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Wu X, Xi X, Xu M, Gao M, Liang Y, Sun M, Hu X, Mao L, Liu X, Zhao C, Sun X, Yuan H. Prediction of early bladder outcomes after spinal cord injury: The HALT score. CNS Neurosci Ther 2024; 30:e14628. [PMID: 38421138 PMCID: PMC10850821 DOI: 10.1111/cns.14628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/28/2023] [Accepted: 01/15/2024] [Indexed: 03/02/2024] Open
Abstract
AIMS Neurogenic bladder (NB) is a prevalent and debilitating consequence of spinal cord injury (SCI). Indeed, the accurate prognostication of early bladder outcomes is crucial for patient counseling, rehabilitation goal setting, and personalized intervention planning. METHODS A retrospective exploratory analysis was conducted on a cohort of consecutive SCI patients admitted to a rehabilitation facility in China from May 2016 to December 2022. Demographic, clinical, and electrophysiological data were collected within 40 days post-SCI, with bladder outcomes assessed at 3 months following SCI onset. RESULTS The present study enrolled 202 SCI patients with a mean age of 40.3 ± 12.3 years. At 3 months post-SCI, 79 participants exhibited complete bladder emptying. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analyses identified the H-reflex of the soleus muscle, the American Spinal Injury Association Lower Extremity Motor Score (ASIA-LEMS), and the time from lesion to rehabilitation facility (TLRF) as significant independent predictors for bladder emptying. A scoring system named HALT was developed, yielding a strong discriminatory performance with an area under the receiver operating characteristics curve (aROC) of 0.878 (95% CI: 0.823-0.933). A simplified model utilizing only the H-reflex exhibited excellent discriminatory ability with an aROC of 0.824 (95% CI: 0.766-0.881). Both models demonstrated good calibration via the Hosmer-Lemeshow test and favorable clinical net benefits through decision curve analysis (DCA). In comparison to ASIA-LEMS, both the HALT score and H-reflex showed superior predictive accuracy for bladder outcome. Notably, in individuals with incomplete injuries, the HALT score (aROC = 0.973, 95% CI: 0.940-1.000) and the H-reflex (aROC = 0.888, 95% CI: 0.807-0.970) displayed enhanced performance. CONCLUSION Two reliable models, the HALT score and the H-reflex, were developed to predict bladder outcomes as early as 3 months after SCI onset. Importantly, this study provides hitherto undocumented evidence regarding the predictive significance of the soleus H-reflex in relation to bladder outcomes in SCI patients.
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Affiliation(s)
- Xiangbo Wu
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Xiao Xi
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Mulan Xu
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
- Department of Rehabilitation Medicine, Shenshan Medical Center, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityShanweiGuangdongChina
| | - Ming Gao
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Ying Liang
- Department of Health StatisticsAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Miaoqiao Sun
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Xu Hu
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Li Mao
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Xingkai Liu
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Chenguang Zhao
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Xiaolong Sun
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
| | - Hua Yuan
- Department of Rehabilitation Medicine, Xijing HospitalAir Force Medical University (Fourth Military Medical University)Xi'anChina
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Smith AC, Draganich C, Thornton WA, Berliner JC, Lennarson PJ, Rejc E, Sevigny M, Charlifue S, Tefertiller C, Weber KA. A Single Dermatome Clinical Prediction Rule for Independent Walking 1 Year After Spinal Cord Injury. Arch Phys Med Rehabil 2024; 105:10-19. [PMID: 37414239 PMCID: PMC10766862 DOI: 10.1016/j.apmr.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/24/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To derive and validate a simple, accurate CPR to predict future independent walking ability after SCI at the bedside that does not rely on motor scores and is predictive for those initially classified in the middle of the SCI severity spectrum. DESIGN Retrospective cohort study. Binary variables were derived, indicating degrees of sensation to evaluate predictive value of pinprick and light touch variables across dermatomes. The optimal single sensory modality and dermatome was used to derive our CPR, which was validated on an independent dataset. SETTING Analysis of SCI Model Systems dataset. PARTICIPANTS Individuals with traumatic SCI. The data of 3679 participants (N=3679) were included with 623 participants comprising the derivation dataset and 3056 comprising the validation dataset. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Self-reported ability to walk both indoors and outdoors. RESULTS Pinprick testing at S1 over lateral heels, within 31 days of SCI, accurately identified future independent walkers 1 year after SCI. Normal pinprick in both lateral heels provided good prognosis, any pinprick sensation in either lateral heel provided fair prognosis, and no sensation provided poor prognosis. This CPR performed satisfactorily in the middle SCI severity subgroup. CONCLUSIONS In this large multi-site study, we derived and validated a simple, accurate CPR using only pinprick sensory testing at lateral heels that predicts future independent walking after SCI.
