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

Pattern of neurological recovery in persons with an acute cervical spinal cord injury over the first 14 days post injury

Introduction

Following a traumatic spinal cord injury (SCI) it is critical to document the level and severity of injury. Neurological recovery occurs dynamically after injury and a baseline neurological exam offers a snapshot of the patient's impairment at that time. Understanding when this exam occurs in the recovery process is crucial for discussing prognosis and acute clinical trial enrollment. The objectives of this study were to: (1) describe the trajectory of motor recovery in persons with acute cervical SCI in the first 14 days post-injury; and (2) evaluate if the timing of the baseline neurological assessment in the first 14 days impacts the amount of motor recovery observed.

Methods

Data were obtained from the Rick Hansen Spinal Cord Injury Registry (RHSCIR) site in Vancouver and additional neurological data was extracted from medical charts. Participants with a cervical injury (C1-T1) who had a minimum of three exams (including a baseline and discharge exam) were included. Data on the upper-extremity motor score (UEMS), total motor score (TMS) and American Spinal Injury Association (ASIA) Impairment Scale (AIS) were included. A linear mixed-effect model with additional variables (AIS, level of injury, UEMS, time, time2, and TMS) was used to explore the pattern and amount of motor recovery over time.

Results

Trajectories of motor recovery in the first 14 days post-injury showed significant improvements in both TMS and UEMS for participants with AIS B, C, and D injuries, but was not different for high (C1-4) vs. low (C5-T1) cervical injuries or AIS A injuries. The timing of the baseline neurological examination significantly impacted the amount of motor recovery in participants with AIS B, C, and D injuries.

Discussion

Timing of baseline neurological exams was significantly associated with the amount of motor recovery in cervical AIS B, C, and D injuries. Studies examining changes in neurological recovery should consider stratifying by severity and timing of the baseline exam to reduce bias amongst study cohorts. Future studies should validate these estimates for cervical AIS B, C, and D injuries to see if they can serve as an "adjustment factor" to control for differences in the timing of the baseline neurological exam.

Enabling knowledge translation: implementation of a web-based tool for independent walking prediction after traumatic spinal cord injury

Introduction

Several clinical prediction rules (CPRs) have been published, but few are easily accessible or convenient for clinicians to use in practice. We aimed to develop, implement, and describe the process of building a web-based CPR for predicting independent walking 1-year after a traumatic spinal cord injury (TSCI).

Methods

Using the published and validated CPR, a front-end web application called "Ambulation" was built using HyperText Markup Language (HTML), Cascading Style Sheets (CSS), and JavaScript. A survey was created using QualtricsXM Software to gather insights on the application's usability and user experience. Website activity was monitored using Google Analytics. Ambulation was developed with a core team of seven clinicians and researchers. To refine the app's content, website design, and utility, 20 professionals from different disciplines, including persons with lived experience, were consulted.

Results

After 11 revisions, Ambulation was uploaded onto a unique web domain and launched (www.ambulation.ca) as a pilot with 30 clinicians (surgeons, physiatrists, and physiotherapists). The website consists of five web pages: Home, Calculation, Team, Contact, and Privacy Policy. Responses from the user survey (n = 6) were positive and provided insight into the usability of the tool and its clinical utility (e.g., helpful in discharge planning and rehabilitation), and the overall face validity of the CPR. Since its public release on February 7, 2022, to February 28, 2023, Ambulation had 594 total users, 565 (95.1%) new users, 26 (4.4%) returning users, 363 (61.1%) engaged sessions (i.e., the number of sessions that lasted 10 seconds/longer, had one/more conversion events e.g., performing the calculation, or two/more page or screen views), and the majority of the users originating from the United States (39.9%) and Canada (38.2%).

Discussion

Ambulation is a CPR for predicting independent walking 1-year after TSCI and it can assist frontline clinicians with clinical decision-making (e.g., time to surgery or rehabilitation plan), patient education and goal setting soon after injury. This tool is an example of adapting a validated CPR for independent walking into an easily accessible and usable web-based tool for use in clinical practice. This study may help inform how other CPRs can be adopted into clinical practice.

The gray matter atrophy and related network changes occur in the higher cognitive region rather than the primary sensorimotor cortex after spinal cord injury

Objective

This study used functional magnetic resonance imaging (fMRI) to explore brain structural and related network changes in patients with spinal cord injury (SCI).

Methods

Thirty-one right-handed SCI patients and 31 gender- and age-matched healthy controls (HC) were included. The gray matter volume (GMV) changes in SCI patients were observed using voxel-based morphometry (VBM). Then, these altered gray matter clusters were used as the regions of interest (ROIs) for whole-brain functional connectivity (FC) analysis to detect related functional changes. The potential association between GMV and FC values with the visual analog scale (VAS), the American Spinal Injury Association (ASIA) score, and the course of injuries was investigated through partial correlation analysis.

Results

GMV of the frontal, temporal, and insular cortices was lower in the SCI group than in the HC group. No GMV changes were found in the primary sensorimotor area in the SCI group. Besides, the altered FC regions were not in the primary sensorimotor area but in the cingulate gyrus, supplementary motor area, precuneus, frontal lobe, and insular. Additionally, some of these altered GMV and FC regions were correlated with ASIA motor scores, indicating that higher cognitive regions can affect motor function in SCI patients.

Conclusions

This study demonstrated that gray matter and related network reorganization in patients with SCI occurred in higher cognitive regions. Future rehabilitation strategies should focus more on cognitive functions.

Computer International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) algorithms: a review

STUDY DESIGN

Literature review and survey.

OBJECTIVES

To provide an overview of existing computerized International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) algorithms and to evaluate the use of the current algorithms in research and clinical care.

SETTING

Not applicable.

METHODS

Literature review according to three organizing concepts for evaluation of Health Information Products (reach, usefulness, and use) was conducted.

RESULTS

While the use of computerized ISNCSCI algorithms has been around for many years, many were developed and used internally for specific projects or not maintained. Today the International SCI community has free access to algorithms from the European Multicenter Study about Spinal Cord Injury (EMSCI) and the Praxis Spinal Cord Institute. Both algorithms have been validated in large datasets and are used in different SCI registries for quality control and education purposes. The use of the Praxis Institute algorithm by clinicians was highlighted through the Praxis User Survey (n = 76) which included participants from 27 countries. The survey found that over half of the participants using the algorithm (N = 69) did so on a regular basis (51%), with 54% having incorporated it into their regular workflow.

CONCLUSIONS

Validated computerized ISNCSCI classification tools have evolved substantially and support education, clinical documentation, communication between clinicians and their patients, and ISNCSCI data quality around the world. They are not intended to replace well-trained clinicians, but allow for reclassification of ISNCSCI datasets with updated versions of the ISCNSCI, and support rapid classification of large datasets.

Validity and responsiveness of the Standing and Walking Assessment Tool for sub-acute traumatic spinal cord injury

STUDY DESIGN

This is a retrospective longitudinal study.

OBJECTIVE

The Standing and Walking Assessment Tool (SWAT) combines stages of standing and walking recovery (SWAT stages) with established measures (Berg Balance Scale (BBS), 10-m walk test (10MWT), 6-min walk test (6MWT), and modified Timed Up-and-Go (mTUG)). We evaluated the SWAT's validity (known-groups and convergent) and responsiveness among inpatients with sub-acute, traumatic spinal cord injury (SCI).

SETTING

Ten Canadian rehabilitation hospitals.

METHODS

Upon admission, SWAT stage and core measures (BBS, 10MWT, 6MWT, and mTUG), International Standards for Neurological Classification of SCI sensory and motor scores, and Spinal Cord Independence Measure III (SCIM) were collected from 618 adults with SCI. Known-groups validity was evaluated by comparing SWAT stage distributions across American Spinal Injury Association Impairment Scale (AIS) classification. Convergent validity was evaluated by correlating SWAT stages with scores on other measures using Spearman's rho. The SWAT (stage and core measures) was re-administered at discharge. To evaluate responsiveness, SWAT stages at admission and discharge were compared. The standardized response mean (SRM) was used to evaluate the responsiveness of core SWAT measures.

RESULTS

The SWAT stage distribution of participants with AIS D injuries differed from those of participants with AIS A-C injuries (p ≤ 0.002). SWAT stages correlated strongly with BBS and motor scores (ρ = 0.778-0.836), and moderately with SCIM, mTUG, 10MWT, 6MWT, and sensory scores (ρ = 0.409-0.692). Discharge SWAT stage was greater than the admission stage (p < 0.0001). The BBS was the most responsive core SWAT measure (SRM = 1.26).

CONCLUSIONS

The SWAT is a valid and responsive approach to the measurement of standing and walking ability during sub-acute SCI.

Neglected floating cervical spine fracture with myelopathy and Anderson lesion of D2 D3: report of an unusual case

INTRODUCTION

The cervical spine is the most commonly affected region in traumatic spine injuries of patients with Ankylosing Spondylitis (AS), accounting for 75% of cases, followed by the thoracic and lumbar spine. The fracture may not be detectable in plain radiographs alone due to pre-existing kyphotic deformity with distorted anatomy and high-riding shoulders.

CASE PRESENTATION

We present a case with a floating cervical spine following a trivial trauma injury and with cervical myelopathy symptoms. After posterior fixation of the cervico-thoracic spine, the patient improved with Nurick score and mJOA score improvement. After 6 months follow up the patient was walking without support, and myelopathy symptoms were negligible.

DISCUSSION

In this patient, a posterior approach was performed. We obtained a rigid construct so that we were able to mobilize a patient on the very next day and his myelopathy symptoms improved with minimal postoperative complications.

Correlation of neurological level and sweating level of injury in persons with spinal cord injury

Objective: Thermoregulatory dysfunction after spinal cord injury (SCI) impairs quality of life and predisposes persons to life-threatening sequela of heat-related illness (HRI) in conditions of high ambient temperature. SCI clinicians currently have no objective way to predict which persons are at greatest risk of HRI. Evaporative cooling via sweating is the body's most efficient mechanism of heat dissipation. The relationship between the neurological level of injury (NLOI) and the degree of sudomotor dysfunction is not well defined. This study examines the relationship between the NLOI and sweating level of injury (SwLOI). This information can assist SCI clinicians in identifying individuals with SCI who have most impaired sudomotor function and thus highest risk of HRI.Design: Observational.Setting: Human physiology laboratory.Participants: 10 persons with tetraplegia (TP), 14 with paraplegia (PP) and 10 able-bodied (AB).Intervention: Passive heat stress (1°C rise in core temperature) with sweat responses (SR) quantified with the starch iodine test.Outcome measures: The most caudal dermatomal level in which sweating was visualized was recorded as the SwLOI, which was compared to the NLOI. Minimum, maximum and median differences between NLOI and SwLOI were calculated.Results: Persons with tetraplegia demonstrated no SR. Persons with paraplegia demonstrated SR at a median of 1 level below NLOI. Able-bodied controls demonstrated sweating on all skin surface areas.Conclusions: Persons with motor complete tetraplegia lack evaporative cooling capacity through SR during passive heat stress predisposing them to HRI. Meanwhile, persons with paraplegia sweat on average 1 dermatomal level below their NLOI.

Implementation of multilingual support of the European Multicenter Study about Spinal Cord Injury (EMSCI) ISNCSCI calculator

Objectives

Since their introduction, electronic International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) calculators have evolved to powerful tools providing error-free ISNCSCI classifications in education, research and clinical practice. For increased accessibility and dissemination, a multilingual support is mandatory. The aim of this work was to setup a general multilingual framework for the freely available ISNCSCI calculator (https://ais.emsci.org) of the European Multicenter Study about Spinal Cord Injury (EMSCI).

Methods

The graphical user interface (GUI) and PDF export of the ISNCSCI worksheet were adapted for multilingual implementations. Their language-dependent content was identified. These two steps called internationalization have to be performed by a programmer in preparation of the translations of the English terms into the target language. This step following the internationalization is called localization and needs input by a bi-lingual clinical expert. Two EMSCI partners provided Standard Mandarin Chinese and Czech translations. Finally, the translations are made available in the application.

Results

The GUI and PDF export of the ISNCSCI worksheet were internationalized. The default language of the calculator is set according to the user’s preferences with the additional possibility for manual language selection. The Chinese as well as a Czech translation were provided freely to the SCI community.

Conclusions

The possibility of multilingual implementations independent from software developers opens the use of ISNCSCI computer algorithms as an efficient training tool on a larger scale.

The Serum SIRT1 Protein is Associated with the Severity of Injury and Neurological Recovery in Mice with Traumatic Spinal Cord Injury

The present study aimed to investigate the association between the serum SIRT1 protein and the severity of spinal cord injury (SCI) as well as the neurological recovery in mice. In this study, the wild-type (WT), Mx1-Cre⁺ SIRT1^loxP/loxP (Mx1), and LCK-Cre⁺SIRT1^loxP/loxP (LCK) mice were subjected to sham surgery, mild, moderate, or severe SCI, respectively. The serum was collected at intervals of 12 h, 1 day (d), 3 d, 5 d, 7 d, 10 d, 14 d, and 21 d after the injury. The locomotor function of all the animals was assessed using the Basso mouse scale (BMS) and the serum SIRT1 proteins were analyzed using enzyme-linked immunosorbent assay (ELISA). The results demonstrated that about 7-10 d after SCI, the levels of SIRT1 protein in the serum correlated significantly with the severity of the injury and at 28 d post-injury, there was a distant neurological recovery (BMS score). The serum SIRT1 concentration in both the Mx1 and LCK mice in the sham group was significantly reduced compared to that in the WT mice, and there was a delayed increase in the serum SIRT1 levels after injury. These findings indicate that the SIRT1 concentrations in the serum of the SCI mice closely correlated with the acute severity and neurological outcome.

A taxonomy for consistent handling of conditions not related to the spinal cord injury (SCI) in the International Standards for Neurological Classification of SCI (ISNCSCI)

STUDY DESIGN

Committee consensus process including additional structured feedback from spinal cord injury (SCI) experts attending a focus group workshop.

OBJECTIVES

To define a taxonomy for standardized documentation of non-SCI-related conditions in the International Standards for Neurological Classification of SCI (ISNCSCI).

SETTING

Americal Spinal Injury Association (ASIA) International Standards Committee with 16 international ISNCSCI experts.

METHODS

With the new taxonomy, not-normal sensory or motor scores should be tagged with an asterisk ("*"), if they are impacted by a non-SCI condition such as burns, casts, joint contractures, peripheral nerve injuries, amputations, pain, or generalized weakness. The non-SCI condition and instructions on how to handle the "*"-tagged scores during classification should be detailed in the comments box. While sum scores are always calculated based on examined scores, classification variables such as the neurological level of injury (NLI) or the ASIA Impairment Scale (AIS) grades are tagged with an "*", when they have been determined on the basis of clinical assumptions.

RESULTS

With the extended "*"-tag concept, sensory and motor examination results impacted by non-SCI conditions above, at, or below the NLI can be consistently documented, scored, and classified. Feedback from workshop participants confirms agreement on its clinical relevance, logic and soundness, easiness of understanding, communicability, and applicability in daily work.

