Conversion in ASIA impairment scale during the first year after traumatic spinal cord injury

How do early perioperative changes in AIS grade correlate with long-term neurological recovery? A retrospective cohort study

Context/Objective: Providing accurate counseling on neurological recovery is crucial after traumatic spinal cord injury (TSCI). The early neurological changes that occur in the subacute phase of the injury (i.e. within 14 days of early decompressive surgery) have never been documented. The objective of this study was to assess peri-operative neurological improvements after acute TSCI and determine their relationship with long-term neurological outcomes, measured 6-12 months following the injury.Methods: A retrospective cohort study of 142 adult TSCI patients was conducted. Early peri-operative improvement was defined as improvement of at least 1 AIS grade between the pre-operative and follow-up (6-12 months post-TSCI) assessment. neurological improvement of at least 1 AIS grade.Results: Out of the 142 patients, 18 achieved a peri-operative improvement of at least 1 AIS grade. Presenting a pre-operative AIS grade B and having shorter surgical delays were the main factors associated with stronger odds of achieving this outcome. Out of the 140 patients who still had potential for improvement at the time of the post-operative assessment, 44 achieved late neurological recovery (improvement of at least 1 AIS grade between the post-operative assessment and follow-up). Patients who presented a perioperative improvement seemed more likely to achieve later neurological improvement as well, although this was not statistically significant.Conclusion: Our results suggest that it is important to assess early perioperative neurological changes within 14 days of surgery because it can provide beneficial insight on long-term neurological outcomes for some patients. In addition, earlier surgery may promote early neurological recovery.

Spotlight on plasticity-related genes: Current insights in health and disease

The development of the central nervous system is highly complex, involving numerous developmental processes that must take place with high spatial and temporal precision. This requires a series of complex and well-coordinated molecular processes that are tighly controlled and regulated by, for example, a variety of proteins and lipids. Deregulations in these processes, including genetic mutations, can lead to the most severe maldevelopments. The present review provides an overview of the protein family Plasticity-related genes (PRG1-5), including their role during neuronal differentiation, their molecular interactions, and their participation in various diseases. As these proteins can modulate the function of bioactive lipids, they are able to influence various cellular processes. Furthermore, they are dynamically regulated during development, thus playing an important role in the development and function of synapses. First studies, conducted not only in mouse experiments but also in humans, revealed that mutations or dysregulations of these proteins lead to changes in lipid metabolism, resulting in severe neurological deficits. In recent years, as more and more studies have shown their involvement in a broad range of diseases, the complexity and broad spectrum of known and as yet unknown interactions between PRGs, lipids, and proteins make them a promising and interesting group of potential novel therapeutic targets.

Prognostic value of tissue bridges in cervical spinal cord injury: a longitudinal, multicentre, retrospective cohort study

BACKGROUND

The accuracy of prognostication in patients with cervical spinal cord injury (SCI) needs to be improved. We aimed to explore the prognostic value of preserved spinal tissue bridges-injury-spared neural tissue adjacent to the lesion-for prediction of sensorimotor recovery in a large, multicentre cohort of people with SCI.

METHODS

For this longitudinal study, we included patients with acute cervical SCI (vertebrae C1-C7) admitted to one of three trauma or rehabilitation centres: Murnau, Germany (March 18, 2010-March 1, 2021); Zurich, Switzerland (May 12, 2002-March 2, 2019); and Denver, CO, USA (Jan 12, 2010-Feb 16, 2017). Patients were clinically assessed at admission (baseline), at discharge (3 months), and at 12 months post SCI. Midsagittal tissue bridges were quantified from T2-weighted images assessed at 3-4 weeks post SCI. Fractional regression and unbiased recursive partitioning models, adjusted for age, sex, centre, and neurological level of injury, were used to assess associations between tissue bridge width and baseline-adjusted total motor score, pinprick score, and light touch scores at 3 months and 12 months. Patients were stratified into subgroups according to whether they showed better or worse predicted recovery.

FINDINGS

The cohort included 227 patients: 93 patients from Murnau (22 [24%] female); 43 patients from Zurich (four [9%] female); and 91 patients from Denver (14 [15%] female). 136 of these participants (from Murnau and Zurich) were followed up for up to 12 months. At 3 months, per preserved 1 mm of tissue bridge at baseline, patients recovered a mean of 9·3% (SD 0·9) of maximal total motor score (95% CI 7·5-11.2), 8·6% (0·8) of maximal pinprick score (7·0-10·1), and 10·9% (0·8) of maximal light touch score (9·4-12·5). At 12 months post SCI, per preserved 1 mm of tissue bridge at baseline, patients recovered a mean of 10·9% (1·3) of maximal total motor score (8·4-13·4), 5·7% (1·3) of maximal pinprick score (3·3-8·2), and 6·9% (1·4) of maximal light touch score (4·1-9·7). Partitioning models identified a tissue bridge cutoff width of 2·0 mm to be indicative of higher or lower 3-month total motor, pinprick, and light touch scores, and a cutoff of 4·0 mm to be indicative of higher and lower 12-month scores. Compared with models that contained clinical predictors only, models additionally including tissue bridges had significantly improved prediction accuracy across all three centres.

INTERPRETATION

Tissue bridges, measured in the first few weeks after SCI, are associated with short-term and long-term clinical improvement. Thus, tissue bridges could potentially be used to guide rehabilitation decision making and to stratify patients into more homogeneous subgroups of recovery in regenerative and neuroprotective clinical trials.

FUNDING

Wings for Life, International Foundation for Research in Paraplegia, EU project Horizon 2020 (NISCI grant), and ERA-NET NEURON.

Neuromuscular consequences of spinal cord injury: New mechanistic insights and clinical considerations

The spinal cord facilitates communication between the brain and the body, containing intrinsic systems that work with lower motor neurons (LMNs) to manage movement. Spinal cord injuries (SCIs) can lead to partial paralysis and dysfunctions in muscles below the injury. While traditionally this paralysis has been attributed to disruptions in the corticospinal tract, a growing body of work demonstrates LMN damage is a factor. Motor units, comprising the LMN and the muscle fibers with which they connect, are essential for voluntary movement. Our understanding of their changes post-SCI is still emerging, but the health of motor units is vital, especially when considering innovative SCI treatments like nerve transfer surgery. This review seeks to collate current literature on how SCI impact motor units and explore neuromuscular clinical implications and treatment avenues. SCI reduced motor unit number estimates, and surviving motor units had impaired signal transmission at the neuromuscular junction, force-generating capacity, and excitability, which have the potential to recover chronically, yet the underlaying mechanisms are unclear. Furthermore, electrodiagnostic evaluations can aid in assessing the health lower and upper motor neurons, identify suitable targets for nerve transfer surgeries, and detect patients with time sensitive injuries. Lastly, many electrodiagnostic abnormalities occur in both chronic and acute SCI, yet factors contributing to these abnormalities are unknown. Future studies are required to determine how motor units adapt following SCI and the clinical implications of these adaptations.

Electrophysiology Methods for Assessing of Neurodegenerative and Post-Traumatic Processes as Applied to Translational Research

Electrophysiological studies have long established themselves as reliable methods for assessing the functional state of the brain and spinal cord, the degree of neurodegeneration, and evaluating the effectiveness of therapy. In addition, they can be used to diagnose, predict functional outcomes, and test the effectiveness of therapeutic and rehabilitation programs not only in clinical settings, but also at the preclinical level. Considering the urgent need to develop potential stimulators of neuroregeneration, it seems relevant to obtain objective data when modeling neurological diseases in animals. Thus, in the context of the application of electrophysiological methods, not only the comparison of the basic characteristics of bioelectrical activity of the brain and spinal cord in humans and animals, but also their changes against the background of neurodegenerative and post-traumatic processes are of particular importance. In light of the above, this review will contribute to a better understanding of the results of electrophysiological assessment in neurodegenerative and post-traumatic processes as well as the possibility of translating these methods from model animals to humans.

Impact of Upper Limb Motor Recovery on Functional Independence After Traumatic Low Cervical Spinal Cord Injury

Cervical spinal cord injury (SCI) causes devastating loss of upper limb function and independence. Restoration of upper limb function can have a profound impact on independence and quality of life. In low-cervical SCI (level C5-C8), upper limb function can be restored via reinnervation strategies such as nerve transfer surgery. The translation of recovered upper limb motor function into functional independence in activities of daily living (ADLs), however, remains unknown in low cervical SCI (i.e., tetraplegia). The objective of this study was to evaluate the association of patterns in upper limb motor recovery with functional independence in ADLs. This will then inform prioritization of reinnervation strategies focused to maximize function in patients with tetraplegia. This retrospective study performed a secondary analysis of patients with low cervical (C5-C8) enrolled in the SCI Model Systems (SCIMS) database. Baseline neurological examinations and their association with functional independence in major ADLs-i.e., eating, bladder management, and transfers (bed/wheelchair/chair)-were evaluated. Motor functional recovery was defined as achieving motor strength, in modified research council (MRC) grade, of ≥ 3 /5 at one year from ≤ 2/5 at baseline. The association of motor function recovery with functional independence at one-year follow-up was compared in patients with recovered elbow flexion (C5), wrist extension (C6), elbow extension (C7), and finger flexion (C8). A multi-variable logistic regression analysis, adjusting for known factors influencing recovery after SCI, was performed to evaluate the impact of motor function at one year on a composite outcome of functional independence in major ADLs. Composite outcome was defined as functional independence measure score of 6 or higher (complete independence) in at least two domains among eating, bladder management, and transfers. Between 1992 and 2016, 1090 patients with low cervical SCI and complete neurological/functional measures were included. At baseline, 67% of patients had complete SCI and 33% had incomplete SCI. The majority of patients were dependent in eating, bladder management, and transfers. At one-year follow-up, the largest proportion of patients who recovered motor function in finger flexion (C8) and elbow extension (C7) gained independence in eating, bladder management, and transfers. In multi-variable analysis, patients who had recovered finger flexion (C8) or elbow extension (C7) had higher odds of gaining independence in a composite of major ADLs (odds ratio [OR] = 3.13 and OR = 2.87, respectively, p < 0.001). Age 60 years (OR = 0.44, p = 0.01), and complete SCI (OR = 0.43, p = 0.002) were associated with reduced odds of gaining independence in ADLs. After cervical SCI, finger flexion (C8) and elbow extension (C7) recovery translate into greater independence in eating, bladder management, and transfers. These results can be used to design individualized reinnervation plans to reanimate upper limb function and maximize independence in patients with low cervical SCI.

Prognostic value of the systemic inflammatory index (SII) and systemic inflammatory response index (SIRI) in patients with traumatic spinal cord injury

PURPOSE

The overwhelming inflammatory response plays a critical role in the secondary injury cascade of traumatic spinal cord injury (tSCI). The systemic immune inflammatory index (SII) and systemic inflammatory response index (SIRI) are two novel inflammatory biomarkers. The SII was calculated based on lymphocyte, neutrophil, and platelet counts, while the SIRI was calculated based on lymphocyte, neutrophil, and monocyte counts. Their prognostic value in patients with tSCI remains unclear.

METHODS

Patients with tSCI admitted within 24 h of trauma were retrospectively and consecutively enrolled. Peripheral blood samples were collected on admission. The primary outcome was American Spinal Injury Association Impairment Scale (AIS) grade conversion at discharge. Multivariable logistic regression analysis was performed to determine the relationship between SII and SIRI and AIS grade conversion. We performed receiver operating characteristic curve (ROC) analysis to assess the discriminative ability of SII, and SIRI in predicting AIS grade conversion.

RESULTS

Among 280 included patients, 77 (27.5%) had improved AIS grade conversion at discharge. After adjustment for confounders, SII was independently associated with AIS grade conversion (per SD, odds ratio [OR], 0.68; 95% confidence interval [CI] 0.47-0.98, p = 0.040), while the association between SIRI and AIS grade conversion was insignificant (per 1 SD, OR, 0.77; 95% CI 0.55-1.08, p = 0.130). The ROC analysis revealed that the SII had the best predictive value for AIS grade conversion (area under curve: 0.608, 95% CI 0.536-0.678).

CONCLUSIONS

Increased SII was independently associated with a decreased likelihood of improved AIS grade conversion.

Clinical Delivery of Overground Exoskeleton Gait Training in Persons With Spinal Cord Injury Across the Continuum of Care: A Retrospective Analysis

Background

After spinal cord injury (SCI), inpatient rehabilitation begins and continues through outpatient therapy. Overground exoskeleton gait training (OEGT) has been shown to be feasible in both settings, yet its use as an intervention across the continuum has not yet been reported.

Objectives

This study describes OEGT for patients with SCI across the continuum and its effects on clinical outcomes.

Methods

Medical records of patients with SCI who completed at least one OEGT session during inpatient and outpatient rehabilitation from 2018 to 2021 were retrospectively reviewed. Demographic data, Walking Index for Spinal Cord Injury-II (WISCI-II) scores, and OEGT session details (frequency, "walk" time, "up" time, and step count) were extracted.

Results

Eighteen patients [male (83%), White (61%), aged 37.4 ± 15 years, with tetraplegia (50%), American Spinal Injury Association Impairment Scale A (28%), B (22%), C (39%), D (11%)] completed OEGT sessions (motor complete, 18.2 ± 10.3; motor incomplete, 16.7 ± 7.7) over approximately 18 weeks (motor complete, 15.1 ± 6.4; motor incomplete, 19.0 ± 8.2). Patients demonstrated improved OEGT session tolerance on device metrics including "walk" time (motor complete, 7:51 ± 4:42 to 24:50 ± 9:35 minutes; motor incomplete, 12:16 ± 6:01 to 20:01 ± 08:05 minutes), "up" time (motor complete, 16:03 ± 7:41 to 29:49 ± 12:44 minutes; motor incomplete, 16:38 ± 4:51 to 23:06 ± 08:50 minutes), and step count (motor complete, 340 ± 295.9 to 840.2 ± 379.4; motor incomplete, 372.3 ± 225.2 to 713.2 ± 272). Across therapy settings, patients with motor complete SCI experienced improvement in WISCI-II scores from 0 ± 0 at inpatient admission to 3 ± 4.6 by outpatient discharge, whereas the motor incomplete group demonstrated a change of 0.2 ± 0.4 to 9.0 ± 6.4.

Conclusion

Patients completed OEGT across the therapy continuum. Patients with motor incomplete SCI experienced clinically meaningful improvements in walking function.

Does Improvement in American Spinal Injury Association Impairment Scale Grade Correlate With Functional Recovery in All Patients With a Traumatic Spinal Cord Injury?

OBJECTIVE

The aim of the study is to determine what improvement on the American Spinal Injury Impairment Scale correlates with functional status after a traumatic spinal cord injury.

DESIGN

We performed an observational cohort study, analyzing prospective data from 168 patients with traumatic spinal cord injury admitted to a single level 1 trauma center. A multivariable analysis was performed to assess the relationship between functional status (from the Spinal Cord Independence Measure) at 1-year follow-up and American Spinal Injury Impairment Scale grade (baseline and 1-yr follow-up), while taking into account covariables describing the sociodemographic status, trauma severity, and level of neurological injury.

RESULTS

Individuals improving to at least American Spinal Injury Impairment Scale grade D had significantly higher Spinal Cord Independence Measure score compared with those not reaching American Spinal Injury Impairment Scale D (89.3 ± 15.2 vs. 52.1 ± 20.4) and were more likely to reach functional independence (68.5% vs. 3.6%), regardless of the baseline American Spinal Injury Impairment Scale grade. Higher final Spinal Cord Independence Measure was more likely with an initial American Spinal Injury Impairment Scale grade D (β = 1.504; 95% confidence interval = 0.46-2.55), and a final American Spinal Injury Impairment Scale grade D (β = 3.716; 95% CI = 2.77-4.66) or E (β = 4.422; 95% CI = 2.91-5.93).

CONCLUSIONS

Our results suggest that reaching American Spinal Injury Impairment Scale grade D or better 1 yr after traumatic spinal cord injury is highly predictive of significant functional recovery, more so than the actual improvement in American Spinal Injury Impairment Scale grade from the injury to the 1-yr follow-up.

Effectiveness of the Combined Use of a Brain-Machine Interface System and Virtual Reality as a Therapeutic Approach in Patients with Spinal Cord Injury: A Systematic Review

Spinal cord injury has a major impact on both the individual and society. This damage can cause permanent loss of sensorimotor functions, leading to structural and functional changes in somatotopic regions of the spinal cord. The combined use of a brain-machine interface and virtual reality offers a therapeutic alternative to be considered in the treatment of this pathology. This systematic review aimed to evaluate the effectiveness of the combined use of virtual reality and the brain-machine interface in the treatment of spinal cord injuries. A search was performed in PubMed, Web of Science, PEDro, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and Medline, including articles published from the beginning of each database until January 2023. Articles were selected based on strict inclusion and exclusion criteria. The Cochrane Collaboration's tool was used to assess the risk of bias and the PEDro scale and SCIRE systems were used to evaluate the methodological quality of the studies. Eleven articles were selected from a total of eighty-two. Statistically significant changes were found in the upper limb, involving improvements in shoulder and upper arm mobility, and weaker muscles were strengthened. In conclusion, most of the articles analyzed used the electroencephalogram as a measurement instrument for the assessment of various parameters, and most studies have shown improvements. Nonetheless, further research is needed with a larger sample size and long-term follow-up to establish conclusive results regarding the effect size of these interventions.

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

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

Challenges in Translating Regenerative Therapies for Spinal Cord Injury

Regenerating the injured spinal cord is a substantial challenge with many obstacles that need to be overcome to achieve robust functional benefits. This abundance of hurdles can partly explain the limited success when applying regenerative intervention treatments in animal models and/or people. In this article, we elaborate on a few of these obstacles, starting with the applicability of animal models and how they compare to the clinical setting. We then discuss the requirement for combinatorial interventions and the associated problems in experimental design, including the addition of rehabilitative training. The article expands on differences in lesion sizes and locations between humans and common animal models, and how this difference can determine the success or failure of an intervention. An additional and frequently overlooked problem in the translation of interventions that applies beyond the field of neuroregeneration is the reporting bias and the lack of transparency in reporting findings. New data mandates are tackling this problem and will eventually result in a more balanced view of the field. Finally, we will discuss strategies to negotiate the challenging course of successful translation to facilitate successful translation of regeneration promoting interventions.

The impact of time from injury to surgery on the risk of neuropathic pain after traumatic spinal cord injury

Traumatic spinal cord injury (SCI) is a devastating neurological disorder often accompanied by neuropathic pain (NeP), significantly affecting patients' quality of life. This retrospective study aimed to investigate the impact of the time from injury to surgery on the development of NeP following traumatic SCI. Medical records of patients with traumatic SCI who underwent surgical intervention between January 2017 and January 2021 at two specialized centers were reviewed. Variables associated with NeP including demographics, injury profiles, medical history, surgical details, and pain assessments were investigated. Independent risk factors related to NeP were identified using multivariate logistic regression analysis. A total of 320 patients met the inclusion criteria, with 245 (76.6%) being male and a mean age of 56.5 ± 13.2 years. NeP was identified in 48.4% of patients (155 of 320). The multivariate analysis identifies age at injury, Injury Severity Score, and the neurological level of injury as independent risk factors for the development of NeP in both AIS A and AIS B, C, and D subgroups. Additionally, a significant association between the time from injury to surgery and NeP was observed in AIS B, C, and D patients, while no such association was found in AIS A patients. This study highlights the benefits of early and ultra-early surgical intervention in preventing NeP in patients with incomplete traumatic SCI (AIS B, C, and D), underscoring the importance of optimizing surgical timing to improve patient outcomes. Prospective studies are warranted to establish evidence-based surgical guidelines for managing traumatic SCI and preventing NeP effectively.

Epidemiology and Assessment of Traumatic Spinal Cord Injury With Concomitant Brain Injury: An Observational Study in a Regional Trauma Center

OBJECTIVE

: To analyze the epidemiological information of patients with traumatic spinal cord injury (SCI) and concomitant traumatic brain injury (TBI) and to suggest points to be aware of during the initial physical examination of patients with SCI.

METHODS

: This study was a retrospective, observational study conducted in a regional trauma center. All the records of patients diagnosed with traumatic SCI between 2016 and 2020 were reviewed. A total of 627 patients with confirmed traumatic SCI were hospitalized. A retrospective study was conducted on 363 individuals.

RESULTS

: The epidemiological data of 363 individuals were investigated. Changes in American Spinal Injury Association Impairment Scale (AIS) scores in patients with SCI were evaluated. The initial evaluation was performed on average 11 days after the injury, and a follow-up examination was performed 43 days after. Fourteen of the 24 patients identified as having AIS A and SCI with concomitant TBI in the initial evaluation showed neurologic level of injury (NLI) recovery with AIS B or more. The conversion rate in patients with SCI and concomitant TBI exceeded that reported in previous studies in individuals with SCI.

CONCLUSIONS

: Physical, cognitive, and emotional impairments caused by TBI present significant challenges in rehabilitating patients with SCI. In this study, the influence of concomitant TBI lesions could have caused the initial AIS assessment to be incorrect.

A dynamic nomogram for predicting the probability of irreversible neurological dysfunction after cervical spinal cord injury: research based on clinical features and MRI data

BACKGROUND

Irreversible neurological dysfunction (IND) is an adverse event after cervical spinal cord injury (CSCI). However, there is still a shortage of objective criteria for the early prediction of neurological function. We aimed to screen independent predictors of IND and use these findings to construct a nomogram that could predict the development of neurological function in CSCI patients.

METHODS

Patients with CSCI attending the Affiliated Hospital of Southwest Medical University between January 2014 and March 2021 were included in this study. We divided the patients into two groups: reversible neurological dysfunction (RND) and IND. The independent predictors of IND in CSCI patients were screened using the regularization technique to construct a nomogram, which was finally converted into an online calculator. Concordance index (C-index), calibration curves analysis and decision curve analysis (DCA) evaluated the model's discrimination, calibration, and clinical applicability. We tested the nomogram in an external validation cohort and performed internal validation using the bootstrap method.

RESULTS

We enrolled 193 individuals with CSCI in this study, including IND (n = 75) and RND (n = 118). Six features, including age, American spinal injury association Impairment Scale (AIS) grade, signal of spinal cord (SC), maximum canal compromise (MCC), intramedullary lesion length (IMLL), and specialized institution-based rehabilitation (SIBR), were included in the model. The C-index of 0.882 from the training set and its externally validated value of 0.827 demonstrated the model's prediction accuracy. Meanwhile, the model has satisfactory actual consistency and clinical applicability, verified in the calibration curve and DCA.

CONCLUSION

We constructed a prediction model based on six clinical and MRI features that can be used to assess the probability of developing IND in patients with CSCI.

Integration of MRI and somatosensory evoked potentials facilitate diagnosis of spinal cord compression

This study aimed to integrate magnetic resonance imaging (MRI) and related somatosensory evoked potential (SSEP) features to assist in the diagnosis of spinal cord compression (SCC). MRI scans were graded from 0 to 3 according to the changes in the subarachnoid space and scan signals to confirm differences in SCC levels. The amplitude, latency, and time-frequency analysis (TFA) power of preoperative SSEP features were extracted and the changes were used as standard judgments to detect neurological function changes. Then the patient distribution was quantified according to the SSEP feature changes under the same and different MRI compression grades. Significant differences were found in the amplitude and TFA power between MRI grades. We estimated three degrees of amplitude anomalies and power loss under each MRI grade and found the presence or absence of power loss occurs after abnormal changes in amplitude only. For SCC, few integrated approach combines the advantages of both MRI and evoked potentials. However, integrating the amplitude and TFA power changes of SSEP features with MRI grading can help in the diagnosis and speculate progression of SCC.

Identification of Serum Metabolites as Prognostic Biomarkers Following Spinal Cord Injury: A Pilot Study

The assessment, management, and prognostication of spinal cord injury (SCI) mainly rely upon observer-based ordinal scales measures. ¹H nuclear magnetic resonance (NMR) spectroscopy provides an effective approach for the discovery of objective biomarkers from biofluids. These biomarkers have the potential to aid in understanding recovery following SCI. This proof-of-principle study determined: (a) If temporal changes in blood metabolites reflect the extent of recovery following SCI; (b) whether changes in blood-derived metabolites serve as prognostic indicators of patient outcomes based on the spinal cord independence measure (SCIM); and (c) whether metabolic pathways involved in recovery processes may provide insights into mechanisms that mediate neural damage and repair. Morning blood samples were collected from male complete and incomplete SCI patients (n = 7) following injury and at 6 months post-injury. Multivariate analyses were used to identify changes in serum metabolic profiles and were correlated to clinical outcomes. Specifically, acetyl phosphate, 1,3,7-trimethyluric acid, 1,9-dimethyluric acid, and acetic acid significantly related to SCIM scores. These preliminary findings suggest that specific metabolites may serve as proxy measures of the SCI phenotype and prognostic markers of recovery. Thus, serum metabolite analysis combined with machine learning holds promise in understanding the physiology of SCI and aiding in prognosticating outcomes following injury.