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Affiliation(s)
- Andrew C Smith
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO.
| | - Christina Draganich
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO; Craig Hospital, Englewood, CO
| | - Wesley A Thornton
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO
| | - Jeffrey C Berliner
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO
| | - Peter J Lennarson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO
| | - Enrico Rejc
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY; Department of Medicine, University of Udine, Udine, Italy
| | | | | | | | - Kenneth A Weber
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA
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Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury. J Pers Med 2022; 12:jpm12071126. [PMID: 35887623 PMCID: PMC9323191 DOI: 10.3390/jpm12071126] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 12/25/2022] Open
Abstract
The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a spinal cord injury (SCI), supraspinal influences on the spinal segmental control system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, pain and dysesthesia, sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of traumatic SCI, current and emerging methods of classification, and its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue.
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Romanini F, Lima TDS, Abou L, Ilha J. 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. Rev Bras Ortop 2022; 57:384-391. [PMID: 35785125 PMCID: PMC9246521 DOI: 10.1055/s-0041-1735233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/08/2021] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Francielle Romanini
- Núcleo de Pesquisa em Lesão Medular, Universidade do Estado de Santa Catarina, Programa de Pós-Graduação em Neurociência, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - Thays de Souza Lima
- Núcleo de Pesquisa em Lesão Medular, Universidade do Estado de Santa Catarina, Florianópolis, SC, Brasil
| | - Libak Abou
- Departamento de Cinesiologia e Saúde Comunitária, Faculdade de Ciências Aplicadas à Saúde, Universidade de Illinois em Urbana-Champaign, Urbana, Illinois, Estados Unidos
| | - Jocemar Ilha
- Núcleo de Pesquisa em Lesão Medular, Universidade do Estado de Santa Catarina, Programa de Pós-Graduação em Neurociência, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
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5
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Kirshblum S, Botticello A, Benedetto J, Donovan J, Marino R, Hsieh S, Wagaman N. A Comparison of Diagnostic Stability of the ASIA Impairment Scale Versus Frankel Classification Systems for Traumatic Spinal Cord Injury. Arch Phys Med Rehabil 2020; 101:1556-1562. [DOI: 10.1016/j.apmr.2020.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/20/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
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6
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Marino RJ, Schmidt-Read M, Chen A, Kirshblum SC, Dyson-Hudson TA, Field-Fote E, Zafonte R. Reliability of S3 pressure sensation and voluntary hip adduction/toe flexion and agreement with deep anal pressure and voluntary anal contraction in classifying persons with traumatic spinal cord injury. J Spinal Cord Med 2020; 43:616-622. [PMID: 31204908 PMCID: PMC7534209 DOI: 10.1080/10790268.2019.1628496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Context/Objective: The sacral examination components of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), namely deep anal pressure (DAP) and voluntary anal sphincter contraction (VAC), are often difficult to perform. We evaluated whether pressure sensation at the S3 dermatome (S3P), and voluntary hip adductor or toe flexor contraction (VHTC) are tenable alternatives. Here we report test-retest reliability and agreement of these components at 1 month after spinal cord injury (SCI), and impact of disagreement on American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades. Design: Longitudinal cohort. ISNCSCI examination, S3P and VHTC conducted at 1-month post-injury; retest of the sacral exam, S3P and VHTC within 3 days. Follow-up examinations performed at 3, 6, and 12 months. Setting: Five Spinal Cord Injury Model System Centers. Participants: Subjects with acute traumatic SCI, neurological levels T12 and above, AIS grades A-C. Interventions: None. Outcome Measures: ISNCSCI exam, AIS grades. Results: Fifty-one subjects had 1-month data, and 39 had at least one follow-up examination. Test-retest reliability indicated perfect agreement (kappa = 1.0) for all data except S3P (kappa = 0.96). The agreement was almost perfect between S3P and DAP (kappa = 0.84) and between VHTC and VAC (kappa = 0.81). VHTC and VAC differed more often with neurologic levels below T10, possibly due to root escape in conus medullaris injuries. Conclusion: S3P and VHTC show promise as alternatives to DAP and VAC for determining sacral sparing in persons with neurologic levels T10 and above. Reliability and agreement should be evaluated at earlier timepoints and in children with SCI.
