improvement of ISNCSCI-scored motor and sensory function following these injuries, whereas conversions to higher AIS grades occur at a frequency of ~20%. These data inform the development of future clinical trial protocols in this important patient population for the interpretation of the safety and potential clinical benefit of new therapies, and the potential applicability in a multinational setting.

SPONSORSHIP

InVivo Therapeutics.

Residual descending motor pathways influence spasticity after spinal cord injury

OBJECTIVE

Spasticity is one of the most common symptoms manifested in humans with spinal cord injury (SCI). The neural mechanisms contributing to its development are not yet understood. Using neurophysiological and imaging techniques, we examined the influence of residual descending motor pathways on spasticity in humans with SCI.

METHODS

We measured spasticity in 33 individuals with motor complete SCI (determined by clinical examination) without preservation of voluntary motor output in the quadriceps femoris muscle. To examine residual descending motor pathways, we used magnetic and electrical stimulation over the leg motor cortex to elicit motor evoked potentials (MEPs) in the quadriceps femoris muscle and structural magnetic resonance imaging to measure spinal cord atrophy.

RESULTS

We found that 60% of participants showed symptoms of spasticity, whereas the other 40% showed no spasticity, demonstrating the presence of 2 clear subgroups of humans with motor complete SCI. MEPs were only present in individuals who had spasticity, and MEP size correlated with the severity of spasticity. Spinal cord atrophy was greater in nonspastic compared with spastic subjects. Notably, the degree of spared tissue in the lateral regions of the spinal cord was positively correlated with the severity of spasticity, indicating preservation of white matter related to motor tracts when spasticity was present.

INTERPRETATION

These results support the hypothesis that preservation of descending motor pathways influences spasticity in humans with motor complete SCI; this knowledge might help the rehabilitation and assessment of people with SCI. ANN NEUROL 2019.

Duplex ultrasound surveillance for deep vein thrombosis after acute traumatic spinal cord injury at rehabilitation admission

Context/objective: To determine the prevalence of deep vein thrombosis (DVT) detected through routine duplex screening and factors associated with DVT in spinal cord injury (SCI) patients on admission to rehabilitation.Design: Retrospective chart review of medical records.Setting: Acute inpatient rehabilitation.Participants: One hundred and eighty-nine individuals admitted to rehabilitation within 2 weeks of initial traumatic SCI who underwent routine surveillance with duplex scan for DVT.Interventions: Duplex scan of lower extremities.Outcome measures: The dependent variable was positive duplex screening for either any DVT (distal and/or proximal) or proximal DVT.Results: Of the 189 patients, 31 patients (16.4%) had a positive scan for any (proximal and/or distal) DVT, with 9 (4.8%) positive for a proximal DVT and 22 (11.6%) positive for isolated distal DVT. Of those with isolated distal DVT, 31.8% later developed propagation with either proximal DVTs or pulmonary embolism (mean = 22 days). Factors significantly associated with positive duplex scans for any (proximal and/or distal) DVT include more severe neurological injury (AIS A, B or C versus AIS D: χ² = 7.1791, df = 1, P = 0.007) and older age (age ≥50 years old: χ² = 14.9410, df = 1, P = 0.000).Conclusion: In acute traumatic SCI, older age and more severe neurological impairment (AIS A, B, and C) are independent risk factors for positive duplex screening for any (proximal and/or distal) DVT detected on rehabilitation admission. Individuals with an acute distal DVT have a high likelihood for future thrombus progression. Routine surveillance for these patients may be warranted.

Sacral examination in spinal cord injury: Is it really needed?

OBJECTIVE

To determine if a self-report measure of S4-5 motor and sensory function in patients with chronic SCI accurately predicts sacral examination results.

DESIGN

Prospective, single-blinded self-report survey compared with sacral exam.

SETTING

Outpatient SCI clinic.

PARTICIPANTS

116 patients aged 18+ with chronic SCI > 6 months who have undergone sacral exam.

INTERVENTIONS

The survey included demographic/clinical and sacral function information such as light tough (LT), pinprick sensation (PP), deep anal pressure (DAP) and voluntary anal contraction (VAC). Survey results and sacral exam were compared and stratified by the patient's American Spinal Cord Injury Association Impairment Scale (AIS) category.

OUTCOME MEASURES

Sacral self-report survey, AIS examination.

RESULTS

Mean age was 41.3 ± 14.4 years with majority male (69%) and Caucasian (71.6%). Overall, Positive Predictive Value (PPV) ranged between 48% (VAC) to 73% (DAP) and Negative Predictive Value (NPV) between 92% (VAC) to 100% (LT). AIS-A had NPV of 100% across all categories, and AIS-D had PPV of 100% across all categories.

CONCLUSION

Patient report of sacral sparing can predict negative sensation in patients with AIS-A and predict positive sensation in persons with AIS-D. Overall, the self-report of sacral sparing of motor and sensory function is not predictive enough to rely on for accurate classification.

