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Ariji Y, Hayashi T, Ideta R, Koga R, Murai S, Naka T, Ifuku R, Towatari F, Sakai H, Kurata H, Maeda T. Identification of a reliable sacral-sparing examination to assess the ASIA impairment scale in patients with traumatic spinal cord injury. J Spinal Cord Med 2024; 47:286-292. [PMID: 35352975 PMCID: PMC10885764 DOI: 10.1080/10790268.2022.2047548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES We evaluated the time course of the American Spinal Cord Injury Association (ASIA) impairment scale (AIS) for up to three months in participants within 72 h after traumatic spinal cord injury (TSCI) with complete paralysis. We aimed to determine the most useful sacral-sparing examination (deep anal pressure [DAP], voluntary anal contraction [VAC], S4-5 light touch [LT], or pin prick [PP] sensation) in determining AIS grades. DESIGN Retrospective cohort study. SETTING Spinal Injuries Center, Fukuoka, Japan. PARTICIPANTS Among 668 TSCI participants registered in the Japan Single Center study for Spinal Cord Injury Database (JSSCI-DB) between January 2012 and May 2020, we extracted the data of 80 patients with AIS grade A within 72 h after injury and neurological level of injury (NLI) at T12 or higher. INTERVENTIONS None. OUTCOME MEASURES The sacral-sparing examination at the time of the change to incomplete paralysis was compared to the AIS determination using a standard algorithm and with each assessment including the VAC, DAP, S4-5LT, and S4-5PP examinations at the time of AIS functional change. Agreement among assessments was evaluated using weighted kappa coefficients. The relationship was evaluated using Spearman's rank correlation coefficients. RESULTS Fifteen participants (18.8%) improved to incomplete paralysis (AIS B to D) within three months after injury. The single assessment among the sacral-sparing examinations with the highest agreement and strongest correlation with AIS determination was the S4-5LT examination (k = 0.89, P < 0.01, r = 0.84, P < 0.01). CONCLUSIONS The S4-5LT examination is key in determining complete or incomplete paralysis due to its high discriminatory power.
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Affiliation(s)
- Yuto Ariji
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Tetsuo Hayashi
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryosuke Ideta
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryuichiro Koga
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Satoshi Murai
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Tomoki Naka
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Ryusei Ifuku
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Fumihiro Towatari
- Department of Rehabilitation Medicine, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Hiroaki Sakai
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
| | - Hiroyuki Kurata
- Department of Bioscience and Bioinformatics, Kyushu Institute of Technology - Iizuka Campus, Fukuoka, Japan
| | - Takeshi Maeda
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety, Spinal Injuries Center, Fukuoka, Japan
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Tsuji O, Suda K, Michikawa T, Takahata M, Ozaki M, Konomi T, Matsumoto Harmon S, Komatsu M, Ushiku C, Menjo Y, Iimoto S, Watanabe K, Nakamura M, Matsumoto M, Minami A, Iwasaki N. Risk factors of AIS C incomplete cervical spinal cord injury for poor prognosis-The significance of anorectal evaluation. J Orthop Sci 2023; 28:1227-1233. [PMID: 36334964 DOI: 10.1016/j.jos.2022.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 09/28/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although the prognosis of incomplete cervical spinal cord injury (SCI) diagnosed as American Spinal Injury Association Impairment Scale grade C (AIS C) is generally favorable, some patients remain non-ambulatory. The present study explored the clinical factors associated with the non-ambulatory state of AIS C patients. METHODS This study was a single-center retrospective observational study. Seventy-three participants with AIS C on admission were enrolled and divided into two groups according to ambulatory ability after one year. Prognostic factors of SCI were compared in ambulatory (A-group) and non-ambulatory participants (NA-group). Univariable and multivariable logistic regression analyses were performed on demographic information, medical history, mechanism of injury, presence of fracture, ASIA motor scores (MS) of the extremities, neurological findings, including an anorectal examination on admission, and imaging findings. RESULTS Forty-one patients were included in the A-group and 32 in the NA-group. Univariable analysis revealed that the following factors were related to poor outcomes (p < 0.05): older age, history of cerebrovascular disorder, impairment/absence of S4-5 sensory score, deep anal pressure (DAP) (-), voluntary anal contraction (VAC) (-), anorectal tone (-), anal wink reflex (-), and low MS of the upper and lower extremities. In the multivariable analysis using age, presence or absence of sacral abnormality, and history of cerebrovascular disorders (adjusted for these three factors), older age and presence of sacral abnormality on admission were independent risk factors for a non-ambulatory state at the 1-year follow-up. CONCLUSIONS Incomplete AIS C SCI individuals with older age and/or impairment of anorectal examination could remain non-ambulatory at 1-year follow-up.
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Affiliation(s)
- Osahiko Tsuji
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan; Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Kota Suda
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.
| | - Takehiro Michikawa
- Department of Environmental and Occupational Health, School of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, 060-8638, Japan.
| | - Masahiro Ozaki
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan; Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Tsunehiko Konomi
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan; Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Satoko Matsumoto Harmon
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.
| | - Miki Komatsu
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.
| | - Chikara Ushiku
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.
| | - Yusuke Menjo
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.
| | - Seiji Iimoto
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, 060-8638, Japan.
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Furbish CL, Anderson RK, Field-Fote EC. Accuracy of self-reported severity and level of spinal cord injury. Spinal Cord 2022; 60:934-941. [PMID: 36097066 PMCID: PMC9464614 DOI: 10.1038/s41393-022-00855-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/09/2022]
Abstract
Study design Observational. Objectives To assess accuracy of self-reported level of injury (LOI) and severity in individuals with chronic spinal cord injury (SCI) as compared with clinical examination. Setting An SCI Model System Hospital. Methods A 20-item survey evaluated demographics, physical abilities, and self-reported injury level and severity. A decision tree algorithm used responses to categorize participants into injury severity groups. Following the survey, participants underwent clinical examination to determine current injury level and severity. Participants were later asked three questions regarding S1 sparing. Chart abstraction was utilized to obtain initial injury level and severity. Injury level and severity from self-report, decision tree, clinical exam, and chart abstraction were compared. Results Twenty-eight individuals participated. Ninety-three percent correctly self-reported anatomical region of injury (ROI). Self-report of specific LOI matched current clinical LOI for 25% of participants, but matched initial LOI for 61%. Self-report of ASIA Impairment Scale (AIS) matched clinical AIS for 36%, but matched initial AIS for 46%. The injury severity decision tree was 75% accurate without, but 79% accurate with additional S1 questions. Self-report of deep anal pressure (DAP) was correct for 86% of participants, while self-report of voluntary anal contraction (VAC) was correct for 82%. Conclusion Individuals with SCI are more accurate reporting ROI than specific LOI. Self-reported injury level and severity align more closely with initial clinical examination results than current exam results. Using aggregate data from multiple questions can categorize injury severity more reliably than self-report. Using this type of decision tree may improve injury severity classification in large survey studies.
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What is the clinical meaning of a negative bulbocavernosus reflex in spinal cord injury patients? Spinal Cord Ser Cases 2022; 8:24. [PMID: 35181651 PMCID: PMC8857246 DOI: 10.1038/s41394-022-00495-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE To highlight some issues about the clinical meaning of a negative bulbocavernosus reflex (BCR) in spinal cord injury (SCI) patients. SETTINGS Research group University Antwerp Belgium. METHODS The study included 170 patients in whom the BCR was examined at a mean of 7 years post SCI. Changes over time were explored in a subset of patients. RESULTS BCR was negative in 45%. There was no influence of age and gender, nor could a relation be found with the American Spinal Injury Association Impairment Scale score. The anal sphincter reflex (ASR) was positive in 13% of patients with negative BCR. With a mean interval of 45 weeks, BCR changed in 32% of a subset of 44 patients (14 became positive, 3 negative), while the neurological condition did not change and no treatments had been given that could influence the outcome. The data show that a negative BCR may not only be due to a disrupted reflex nervous pathway (which in some patients is different from that of ASR), but may also be caused by a difficulty to provoke the reflex. CONCLUSION A negative BCR test indicates interruption of the reflex neurologic pathways, but can also depend on the ease to elicit the reflex. By also doing ASR, this dilemma can be partly solved.
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Kirshblum S, Eren F. Anal reflex versus bulbocavernosus reflex in evaluation of patients with spinal cord injury. Spinal Cord Ser Cases 2020; 6:2. [PMID: 31934354 PMCID: PMC6946655 DOI: 10.1038/s41394-019-0251-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/30/2019] [Accepted: 10/27/2019] [Indexed: 12/14/2022] Open
Abstract
The examination of sacral reflexes provides an important method to differentiate an upper motor neuron vs lower motor neuron spinal cord injury (SCI). Two common sacral mediated reflexes used as part of the neurological assessment include the bulbocavernosus reflex (BCR) and anal reflex. As the clinical information from these tests are similar, we suggest that the anal reflex provides a better first option as a non-invasive clinical assessment of sacral reflex status in clinical practice in SCI as the testing for the anal reflex is less intrusive and already being performed as part of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) by pinprick stimulation of the S4-5 dermatome.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institution for Rehabilitation, West Orange, NJ USA
- 2Department of PM&R, Rutgers New Jersey Medical School, Newark, NJ USA
- 3Kessler Foundation, West Orange, NJ USA
| | - Fatma Eren
- 2Department of PM&R, Rutgers New Jersey Medical School, Newark, NJ USA
- 3Kessler Foundation, West Orange, NJ USA
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Donovan WH. The importance of the anal exam in neurologic classification of spinal cord injury. Spinal Cord Ser Cases 2018; 4:4. [PMID: 29423309 PMCID: PMC5798752 DOI: 10.1038/s41394-017-0014-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 09/27/2017] [Accepted: 09/27/2017] [Indexed: 11/09/2022] Open
Abstract
The examination of the sensation of the anal orifice and the contraction of the external anal sphincter, either voluntarily or reflexly, has always been an integral part of the International Standards for Neurologic Classification of Spinal Cord Injury (ISNCSCI). Yet the importance of this component has been defended and challenged. This paper compares these two points of view as expressed by Previnaire and Marino, respectively. Both authors make important points but as the papers do not address the same aspect of the anal exam, room for further refinement of ISNCSCI both regarding the details of the exam and the use of components of the exam for prognostication of neurologic recovery is apparent.
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Affiliation(s)
- William H. Donovan
- The Institute for Rehabilitation and Research (TIRR), TIRR 1333 Moursund St., Houston, TX 77030 USA
- Department of PM&R McGovern UT Medical School, Houston, TX USA
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