The impact of sacral sensory sparing in motor complete spinal cord injury

Machine Learning Web Application for Predicting Functional Outcomes in Patients With Traumatic Spinal Cord Injury Following Inpatient Rehabilitation

Accurately predicting functional outcomes in patients with spinal cord injury (SCI) helps clinicians set realistic functional recovery goals and improve the home environment after discharge. The present study aimed to develop and validate machine learning (ML) models to predict functional outcomes in patients with SCI and deploy the models within a web application. The study included data from the Japan Association of Rehabilitation Database from January 1, 1991, to December 31, 2015. Patients with SCI who were admitted to an SCI center or transferred to a participating post-acute rehabilitation hospital after receiving acute treatment were enrolled in this database. The primary outcome was functional ambulation at discharge from the rehabilitation hospital. The secondary outcome was the total motor Functional Independence Measure (FIM) score at discharge. We used binary classification models to predict whether functional ambulation was achieved, as well as regression models to predict total motor FIM scores at discharge. In the training dataset (70% random sample) using demographic characteristics and neurological and functional status as predictors, we built prediction performance matrices of multiple ML models and selected the best one for each outcome. We validated each model's predictive performance in the test dataset (the remaining 30%). Among the 4181 patients, 3827 were included in the prediction model for the total motor FIM score. The mean (standard deviation [SD]) age was 50.4 (18.7) years, and 3211 (83.9%) patients were male. There were 3122 patients included in the prediction model for functional ambulation. The CatBoost Classifier and regressor models showed the best performances in the training dataset. On the test dataset, the CatBoost Classifier had an area under the receiver operating characteristic curve of 0.8572 and an accuracy of 0.7769 for predicting functional ambulation. Likewise, the CatBoost Regressor performed well, with an R2 of 0.7859, a mean absolute error of 9.2957, and a root mean square error of 13.4846 for predicting the total motor FIM score. The final models were deployed in a web application to provide functional predictions. The application can be found at http://3.138.174.54:8501. In conclusion, our prediction models developed using ML successfully predicted functional outcomes in patients with SCI and were deployed in an open-access web application.

An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery

STUDY DESIGN

Clinical practice guideline development.

OBJECTIVES

Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI).

METHODS

A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence.

CONCLUSIONS

It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

Can the Initial Parameters of Functional Scales Predict Recovery in Patients with Complete Spinal Cord Injury? A Retrospective Cohort Study

Regaining greater independence in performing daily activities constitutes a priority for people with tetraplegia following spinal cord injury (SCI). The highest expectations are connected with the improvement of hand function. Therefore, it is so important for the clinician to identify reliable and commonly applicable prognostic factors for functional improvement. The aim of this study was to conduct an analysis to assess the impact of initial functional factors on the clinical improvement in patients during early neurological rehabilitation (ENR). This study assessed 38 patients with complete SCI aged 17-78 who underwent ENR in 2012-2022. The analysis included the motor score from the AIS (MS), the Barthel Index (BI) and the SCIM scale values at the beginning of the ENR program and after its completion. During ENR, patients achieved a statistically significant improvement in MS, BI and SCIM. The initial MS and the level of neurological injury constituted the predictors of functional improvement during ENR. Significant statistical relationships were observed primarily in the correlations between the initial MS and BI, and the increase in the analyzed functional scales of SCI patients. Higher initial MS may increase the chances of a greater and faster functional improvement during ENR.

Profiling Immunological Phenotypes in Individuals During the First Year After Traumatic Spinal Cord Injury: A Longitudinal Analysis

Abstract Individuals with SCI are severely affected by immune system changes, resulting in increased risk of infections and persistent systemic inflammation. While recent data support that immunological changes after SCI differ in the acute and chronic phases of living with SCI, only limited immunological phenotyping in humans is available. To characterize dynamic molecular and cellular immune phenotypes over the first year, we assess RNA (bulk-RNA sequencing), protein, and flow cytometry (FACS) profiles of blood samples from 12 individuals with SCI at 0-3 days and at 3, 6, and 12 months post injury (MPI) compared to 23 uninjured individuals (controls). We identified 967 differentially expressed (DE) genes in individuals with SCI (FDR <0.001) compared to controls. Within the first 6 MPI we detected a reduced expression of NK cell genes, consistent with reduced frequencies of CD56bright, CD56dim NK cells present at 12 MPI. Over 6MPI, we observed increased and prolonged expression of genes associated with inflammation (e.g. HMGB1, Toll-like receptor signaling) and expanded frequencies of monocytes acutely. Canonical T-cell related DE genes (e.g. FOXP3, TCF7, CD4) were upregulated during the first 6 MPI and increased frequencies of activated T cells at 3-12 MPI. Neurological injury severity was reflected in distinct whole blood gene expression profiles at any time after SCI, verifying a persistent 'neurogenic' imprint. Overall, 2876 DE genes emerge when comparing motor complete to motor incomplete SCI (ANOVA, FDR <0.05), including those related to neutrophils, inflammation, and infection. In summary, we identify a dynamic immunological phenotype in humans, including molecular and cellular changes which may provide potential targets to reduce inflammation, improve immunity, or serve as candidate biomarkers of injury severity.

Prediction Model for Neurogenic Bladder Recovery One Year After Traumatic Spinal Cord Injury

INTRODUCTION

Neurogenic bladder is a common complication after spinal cord injury (SCI) that carries substantial burdens on the inflicted individual. The objective of this study is to build a prediction model for neurogenic bladder recovery 1 year after traumatic SCI.

METHODS

We queried the National Spinal Cord Injury Model Systems database for patients with traumatic SCI who had neurogenic bladder at the time of injury. The primary outcome of interest was the complete recovery of bladder function at 1 year. Multiple imputations were performed to generate replacement values for missing data, and the final imputed data were used for our analysis. A multivariable odds logistic regression model was developed for complete bladder recovery at 1 year.

RESULTS

We identified a total of 2515 patients with abnormal bladder function at baseline who had an annual follow-up. A total of 417 patients (16.6%) recovered bladder function in 1 year. Predictors of complete bladder recovery included the following baseline parameters: sacral sensation, American Spinal Injury Association (ASIA) impairment score, bowel function at baseline, voluntary sphincter contraction, anal sensation, S1 motor scores, and the number of days in the rehabilitation facility. The model performed with a discriminative capacity of 90.5%.

CONCLUSIONS

We developed a prediction model for the probability of complete bladder recovery 1 year after SCI. The model performed with a high discriminative capacity. This prediction model demonstrates potential utility in the counseling, research allocation, and management of individuals with SCI.

Sensory sparing does not change long-term outcomes in motor complete spinal cord injuries

BACKGROUND CONTEXT

In the acute postinjury setting, the prognostic value of sensory sparing among motor complete spinal injury patients has been well demonstrated. However, once final AIS grade is achieved 1 year postinjury, the value of sensory sparing alone has not been elucidated. We hypothesized that sensory sparing would lead to better outcomes in AIS B over AIS A patients at long-term, postrecovery follow-up.

PURPOSE

To evaluate for differences in medical, Physical and Social outcomes between AIS A and B patients at least 1 year postinjury.

STUDY DESIGN

Retrospective Cohort.

PATIENT SAMPLE

Adults over the age of 18 with AIS A or B spinal cord injury sustained between January 1, 1995 and September 13, 2019. Data Collected from the Spinal Cord Injury Model Systems Database.

OUTCOME MEASURES

Self-reported Measures: PHQ-9 score; SCI-QOL Resilience Short Form score; VAS pain score; Life Satisfaction Score; Self-reported depression and sleep disturbances. Physiologic Measures: Body Mass Index, Diabetes Mellitus, Hypertension, Hyperlipidemia, Mortality, Incidence of Pressure Sores. Functional Measures: Bowel and Bladder Management; Illicit Substance use; Level of Education; Marital Status; Rehospitalization Rate.

METHODS

Patient data from the Spinal Cord Injury Model Systems Database were extracted for patients with a final, recovered American Spinal Injury Association Impairment Scale (AIS) grade of A or B at 1-year postinjury. Variables related to physical, mental and social functioning were compared between the two groups.

RESULTS

A total of 2,562 AIS A and 675 AIS B patient met inclusion criteria. Occurrence of pressure ulcers was 7% less in AIS B versus A (34.5% vs. 41.9%, p=.003). There were no statistical differences between groups in pain, bowel or bladder accidents, urinary tract infections, or the level of assistance for bowel or bladder management. There was no statistical difference for PHQ-9 depression scores, SCI-QOL Resilience Scores, rates of suicidality or sleep disturbance. There was no difference for illicit drug or alcohol abuse, life satisfaction scores, perceived health, and marriage or divorce rates.