Clinical Trials in Traumatic Spinal Cord Injury

Traumatic spinal cord injury (SCI) results in impaired neurologic function that for many individuals is permanent and significantly impacts health, function, quality of life, and life expectancy. Many efforts have been taken to develop effective treatments for SCI; nevertheless, proven therapies targeting neurologic regeneration and functional recovery have been limited. Existing therapeutic approaches, including early surgery, strict blood pressure control, and consideration of treatment with steroids, remain debated and largely focus on mitigating secondary injury after the primary trauma has occurred. Today, there is more research being performed in SCI than ever before. Current clinical trials are exploring pharmacologic, cell-based, physiologic, and rehabilitation approaches to reduce secondary injury and also overcome barriers to neurorecovery. In the future, it is likely that tailored treatments combining many of these strategies will offer significant benefits for persons with SCI. This article aims to review key past, current and emerging neurologic and rehabilitation therapeutic approaches for adults with traumatic SCI.

Long-Term Cost-Effectiveness of Transanal Irrigation in Patients with Neurogenic Bowel Dysfunction

Background

People suffering from neurogenic bowel dysfunction (NBD) and an ineffective bowel regimen often suffer from fecal incontinence (FI) and related symptoms, which have a huge impact on their quality of life. In these situations, transanal irrigation (TAI) has been shown to reduce these symptoms and improve quality of life.

Aim

To investigate the long-term cost-effectiveness of initiating TAI in patients with NBD who have failed standard bowel care (SBC).

Methods

A deterministic Markov decision model was developed to project the lifetime health economic outcomes, including quality-adjusted life years (QALYs), episodes of FI, urinary tract infections (UTIs), and stoma surgery when initiating TAI relative to continuing SBC. A data set consisting of 227 patients with NBD due to spinal cord injury (SCI), multiple sclerosis, spina bifida and cauda equina syndrome was used in the analysis. In the model a 30-year old individual with SCI was used as a base-case. A probabilistic sensitivity analysis was applied to evaluate the robustness of the model.

Results

The model predicts that a 30-year old SCI patient with a life expectancy of 37 years initiating TAI will experience a 36% reduction in FI episodes, a 29% reduction in UTIs, a 35% reduction in likelihood of stoma surgery and a 0.4 improvement in QALYs, compared with patients continuing SBC. A lifetime cost-saving of £21,768 per patient was estimated for TAI versus continuing SBC alone.

Conclusion

TAI is a cost-saving treatment strategy reducing risk of stoma surgery, UTIs, episodes of FI and improving QALYs for NBD patients who have failed SBC.

Development and validation of a computerized algorithm for International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

STUDY DESIGN

Validation study.

OBJECTIVES

To describe the development and validation of a computerized application of the international standards for neurological classification of spinal cord injury (ISNCSCI).

SETTING

Data from acute and rehabilitation care.

METHODS

The Rick Hansen Institute-ISNCSCI Algorithm (RHI-ISNCSCI Algorithm) was developed based on the 2011 version of the ISNCSCI and the 2013 version of the worksheet. International experts developed the design and logic with a focus on usability and features to standardize the correct classification of challenging cases. A five-phased process was used to develop and validate the algorithm. Discrepancies between the clinician-derived and algorithm-calculated results were reconciled.

RESULTS

Phase one of the validation used 48 cases to develop the logic. Phase three used these and 15 additional cases for further logic development to classify cases with 'Not testable' values. For logic testing in phases two and four, 351 and 1998 cases from the Rick Hansen SCI Registry (RHSCIR), respectively, were used. Of 23 and 286 discrepant cases identified in phases two and four, 2 and 6 cases resulted in changes to the algorithm. Cross-validation of the algorithm in phase five using 108 new RHSCIR cases did not identify the need for any further changes, as all discrepancies were due to clinician errors. The web-based application and the algorithm code are freely available at www.isncscialgorithm.com.

CONCLUSION

The RHI-ISNCSCI Algorithm provides a standardized method to accurately derive the level and severity of SCI from the raw data of the ISNCSCI examination. The web interface assists in maximizing usability while minimizing the impact of human error in classifying SCI.

SPONSORSHIP

This study is sponsored by the Rick Hansen Institute and supported by funding from Health Canada and Western Economic Diversification Canada.

Updates for the International Standards for Neurological Classification of Spinal Cord Injury

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most widely used classification in the field of spinal cord injury medicine. Since its first publication in 1982, multiple revisions refining the recommended examination, scaling, and classification have taken place to improve communication, consistency, and clarity. This article describes a brief historical perspective on the development and changes over the years leading to the current ISNCSCI, detailing the most recent updates of 2011 and the worksheet 2013 as well as issues facing the ISNCSCI for the future.

Racial and ethnic disparities in functioning at discharge and follow-up among patients with motor complete spinal cord injury

OBJECTIVE

To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up.

DESIGN

Retrospective cohort study.

SETTING

Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database.

PARTICIPANTS

Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up.

RESULTS

Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category.

CONCLUSIONS

Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation.