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Snider BA, Eren F, Reeves RK, Rupp R, Kirshblum SC. The International Standards for Neurological Classification of Spinal Cord Injury: Classification Accuracy and Challenges. Top Spinal Cord Inj Rehabil 2023; 29:1-15. [PMID: 36819931 PMCID: PMC9936898 DOI: 10.46292/sci22-00036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Background Successful utilization of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) requires a comprehensive understanding of its rules, terminology, and several complex concepts. There have been no studies investigating classification accuracy since the newest ISNCSCI revision (2019). Objectives To evaluate classification accuracy of SCI professionals using the 2019 ISNCSCI edition, identify common mistakes and areas of confusion, and assess associations between experience in ISNCSCI classification and performance. Methods Members of the International Spinal Cord Society (ISCoS) and attendees of the ISCoS Annual Scientific Meeting 2021 were invited to complete an online survey that included six ISNCSCI cases to classify. Results A total of 107 persons completed the survey, with overall classification accuracy of 74.6%. Accuracy was highest for injury completeness (95.3%) and sensory level (91.1%) and lowest for motor zone of partial preservation (ZPP; 54.7%) and ASIA Impairment Scale (AIS) grade (57.3%). Newer concepts, including the appropriate documentation of non-SCI conditions and classification of ZPP in incomplete injuries, contributed to several common errors. There was a significant association between overall classification accuracy and self-rated experience in the ISNCSCI classification (p = .017). Experience with the ISNCSCI examination, experience in SCI medicine, and occupation were not found to be significantly associated with overall classification accuracy. Conclusion Classification accuracy of an international cohort of SCI professionals was modest but greater than previous reports. Knowledge deficits about the 2019 ISNCSCI updates are prevalent and contribute to common classification errors. Further training in the utilization of the ISNCSCI is needed.
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Affiliation(s)
- Brittany A. Snider
- Kessler Institute for Rehabilitation, West Orange, New Jersey
- Kessler Foundation, West Orange, New Jersey
- Rutgers New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, New Jersey
| | - Fatma Eren
- Kessler Foundation, West Orange, New Jersey
- Rutgers New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, New Jersey
| | - Ronald K. Reeves
- Mayo Clinic College of Medicine, Department of Physical Medicine and Rehabilitation, Rochester, Minnesota
| | - Rüdiger Rupp
- Heidelberg University Hospital, Heidelberg, Germany
| | - Steven C. Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersey
- Kessler Foundation, West Orange, New Jersey
- Rutgers New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, New Jersey
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Kopp MA, Lübstorf T, Blex C, Schwab JM, Grittner U, Auhuber T, Ekkernkamp A, Niedeggen A, Prillip E, Hoppe M, Ludwig J, Kreutzträger M, Liebscher T. Association of age with the timing of acute spine surgery-effects on neurological outcome after traumatic spinal cord injury. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:56-69. [PMID: 34533643 DOI: 10.1007/s00586-021-06982-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 08/02/2021] [Accepted: 08/24/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the association of age with delay in spine surgery and the effects on neurological outcome after traumatic spinal cord injury (SCI). METHODS Ambispective cohort study (2011-2017) in n = 213 patients consecutively enrolled in a Level I trauma center with SCI care in a metropolitan region in Germany. Age-related differences in the injury to surgery interval and conditions associated with its delay (> 12 h after SCI) were explored using age categories or continuous variables and natural cubic splines. Effects of delayed surgery or age with outcome were analyzed using multiple logistic regression. RESULTS The median age of the study population was 58.8 years (42.0-74.6 IQR). Older age (≥ 75y) was associated with a prolonged injury to surgery interval of 22.8 h (7.2-121.3) compared to 6.6 h (4.4-47.9) in younger patients (≤ 44y). Main reasons for delayed surgery in older individuals were secondary referrals and multimorbidity. Shorter time span to surgery (≤ 12 h) was associated with higher rates of ASIA impairment scale (AIS) conversion (OR 4.22, 95%CI 1.85-9.65), as mirrored by adjusted spline curves (< 20 h 20-25%, 20-60 h 10-20%, > 60 h < 10% probability of AIS conversion). In incomplete SCI, the probability of AIS conversion was lower in older patients [e.g., OR 0.09 (0.02-0.44) for'45-59y' vs.' ≤ 44y'], as confirmed by spline curves (< 40y 20-80%, ≥ 40y 5-20% probability). CONCLUSION Older patient age complexifies surgical SCI care and research. Tackling secondary referral to Level I trauma centers and delayed spine surgery imposes as tangible opportunity to improve the outcome of older SCI patients.
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Affiliation(s)
- Marcel A Kopp
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Berlin Institute of Health, QUEST-Center for Transforming Biomedical Research, Berlin, Germany.
| | - Tom Lübstorf
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Blex
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jan M Schwab
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Belford Center for Spinal Cord Injury, Departments of Neurology, Physical Medicine and Rehabilitation, and Neurosciences, The Neuroscience Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Thomas Auhuber
- Medical Management, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
- University of Applied Sciences of the German Statutory Accident Insurance (HGU), Bad Hersfeld, Germany
| | - Axel Ekkernkamp
- Clinic for Trauma Surgery and Orthopaedics, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Andreas Niedeggen
- Brandenburg Center for Spinal Cord Injuries, Kliniken Beelitz, Beelitz-Heilstätten, Germany
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Erik Prillip
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Magdalena Hoppe
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Johanna Ludwig
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Martin Kreutzträger
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Thomas Liebscher
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
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Kirshblum S, Schmidt Read M, Rupp R. Classification challenges of the 2019 revised International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Spinal Cord 2022; 60:11-17. [PMID: 34088981 PMCID: PMC8737267 DOI: 10.1038/s41393-021-00648-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective review of ISNCSCI datasets. OBJECTIVES To discuss the correct classification of ISNCSCI datasets considered as challenging. SETTING International expert collaboration. METHODS The International Standards Committee of the American Spinal Injury Association (ASIA) receives challenging case scenarios regarding the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI). Among those cases received, sample cases representing different categories of typical classification difficulties were identified by members of the International Standards committee. RESULTS From the cases received, five sample cases were identified as representative for publication. These cases are related to the correct classification in the presence of non-SCI related conditions, the determination of motor zones of partial preservation in regions with no myotomes to test, the classification of the ASIA Impairment Scale in patients with substantial motor function below the motor level but no sacral sparing, the inclusion of non-key muscle functions in the classification of sensory incomplete individuals, and the correct classification of individuals with an amputation. CONCLUSION Presenting cases with challenging classifications, along with responses and explanations, will serve spinal cord injury professionals to better understand and utilize the ISNCSCI classification. As the ISNCSCI endorsed by ASIA and the International Spinal Cord Society (ISCoS) evolves over time, such resources are important to clarify inquiries from the spinal cord injury community and to understand the rationale for revisions.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany.
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Oña A, Strøm V, Lee BS, Le Fort M, Middleton J, Gutenbrunner C, Pacheco Barzallo D. Health inequalities and income for people with spinal cord injury. A comparison between and within countries. SSM Popul Health 2021; 15:100854. [PMID: 34258374 PMCID: PMC8259327 DOI: 10.1016/j.ssmph.2021.100854] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 12/20/2022] Open
Abstract
Income and health are related in a bi-directional manner, whereby level of income affects health and vice versa. People in poorer households tend to experience worse health status and higher mortality rates than people in wealthier households, and, at the same time, having poor health could restrict workability leading to less income. This gap exists in almost every country, and it is more pronounced in more unequal countries and in vulnerable populations, such as people experiencing disability. The goal of this paper is to estimate the health-income gap in people with a Spinal Cord Injury (SCI), which is a chronic health condition often associated with multiple comorbidities that leads to disability. As data on mortality is inexistent, to estimate the health-income gap for persons with SCI, this paper uses two health outcomes: the number of years a person has lived with the injury, and a comorbidity index. Data was obtained from the International Spinal Cord Injury survey (InSCI), which is the first worldwide survey on community-dwelling persons with SCI. To compare across countries, the health outcomes were adjusted through hierarchical models, accounting for country fixed-effects, individual characteristics such as age and gender, and injury characteristics (cause, type and degree). Our results suggest that for the years living with SCI, the gap varies from 1 to 6 years between the lowest and the highest income groups. The main driver of such a difference is the cause of injury, where injuries caused by work accidents showed the biggest gap. Similarly, for the comorbidity index, persons with SCI in poorer deciles reported significantly more comorbidities, forty times more, than people in richer deciles.