CONCLUSIONS

Except for a 7% reduction in pressure ulcer occurrence, there is no apparent long-term outcome advantage for motor complete spinal cord injury patients with AIS B sensory sparing over AIS A sensory complete. All other physical function domains were not different, nor were mental and social outcomes.

Adaptação transcultural para o Português do questionário de autorrelato da função sensorial e motora de S4-5 (S4-5Q) em pessoas com lesão medular espinhal

Objective  The “Self-report S4-5 sensory and motor function questionnaire (S4-5Q)” is a short questionnaire that aims to assess the function of the sacral segments, S4 and S5, after a spinal cord injury (SCI), with the purpose of replacing the rectal exam test. The aim of the present study was to carry out a cross-cultural adaptation of the S4-5Q to the Brazilian Portuguese language and to investigate the test-retest reliability of this version.

Method  The translation and cross-cultural adaptation was performed using the methodology of translation and backtranslation. Initially, translations were done by three independent translators. Their synthesis was then submitted to an expert committee for analysis (SCI health professionals); then, the backtranslation to the original language was sent to the original author and, after all the adjustments, the final version was completed. For test-retest reliability, 24 individuals with chronic SCI were recruited (2 evaluations with an interval of 7 to 14 days between them). Statistical analysis was performed using IBM-SPSS (Version 20, SPSS Inc, Chicago, IL, USA) with data pretabulated in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). Reliability was tested with Cohen Kappa, and internal consistency with Cronbach α, both adopting p  < 0.05 as significant.

Results  In the reliability analysis, the results of all questions showed almost perfect agreement (Kappa > 0.81) and good internal consistency (Cronbach α: 0.65–0.77) between the questions and final classification.

Conclusion  The cross-culturally adapted S4-5Q is reliable to be applied to the Brazilian population with chronic SCI to determine their S4-5 sensory and motor function.

A NEW SCORE BASED ON THE INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY FOR INTEGRATIVE EVALUATION OF CHANGES IN SENSORIMOTOR FUNCTIONS

Sensorimotor function of patients with spinal cord injury (SCI) is commonly assessed according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). From the ISNCSCI segmental motor and sensory assessments, upper and lower extremity motor scores (UEMS and LEMS), sum scores of pin prick (PP) and light touch (LT) sensation, the neurological level of injury (NLI) and the classification of lesion severity according to the American Spinal Injury Association Impairment Scale (AIS) grade are derived. Changes of these parameters over time are widely used to evaluate neurological recovery. However, evaluating recovery based on a single ISNCSCI scoring or classification variable may misestimate overall recovery. Here, we propose an Integrated Neurological Change Score (INCS) based on the combination of normalized changes between two-time points of UEMS, LEMS, and total PP and LT scores. To assess the agreement of INCS with clinical judgement of meaningfulness of neurological changes, changes of ISNCSCI variables between two time-points of 88 patients from an independent cohort were rated by 20 clinical experts according to a 5-categories Likert Scale. As for individual ISNCSCI variables, neurological change measured by INCS is associated to severity (AIS grade), age and time since injury, but INCS better reflects clinical judgment about meaningfulness of neurological changes than individual ISNCSCI variables. In addition, INCS is related with changes in functional independence measured by the Spinal Cord Independence Measure (SCIM) in patients with tetraplegia. INCS may be a useful measure of overall neurological change in clinical studies.

Evaluation of Functional Independence in Cervical Spinal Cord Injury: Implications for Surgery to Restore Upper Limb Function

PURPOSE

To help individuals make informed choices regarding the optimal type and timing of restorative surgical treatment for cervical spinal cord injury (SCI), more precise information is needed on their ability to perform activities of daily living. The goal of this work was to describe functional independence achieved by individuals with differing levels of cervical SCI.

METHODS

Using the comprehensive European Multicenter Study of Spinal Cord Injury dataset, analysis was undertaken of individuals with traumatic SCI, motor-level C5-C8. Data on feeding, bladder management, and transfers (bed to wheelchair) were compared between individuals with different levels of injury. Subgroup analyses of symmetrical and asymmetrical SCI and between complete and incomplete SCI were performed. The impact of age, sex, and time postinjury on functional independence was ascertained.

RESULTS

Data were available for individuals with symmetrical (n = 204) and asymmetrical (n = 95) patterns of SCI. Independence with feeding, urinary function, and transfer ability was increased in individuals with strong finger flexion. Unexpectedly, the presence of strong elbow extension did not uniformly result in the ability to transfer independently. There was no change in any of the analyzed activities between 6 and 12 months postinjury.