CONCLUSIONS

After multiple internal revisions, a taxonomy for structured documentation of conditions superimposed on the impairments caused by the SCI together with guidelines for consistent scoring and classification was released with the 2019 ISNCSCI revision. This taxonomy is intended to increase the accuracy of ISNCSCI classifications.

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.

Early Management of Spinal Cord Injury: WFNS Spine Committee Recommendations

Scientific knowledge today is being generated more rapidly than we can assimilate thus requiring continuous review of gold-standards for diagnosis and treatment of specific pathologies. The aim of this paper is to provide an update on the best early management of spinal cord injury (SCI), in order to produce acceptable worldwide recommendations to standardize clinical practice as much as possible.The WFNS Spine Committee voted recommendations regarding management of SCI based on literature review of the last 10 years. The committee stated 9 recommendations on 3 main topics: (1) clinical assessment and classification of SCI; (2) emergency care and early management; (3) cardiopulmonary management. American Spinal Injury Association impairment scale, Spinal Cord Independence Measure, and International Spinal Cord Injury Basic Pain Data Set are considered the most useful and feasible in emergency evaluation and follow-up in case of SCI. Magnetic resonance imaging is the most indicated examination to evaluate patients with symptomatic SCI. In early phase, correction of hypotension (systolic blood pressure < 90 mmHg), and bradycardia are strongly recommended. Surgical decompression should be performed as soon as possible with the ideal surgical time being within 8 hours for both complete and incomplete lesions.

In-Hospital Mortality for the Elderly with Acute Traumatic Spinal Cord Injury

As the incidence of traumatic spinal cord injury (tSCI) in the elderly rises, clinicians are increasingly faced with difficult discussions regarding aggressiveness of management, likelihood of recovery, and survival. Our objective was to outline risk factors associated with in-hospital mortality in elderly surgical and non-surgical patients following tSCI and to determine those unlikely to have a favorable outcome. Data from elderly patients (≥ 65 years of age) in the Canadian Rick Hansen SCI Registry from 2004 to 2017 were analyzed using descriptive analysis. Survival and mortality groups in each of the surgical and non-surgical group were compared to explore factors associated with in-hospital mortality and their impact, using logistical regression. Of 1340 elderly patients, 1018 had surgical data with 826 having had surgery. In the surgical group, the median time to death post-injury was 30 days with 75% dying within 50 days compared with 7 days and 20 days, respectively, in the non-surgical group. Significant predictors for in-hospital mortality following surgery are age, comorbidities, neurological injury severity (American Spinal Injury Association [ASIA] Impairment Scale [AIS]), and ventilation status. The odds of dying 50 days post-surgery are six times higher for patients ≥77 years of age versus those 65–76 years of age, five times higher for those with AIS A versus those with AIS B/C/D, and seven times higher for those who are ventilator dependent. An expected probability of dying within 50 days post-surgery was determined using these results. In-hospital mortality in the elderly after tSCI is high. The trend with age and time to death and the significant predictors of mortality identified in this study can be used to inform clinical decision making and discussions with patients and their families.

Traumatic spinal cord injuries among Aboriginal and non-Aboriginal populations of Saskatchewan: a prospective outcomes study

Background

People of Aboriginal (Indigenous) ancestry are more likely to experience traumatic spinal cord injury (TSCI) than other Canadians; however, outcome studies are limited. This study aims to compare Aboriginal and non-Aboriginal populations with acute TSCI with respect to preinjury baseline characteristics, injury severity, treatment, outcomes and length of stay.

Methods

This was a retrospective analysis of participants with a TSCI who were enrolled in the prospective Rick Hansen Spinal Cord Injury Registry (RHSCIR), Saskatoon site (Royal University Hospital), between Feb. 13, 2010, and Dec. 17, 2016. Demographic, injury and management data were assessed to identify any differences between the populations.

Results

Of the 159 patients admitted to Royal University Hospital with an acute TSCI during the study period, 62 provided consent and were included in the study. Of these, 21 self-identified as Aboriginal (33.9%) and 41 as non-Aboriginal (66.1%) on treatment intake forms. Compared with non-Aboriginal participants, Aboriginal participants were younger, had fewer medical comorbidities, had a similar severity of neurologic injury and had similar clinical outcomes. However, the time to discharge to the community was significantly longer for Aboriginal participants (median 104.0 v. 34.0 d, p = 0.016). Although 35% of non-Aboriginal participants were discharged home from the acute care site, no Aboriginal participants were transferred home directly.

Conclusion

This study suggests a need for better allocation of resources for transition to the community for Aboriginal people with a TSCI in Saskatchewan. We plan to assess outcomes from TSCI for Aboriginal people across Canada.

Effects of water immersion on gait initiation: part II of a case series after incomplete spinal cord injury

Study design

Case series.

Objectives

This case series describes how the aquatic environment influences gait initiation in terms of the center of pressure (COP) excursion, impulses, trunk acceleration, and perceptions of participants with incomplete spinal cord injury (iSCI).

Setting

Tertiary Rehabilitation Hospital, Ontario, Canada.

Methods

Five individuals with iSCI (four cervical injuries/one thoracic injury, AIS D) participated in the study. Baseline clinical balance was evaluated by Berg Balance Scale and Mini-Balance Evaluation System Test. Participants initiated gait on a waterproof force plate and walked ~4 steps, in water and on land. COP trajectories during anticipatory and execution phases, impulses, and trunk acceleration parameters were investigated. Perceptions of walking in both environments were obtained using an interview.

Results

COP trajectory was prominently longer when individuals stepped forward. A decrease in velocity of COP was observed predominantly in the AP direction during stepping. Non-normalized vertical impulses decreased as the AP impulses increased, in water compared to land. Upper to lower trunk acceleration ratios showed how water resistance influenced the lower trunk acceleration. Most of participants reported that walking in water was challenging, but safer than on land.

Conclusions

Participants with higher balance function seemed to have more pronounced changes in anticipatory and execution phases' duration, length and velocity of COP. A faster anticipatory phase and a slower execution phase were observed in water than on land. Participants walked in water using a different trunk control strategy than on land and reported no fear of falling when walking in water versus land.

Unbiased Recursive Partitioning to Stratify Patients with Acute Traumatic Spinal Cord Injuries: External Validity in an Observational Cohort Study

Clinical trials of novel therapies for acute spinal cord injury (SCI) are challenging because variability in spontaneous neurologic recovery can make discerning actual treatment effects difficult. Unbiased Recursive Partitioning regression with Conditional Inference Trees (URP-CTREE) is a novel approach developed through analyses of a large European SCI database (European Multicenter Study about Spinal Cord Injury). URP-CTREE uses early neurologic impairment to predict achieved motor recovery, with potential to optimize clinical trial design by optimizing patient stratification and decreasing sample sizes. We performed external validation to determine how well a previously reported URP-CTREE model stratified patients into distinct homogeneous subgroups and predicted subsequent neurologic recovery in an independent cohort. We included patients with acute cervical SCI level C4-C6 from a prospective registry at a quaternary care center from 2004-2018 (n = 101) and applied the URP-CTREE model and evaluated Upper Extremity Motor Score (UEMS) recovery, considered correctly predicted when final UEMS scores were within a pre-specified threshold of 9 points from median; sensitivity analyses evaluated the effect of timing of baseline neurological examination. We included 101 patients, whose mean times from injury baseline and follow-up examinations were 6.1 days (standard deviation [SD] 17) and 235.0 days (SD 71), respectively. Median UEMS recovery was 7 points (interquartile range 2-12). One of the predictor variables was not statistically significant in our sample; one group did not fit progressively improving UEMS scores, and three of five groups had medians that were not significantly different from adjacent groups. Overall accuracy was 75%, but varied from 82% among participants whose examinations occurred at <12 h, to 64% at 12-24 h, and 58% at >24 h. A previous URP-CTREE model had limited ability to stratify an independent into homogeneous subgroups. Overall accuracy was promising, but may be sensitive to timing of baseline neurological examinations. Further evaluation of external validity in incomplete injuries, influence of timing of baseline examinations, and investigation of additional stratification strategies is warranted.

Effects of water immersion on quasi-static standing exploring center of pressure sway and trunk acceleration: a case series after incomplete spinal cord injury

Study design

This work is a case series.

Objectives

We assessed the influence of the aquatic environment on quasi-static posture by measuring center of pressure (COP) sway and trunk acceleration parameters after incomplete spinal cord injury (iSCI) in water and on land.

Setting

Tertiary Rehabilitation Hospital, Ontario, Canada.

Methods

Six adult participants with iSCI (4 cervical/2 thoracic injuries, AIS D) were enrolled. Baseline balance was assessed by the Berg Balance Scale and Mini-Balance Evaluation System Test. Participants stood on a waterproof force plate for one minute per trial on land and in water; participants completed testing with their eyes open or closed in random order over 10 trials. Individuals' perceptions of their standing balance were obtained. COP and trunk acceleration parameters were analyzed in the time-domain.

Results

COP sway and upper to lower trunk acceleration ratios in the AP direction increased in water, which was in contrast to standing on land in both visual conditions for 5/6 participants. Three participants (P1, P3 & P4) with greater sensorimotor deficits had larger COP sway in water with the eyes closed. Two (P1 & P4) of six participants reported more discomfort standing in water than standing on land.

Conclusions

Increased COP sway seemed to reflect the balance and sensorimotor impairments of the participants, especially when standing with eyes closed in water. Although most participants (4/6) perceived that they swayed more in water in contrast to on land, 5 out of 6 participants reported that water felt like a safer environment in which to stand.

Implementation of a Standardized Dataset for Collecting Information on Patients With Spinal Cord Injury

Background: Over the last decade, the International Spinal Cord Injury Data Sets project developed a number of International Spinal Cord Injury Data Sets (ISCIDS) that can be used to collect standardized information on patients with SCI. Objective and Methods: The aim of this article is to describe the process of translating the ISCIDS into Dutch and reaching consensus on a Dutch National SCI Data Set (NDD). The interrater reliability of the NDD and implementation of the NDD at eight rehabilitation centers with a specialty in rehabilitation after SCI in the Netherlands are described. Results: NDD was implemented successfully at all eight centers. Some adaptations were made to the ISCIDS, especially to the core data set. The reliability coefficients of the NDD items were at least sufficient (mean kappa per data set ranged between .68 and .91), and mean agreement per data set ranged from 66% to 97%. Experiences from the participating centers were mainly positive as well. The main obstacle for use was thought to be the absence of a link between the local patient files and the national database, which necessitates double data entry. Conclusion: Although the results on interrater reliability are based on a small sample size and the assessment situation is different from the normal clinical situation, this study showed the NDD to be a useful instrument to collect standardized information on patients with SCI in the Netherlands. In the future, a connection between systems or another way to centrally collect the data is recommended to prevent double data entry and to guarantee continuation of administration of the NDD.

Electronic medical record: data collection and reporting for spinal cord injury

STUDY DESIGN

Presentation of implementation of International Spinal Cord Injury (SCI) Data Sets, International Standards for Neurological Classification of SCI (ISNCSCI), and other structured SCI tools in to the Electronic Medical Record (EMR) Epic.

OBJECTIVES

To describe the implementation of SCI tools in Epic at Rigshospitalet, University of Hospital, Capital Region of Denmark, and the ambitions for the future development of SCI related structured data and their reporting in the Epic EMR to be able to standardize data collection to facilitate research within institutions and collaboratively with other institutions locally and globally.

SETTING

Denmark and United States of America.

METHODS

The general content of the EMR Epic and the SCI-specific structured data implemented are described as well as the tools for reporting.

RESULTS

The ISNCSCI is made available via access to http://isncscialgorithm.azurewebsites.net/. After filling in the test data on the website, one can save the completed form as an image within the patient's chart. The International SCI Core Data Set and 13 International SCI Basic Data Sets (Table 1) are nearly completely implemented in the Danish version of Epic as SmartForms. In addition, 14 functional measures, including the Spinal Cord Independence Measure III, are implemented as flowsheets (Table 2).

CONCLUSIONS

The possibility of entering international recognized structured data into the EMR gives better possibility for data sharing across SCI centers worldwide.

SPONSORSHIP

Gianna Maria Rodriguez, Stacey Cohen, and Fin Biering-Sørensen are users of Epic, but have no economic relationship with Epic. Kelly Tausk and Josh Martin are employees of Epic.

Progress of the Dutch Spinal Cord Injury Database: Completeness of Database and Profile of Patients Admitted for Inpatient Rehabilitation in 2015

Background: In the Dutch International Spinal Cord Injury (SCI) Data Sets project, we translated all International SCI Data Sets available in 2012 and created a Dutch SCI Database (NDD). Objective: To describe the number of included patients and completeness of the NDD, and to use the NDD to provide a profile of people with traumatic SCI (T-SCI) and non-traumatic SCI (NT-SCI) in the Netherlands. Methods: The NDD includes patients admitted for their first inpatient rehabilitation after onset of SCI to 1 of the 8 rehabilitation centers with a specialty in SCI rehabilitation in the Netherlands. Data of patients admitted in 2015 were analyzed. Results: Data for 424 patients were available at admission; for 310 of these patients (73.1%), discharge data were available. No significant differences were found between patients with and without data at discharge. Data were nearly complete (>90%) for lower urinary tract, bowel, pain, and skin. Data on sexual function has the lowest completion rate. Complete neurological and functional data were available for 41.7% and 38%, respectively. Most patients were male (63.4%), had NT-SCI (65.5%), and had incomplete SCI (58.4% D). Patients with T-SCI differed from patients with NT-SCI on most characteristics, and they stayed considerably longer in the rehabilitation center (112 days vs 65 days, p < .001). Place of discharge was not different between both groups. Conclusion: With the NDD, we collect important data on the majority of Dutch SCI patients, although much work needs to be done to improve the completeness of the data collection.

The impact of spine stability on cervical spinal cord injury with respect to demographics, management, and outcome: a prospective cohort from a national spinal cord injury registry

BACKGROUND CONTEXT

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

PURPOSE

The study aimed to test the authors' hypothesis that spine stability can identify a unique group of patients with regard to demographics, management, and outcomes, which classic CCS definitions do not.

STUDY DESIGN/SETTING

This is a prospective observational study.

PATIENT SAMPLE

The sample included participants with cervical SCI included in a prospective Canadian registry.

OUTCOME MEASURES

The outcome measures were initial hospitalization length of stay, change in total motor score from admission to discharge, and in-hospital mortality.

METHODS

Patients with cervical SCI from a prospective Canadian SCI registry were grouped into stable and unstable spine cohorts. Bivariate analyses were used to identify differences in demographic, injury, management, and outcomes. Multivariate analysis was used to better understand the impact of spine stability on motor score improvement. No conflicts of interest were identified.

RESULTS

Compared with those with an unstable spine, patients with cervical SCI and a stable spine were older (58.8 vs. 44.1 years, p<.0001), more likely male (86.4% vs. 76.1%, p=.0059), and have more medical comorbidities. Patients with stable spine cervical SCI were more likely to have sustained their injury by a fall (67.4% vs. 34.9%, p<.0001), and have high cervical (C1-C4; 58.5% vs. 43.3%, p=.0009) and less severe neurologic injuries (ASIA Impairment Scale C or D; 81.3% vs. 47.5%, p<.0001). Those with stable spine injuries were less likely to have surgery (67.6% vs. 92.6%, p<.0001), had shorter in-hospital lengths of stay (median 84.0 vs. 100.5 days, p=.0062), and higher total motor score change (20.7 vs. 19.4 points, p=.0014). Multivariate modeling revealed that neurologic severity of injury and spine stability were significantly related to motor score improvement; patients with stable spine injuries had more motor score improvement.

CONCLUSIONS

We propose that classification of stable cervical SCI is more clinically relevant than classic CCS classification as this group was found to be unique with regard to demographics, neurologic injury, management, and outcome, whereas classic CCS classifications do not . This classification can be used to assess optimal management in patients where it is less clear if and when surgery should be performed.

Sensitivity and specificity of the 'knee-up test' for estimation of the American Spinal Injury Association Impairment Scale in patients with acute motor incomplete cervical spinal cord injury

STUDY DESIGN

A retrospective study.

OBJECTIVE

Precise classification of the neurological state of patients with acute cervical spinal cord injury (CSCI) can be challenging. This study proposed a useful and simple clinical method to help classify patients with incomplete CSCI.

SETTING

Spinal Injuries Centre, Japan.

METHODS

The sensitivity and specificity of the 'knee-up test' were evaluated in patients with acute CSCI classified as American Spinal Injury Association Impairment Scale (AIS) C or D. The result is positive if the patient can lift the knee in one or both legs to an upright position, whereas the result is negative if the patient is unable to lift the knee in either leg to an upright position. The AIS of these patients was classified according to a strict computerised algorithm designed by Walden et al., and the knee-up test was tested by non-expert examiners.

RESULTS

Among the 200 patients, 95 and 105 were classified as AIS C and AIS D, respectively. Overall, 126 and 74 patients demonstrated positive and negative results, respectively, when evaluated using the knee-up test. A total of 104 patients with positive results and 73 patients with negative results were classified as AIS D and AIS C, respectively. The sensitivity, specificity, positive predictive and negative predictive values of this test for all patients were 99.1, 76.8, 82.5 and 98.7, respectively.

CONCLUSIONS

The knee-up test may allow easy and highly accurate estimation, without the need for special skills, of AIS classification for patients with incomplete CSCI.

A simplified clinical prediction rule for prognosticating independent walking after spinal cord injury: a prospective study from a Canadian multicenter spinal cord injury registry

BACKGROUND CONTEXT

Traumatic spinal cord injury (SCI) is a debilitating condition with limited treatment options for neurologic or functional recovery. The ability to predict the prognosis of walking post injury with emerging prediction models could aid in rehabilitation strategies and reintegration into the community.

PURPOSE

To revalidate an existing clinical prediction model for independent ambulation (van Middendorp et al., 2011) using acute and long-term post-injury follow-up data, and to investigatethe accuracy of a simplified model using prospectively collected data from a Canadian multicenter SCI database, the Rick Hansen Spinal Cord Injury Registry (RHSCIR).

STUDY DESIGN

Prospective cohort study.

PARTICIPANT SAMPLE

The analysis cohort consisted of 278 adult individuals with traumatic SCI enrolled in the RHSCIR for whom complete neurologic examination data and Functional Independence Measure (FIM) outcome data were available.

OUTCOME MEASURES

The FIM locomotor score was used to assess independent walking ability (defined as modified or complete independence in walk or combined walk and wheelchair modality) at 1-year follow-up for each participant.

METHODS

A logistic regression (LR) model based on age and four neurologic variables was applied to our cohort of 278 RHSCIR participants. Additionally, a simplified LR model was created. The Hosmer-Lemeshow goodness of fit test was used to check if the predictive model is applicable to our data set. The performance of the model was verified by calculating the area under the receiver operating characteristic curve (AUC). The accuracy of the model was tested using a cross-validation technique. This study was supported by a grant from The Ottawa Hospital Academic Medical Organization ($50,000 over 2 years). The RHSCIR is sponsored by the Rick Hansen Institute and is supported by funding from Health Canada, Western Economic Diversification Canada, and the provincial governments of Alberta, British Columbia, Manitoba, and Ontario. ET and JP report receiving grants from the Rick Hansen Institute (approximately $60,000 and $30,000 per year, respectively). DMR reports receiving remuneration for consulting services provided to Palladian Health, LLC and Pacira Pharmaceuticals, Inc ($20,000-$30,000 annually), although neither relationship presents a potential conflict of interest with the submitted work. KEH received a grant for involvement in the present study from the Government of Canada as part of the Canada Summer Jobs Program ($3,000). JP reports receiving an educational grant from Medtronic Canada outside of the submitted work ($75,000 annually). TM reports receiving educational fellowship support from AO Spine, AO Trauma, and Medtronic; however, none of these relationships are financial in nature. All remaining authors have no conflicts of interest to disclose.

RESULTS

The fitted prediction model generated 85% overall classification accuracy, 79% sensitivity, and 90% specificity. The prediction model was able to accurately classify independent walking ability (AUC 0.889, 95% confidence interval [CI] 0.846-0.933, p<.001) compared with the existing prediction model, despite the use of a different outcome measure (FIM vs. Spinal Cord Independence Measure) to qualify walking ability. A simplified, three-variable LR model based on age and two neurologic variables had an overall classification accuracy of 84%, with 76% sensitivity and 90% specificity, demonstrating comparable accuracy with its five-variable prediction model counterpart. The AUC was 0.866 (95% CI 0.816-0.916, p<.01), only marginally less than that of the existing prediction model.