Predicting the Role of Preoperative Intramedullary Lesion Length and Early Decompressive Surgery in ASIA Impairment Scale Grade Improvement Following Subaxial Traumatic Cervical Spinal Cord Injury

BACKGROUND

 Traumatic cervical spinal cord injury (TCSCI) is a disabling condition with uncertain neurologic recovery. Clinical and preclinical studies have suggested early surgical decompression and other measures of neuroprotection improve neurologic outcome. We investigated the role of intramedullary lesion length (IMLL) on preoperative magnetic resonance imaging (MRI) and the effect of early cervical decompressive surgery on ASIA impairment scale (AIS) grade improvement following TCSCI.

METHODS

 In this retrospective study, we investigated 34 TCSCI patients who were admitted over a 12-year period, from January 1, 2008 to January 31, 2020. We studied the patient demographics, mode of injury, IMLL and timing of surgical decompression. The IMLL is defined as the total length of edema and contusion/hemorrhage within the cord. Short tau inversion recovery (STIR) sequences or T2-weighted MR imaging with fat saturation increases the clarity of edema and depicts abnormalities in the spinal cord. All patients included had confirmed adequate spinal cord decompression with cervical fixation and a follow-up of at least 6 months.

RESULTS

 Of the 34 patients, 16 patients were operated on within 24 hours (early surgery group) and 18 patients were operated on more than 24 hours after trauma (delayed surgery group). In the early surgery group, 13 (81.3%) patients had improvement of at least one AIS grade, whereas in the delayed surgery group, AIS grade improvement was seen in only in 8 (44.5%) patients (early vs. late surgery; odds ratio [OR] = 1.828; 95% confidence interval [CI]: 1.036-3.225). In multivariate regression analysis coefficients, the timing of surgery and intramedullary edema length on MRI were the most significant factors in improving the AIS grade following cervical SCI. Timing of surgery as a unique variance predicted AIS grade improvement significantly (p < 0.001). The mean IMLL was 41.47 mm (standard deviation [SD]: 18.35; range: 20-87 mm). IMLL was a predictor of AIS grade improvement on long-term outcome in bivariate analysis (p < 0.001). This study suggests that patients who had IMLL of less than 30 mm had a better chance of grade conversion irrespective of the timing of surgery. Patients with an IMLL of 31 to 60 mm had chances of better grade conversion after early surgery. A longer IMLL predicts lack of improvement (p < 0.05). If the IMLL is greater than 61 mm, the probability of nonconversion of AIS grade is higher, even if the patient is operated on within 24 hours of trauma.

CONCLUSION

 Surgical decompression within 24 hours of trauma and shorter preoperative IMLL are significantly associated with improved neurologic outcome, reflected by better AIS grade improvement at 6 months' follow-up. The IMLL on preoperative MRI can reliably predict outcome after 6 months. The present study suggests that patients have lesser chances of AIS grade improvement when the IMLL is ≥61 mm.

Early Predictors and Outcomes of American Spinal Injury Association Conversion at Discharge in Surgical and Nonsurgical Management of Sports-Related Spinal Cord Injury

OBJECTIVE

This study aims to evaluate the rate of improvement in neurologic recovery of patients with sports-related spinal cord injury (SRSCI) who had surgical intervention (SS) and those who did not (NSS). We aimed to 1) evaluate the rate of American Spinal Injury Association (ASIA) conversion in patients with and without surgery, and 2) assess predictors of conversion in ASIA grade.

METHODS

The National Spinal Cord Injury Model Systems Database (SCIMS) was used from 1973 to 2016. Patients with SRSCI were included. The primary outcome was rate of conversion in ASIA grade. Multivariate logistic regression was performed with separate subgroup analysis on patients with cervical injury (represented by odds ratio [OR]; 95% confidence interval [CI]).

RESULTS

A total of 1647 patients had SRSCI with 1502 (91%) SSs. Most patients (88%) were male, white (87%), and between the ages of 15 and 29 years (63%). Patients undergoing SS had significantly longer inpatient rehabilitation length of stay (LOS) (P < 0.001) and a more patients undergoing SS had complete motor or sensory loss compared with the NSS group. Multivariate logistic regression showed that injury at the thoracic level (OR, 0.41; 95% CI, 0.21-0.78), age 15-29 years (OR, 0.44; 95% CI, 0.20-0.97]), water-based injury (OR, 0.45; 95% CI, 0.21-0.95), and ASIA impairment grades of B, C, and D at admission were significantly associated with ASIA SCORE conversion.

CONCLUSIONS

We found that patients undergoing SS had longer LOS and a higher prevalence of complete injuries. Surgical intervention was not associated with conversion in ASIA grade to an improved status at time of discharge in a large cohort of patients with SRSCI and in a subcohort of patients with cervical SRSCI.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

Retrospective Cohort.

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute Implantation of a Bioresorbable Polymer Scaffold in Patients With Complete Thoracic Spinal Cord Injury: 24-Month Follow-up From the INSPIRE Study

BACKGROUND

Based on 6-month data from the InVivo Study of Probable Benefit of the Neuro-Spinal Scaffold for Safety and Neurological Recovery in Patients with Complete Thoracic Spinal Cord Injury (INSPIRE) study (NCT02138110), acute implantation of an investigational bioresorbable polymer device (Neuro-Spinal Scaffold [NSS]) appeared to be safe in patients with complete thoracic spinal cord injury (SCI) and was associated with an ASIA Impairment Scale (AIS) conversion rate that exceeded historical controls.

OBJECTIVE

To evaluate outcomes through 24 months postimplantation.

METHODS

INSPIRE was a prospective, open-label, multicenter, single-arm study. Eligible patients had traumatic nonpenetrating SCI with a visible contusion on MRI, AIS A classification, neurological level of injury at T2-T12, and requirement for open spine surgery ≤96 hours postinjury.

RESULTS

Nineteen patients underwent NSS implantation. Three patients had early death determined by investigators to be unrelated to the NSS or its implantation procedure. Seven of 16 evaluable patients (44%) had improvement of ≥1 AIS grade at 6 months (primary end point) to AIS B (n = 5) or AIS C (n = 2). Three patients with AIS B at 6 months had further neurological improvement to AIS C by 12 (n = 2) and 24 (n = 1) months, respectively; none have deteriorated per latest available follow-up. No unanticipated or serious adverse device effects were reported.

CONCLUSION

In this small group of patients with complete thoracic SCI, acute NSS implantation within the spinal cord appeared to be safe with no long-term neurological issues identified during the 24-month follow-up. Patients remain stable, with additional AIS conversions observed in some patients at 12 months and beyond. These data further support the safety and probable benefit of NSS implantation in this patient population.

Rehabilitation processes, stress and depression in patients with spinal cord injury during the COVID-19 pandemic in Turkey: a telephone survey

Background/Aims

Spinal cord injury is a chronic disease that can develop various complications and multisystem dysfunctions. Patients with spinal cord injury need long-term follow up and rehabilitation. During the COVID-19 pandemic, people had to observe social distancing and stay at home. The aim of this study was to evaluate the effects of the COVID-19 pandemic on the rehabilitation and health status of patients with spinal cord injury and assesses their stress levels and depression status.

Methods

A telephone-based survey was conducted with patients followed up by a spinal cord injury outpatient clinic about rehabilitation processes and any health problems experienced. Stress levels were assessed using the Perceived Stress Scale, while depression was assessed using the Beck Depression Inventory. Demographic characteristics, American Spinal Injury Association Impairment Scale levels, Functional Ambulation Categories and Spinal Cord Independence Measure scores were retrieved from the patients' files.

Results

The study included 115 patients, none of whom had contracted COVID-19. Of these patients, 44.3% joined the rehabilitation programme before the pandemic, and 3.5% had been able to participate in the rehabilitation programme during the pandemic. An increase in spasticity was recorded in 43.5% of the respondents, an increase of neuropathic pain was recorded in 37.4% of patients and complaints of neurogenic bladder and neurogenic bowel increased by 26.1% and 16.5% respectively. In addition, 4.3% reported novel decubitus ulcers, while 5.2% reported having experienced autonomic dysreflexia episodes. The Perceived Stress Scale scores were 18.32 ± 5.91. No significant difference was detected between the Beck Depression Inventory scores taken at the time of the study and those recorded before the pandemic.

Conclusions

An insufficiency in the rehabilitation process was noted among patients with spinal cord injuries, accompanied by increased complications. New approaches need to be developed to ensure that the rehabilitation processes of patients with spinal cord injury are not interrupted during a pandemic, and that patients' mental health is not ignored.

An observational study on body mass index during rehabilitation and follow-up in people with spinal cord injury in Denmark

STUDY DESIGN

Observational study OBJECTIVE: To describe body mass index (BMI) during rehabilitation in people with a newly sustained spinal cord injury (SCI).

SETTING

Inpatient SCI rehabilitation in Denmark.

PARTICIPANTS

Inpatients, >18 years, having sustained a SCI within the last 12 months at admission to primary rehabilitation, inclusive of various SCI etiology, neurological level, completeness of the lesion or mobility status.

METHODS

Measures of BMI were obtained at admission and discharge as part of standard care. At one SCI center measures of BMI were sampled at follow up 9.5 months after discharge as well. BMI was described by mean and standard deviation (SD). Paired t-test was used to test difference in BMI between admission and discharge. Repeated measures Analysis of Variance (ANOVA) was used for analyzing BMI deriving from three time points.

RESULTS

Overall BMI was stable with no change (25.4 kg/m² at admission and 25.6 kg/m² at discharge) during rehabilitation at the two national centers. In participants with an American Spinal Injury Association (ASIA) Impairment Scale (AIS) D classification, BMI was higher during rehabilitation compared to the other groups and increased significantly (p = 0.008) from discharge to follow up.

CONCLUSIONS

Overall BMI was stable but higher than recommended in people with SCI undergoing rehabilitation at the two national centers in Denmark. Participants with an AIS D SCI were obese according to SCI adjusted BMI and the World Health Organization (WHO) recommendations during rehabilitation and at follow up.

Development and Evaluation of the Korean Version of Hospital-Based Transitional Rehabilitation Program Using Daily Living Home for Spinal Cord Injury

Objective

To develop and evaluate the Korean version of a hospital-based transitional rehabilitation program (TRP), using daily living home for spinal cord injury (SCI) patients.

Methods

In this study, we developed the Korean version of a hospital-based TRP through domestic and overseas surveys and focus group meetings. By applying this to chronic SCI patients, we observed the functional and quality of life (QOL) changes and evaluated the degree of achievement of the core goals set for each patient during hospital-based TRP.

Results

Hospital-based TRP, for 21.8±3.9 days on average, was applied to four chronic SCI patients (two patients with long-term hospital stays and two homebound disabled individuals) with an average injury period of 736.8±185.4 days. The Korean version of the Spinal Cord Independence Measure (49.3±6.9 vs. 62.5±6.0; p<0.05) showed functional improvement at the end of TRP, when compared to that before the TRP. The Korean version of the World Health Organization’s QOL scale, abbreviated version (159.8±36.6 vs. 239.8±36.1; p<0.05), showed improvement in QOL. Goal attainment scaling showed a significant degree of achievement for the core goals through TRP (33.6±4.4 vs. 70.0±2.8; p<0.05). These results confirmed that the effect was maintained 1 month after the end of TRP. Additionally, two patients were successfully discharged after TRP completion, and the other two could start social activities.

Conclusion

The Korean version of the hospital-based TRP, applied to chronic SCI patients, showed the potential to improve the patients’ functioning and QOL and appeared to be effective in successful discharge and social participation.

Early Trauma Predictors of Mobility in People with Spinal Cord Injury

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

This study aims to assess the potential value of very early trauma variables such as Abbreviated Injury Scale (AIS) and the Injury Severity Score for predicting independent ambulation following a traumatic spinal cord injury (TSCI).

SUMMARY OF BACKGROUND DATA

Several models for prediction of ambulation early after TSCI have been published and validated. The vast majority rely on the initial examination of American Spinal Injury Association (ASIA) impairment scale and level of injury; however, in many locations and clinical situations this examination is not feasible early after the injury.

METHODS

Patient characteristics, trauma data, and ASIA scores on admission to rehabilitation were collected for each of the 144 individuals in the study. Outcome measure was the indoor mobility item of the Spinal Cord Independence Measure taken upon discharge from rehabilitation. Univariate and multivariable models were created for each predictor, Odds ratios (ORs) were obtained by a multivariable logistic regression analysis, and area under the receiver operator curve was calculated for each model.

RESULTS

We observed a significant correlation between the trauma variables and independent ambulation upon discharge from rehabilitation. Of the early variables, the AIS for the spine region showed the strongest correlation.

CONCLUSION

These findings support using preliminary trauma variables for early prognostication of ambulation following a TSCI, allowing for tailored individual interventions.Level of Evidence: 3.

Contralateral Axon Sprouting but Not Ipsilateral Regeneration Is Responsible for Spontaneous Locomotor Recovery Post Spinal Cord Hemisection

Spinal cord injury (SCI) usually results in permanent functional impairment and is considered a worldwide medical problem. However, both motor and sensory functions can spontaneously recover to varying extents in humans and animals with incomplete SCI. This study observed a significant spontaneous hindlimb locomotor recovery in Sprague-Dawley rats at four weeks after post-right-side spinal cord hemisection at thoracic 8 (T8). To verify whether the above spontaneous recovery derives from the ipsilateral axonal or neuronal regeneration to reconnect the lesion site, we resected either the scar tissue or right side T7 spinal cord at five weeks post-T8 hemisected injury. The results showed that the spontaneously achieved right hindlimb locomotor function had little change after resection. Furthermore, when T7 left hemisection was performed five weeks after the initial injury, the spontaneously achieved right hindlimb locomotor function was dramatically abolished. A similar result could also be observed when T7 transection was performed after the initial hemisection. The results indicated that it might be the contralateral axonal remolding rather than the ipsilateral axonal or neuronal regeneration beyond the lesion site responsible for the spontaneous hindlimb locomotor recovery. The immunostaining analyses and corticospinal tracts (CSTs) tracing results confirmed this hypothesis. We detected no substantial neuronal and CST regeneration throughout the lesion site; however, significantly more CST fibers were observed to sprout from the contralateral side at the lumbar 4 (L4) spinal cord in the hemisection model rats than in intact ones. In conclusion, this study verified that contralateral CST sprouting, but not ipsilateral CST or neuronal regeneration, is primarily responsible for the spontaneous locomotor recovery in hemisection SCI rats.

Perioperative major neurologic deficits as a complication of spine surgery

STUDY DESIGN

Retrospective review of spine surgery patients with new major neurologic complication.

OBJECTIVE

To define the causes and severity of new neurologic damage to the spinal cord or cauda equina caused by spinal surgery.

MATERIALS AND METHODS

Consult records were reviewed for all postoperative spine surgery patients referred to a tertiary spinal cord injury rehabilitation center over a 12-year period. Any patients with a new perioperative surgery-related decrement in American Spinal Injury Association (ASIA) Impairment Scale (AIS), loss of bowel or bladder function, or loss of ability to ambulate were examined and final 1-year gaps for neurologic loss reported.

RESULTS

64 patients had a new perioperative major neurologic event with: 41% thoracic, 39% cervical, and 20% lumbar; 61% intraoperative, 31% in the immediate 2-week postoperative period, 8% unknown. Chronic myelopathy (44%) was the most common indication. The causes of neurologic injury were postoperative fluid collection (25%), malposition of instrumentation (14%), traumatic decompression (14%), cord infarct (11%), deformity correction (2%), and unknown (34%). Overall, 87% lost the ability to ambulate and 66% lost volitional bowel-bladder control. AIS decrement and loss of ambulation and bowel-bladder function did not differ statistically significantly by surgical indication. However, among the main root causes, traumatic decompressions and cord infarcts had significantly worse neurologic deterioration than fluid collections or malposition of instrumentation.

CONCLUSION

The relative rate of major neurologic injury in spine surgery is higher in thoracic and cervical cases at spinal cord levels, especially when done for myelopathy, even though lumbar surgeries are most common. The most common causes of neurologic injury were potentially avoidable postoperative fluid collections, malposition of instrumentation, and traumatic decompression.

Walking Ability Outcome Measures in Individuals with Spinal Cord Injury: A Systematic Review

Walking function recovery in spinal cord injury (SCI) is tackled through several therapeutic approaches in which precise evaluation is essential. A systematic review was performed to provide an updated qualitative review of walking ability outcome measures in SCI and to analyze their psychometric properties. PubMed, Cochrane, and PEDro databases were consulted until 1 April 2020. Seventeen articles written in English were included. Five of them studied the walking index for SCI, four studied the 10 meter walk test, and two studied the six-minute walk test, the timed Up and go test, and the Berg balance scale. The rest of the articles studied the following metrics: gait profile score, spinal cord injury functional ambulation profile, five times sit-to-stand test, spinal cord injury functional ambulation inventory, spinal cord independence measure (indoors and outdoors mobility items), locomotor stages in spinal cord injury, community balance and mobility scale, and activity-based balance level evaluation scale. The choice of a single or a set of metrics should be determined by the clinician. Based on the results obtained in this review, a combination of outcome measures is proposed to assess walking ability. Future work is required to integrate a more realistic environment for walking assessment.

Urinary biomarkers indicative of recovery from spinal cord injury: A pilot study

Current assessments of recovery following spinal cord injury (SCI) focus on clinical outcome measures. These assessments bear an inherent risk of bias, emphasizing the need for more reliable prognostic biomarkers to measure SCI severity. This study evaluated fluid biomarkers as an objective tool to aid with prognosticating outcomes following SCI. Using a 1H nuclear magnetic resonance (NMR)-based quantitative metabolomics approach of urine samples, the objectives were to determine (a) if alterations in metabolic profiles reflect the extent of recovery of individual SCI patients, (b) whether changes in urine metabolites correlate to patient outcomes, and (c) whether biological pathway analysis reflects mechanisms of neural damage and repair. An inception cohort exploratory pilot study collected morning urine samples from male SCI patients (n=6) following injury and again at 6-months post-injury. A 700 MHz Bruker Avance III HD NMR spectrometer was used to acquire the metabolic signatures of urine samples, which were used to derive metabolic pathways. Multivariate statistical analyses were used to identify changes in metabolic signatures, which were correlated to clinical outcomes in the Spinal Cord Independence Measure (SCIM). Among SCI-induced metabolic changes, biomarkers which significantly correlated to patient SCIM scores included caffeine (R = -0.76, p < 0.01), 3-hydroxymandelic acid (R= -0.85, p < 0.001), L-valine (R = 0.90, p < 0.001; R = -0.64, p < 0.05), and N-methylhydantoin (R = -0.90, p < 0.001). The most affected pathway was purine metabolism. These findings indicate that urinary metabolites reflect SCI lesion severity and recovery and provide potentially prognostic biomarkers of SCI outcome in precision medicine approaches.

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.

Updated Review: The Steroid Controversy for Management of Spinal Cord Injury

BACKGROUND

Acute spinal cord injury (ASCI) is a devastating event that can have a profound impact on the lives of patients and their families. While no definitive medical treatment exists, the role of methylprednisolone (MP) in the management of ASCI and other spinal cord pathologies has been investigated in depth; however, its use remains contentious. While MP initially showed promise in the efficacy of ASCI treatment, more recent studies have questioned its use citing numerous systemic adverse effects. Pharmacologic treatments in this area are poorly understood due to the scarcity of knowledge surrounding the pathophysiology and heterogeneity of patients presenting with these conditions. Despite these shortcomings and due to the lack of alternative treatment options, MP is still widely used by physicians.

METHODS

We review prior and current literature on the use of MP treatment for ASCI patients with a discussion of novel drug delivery systems that have demonstrated the potential to improve MP's bioavailability at the site of injury while minimizing systemic side effects. In addition, current views on the role of MP and dexamethasone in metastatic spinal cord compression and postoperative infection are reviewed.

RESULTS

While some data support benefits in the use of steroids on spinal cord pathology, extensive research suggests at best limited effects and an unresolvable risk/benefit problem.

CONCLUSIONS

At present, evidence regarding use of dexamethasone for MSCC is contentious, especially regarding dose regiments. Ultimately, further investigation into the use of steroids is required to determine its utility in treating patients with spinal cord pathology.

Trends in Demographics and Markers of Injury Severity in Traumatic Cervical Spinal Cord Injury

Over the past four decades, there have been progressive changes in the epidemiology of traumatic spinal cord injury (tSCI). We assessed trends in demographic and injury-related variables in traumatic cervical spinal cord injury (tCSCI) patients over an 18-year period at a single Level I trauma center. We included all magnetic resonance imaging-confirmed tCSCI patients ≥15 years of age for years 2001-2018. Among 1420 patients, 78.3% were male with a mean age 51.5 years. Etiology included falls (46.9%), motor vehicle collisions (MVCs; 34.2%), and sports injuries (10.9%). Median American Spinal Injury Association (ASIA) Motor Score (AMS) was 44, complete tCSCI was noted in 29.6% of patients, fracture dislocations were noted in 44.7%, and median intramedullary lesion length (IMLL) was 30.8 mm (complete injuries 56.3 mm and incomplete injuries 27.4 mm). Over the study period, mean age and proportion of falls increased (p < 0.001) whereas proportion attributable to MVCs and sports injuries decreased (p < 0.001). Incomplete injuries, AMS, and the proportion of patients with no fracture dislocations increased whereas complete injuries decreased significantly. IMLL declined (p = 0.17) and proportion with hematomyelia did not change significantly. In adjusted regression models, increase in age and decreases in prevalence of MVC mechanism and complete injuries over time remained statistically significant. Changes in demographic and injury-related characteristics of tCSCI patients over time may help explain the observed improvement in outcomes. Further, improved clinical outcomes and drop in IMLL may reflect improvements in initial risk assessment and pre-hospital management, advances in healthcare delivery, and preventive measures including public education.

Predictive Value of Midsagittal Tissue Bridges on Functional Recovery After Spinal Cord Injury

Background

The majority of patients with spinal cord injury (SCI) have anatomically incomplete lesions and present with preserved tissue bridges, yet their outcomes vary.

Objective

To assess the predictive value of the anatomical location (ventral/dorsal) and width of preserved midsagittal tissue bridges for American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion and SCI patient stratification into recovery-specific subgroups.

Methods

This retrospective longitudinal study includes 70 patients (56 men, age: 52.36 ± 18.58 years) with subacute (ie, 1 month) SCI (45 tetraplegics, 25 paraplegics), 1-month neuroimaging data, and 1-month and 12-month clinical data. One-month midsagittal T2-weighted scans were used to determine the location and width of tissue bridges. Their associations with functional outcomes were assessed using partial correlation and unbiased recursive partitioning conditional inference tree (URP-CTREE).

Results

Fifty-seven (81.4%) of 70 patients had tissue bridges (2.53 ± 2.04 mm) at 1-month post-SCI. Larger ventral (P = .001, r = 0.511) and dorsal (P < .001, r = 0.546) tissue bridges were associated with higher AIS conversion rates 12 months post-SCI (n = 39). URP-CTREE analysis identified 1-month ventral tissue bridges as predictors of 12-month total motor scores (0.4 mm cutoff, P = .008), recovery of upper extremity motor scores at 12 months (1.82 mm cutoff, P = .002), 12-month pin-prick scores (1.4 mm cutoff, P = .018), and dorsal tissue bridges at 1 month as predictors of 12-month Spinal Cord Independence Measure scores (0.5 mm cutoff, P = .003).

Conclusions

Midsagittal tissue bridges add predictive value to baseline clinical measures for post-SCI recovery. Based on tissue bridges’ width, patients can be classified into subgroups of clinical recovery profiles. Midsagittal tissue bridges provide means to optimize patient stratification in clinical trials.

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

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

Longitudinal Assessment of Autonomic Function during the Acute Phase of Spinal Cord Injury: Use of Low-Frequency Blood Pressure Variability as a Quantitative Measure of Autonomic Function

High-level spinal cord injury (SCI) can disrupt cardiovascular autonomic function. However, the evolution of cardiovascular autonomic function in the acute phase following injury is unknown. We evaluated the timing, severity, progression, and implications of cardiovascular autonomic injury following acute SCI. We tested 63 individuals with acute traumatic SCI (aged 48 ± 2 years) at five time-points: <2 weeks, and 1, 3, 6-12, and >12 months post-injury. Supine beat-to-beat systolic arterial pressure (SAP) and R-R interval (RRI) were recorded and low-frequency variability (LF SAP and LF RRI) determined. Cross-spectral analyses were used to determine baroreflex function (low frequency) and cardiorespiratory interactions (high frequency). Known electrocardiographic (ECG) markers for arrhythmia and self-reported symptoms of cardiovascular dysfunction were determined. Comparisons were made with historical data from individuals with chronic SCI and able-bodied controls. Most individuals had high-level (74%) motor/sensory incomplete (63%) lesions. All participants had decreased LF SAP at <2 weeks (2.22 ± 0.65 mm Hg²). Autonomic injury was defined as high-level SCI with LF SAP <2 mm Hg². Two distinct groups emerged by 1 month: autonomically complete SCI with sustained low LF SAP (0.76 ± 0.17 mm Hg²) and autonomically incomplete SCI with increased LF SAP (5.46 ± 1.0 mm Hg², p < 0.05). Autonomically complete injuries did not recover over time. Cardiovascular symptoms were prevalent and worsened with time, especially in those with autonomically complete lesions, and chronic SCI. Baroreflex function and cardiorespiratory interactions were impaired after SCI. Risk of arrhythmia increased immediately after SCI, and remained elevated throughout the acute phase. Acute SCI is associated with severe cardiovascular dysfunction. LF SAP provides a simple, non-invasive, translatable, quantitative assessment of autonomic function, and is most informative 1 month after injury.