CONCLUSIONS

People with cervical SCI who gain finger flexion have greater independence with feeding, urinary, and transfer activities. Restoration of finger flexion should be a reconstructive priority for individuals with midcervical-level SCI.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Characterizing Natural Recovery after Traumatic Spinal Cord Injury

The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6-9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.

The neuroanatomical-functional paradox in spinal cord injury

Although lesion size is widely considered to be the most reliable predictor of outcome after CNS injury, lesions of comparable size can produce vastly different magnitudes of functional impairment and subsequent recovery. This neuroanatomical-functional paradox is likely to contribute to the many failed attempts to independently replicate findings from animal models of neurotrauma. In humans, the analogous clinical-radiological paradox could explain why individuals with similar injuries can respond differently to rehabilitation. We describe the neuroanatomical-functional paradox in the context of traumatic spinal cord injury (SCI) and discuss the underlying mechanisms of the paradox, including the concepts of lesion-affected and recovery-related networks. We also consider the various secondary complications that further limit the accuracy of outcome prediction in SCI and provide suggestions for how to increase the predictive, translational value of preclinical SCI models.

Trends in Rates of ASIA Impairment Scale Conversion in Traumatic Complete Spinal Cord Injury

Recent studies of persons with spinal cord injury (SCI) report higher conversion rates of the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades, especially for complete injuries. We examined the rate of conversion over time after complete SCI, accounting for demographic and injury characteristics. Subjects were 16 years of age and older with a complete SCI injury between 1995 and 2015, enrolled in the National SCI Database as day-1 admissions. We grouped subjects into 3-year intervals and assessed trends in conversion for the total sample and by tetraplegia (Tetra), high paraplegia (levels T1–9, HPara), and low paraplegia (levels T10–12, LPara).We used logistic regression to identify factors related to conversion such as age, sex, etiology, and level of injury. Of 2036 subjects, 1876 subjects had a follow-up examination between 30 and 730 days post-injury. Average age at injury was 34.2 ± 14.6 years; 79.8% were male, 44.6% Tetra, 35.3% HPara, and 20.1% LPara. There was a strong trend toward increased rates of conversion over time (p < 0.01 for all groups), especially for Tetra (to incomplete from 17.6% in 1995–1997 to 50% in 2013–2015, and to motor incomplete from 9.4% to 28.1%). Conversion rates for Para were less dramatic. There were increased odds of converting to incomplete for year of injury, level of injury (Tetra >LPara >HPara), non-violent etiology, and age (older is better). We found similar factors for conversion to motor incomplete, except sex was significant and etiology was not. Conversion rates from complete to incomplete and motor incomplete injury have been increasing, particularly for persons with tetraplegia. This has implications for acute clinical trials and for prognostication early after SCI.

Assessing the ability of the Sacral Autonomic Standards to document bladder and bowel function based upon the Asia Impairment Scale

Study design

Retrospective review of data.

Objective

To determine if there is a relationship between the Asia Impairment Scale (AIS) and the bladder and bowel components of the International Standards to Document Remaining Autonomic Function after SCI (ISAFSCI).

Setting

University-Based Academic Rehabilitation Program.

Methods

Retrospective cross-sectional study assessing International Standards for Neurologic Classification After SCI (ISNCSCI) examination along with bladder and bowel components of the ISAFSCI.

Results

Subjects with AIS A injuries were statistically less likely to have history of bladder control and bowel control per investigator determination and bladder sensation via self-report versus patients categorized with AIS B injuries. Self-reported history of bowel sensation and control of voiding were more likely in subjects with C, D, or E injuries than with B injuries. Bowel and bladder control as determined by investigator and bladder and bowel sensation and control as self-reported were all statistically less likely in persons with AIS A injuries versus CDE.

Conclusions

This retrospective study provides initial data regarding components of the bladder and bowel sections of the sacral ISAFSCI and AIS. Further prospective research is needed to further characterize the relationship between retention of bladder and bowel sensation and function and the AIS. We suggest that incorporation of the sacral components of the ISAFSCI into the ISNCSCI may be beneficial to obtain further information about retention of sacral function with specific patterns of injury.

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.

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.