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Affiliation(s)
- Ana Oña
- Swiss Paraplegic Research, Guido A. Zäch Institute, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Vegard Strøm
- Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | | | - Marc Le Fort
- Universitaire de Médecine Physique et Réadaptation, France
| | - James Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute of Medical Research, Royal North Shore Hospital, Australia
- Sydney Medical School - Northern, Faculty of Medicine and Health, The University of Sydney, Australia
| | | | - Diana Pacheco Barzallo
- Swiss Paraplegic Research, Guido A. Zäch Institute, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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Kirshblum S, Snider B, Eren F, Guest J. Characterizing Natural Recovery after Traumatic Spinal Cord Injury. J Neurotrauma 2021; 38:1267-1284. [PMID: 33339474 PMCID: PMC8080912 DOI: 10.1089/neu.2020.7473] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersy, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Brittany Snider
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Fatma Eren
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - James Guest
- Neurological Surgery, Miller School of Medicine, Miami, Florida, USA
- The Miami Project to Cure Paralysis, Miami, Florida, USA
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Incidence of Pressure Injury in Individuals With Spinal Cord Injury: A Systematic Review and Meta-analysis. J Wound Ostomy Continence Nurs 2021; 47:215-223. [PMID: 32384524 DOI: 10.1097/won.0000000000000633] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE The purpose of this systematic review and quantitative analysis of pooled data was to assess the global incidence of pressure injury (PI), across time frames and countries, in individuals with spinal cord injury (SCI). DESIGN Systematic review and meta-analysis. SEARCH STRATEGY PubMed, Web of Science, and EMBASE databases were systematically searched for studies published from database inception to January 2019, with only English language studies that reported the incidence of PIs in individuals with SCI were included. Study quality was assessed by a 14-item standardized checklist. We calculated the incidence of PIs as the number of new PIs in individuals with SCI and the total number of individuals with SCI during the study period. Findings are presented as incidence rate with 95% confidence intervals (CIs). RESULTS The search yielded 1652 studies; after studies were reviewed for inclusion criteria, 29 studies representing N = 82,722 patients were retained for data extraction. The global incidence of PIs was 0.23 (95% CI, 0.20-0.26). Data for regional distribution by country showed a pooled incidence of 0.43 (95% CI, 0.28-0.57) in individuals with SCI in South American countries, 0.36 (95% CI, 0.16-0.56) in African countries, 0.25 (95% CI, 0.14-0.37) in European countries, 0.23 (95% CI, 0.19-0.27) in North American countries, and 0.16 (95% CI, 0.06-0.25) in Asian countries. The incidence was 0.22 (95% CI, 0.19-0.26) in developing countries versus 0.27 (95% CI, 0.17-0.37) in developed countries. From 2000 to 2009, the incidence of PIs in individuals with SCI was 0.28 (95% CI, 0.09-0.47). The incidence rate of PIs before 2000 and after 2009 was 0.23. The hospital- and community-acquired PI incidence was 0.22 (95% CI, 0.19-0.26) and 0.26 (95% CI, 0.20-0.32), respectively. CONCLUSIONS Study findings indicate that more than 1 in 5 individuals with SCI will develop a PI. Individuals with SCI are at high risk of developing PI, especially in community settings or low- and middle-income developing countries. The findings highlight the importance of further investigation of risk factors and prevention and management strategies for PIs in individuals with SCI.
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The 2019 revision of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)-What's new? Spinal Cord 2019; 57:815-817. [PMID: 31530900 DOI: 10.1038/s41393-019-0350-9] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/07/2019] [Indexed: 01/01/2023]
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Thomas FP, Murphy C. Celebrating advances in spinal cord injury care and research. J Spinal Cord Med 2018; 41:501. [PMID: 30132750 PMCID: PMC6117568 DOI: 10.1080/10790268.2018.1500825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Assessor accuracy of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)-recommendations for reporting items. Spinal Cord 2018; 56:819-820. [PMID: 29904186 DOI: 10.1038/s41393-018-0133-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 03/27/2018] [Indexed: 11/09/2022]
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