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Affiliation(s)
- Ralph J. Marino
- Department of Rehabilitation Medicine, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA,Correspondence to: Ralph J. Marino, Department of Rehabilitation Medicine, Sidney Kimmel Medical College, 132 South 10th Street, Suite 375 Main Building, Philadelphia, PA19107, USA; Ph: 215-955-5756.
| | | | - Anna Chen
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Steven C. Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA,Rutgers NJ Medical School, Newark, New Jersey, USA
| | - Trevor A. Dyson-Hudson
- Rutgers NJ Medical School, Newark, New Jersey, USA,Kessler Foundation, West Orange, New Jersey, USA
| | | | - Ross Zafonte
- Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA,Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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7
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The Expedited International Standards for Neurological Classification of Spinal Cord Injury (E-ISNCSCI). Spinal Cord 2020; 58:633-634. [PMID: 32249829 DOI: 10.1038/s41393-020-0462-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 11/08/2022]
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8
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Chun A, Delgado AD, Tsai CY, Spielman L, Taylor K, Ramirez A, Huang V, Kolakowsky-Hayner SA, Escalon MX, Bryce TN. An interview based approach to the anorectal portion of the International Standards of Neurological Classification of Spinal Cord Injury Exam (I-A-ISNCSCI): a pilot study. Spinal Cord 2019; 58:553-559. [PMID: 31822807 DOI: 10.1038/s41393-019-0399-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/28/2019] [Accepted: 11/28/2019] [Indexed: 12/12/2022]
Abstract
STUDY DESIGN Prospective, single-blinded study. OBJECTIVE To design and evaluate the use of an interview based version of the anorectal portion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam in the acute inpatient rehabilitation (AIR) setting. SETTING AIR unit. METHODS Participants admitted to AIR underwent standard ISNCSCI exams (S-ISNCSCI) as part of routine inpatient care within 3 days of being administered an interview version of the anorectal portion of the ISNCSCI (I-A-ISNCSCI). Agreement between the anorectal portion of the S-ISNCSCI (S-A-ISNCSCI) and the I-A-ISNCSCI was evaluated. RESULTS Forty of forty-five enrolled participants completed the assessments. Agreement between the I-A-ISNCSCI and S-A-ISNCSCI was substantial for anorectal sensation to light touch (k = 0.71, 95% CI 0.52-0.90, N = 36), pin prick (k = 0.68, 95% CI 0.48-0.87, N = 38), deep anal pressure (k = 0.77, 95% CI 0.53-1.00, N = 37), and completeness of injury based on combined sacral sensory criteria (k = 0.72, 95% CI 0.47-0.97, N = 40); and fair for voluntary anal contraction (k = 0.29, 95% CI -0.01 to 0.59, N = 36). Responses of "I don't know" were excluded from agreement analyses. CONCLUSIONS This pilot study was a first step in developing interview based tools such as the I-A-ISNCSCI in an AIR setting providing convenient access to individuals with SCI and their direct feedback. The study design introduces potential recall bias and may not match true clinical situations such as remote follow-up of neurological changes for chronic patients. The use of interview based tools for assessing individuals with SCI remains worthy of further study.
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Affiliation(s)
- Audrey Chun
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA.
| | - Andrew D Delgado
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA.,The Graduate School of Biomedical Sciences, ISMMS, New York, NY, USA
| | - Chung-Ying Tsai
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Lisa Spielman
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Kristell Taylor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA.,The Graduate School of Biomedical Sciences, ISMMS, New York, NY, USA
| | - Arianny Ramirez
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Vincent Huang
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Stephanie A Kolakowsky-Hayner
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Miguel X Escalon
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
| | - Thomas N Bryce
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai (ISMMS), New York, NY, USA
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Pavese C, Bachmann LM, Schubert M, Curt A, Mehnert U, Schneider MP, Scivoletto G, Finazzi Agrò E, Maier D, Abel R, Weidner N, Rupp R, Kessels AG, Kessler TM. Bowel Outcome Prediction After Traumatic Spinal Cord Injury: Longitudinal Cohort Study. Neurorehabil Neural Repair 2019; 33:902-910. [DOI: 10.1177/1545968319868722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background. Predicting functional outcomes after traumatic spinal cord injury (SCI) is essential for counseling, rehabilitation planning, and discharge. Moreover, the outcome prognosis is crucial for patient stratification when designing clinical trials. However, no valid prediction rule is currently available for bowel outcomes after a SCI. Objective. To generate a model for predicting the achievement of independent, reliable bowel management at 1 year after traumatic SCI. Methods. We performed multivariable logistic regression analyses of data for 1250 patients with traumatic SCIs that were included in the European Multicenter Study about Spinal Cord Injury. The resulting model was prospectively validated on data for 186 patients. As potential predictors, we evaluated age, sex, and variables from the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and the Spinal Cord Independence Measure (SCIM), measured within 40 days of the injury. A positive outcome at 1 year post-SCI was assessed with item 7 of the SCIM. Results. The model relied on a single predictor, the ISNCSCI total motor score—that is, the sum of muscle strengths in 5 key muscle groups in each limb. The area under the receiver operating characteristics curve (aROC) was 0.837 (95% CI: 0.815-0.859). The prospective validation confirmed high predictive power: aROC = 0.817 (95% CI: 0.754-0.881). Conclusions. We generated a valid model for predicting independent, reliable bowel management at 1 year after traumatic SCI. Its application could improve counseling, optimize patient-tailored rehabilitation planning, and become crucial for appropriate patient stratification in future clinical trials.
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Affiliation(s)
- Chiara Pavese
- Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- University of Pavia, Pavia, Italy; Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | | | - Martin Schubert
- Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Armin Curt
- Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Marc P. Schneider
- Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | | | | | | | | | - Rüdiger Rupp
- Heidelberg University Hospital, Heidelberg, Germany
| | | | - Thomas M. Kessler
- Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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10
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Monroe DM, Goldstein RL, Teylan MA, Hart JE, DeVivo I, Orr EH, Garshick E. Clinical associations with telomere length in chronic spinal cord injury. Spinal Cord 2019; 57:1084-1093. [PMID: 31383950 PMCID: PMC6940383 DOI: 10.1038/s41393-019-0336-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Cross-sectional study OBJECTIVES: To determine clinical factors associated with telomere length in persons with chronic spinal cord injury (SCI). SETTING Veterans Affairs Medical Center, Boston, MA. METHODS Two hundred seventy-eight participants with chronic SCI provided blood samples for measurement of C-reactive protein (CRP), interleukin-6 (IL-6), and telomere length, completed respiratory health questionnaires, underwent dual X-ray absorptiometry (DXA) to assess body fat, and completed spirometry. High-throughput real-time PCR assays were used to assess telomere length in leukocyte genomic DNA. Linear regression models were used to assess cross-sectional associations with telomere length. RESULTS Telomere length was inversely related to age (p < 0.0001). In age-adjusted models, gender, race, injury duration, %-total and %-trunk fat, body mass index (BMI), %-predicted forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1), chronic cough or phlegm, CRP, IL-6, wheeze, smoking, diabetes, heart disease, chronic obstructive pulmonary disease (COPD), skin ulcer, urinary tract infection (UTI), or chest illness history were not significantly associated with telomere length. There was a suggestive age-adjusted association between persons with the most severe SCI (cervical motor complete and AIS C) and shorter telomere length (p = 0.055), an effect equivalent to ~8.4 years of premature aging. There were similar age-adjusted associations with telomere length between persons using a wheelchair (p = 0.059) and persons with chronic urinary catheter use (p = 0.082) compared to persons without these characteristics. CONCLUSIONS Our results suggest that clinical characteristics such as decreased mobility and bladder dysfunction that are common in individuals with more severe SCI are associated with shorter telomere length.
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Affiliation(s)
| | - Rebekah L Goldstein
- Research and Development Service, VA Boston Healthcare System, West Roxbury, MA, USA
| | - Merilee A Teylan
- Research and Development Service, VA Boston Healthcare System, West Roxbury, MA, USA
| | - Jaime E Hart
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Immaculata DeVivo
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Esther H Orr
- Brigham and Women's Hospital and Dept of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Eric Garshick
- Pulmonary, Allergy, Sleep and Critical Care Medicine Section, VA Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA. .,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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11
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ter Wengel PV, De Witt Hamer PC, Pauptit JC, van der Gaag NA, Oner FC, Vandertop WP. Early Surgical Decompression Improves Neurological Outcome after Complete Traumatic Cervical Spinal Cord Injury: A Meta-Analysis. J Neurotrauma 2019; 36:835-844. [DOI: 10.1089/neu.2018.5974] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Paula Valerie ter Wengel
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
- Department of Neurosurgery, Slotervaart Hospital, Amsterdam, The Netherlands
| | | | - Jonah Charley Pauptit
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Niels A. van der Gaag
- Department of Neurosurgery, HagaZiekenhuis, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - F. Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - William Peter Vandertop
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
- Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
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12
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The anorectal exam is unnecessary! Spinal Cord Ser Cases 2018; 4:3. [PMID: 29423308 DOI: 10.1038/s41394-017-0013-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 09/25/2017] [Indexed: 11/08/2022] Open
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13
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Alexander M, Aslam H, Marino RJ. Pulse article: How do you do the international standards for neurological classification of SCI anorectal exam? Spinal Cord Ser Cases 2017; 3:17078. [PMID: 29423284 PMCID: PMC5798917 DOI: 10.1038/s41394-017-0015-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/13/2017] [Accepted: 09/18/2017] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Marcalee Alexander
- Birmingham VA Medical Center, 700 South 19th Street, Birmingham, AL 35233 USA
- Department of Physical Medicine and Rehabilitation, University of Alabama School of Medicine, Birmingham, AL USA
- Department of Physical Medicine and Rehabilitation, Harvard School of Medicine, Boston, MA USA
| | - Hammad Aslam
- Department of Physical Medicine and Rehabilitation, University of Alabama School of Medicine, Birmingham, AL USA
| | - Ralph J. Marino
- Department of Rehabilitation Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA USA
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Dvorak MF, Cheng CL, Fallah N, Santos A, Atkins D, Humphreys S, Rivers CS, White BA, Ho C, Ahn H, Kwon BK, Christie S, Noonan VK. Spinal Cord Injury Clinical Registries: Improving Care across the SCI Care Continuum by Identifying Knowledge Gaps. J Neurotrauma 2017; 34:2924-2933. [PMID: 28745934 PMCID: PMC5653140 DOI: 10.1089/neu.2016.4937] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Timely access and ongoing delivery of care and therapeutic interventions is needed to maximize recovery and function after traumatic spinal cord injury (tSCI). To ensure these decisions are evidence-based, access to consistent, reliable, and valid sources of clinical data is required. The Access to Care and Timing Model used data from the Rick Hansen SCI Registry (RHSCIR) to generate a simulation of healthcare delivery for persons after tSCI and to test scenarios aimed at improving outcomes and reducing the economic burden of SCI. Through model development, we identified knowledge gaps and challenges in the literature and current health outcomes data collection throughout the continuum of SCI care. The objectives of this article were to describe these gaps and to provide recommendations for bridging them. Accurate information on injury severity after tSCI was hindered by difficulties in conducting neurological assessments and classifications of SCI (e.g., timing), variations in reporting, and the lack of a validated SCI-specific measure of associated injuries. There was also limited availability of reliable data on patient factors such as multi-morbidity and patient-reported measures. Knowledge gaps related to structures (e.g., protocols) and processes (e.g., costs) at each phase of care have prevented comprehensive evaluation of system performance. Addressing these knowledge gaps will enhance comparative and cost-effectiveness evaluations to inform decision-making and standards of care. Recommendations to do so were: standardize data element collection and facilitate database linkages, validate and adopt more outcome measures for SCI, and increase opportunities for collaborations with stakeholders from diverse backgrounds.
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Affiliation(s)
- Marcel F. Dvorak
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Nader Fallah
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Argelio Santos
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Derek Atkins
- Operations and Logistics Division, Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Chester Ho
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Henry Ahn
- University of Toronto Spine Program, Toronto, Ontario, Canada
| | - Brian K. Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean Christie
- Research Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Development and validation of a bowel-routine-based self-report questionnaire for sacral sparing after spinal cord injury. Spinal Cord 2017; 55:1010-1015. [PMID: 28695901 DOI: 10.1038/sc.2017.77] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 02/06/2023]
Abstract
STUDY DESIGN An observational study. OBJECTIVE To develop a self-administered tool for assessment of sacral sparing after spinal cord injury (SCI) and to test its validity in individuals with SCI. SETTING Peking University Third Hospital, Beijing, China. METHODS A 5-item SCI sacral sparing self-report questionnaire was developed based on several events that most patients might experience during bowel routine. 102 participants who sustained SCI within 12 months were asked to complete the questionnaire followed by an anorectal examination. Agreements of answers to the questionnaire and the physical examination were analyzed. Sensitivity, specificity and Youden's index of each item was calculated. RESULTS The first four questions regarding the S4-5 sensation including deep anal pressure showed high agreement with the results of the physical examination (κ: 0.79-0.93). Sensitivity, specificity and Youden's index were also high (all above 80%). For the fifth question related to the voluntary anal contraction, the agreement was almost perfect with good sensitivity and specificity among patients without increased anal sphincter tone (AST). In patients with increased AST, the agreement was fair. CONCLUSION The validity of this questionnaire for the assessment of sacral sparing in up to 12 months post injury is good except for the motor function when there was increased AST. In some situations it could be considered as an alternative tool for digital rectal examination, especially when repeated examinations are not feasible. It is suggested that change of sacral sparing may be detected by the questionnaire.