Prediction of functional recovery six months following traumatic spinal cord injury during acute care hospitalization

OBJECTIVES

To determine factors associated with functional status six months following a traumatic cervical and thoracic spinal cord injury (SCI), with a particular interest in factors related to the acute care hospitalization stay.

DESIGN

This is a prospective cohort study. Sixteen potential predictive variables were studied. Univariate regression analyses were first performed to determine the strength of association of each variable independently with the total Spinal Cord Independence Measure (SCIM) score. Significant ones were then included in a General linear model in order to determine the most relevant predictive factors among them. Analyses were carried out separately for tetraplegia and paraplegia.

SETTING

A single specialized Level I trauma center.

PARTICIPANTS

One hundred fifty-nine patients hospitalized for an acute traumatic SCI between January 2010 and February 2015.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The SCIM (version 3) functional score.

RESULTS

Motor-complete SCI (AIS-A,B) was the main predictive factor associated with decreased total SCIM score in tetraplegia and paraplegia. Longer acute care length of stay and the occurrence of acute medical complications (either pneumonia, urinary tract infections or pressure ulcers) were predictors of decreased functional outcome following tetraplegia, while increased body mass index and higher trauma severity were predictive of decreased functional outcome following paraplegia.

CONCLUSIONS

This study supports previous work while adding information regarding the importance of optimizing acute care hospitalization as it may influence chronic functional status following traumatic SCI.

Early Predictors of Global Functional Outcome after Traumatic Spinal Cord Injury: A Systematic Review

Accurately predicting functional recovery is an asset for all clinicians and decision makers involved in the care of patients with acute traumatic spinal cord injury (TSCI). Unfortunately, there is a lack of information on the relative importance of significant predictors of global functional outcome. There is also a need for identifying functional predictors that can be timely optimized by the medical and rehabilitation teams throughout the hospitalizations phases. The main objective of this work was to systematically review and rate early factors that are consistently and independently associated with global functional outcome in individuals with TSCI. A literature search using MEDLINE, EMBASE, and Cochrane databases from January 1, 1970 to April 1, 2017 was performed. Two authors independently reviewed the titles and abstracts yielded by this literature search and subsequently selected studies to be included based on predetermined eligibility criteria. Disagreements were resolved by a consensus-based discussion, and if not, by an external reviewer. Data were extracted by three independent reviewers using a standardized table. The quality of evidence of the individual studies was assessed based on the Oxford Center for Evidence-Based Medicine modified by Wright and colleagues (2000) as well as the National Institutes of Health (2014). Fifteen articles identifying early clinical predictors of functional outcome using multiple regression analyses were included in this systematic review. Based on the compiled data, this review proposes a rating of early factors associated to global functional outcome according to their importance and their potential to be modified by the medical/rehabilitation team throughout the early phases of hospitalization. It also proposes a new conceptual framework that illustrates the impact of specific categories of factors and their interaction with each other. Ultimately, this review aims to guide clinicians and researchers in improving the continuum of care throughout early phases post-SCI.

Pulse article: How do you do the international standards for neurological classification of SCI anorectal exam?

STUDY DESIGN

Online survey of spinal cord injury (SCI) practitioners.

OBJECTIVES

Determine provider understanding and routine performance of International Standards for Neurologic Classification of Spinal Cord Injury (ISNCSCI) anorectal examination.

SETTING

International online questionnaire.

METHODS

A descriptive survey was developed to assess current performance of the ISNCSCI anorectal exam. Information about this survey was disseminated through social email and international societies between the months of March and April 2017.

RESULTS

Two hundred and fifteen SCI practitioners completed the survey. Of these, 157 (73%) were specialists in physical medicine and rehabilitation, 32 (15%) were physical therapists, 6 were neurologists, 6 were orthopedists, and 3 were neurosurgeons. Of responders, 90% routinely personally performed the anal exam of the ISNCSCI, of whom, 42 placed firm pressure against the anal sphincter, 58 placed firm pressure against the rectal wall, and 87 placed firm pressure against the anal sphincter and rectal wall as part of the exam. On a routine basis, 74% tested sensation at the junction of the anal sphincter and skin, 82% had the patient attempt to squeeze their finger, and 50% performed the bulbocavernosus reflex.

CONCLUSIONS

Marked inconsistency exists in the performance of the ISNCSCI anal examination. Researchers and clinicians need more education about the performance of the examination. Consideration should be given for the components of deep rectal sensation and anal pressure to be separately documented in the neurologic exam and for researchers to focus separately on recovery of sacral function vs. ambulatory function in clinical trials.