The effect of age and injury severity on clinical prediction rules for ambulation among individuals with spinal cord injury

BACKGROUND CONTEXT

While several models for predicting independent ambulation early after traumatic spinal cord injury (SCI) based upon age and specific motor and sensory level findings have been published and validated, their accuracy, especially in individual American Spinal Injury Association [ASIA] Impairment Scale (AIS) classifications, has been questioned. Further, although age is widely used in prediction rules, its role and possible modifications have not been adequately evaluated until now.

PURPOSE

To evaluate the predictive accuracy of existing clinical prediction rules for independent ambulation among individuals at spinal cord injury model systems (SCIMS) Centers as well as the effect of modifying the age parameter from a cutoff of 65 years to 50 years.

STUDY DESIGN

Retrospective analysis of a longitudinal database.

PATIENT SAMPLE

Adult individuals with traumatic SCI.

OUTCOME MEASURES

The FIM locomotor score was used to assess independent walking ability at the 1-year follow-up.

METHODS

In all, 639 patients were enrolled in the SCIMS database between 2011 and 2015, with complete neurological examination data within 15 days following the injury and a follow-up assessment with functional independence measure (FIM) at 1-year post injury. Two previously validated logistic regression models were evaluated for their ability to predict independent walking at 1-year post injury with participants in the SCIMS database. Area under the receiver operating curve (AUC) was calculated for the individual AIS categories and for different age groups. Prediction accuracy was also calculated for a new modified LR model (with cut-off age of 50).

RESULTS

Overall AUC for each of the previous prediction models was found to be consistent with previous reports (0.919 and 0.904). AUCs for grouped AIS levels (A+D, B+C) were consistent with prior reports, moreover, prediction for individual AIS grades continued to reveal lower values. AUCs by different age categories showed a decline in prognostication accuracy with an increase in age, with statistically significant improvement of AUC when age-cut off was reduced to 50.

CONCLUSIONS

We confirmed previous results that former prediction models achieve strong prognostic accuracy by combining AIS subgroups, yet prognostication of the separate AIS groups is less accurate. Further, prognostication of persons with AIS B+C, for whom a clinical prediction model has arguably greater clinical utility, is less accurate than those with AIS A+D. Our findings emphasize that age is an important factor in prognosticating ambulation following SCI. Prediction accuracy declines for older individuals compared with younger ones. To improve prediction of independent ambulation, the age of 50 years may be a better cutoff instead of age of 65.

The test-retest reliability of individualized VO2peak test modalities in people with spinal cord injury undergoing rehabilitation

STUDY DESIGN

Test-retest study.

OBJECTIVE

To describe the test-retest reliability of an individualized approach for peak oxygen uptake (VO₂peak) testing in a clinical context, accommodating inpatients with heterogeneous levels of physical functioning.

SETTING

Inpatient rehabilitation.

METHOD

Test-retest on two types of devices (recumbent stepper and arm-crank ergometer) with two predefined protocols of varying load increments on each device. No participants performed all four test modalities. VO₂peak, respiratory exchange ratio (RER), peak workload, and the reason for termination were reported. Of 23 participants included, 21 completed the test-retest procedure. Participants were inpatients, ≥18 years, who sustained a spinal cord injury (SCI) within the last 12 months at the time of admission. The median age was 52 years and 74% were male. Median time since injury at the time of the first test (T1) was 5.5 months. Seventeen were classified as American Spinal Injury Association Impairment Scale D. Intraclass correlation coefficients (ICC) and Bland-Altman plots for VO₂peak was calculated to determine intra- and intertester reliability of VO₂peak.

RESULTS

Mean VO₂peak obtained at T1 was 1.91 L/min (95%CI: 1.31-2.51); 1.26 L/min and 2.69 L/min for the recumbent stepper protocols; 0.61 L/min and 1.39 L/min for the arm-crank ergometer protocols. ICC for intra- and intertester reliability was 0.997 (95%CI: 0.986-0.999) and 0.994 (95%CI: 0.978-0.998) respectively. Bland-Altman plots showed a mean difference of -0.005 (SD 0,12) for overall test-retest.

CONCLUSION

Test-retest reliability was high. Mean VO₂peak at discharge from rehabilitation was higher than previously reported and individualized test modalities seemed to yield more optimal results in a heterogenous and representative sample during rehabilitation.

Anatomical Plasticity of Rostrally Terminating Axons as a Possible Bridging Substrate across a Spinal Injury

Transfer of information across a spinal lesion is required for many aspects of recovery across diverse motor systems. Our understanding of axonal plasticity and which subpopulations of neurons may contribute to bridging substrates following injury, however, remains relatively incomplete. Most recently, attention has been directed to propriospinal neurons (PSNs), with research suggesting that they are capable of bridging a spinal lesion in rodents. In the current study, subpopulations of both long (C5) and short (T6, T8) PSNs-as well as a supraspinal system, the rubrospinal tract (RST)-were assessed following low thoracic (T9) hemisection in the cat using the retrograde tracer Fluoro-Gold. Acutely, within 2 weeks post-hemisection, the numbers of short and long PSNs, as well as contralateral RST neurons, with axons crossing the lesion were significantly decreased relative to uninjured controls. This decrease persisted bilaterally and was permanent in the long PSNs and the contralateral red nucleus (RN). However, by 16 weeks post-hemisection, the numbers of ipsilesional and contralesional short PSNs bridging the lesion were significantly increased. Further, the number of contralesional contributing short PSNs was significantly greater in injured animals than in uninjured animals. A significant increase over uninjured numbers also was seen in the ipsilateral (non-axotomized) RN. These findings suggest that a novel substrate of undamaged axons, which normally terminates rostral to the lesion, grows past a thoracic lesion after injury. This rostral population represents a major component of the bridging substrate seen and may represent an important anatomical target for evolving rehabilitation approaches as a substrate capable of contributing to functional recovery.

Association Between SCIM III Total Scores and Individual Item Scores to Predict Independence With ADLs in Persons With Spinal Cord Injury

Objective

To clarify the activities of daily living (ADL) structure of persons with spinal cord injury (SCI) by analyzing the associations between the Spinal Cord Independence Measure III (SCIM III) total score and individual SCIM III item scores.

Design

A retrospective survey.

Setting

A national hospital with 2 SCI units in Japan.

Participants

Inpatients (N=81) within 60 days of SCI onset were included (men, 84%). The mean age was 62 years. Of these, 63 persons had incomplete SCI (47 persons had tetraplegia).

Interventions

Not applicable.

Main Outcome Measure

SCIM III was used to assess the ADL independence level on a monthly basis during hospitalization. SCIM III data were analyzed with ordinal logistic analyses.

Results

The analyses revealed that SCIM III total scores accounted for the probabilities of individual SCIM III item scores. Goodness-of-fit of each logistic model by Wald test was significant (P<.001, R²_McFadden=0.183-0.598). Some items in the self-care domain showed a shallow (ie, less steep) logistic curve. Regarding the feeding item, a total score of 80 was needed to attain the complete independence level, while patients with a total score >10 attained modified independence level.

Conclusions

The SCIM III total score can provide information on the probability and degree of difficulty of attaining independence for each item. Therefore, the present total SCIM III scores could be the indication for ADL attainment. In addition, the higher total SCIM III score and the probability of individual items score are useful for planning efficient rehabilitative approaches, considering the degree of difficulty of attaining independence for each item. Moreover, our results show good generalizability across patients with complete and incomplete SCI.

Clinical Implementation of Novel Spinal Cord Perfusion Pressure Protocol in Acute Traumatic Spinal Cord Injury at U.S. Level I Trauma Center: TRACK-SCI Study

OBJECTIVE

We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center.

METHODS

Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A-C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day 7.

RESULTS

Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A-C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care.

CONCLUSIONS

In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.