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A novel approach for assigning levels to monkey and human lumbosacral spinal cord based on ventral horn morphology. PLoS One 2017; 12:e0177243. [PMID: 28542213 PMCID: PMC5443490 DOI: 10.1371/journal.pone.0177243] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/24/2017] [Indexed: 12/11/2022] Open
Abstract
Proper identification of spinal cord levels is crucial for clinical-pathological and imaging studies in humans, but can be a challenge given technical limitations. We have previously demonstrated in non-primate models that the contours of the spinal ventral horn are determined by the position of motoneuron pools. These positions are preserved within and among individuals and can be used to identify lumbosacral spinal levels. Here we tested the hypothesis that this approach can be extended to identify monkey and human spinal levels. In 7 rhesus monkeys, we retrogradely labeled motoneuron pools that represent rostral, middle and caudal landmarks of the lumbosacral enlargement. We then aligned the lumbosacral enlargements among animals using absolute length, segmental level or a relative scale based upon rostral and caudal landmarks. Inter-animal matching of labeled motoneurons across the lumbosacral enlargement was most precise when using internal landmarks. We then reconstructed 3 human lumbosacral spinal cords, and aligned these based upon homologous internal landmarks. Changes in shape of the ventral horn were consistent among human subjects using this relative scale, despite marked differences in absolute length or age. These data suggest that the relative position of spinal motoneuron pools is conserved across species, including primates. Therefore, in clinical-pathological or imaging studies in humans, one can assign spinal cord levels to even single sections by matching ventral horn shape to standardized series.
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Marino RJ, Schmidt-Read M, Kirshblum SC, Dyson-Hudson TA, Tansey K, Morse LR, Graves DE. Reliability and Validity of S3 Pressure Sensation as an Alternative to Deep Anal Pressure in Neurologic Classification of Persons With Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:1642-6. [DOI: 10.1016/j.apmr.2016.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 01/16/2016] [Accepted: 02/07/2016] [Indexed: 12/27/2022]
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Influence of Age Alone, and Age Combined With Pinprick, on Recovery of Walking Function in Motor Complete, Sensory Incomplete Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:1635-41. [DOI: 10.1016/j.apmr.2016.01.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/21/2016] [Accepted: 01/23/2016] [Indexed: 11/20/2022]
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Pavese C, Schneider MP, Schubert M, Curt A, Scivoletto G, Finazzi-Agrò E, Mehnert U, Maier D, Abel R, Röhrich F, Weidner N, Rupp R, Kessels AG, Bachmann LM, Kessler TM. Prediction of Bladder Outcomes after Traumatic Spinal Cord Injury: A Longitudinal Cohort Study. PLoS Med 2016; 13:e1002041. [PMID: 27327967 PMCID: PMC4915662 DOI: 10.1371/journal.pmed.1002041] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 04/26/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Neurogenic bladder dysfunction represents one of the most common and devastating sequelae of traumatic spinal cord injury (SCI). As early prediction of bladder outcomes is essential to counsel patients and to plan neurourological management, we aimed to develop and validate a model to predict urinary continence and complete bladder emptying 1 y after traumatic SCI. METHODS AND FINDINGS Using multivariate logistic regression analysis from the data of 1,250 patients with traumatic SCI included in the European Multicenter Spinal Cord Injury study, we developed two prediction models of urinary continence and complete bladder emptying 1 y after traumatic SCI and performed an external validation in 111 patients. As predictors, we evaluated age, gender, and all variables of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and of the Spinal Cord Independence Measure (SCIM). Urinary continence and complete bladder emptying 1 y after SCI were assessed through item 6 of SCIM. The full model relies on lower extremity motor score (LEMS), light-touch sensation in the S3 dermatome of ISNCSI, and SCIM subscale respiration and sphincter management: the area under the receiver operating characteristics curve (aROC) was 0.936 (95% confidence interval [CI]: 0.922-0.951). The simplified model is based on LEMS only: the aROC was 0.912 (95% CI: 0.895-0.930). External validation of the full and simplified models confirmed the excellent predictive power: the aROCs were 0.965 (95% CI: 0.934-0.996) and 0.972 (95% CI 0.943-0.999), respectively. This study is limited by the substantial number of patients with a missing 1-y outcome and by differences between derivation and validation cohort. CONCLUSIONS Our study provides two simple and reliable models to predict urinary continence and complete bladder emptying 1 y after traumatic SCI. Early prediction of bladder function might optimize counselling and patient-tailored rehabilitative interventions and improve patient stratification in future clinical trials.
