FUSIMOTOR FUNCTION. I. SPINAL SHOCK OF THE CAT AND THE MONKEY

Spinal shock in severe SCI dogs and early implementation of intensive neurorehabilitation programs

Spinal shock is complex, paradoxical with sudden presentation, possibly leading to a guarded prognosis. Thus, it is suggested the need for early implementation of intensive neurorehabilitation. This prospective controlled blinded cohort study aims to understand the implication of spinal shock in neurorehabilitation of severe SCI dogs and the importance of its evaluation thought a spinal shock scale (SSS). 371 dogs were randomized by stratification according the presence of spinal shock in the SG (n = 245) or CG (n = 126). The SSS, a punctuation scale (0-7), was evaluated at admission and each 6 h for 3 days, each day for 15 days, each week for 6 weeks, each month until 3 months, followed by 3 monthly follow-ups. All dogs had similar land and underwater treadmill training with functional electrical stimulation. Observational dataset allowed an approximate level of power (1-β) of 0.90 and an α (Type I error) of 0.01, with a total of 11,088 SSS observations between two blinded observers and 18% of disagreement. 75% of the dogs were admitted in 24-48 h after injury, allowing early detection of spinal shock, and dogs admitted at 72 h with SSS ≥ 4 were not able to achieve ambulation. Regarding ambulation rate, there was a significant difference between groups, with 66.9% of ambulation in the SG and 97.6% in the CG. Also, there was a difference in regard to time until ambulation, with a mean of 31.57 days for the SG and 23.02 for the CG. The SSS estimated marginal means had an exponential decrease within the first 6 h, followed by a slower decrease, but always faster in spinal shock dogs diagnosed with non-compressive myelopathies. Thus, early intensive neurorehabilitation in dogs after severe SCI may benefit from SSS classifications at admission and during treatment to establish different therapeutic protocols according to each patient's needs, especially in deep pain negative dogs.

Developing a predictive model for spinal shock in dogs with spinal cord injury

BACKGROUND

Reduced pelvic limb reflexes in dogs with spinal cord injury typically suggests a lesion of the L4-S3 spinal cord segments. However, pelvic limb reflexes might also be reduced in dogs with a T3-L3 myelopathy and concurrent spinal shock.

HYPOTHESIS/OBJECTIVES

We hypothesized that statistical models could be used to identify clinical variables associated with spinal shock in dogs with spinal cord injuries.

ANIMALS

Cohort of 59 dogs with T3-L3 myelopathies and spinal shock and 13 dogs with L4-S3 myelopathies.

METHODS

Data used for this study were prospectively entered by partner institutions into the International Canine Spinal Cord Injury observational registry between October 2016 and July 2019. Univariable logistic regression analyses were performed to assess the association between independent variables and the presence of spinal shock. Independent variables were selected for inclusion in a multivariable logistic regression model if they had a significant effect (P ≤ .1) on the odds of spinal shock in univariable logistic regression.

RESULTS

The final multivariable model included the natural log of weight (kg), the natural log of duration of clinical signs (hours), severity (paresis vs paraplegia), and pelvic limb tone (normal vs decreased/absent). The odds of spinal shock decreased with increasing weight (odds ratio [OR] = 0.28, P = .09; confidence interval [CI] 0.07-1.2), increasing duration (OR = 0.44, P = .02; CI 0.21-0.9), decreased pelvic limb tone (OR = 0.04, P = .003; CI 0.01-0.36), and increased in the presence of paraplegia (OR = 7.87, P = .04; CI 1.1-56.62).

CONCLUSIONS AND CLINICAL IMPORTANCE

A formula, as developed by the present study and after external validation, could be useful for assisting clinicians in determining the likelihood of spinal shock in various clinical scenarios and aid in diagnostic planning.

Recovery of neuronal and network excitability after spinal cord injury and implications for spasticity

The state of areflexia and muscle weakness that immediately follows a spinal cord injury (SCI) is gradually replaced by the recovery of neuronal and network excitability, leading to both improvements in residual motor function and the development of spasticity. In this review we summarize recent animal and human studies that describe how motoneurons and their activation by sensory pathways become hyperexcitable to compensate for the reduction of functional activation of the spinal cord and the eventual impact on the muscle. Specifically, decreases in the inhibitory control of sensory transmission and increases in intrinsic motoneuron excitability are described. We present the idea that replacing lost patterned activation of the spinal cord by activating synaptic inputs via assisted movements, pharmacology or electrical stimulation may help to recover lost spinal inhibition. This may lead to a reduction of uncontrolled activation of the spinal cord and thus, improve its controlled activation by synaptic inputs to ultimately normalize circuit function. Increasing the excitation of the spinal cord with spared descending and/or peripheral inputs by facilitating movement, instead of suppressing it pharmacologically, may provide the best avenue to improve residual motor function and manage spasticity after SCI.