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.

Neurological and functional recovery after thoracic spinal cord injury

OBJECTIVE

To describe neurological and functional outcomes after traumatic paraplegia.

DESIGN

Retrospective analysis of longitudinal database.

SETTING

Spinal Cord Injury Model Systems.

PARTICIPANTS

Six hundred sixty-one subjects enrolled in the Spinal Cord Injury Model Systems database, injured between 2000 and 2011, with initial neurological level of injury from T2-12. Two hundred sixty-five subjects had second neurological exams and 400 subjects had Functional Independence Measure (FIM) scores ≥6 months after injury.

OUTCOME MEASURES

American Spinal Injury Association Impairment Scale (AIS) grade, sensory level (SL), lower extremity motor scores (LEMS), and FIM.

RESULTS

At baseline, 73% of subjects were AIS A, and among them, 15.5% converted to motor incomplete. The mean SL increase for subjects with an AIS A grade was 0.33 ± 0.21; 86% remained within two levels of baseline. Subjects with low thoracic paraplegia (T10-12) demonstrated greater LEMS gain than high paraplegia (T2-9), and also had higher 1-year FIM scores, which had not been noted in earlier reports. Better FIM scores were also correlated with better AIS grades, younger age and increase in AIS grade. Ability to walk at 1 year was associated with low thoracic injury, higher initial LEMS, incomplete injury and increase in AIS grade.

CONCLUSION

Little neurological recovery is seen in persons with complete thoracic SCI, especially with levels above T10. Persons who are older at the time of injury have poorer functional recovery than younger persons. Conversion to a better AIS grade is associated with improvement in self-care and mobility at 1 year.

Outcome of the upper limb in cervical spinal cord injury: Profiles of recovery and insights for clinical studies

BACKGROUND

Improved appreciation of recovery profiles of sensory and motor function as well as complex motor functions (prehension) after cervical spinal cord injury (SCI) will be essential to inform clinical studies to consider primary and secondary outcome measures for interventions and the optimization of dosing and timing of therapies in acute and chronic SCI.

OBJECTIVES

(1) To define the sensory, motor, and prehension recovery profiles of the upper limb and hand in acute cervical SCI and (2) to confirm the impact of AIS severity and conversion on upper limb sensorimotor recovery.

METHODS

An observational longitudinal cohort study consisting of serial testing of 53 patients with acute cervical SCI was conducted. International Standards of Neurological Classification of Spinal Cord Injury, Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), Capabilities of Upper Extremity (CUE-Q) Questionnaire, and Spinal Cord Independence Measure III (SCIM-III) were administered at 0-10 days, 1, 3, 6, and 12 months.

ANALYSIS

Change over time was plotted using mean and standard deviation of the total and subgroups of the sample.

RESULTS

Individuals with traumatic tetraplegia show distinct patterns of recovery. Factors that distinguish homogeneous subgroups of the sample are: severity of injury (level of injury, completeness) at baseline and conversion from a complete to an incomplete injury.

CONCLUSIONS

In cervical SCI, clinical recovery can be assessed using standardized measures that distinguish levels of activity and impairment. Specific recovery profiles of the upper limb over the 1-year timecourse provide new insights and opportunity for combined analysis of recovery profiles for different clinical assessment tools of upper limb function which are meaningful to inform the design of study protocols.

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.

Current research outcomes from the spinal cord injury model systems

This article serves as an introduction to this issue of the Archives of Physical Medicine and Rehabilitation that is devoted to current research findings of the Spinal Cord Injury Model Systems (SCIMS) program. The SCIMS program began in 1970, with funding from the National Institute on Disability and Rehabilitation Research in the U.S. Department of Education, to demonstrate a comprehensive care system for spinal cord injury (SCI) and also to conduct research to improve the health and quality of life of persons with SCI. Over the last 20 years, similar collaborative efforts for the dissemination of SCIMS research outcomes have produced conference proceedings in 1990, a book in 1995, and dedicated journal issues in 1999 and 2004. The collection of 24 articles in this issue shows the depth and breadth of work being carried out by the SCIMS investigators, from descriptive epidemiology to a randomized controlled trial, from neurologic recovery to community reintegration, and from health services utilization to assistive technology for mobility. Herein, we provide a brief overview of the SCIMS program, highlight the research initiatives currently underway, and describe the important findings of the original research articles contained in this issue.