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Affiliation(s)
- Chiara Pavese
- Neurology, Spinal Cord Injury Center, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
- Specialization School in Physical Medicine and Rehabilitation, Department of Clinical-Surgical Sciences, University of Pavia, Rehabilitation Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marc P. Schneider
- Neuro-Urology, Spinal Cord Injury Center, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
- Brain Research Institute, University of Zürich, Zürich, Switzerland
| | - Martin Schubert
- Neurology, Spinal Cord Injury Center, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
| | - Armin Curt
- Neurology, Spinal Cord Injury Center, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
| | | | - Enrico Finazzi-Agrò
- Department of Experimental Medicine and Surgery, Tor Vergata University, Rome, Unit for Functional Urology, Department of Urology, Policlinico Tor Vergata, Rome, Italy
| | - Ulrich Mehnert
- Neuro-Urology, Spinal Cord Injury Center, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
| | - Doris Maier
- Spinal Cord Injury Center, BG-Trauma Center, Murnau, Germany
| | - Rainer Abel
- Spinal Cord Injury Center, Hohe Warte, Bayreuth, Germany
| | - Frank Röhrich
- Berufsgenossenschaftliche Kliniken Bergmannstrost, Zentrum für Rückenmarkverletzte und Klinik für Orthopädie, Halle, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Alfons G. Kessels
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Thomas M. Kessler
- Neuro-Urology, Spinal Cord Injury Center, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
- * E-mail:
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21
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Kirshblum SC, Botticello AL, Dyson-Hudson TA, Byrne R, Marino RJ, Lammertse DP. Patterns of Sacral Sparing Components on Neurologic Recovery in Newly Injured Persons With Traumatic Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:1647-55. [PMID: 26971670 DOI: 10.1016/j.apmr.2016.02.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/15/2016] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Steven C Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Kessler Foundation, West Orange, NJ.
| | - Amanda L Botticello
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Kessler Foundation, West Orange, NJ
| | - Trevor A Dyson-Hudson
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Kessler Foundation, West Orange, NJ
| | | | - Ralph J Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Daniel P Lammertse
- Craig Hospital, Englewood, CO; Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO
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Krishna V, Andrews H, Varma A, Mintzer J, Kindy MS, Guest J. Spinal cord injury: how can we improve the classification and quantification of its severity and prognosis? J Neurotrauma 2014; 31:215-27. [PMID: 23895105 DOI: 10.1089/neu.2013.2982] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The preservation of functional neural tissue after spinal cord injury (SCI) is the basis for spontaneous neurological recovery. Some injured patients in the acute phase have more potential for recovery than others. This fact is problematic for the construction of clinical trials because enrollment of subjects with variable recovery potential makes it difficult to detect effects, requires large sample sizes, and risks Type II errors. In addition, the current methods to assess injury and recovery are non-quantitative and not sensitive. It is likely that therapeutic combinations will be necessary to cause substantially improved function after SCI, thus we need highly sensitive techniques to evaluate changes in motor, sensory, autonomic and other functions. We review several emerging neurophysiological techniques with high sensitivity. Quantitative methods to evaluate residual tissue sparing after severe acute SCI have not entered widespread clinical use. This reduces the ability to correlate structural preservation with clinical outcome following SCI resulting in enrollment of subjects with varying patterns of tissue preservation and injury into clinical trials. We propose that the inclusion of additional measures of injury severity, pattern, and individual genetic characteristics may enable stratification in clinical trials to make the testing of therapeutic interventions more effective and efficient. New imaging techniques to assess tract injury and demyelination and methods to quantify tissue injury, inflammatory markers, and neuroglial biochemical changes may improve the evaluation of injury severity, and the correlation with neurological outcome, and measure the effects of treatment more robustly than is currently possible. The ability to test such a multimodality approach will require a high degree of collaboration between clinical and research centers and government research support. When the most informative of these assessments is determined, it may be possible to identify patients with substantial recovery potential, improve selection criteria and conduct more efficient clinical trials.
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Affiliation(s)
- Vibhor Krishna
- 1 Department of Neurosciences, Medical University of South Carolina , Charleston, South Carolina
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