Tendon reflexes for predicting movement recovery after acute spinal cord injury in humans

OBJECTIVE

Use the tendon reflex to examine spinal cord excitability after acute spinal cord injury (SCI), relating excitability findings to prognosis.

METHODS

We conducted repeated measures of reflex responses to mechanical taps at the patellar and Achilles tendons of the lower limbs, and the wrist flexor tendons of the upper limbs in persons with acute SCI, beginning as early as the day of injury. The single largest EMG response (peak-to-peak) for each site was recorded. Subjects were compared based on level of injury and final neurologic status of lower limb motor function (i.e. absence of any voluntary recruitment in a lower limb muscle: motor-complete; voluntary recruitment in 1 or more lower-limb muscles: motor-incomplete).

RESULTS

We studied 229 subjects with acute SCI. Persons with injury to the cervical or thoracic spinal cord and who were (or became) motor-incomplete showed large tendon responses, even at the time of initial evaluation. In combination with larger tendon response amplitudes, the presence of the 'crossed-adductor' response to patellar tendon taps at the acute stage was highly predictive of functional motor recovery following SCI. In marked contrast, tendon responses were small (e.g. < 0.1 mV) or absent in persons with acute, motor-complete injury (and which remained motor-complete), and the crossed-adductor response was never seen. Reflex amplitudes and the incidence of the crossed-adductor response increased somewhat over time in persons with motor-complete SCI, but did not approach the values seen in motor-incomplete subjects.

CONCLUSIONS

Taken together, tendon response amplitude and reflex spread were sensitive and specific indicators of preserved supraspinal control over lower limb musculature in subjects with acute SCI. A simple algorithm using these outcome measures predicted a 'motor-complete' status with 100% accuracy, and a motor-incomplete status with accuracy exceeding 91%.

[Somatosensory evoked potentials and Hoffmann reflex in acute spinal cord lesions; physiopathological and prognostic aspects]

Twenty-four patients with recent and acute spinal cord lesions were examined. The somatosensory cerebral evoked potential (SEP) following stimulation of the peroneus communis nerve tested spinal conduction, whereas the H reflex showed spinal excitability belowe the lesion. After complete spinal cord section, the SEP was always abolished and the H reflex was absent in most cases tested in the first 24 hours. Into other patients, the recruitment curve and the recovery cycle of the H reflex displayed some abnormalities which progressively disappeared. With partial lesions, SEP could occasionally be altered. Some abnormalities of the H reflex recovery cycle, of the same type as those seen in the late stage of complete sections, were also observed. These data give nre information on the physiopathology of spinal shock; they lead to the distinction of several evolutionary stages after acute spinal lesions and also have prognostic disgnificance.

Neurophysiological changes following spinal cord lesions in man

A study has been made of the neurophysiological changes that follow spinal cord lesions in man. The Achilles tendon reflex (ATR) is used to estimate transmission in the Ia monosynaptic pathway, and the tonic vibration reflex (TVR) to estimate transmission in the Ia polysynaptic pathway to motoneurons. The inhibition of the H reflex by vibration is used as an estimate of presynaptic inhibition of the Ia monosynaptic pathway. Immediately following a complete lesion of the spinal cord presynaptic inhibition of the Ia monosynaptic pathway appears to be greatly increased. This enhanced inihibition may last several months but it eventually declines and in some instances becomes less than normal. Transmission in the Ia polysynaptic pathway is permanently abolished by a complete spinal lesion. A hypothesis is developed from these findings to explain the evolution of some of the clinical features that follow complete spinal lesions in man. Distinct differences are observed when the spinal lesion is incomplete. Transmission in the Ia polysynaptic pathway may be preserved and there may be no increase in presynaptic inhibition. These differences may depend upon the integrity of certain spinal long tracts which cannot be tested clinically.

Segmental reflex pathways in spinal shock and spinal spasticity in man

Activity in three segmental pathways was compared in normal subjects, patients with spinal shock, and patients with established spinal spasticity. The Achilles tendon reflex (ATR) was used to estimate transmission in the Ia monosynaptic pathway. Evidence is produced implying that vibration activates motoneurones principally through a polysynaptic pathway. The tonic vibration reflex (TVR) was used to estimate transmission in this Ia polysynaptic pathway. The percentage of the motoneurone pool (M-response) that could be activated by these pathways was used as a measure of transmission. The H reflex (vibration)/H reflex (control) ratio was used as an estimate of the degree of presynaptic inhibition of the Ia monosynaptic pathway. The findings led to the following conclusions. (1) In spinal shock presynaptic inhibition is greater than normal, transmission in the Ia monosynaptic pathway is reduced, and in the Ia polysynaptic pathway virtually abolished. (2) In established spasticity presynaptic inhibition is impaired, transmission in the Ia monosynaptic pathway is increased, but transmission in the Ia polysynaptic pathway never recovers. (3) The failure of presynaptic inhibition associated with spasticity is a gradual process. A hypothesis to explain these findings is proposed.