CONCLUSIONS

A simplified predictive model with similar accuracy to a more complex model for predicting independent walking was created, which improves utility in a clinical setting. Such models will allow clinicians to better predict the prognosis of ambulation in individuals who have sustained a traumatic SCI.

Spinal Cord Injury Clinical Registries: Improving Care across the SCI Care Continuum by Identifying Knowledge Gaps

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.

Development and validation of a bowel-routine-based self-report questionnaire for sacral sparing after spinal cord injury

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.

Natural Killer (NK) Cell Functionality after human Spinal Cord Injury (SCI): protocol of a prospective, longitudinal study

Background

Natural killer (NK) cells comprise the main components of lymphocyte-mediated nonspecific immunity. Through their effector function they play a crucial role combating bacterial and viral challenges. They are also thought to be key contributors to the systemic spinal cord injury-induced immune-deficiency syndrome (SCI-IDS). SCI-IDS increases susceptibility to infection and extends to the post-acute and chronic phases after SCI.

Methods and design

The prospective study of NK cell function after traumatic SCI was carried out in two centers in Berlin, Germany. SCI patients and control patients with neurologically silent vertebral fracture also undergoing surgical stabilization were enrolled. Furthermore healthy controls were included to provide reference data. The NK cell function was assessed at 7 (5–9) days, 14 days (11–28) days, and 10 (8–12) weeks post-trauma. Clinical documentation included the American Spinal Injury Association (ASIA) impairment scale (AIS), neurological level of injury, infection status, concomitant injury, and medications. The primary endpoint of the study is CD107a expression by NK cells (cytotoxicity marker) 8–12 weeks following SCI. Secondary endpoints are the NK cell’s TNF-α and IFN-γ production by the NK cells 8–12 weeks following SCI.

Discussion

The protocol of this study was developed to investigate the hypotheses whether i) SCI impairs NK cell function throughout the post-acute and sub-acute phases after SCI and ii) the degree of impairment relates to lesion height and severity. A deeper understanding of the SCI-IDS is crucial to enable strategies for prevention of infections, which are associated with poor neurological outcome and elevated mortality.

Trial registration

DRKS00009855.

Cerebrospinal Fluid Biomarkers To Stratify Injury Severity and Predict Outcome in Human Traumatic Spinal Cord Injury

Neurologic impairment after spinal cord injury (SCI) is currently measured and classified by functional examination. Biological markers that objectively classify injury severity and predict outcome would greatly facilitate efforts to evaluate acute SCI therapies. The purpose of this study was to determine how well inflammatory and structural proteins within the cerebrospinal fluid (CSF) of acute traumatic SCI patients predicted American Spinal Injury Association Impairment Scale (AIS) grade conversion and motor score improvement over 6 months. Fifty acute SCI patients (29 AIS A, 9 AIS B, 12 AIS C; 32 cervical, 18 thoracic) were enrolled and CSF obtained through lumbar intrathecal catheters to analyze interleukin (IL)-6, IL-8, monocyte chemotactic protein (MCP)-1, tau, S100β, and glial fibrillary acidic protein (GFAP) at 24 h post-injury. The levels of IL-6, tau, S100β, and GFAP were significantly different between patients with baseline AIS grades of A, B, or C. The levels of all proteins (IL-6, IL-8, MCP-1, tau, S100β, and GFAP) were significantly different between those who improved an AIS grade over 6 months and those who did not improve. Linear discriminant analysis modeling was 83% accurate in predicting AIS conversion. For AIS A patients, the concentrations of proteins such as IL-6 and S100β correlated with conversion to AIS B or C. Motor score improvement also was strongly correlated with the 24-h post-injury CSF levels of all six biomarkers. The analysis of CSF can provide valuable biological information about injury severity and recovery potential after acute SCI. Such biological markers may be valuable tools for stratifying individuals in acute clinical trials where variability in spontaneous recovery requires large recruitment cohorts for sufficient power.

Standardization of Data for Clinical Use and Research in Spinal Cord Injury

Increased survival after spinal cord injury (SCI) worldwide has enhanced the need for quality data that can be compared and shared between centers, countries, as well as across research studies, to better understand how best to prevent and treat SCI. Such data should be standardized and be able to be uniformly collected at any SCI center or within any SCI study. Standardization will make it possible to collect information from larger SCI populations for multi-center research studies. With this aim, the international SCI community has obtained consensus regarding the best available data and measures for use in SCI clinical practice and research. Reporting of SCI data is likewise standardized. Data elements are continuously updated and developed using an open and transparent process. There are ongoing internal, as well as external review processes, where all interested parties are encouraged to participate. The purpose of this review paper is to provide an overview of the initiatives to standardize data including the International Spinal Cord Society's International SCI Data Sets and the National Institutes of Health, National Institute of Neurological Disorders and Stroke Common Data Elements Project within SCI and discuss future opportunities.