Relationship of American Spinal Injury Association Impairment Scale Grade to Post-injury Hospitalization and Costs in Thoracic Spinal Cord Injury

BACKGROUND

The lifetime economic burden of thoracic spinal cord injury (SCI) is known to be high, but evidence of variability of costs in relation to the American Spinal Injury Association Impairment Scale (AIS) grade is limited.

OBJECTIVE

To estimate lifetime economic costs of hospitalization by AIS grade in thoracic SCI.

METHODS

Using SCI Model Systems data from January 2000 to March 2016 from the National Spinal Cord Injury Statistical Center, we estimated mean total annual days of all-cause hospitalization by AIS grade among persons with thoracic SCI, based on assessments 1, 5, and 10 yr post-injury. We combined this information with secondary cost data and projections of life expectancy to estimate lifetime economic costs of hospitalization by AIS grade in persons aged 35 yr at time of thoracic SCI. Future costs were discounted to present value at 3% annually.

RESULTS

One year post-injury, mean total annual days of hospitalization ranged from 2.1 for persons with AIS-D injuries to 5.9 for those who were AIS-A. Similar differences were noted 5 and 10 yr post-SCI. The estimated net present value of expected lifetime costs of hospitalization following thoracic SCI at age 35 yr was $321 534, $249 514, $188 989, and $68 120 (2015 US$) for AIS-A, AIS-B, AIS-C, and AIS-D injuries, respectively.

CONCLUSION

Persons with less severe thoracic SCI, as reflected in AIS grade, spend fewer days in hospital over their lifetimes, leading to lower costs of inpatient care. Therapies improving AIS grade following thoracic SCI may provide cost savings in addition to addressing substantial unmet need.

Epidemiology of War-Related Spinal Cord Injury Among Combatants: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

War-related spinal cord injuries (SCIs) are commonly more severe and complex than traumatic SCIs among civilians. This systematic review, for the first time, synthesized and critically appraised the literature on the epidemiology of war-related SCIs. This review aimed to identify distinct features from the civilian SCIs that can have an impact on the management of military and civilian SCIs.

METHODS

Medline, EMBASE, and PsycINFO databases were searched for articles on epidemiology of war-related SCI among combatants, published from 1946 to December 20, 2017. This review included only original publications on epidemiological aspects of SCIs that occur during an act of war. The STROBE statement was used to examine the quality of the publications.

RESULTS

The literature search identified 1594 publications, of which 25 articles fulfilled the inclusion and exclusion criteria. The studies were classified into the following topics: 17 articles reported demographics, level and severity of SCI, mechanism of injury and/or associated bodily injuries; 5 articles reported the incidence of war-related SCI; and 6 articles reported the frequency of SCI among other war-related bodily injuries. Overall, military personnel with war-related SCI were typically young, white men, with predominantly thoracic or lumbar level, complete (American Spinal Injury Association [ASIA] Impairment Scale A) SCI due to gunshot or explosion and often associated with other bodily injuries. Marines appear to be at a greater risk of war-related SCI than the military personal in the Army, Navy, and Air Force.

CONCLUSIONS

The war-related SCIs among soldiers are distinct from the traumatic SCI in the general population. The majority of the current literature is based on the American experiences in most recent wars.

Application of electrophysiological measures in spinal cord injury clinical trials: a narrative review

STUDY DESIGN

Narrative review.

OBJECTIVES

To discuss how electrophysiology may contribute to future clinical trials in spinal cord injury (SCI) in terms of: (1) improvement of SCI diagnosis, patient stratification and determination of exclusion criteria; (2) the assessment of adverse events; and (3) detection of therapeutic effects following an intervention.

METHODS

An international expert panel for electrophysiological measures in SCI searched and discussed the literature focused on the topic.

RESULTS

Electrophysiology represents a valid method to detect, track, and quantify readouts of nerve functions including signal conduction, e.g., evoked potentials testing long spinal tracts, and neural processing, e.g., reflex testing. Furthermore, electrophysiological measures can predict functional outcomes and thereby guide rehabilitation programs and therapeutic interventions for clinical studies.

CONCLUSION

Objective and quantitative measures of sensory, motor, and autonomic function based on electrophysiological techniques are promising tools to inform and improve future SCI trials. Complementing clinical outcome measures, electrophysiological recordings can improve the SCI diagnosis and patient stratification, as well as the detection of both beneficial and adverse events. Specifically composed electrophysiological measures can be used to characterize the topography and completeness of SCI and reveal neuronal integrity below the lesion, a prerequisite for the success of any interventional trial. Further validation of electrophysiological tools with regard to their validity, reliability, and sensitivity are needed in order to become routinely applied in clinical SCI trials.

Ulnar nerve integrity predicts 1-year outcome in cervical spinal cord injury

Background

Accurate predictors of neurological recovery after cervical spinal cord injury are needed. Particularly, to tailor adequate rehabilitation plans. However, objective and quantifiable predictors are sparse.

Methods

Within the prospective European Multicenter Study about Spinal Cord Injury (EMSCI) registry, cervical spinal cord injury patients are monitored at fixed follow up visits (2, 4, 12, 24, and 48 weeks after injury) clinically and with ulnar nerve electroneurography. Associations of ulnar nerve compound muscle action potential amplitudes (CMAP) with American Spinal Cord Injury Association (ASIA) impairment scale (AIS) grades over time were analyzed using linear mixed modeling. Applying logistic regression, the prognostic value of within 4-week ulnar nerve CMAP for 1-year AIS was analyzed. To account for missing data, (1) last observation carried forward and (2) multiple imputation methods were applied. For model derivation, our centers’ cohort (EMSCI-HD) was analyzed. For model validation the cohort of other centers (EMSCI-nonHD) was used.

Results

In the EMSCI-HD cohort, the median age (interquartile range (IQR)) was 52 (34–67) years. 58% were male. The initial AIS distribution was: A = 31%, B = 17%, C = 30%, and D = 22%). In the EMSCI-nonHD cohort, the median age was 49 (32–65) years. Compared to the EMSCI-HD cohort more patients were male (79%, p = 0.0034). The AIS distribution was: A = 33%, B = 13%, C = 21%, and D = 33%).

In complete-case mixed model analyses (EMSCI-HD: n = 114; EMSCI-nonHD: n = 508) higher ulnar nerve CMAP were associated with better AIS grades over the entire follow up period. In complete-case logistic regression (EMSCI-HD: n = 90; EMSCI-nonHD: n = 444) higher ulnar nerve CMAP was an independent predictor of better AIS grades. The odds ratio for within 4-week ulnar nerve CMAP to predict 1-year AIS grade D versus A-C in the EMSCI-HD cohort was 1.24 per millivolt (confidence interval 1.07–1.44). The model was validated in an independent cervical spinal cord injury (EMSCI-nonHD) cohort (odds ratio 1.09, confidence interval 1.03–1.17).

Conclusions

In cervical spinal cord injury, the consideration of early ulnar nerve CMAP improves prognostic accuracy, which is of particular importance in patients with clinical grading uncertainties.

Electronic supplementary material

The online version of this article (10.1186/s42466-019-0017-1) contains supplementary material, which is available to authorized users.

Understanding and modelling the economic impact of spinal cord injuries in the United Kingdom

STUDY DESIGN

Economic modelling analysis.

OBJECTIVES

To determine lifetime direct and indirect costs from initial hospitalisation of all expected new traumatic and non-traumatic spinal cord injuries (SCI) over 12 months.

SETTING

United Kingdom (UK).

METHODS

Incidence-based approach to assessing costs from a societal perspective, including immediate and ongoing health, rehabilitation and long-term care directly attributable to SCI, as well as aids and adaptations, unpaid informal care and participation in employment. The model accounts for differences in injury severity, gender, age at onset and life expectancy.

RESULTS

Lifetime costs for an expected 1270 new cases of SCI per annum conservatively estimated as £1.43 billion (2016 prices). This equates to a mean £1.12 million (median £0.72 million) per SCI case, ranging from £0.47 million (median £0.40 million) for an AIS grade D injury to £1.87 million (median £1.95 million) for tetraplegia AIS A-C grade injuries. Seventy-one percent of lifetime costs potentially are paid by the public purse with remaining costs due to reduced employment and carer time.

CONCLUSIONS

Despite the magnitude of costs, and being comparable with international estimates, this first analysis of SCI costs in the UK is likely to be conservative. Findings are particularly sensitive to the level and costs of long-term home and residential care. The analysis demonstrates how modelling can be used to highlight economic impacts of SCI rapidly to policymakers, illustrate how changes in future patterns of injury influence costs and help inform future economic evaluations of actions to prevent and/or reduce the impact of SCIs.