Recovery of neurologic function after spinal cord injury in Israel

Knowledge, Attitudes, Behavioural Practises, and Psychological Impact Relating to COVID-19 Among People Living With Spinal Cord Injury During In-Patient Rehabilitation in Bangladesh

Aim

The aim of this research is to focus on gaining an insight into the knowledge, attitudes, behavioural practises (KAP), and psychological impact relating to COVID-19 among the people living with spinal cord injury receiving in-patient rehabilitation.

Methods

A prospective, cross-sectional survey of people with SCI (N = 207), who were in active in-patient rehabilitation from two tertiary SCI Rehabilitation Centres in Bangladesh. Data were collected via face-to-face interviews, after voluntary consent, using a pretested, language validated questionnaire on Knowledge, Attitude and Behavioural practises (KAP) and the Depression, Anxiety, Stress Scale (DASS-21). Ethical approval and trial registration were obtained prospectively.

Results

A total of 207 people with SCI responded, among which 87% were men and 13% were women, with a mean age of 34.18 ± 12.9 years. Within the sample group, people living with tetraplegia comprised 33.8%, and people living with paraplegia comprised 66.2%. Overall, 63.8% of the participants were diagnosed with an SCI categorised as ASIA-A. Overall, the “knowledge score” was 8.59 ± 2.3 out of 12, “depression” was 11.18 ± 8, “anxiety” was 7.72 ± 5.1, and “stress” was 9.32 ± 6.7 from a total of 21 scores each category. The strong correlation was between knowledge, DASS scores, and age (p < 0.05). In addition, there was a strong correlation between knowledge, gender (p < 0.05) and education (p < 0.01). Binary logistic regression found a stronger association of knowledge and DASS scores with gender, young age, illiteracy (p < 0.01), and rural residence (p < 0.05). A positive relationship was found between depression and anxiety scores (p < 0.01) and a moderate positive relationship was found between depression and stress scores (p < 0.01). A positive attitude was reported by the majority of participants (p < 0.05). In terms of behavioural practises, participants reported both self and caregiver had followed health advice with regard to consulting health professionals (65.7%), implementing isolation (63.8%), taking droplet precaution care (87.4%), and hygiene care (90.3%).

Conclusion

Participants in this study reported high levels of knowledge, adoption of positive attitudes, and the practise of positive health advisory behaviours related to COVID-19 prevention procedures. However, high levels of depression, anxiety, and stress were also reported. Overall, women and younger participants were more likely to have high KAP, whereas those living in rural areas and with literacy challenges were less likely to report high knowledge scores.

Successful Neurological Recovery with Multimodality Therapy without Surgery for Spinal Metastases from Advanced Gastric Cancer

Advanced gastric cancer with bone metastasis has a very poor prognosis with short median survival. To the best of our knowledge, no reports in literature have described extensive recovery of paralysis with multimodality treatment without surgery in these cases. This report describes the case of a 52-year-old severely paralyzed female patient with spinal metastasis from advanced gastric cancer. She was inoperable, owing to a large thrombus in the inferior vena cava; alternative multimodality treatments, including chemotherapy and radiotherapy, were administered. The paralysis and the bladder and rectal dysfunction improved considerably. In addition, the performance status (PS) and Frankel grade also improved dramatically, from 4 to 1 and grade B to D, respectively. At 1 year after initiation of treatment, she is ambulatory. Patients with poor PS are often offered palliative therapy. However, this case demonstrates that poor PS solely due to paralysis from spinal metastasis may necessitate multimodality treatment instead of palliative care.

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

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

Intrathecal decompression versus epidural decompression in the treatment of severe spinal cord injury in rat model: a randomized, controlled preclinical research

Background

In the setting of severe spinal cord injury (SCI), there is no markedly efficacious clinical therapeutic regimen to improve neurological function. After epidural decompression, as is shown in animal models, the swollen cord against non-elastic dura and elevation of intrathecal pressure may be the main causes of aggravated neurologic function. We performed an intrathecal decompression by longitudinal durotomy to evaluate the neuroprotective effect after severe SCI by comparing with epidural decompression.

Methods

Eighty-four adult male Sprague-Dawley rats were assigned to three groups: sham group (group S), epidural decompression (group C), and intrathecal decompression group (group D). A weight-drop model was performed at T9. The Basso-Beattie-Bresnahan (BBB) score was used to evaluate neurological function. Animals were sacrificed at corresponding time points, and we performed pathohistological examinations including HE staining and immunohistochemical staining (IHC) of glial fibrillary acidic protein (GFAP), neurocan, and ED1 at the epicenter of injured cords. Finally, the lesions were quantitatively analyzed by SPSS 22.0.

Results

The mortality rates were, respectively, 5.55 % (2/36) and 13.9 % (5/36) in groups C and D, and there was no significant difference between groups C and D (P = 0.214). Compared with epidural decompression, intrathecal decompression could obviously improve BBB scores after SCI. HE staining indicated that more white matter was spared, and fewer vacuoles and less axon degradation were observed. The expression peak of GFAP, neurocan, and ED1 occurred at an earlier time and was down-regulated in group D compared to group C.

Conclusions

Our findings based on rat SCI model suggest that intrathecal decompression by longitudinal durotomy can prompt recovery of neurological function, and this neuroprotective mechanism may be related to the down-regulation of GFAP, neurocan, and ED1.

A new grading for easy and concise description of functional status after spinal cord lesions

BACKGROUND

Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes.

STUDY DESIGN

Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS).

OBJECTIVE

To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs).

SETTING

Multi-center study at 13 spinal units in 6 countries.

METHODS

Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them.

RESULTS

Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable.

CONCLUSIONS

A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

Effects of etiology on inpatient rehabilitation outcomes in 65- to 74-year-old patients with incomplete paraplegia from a nontraumatic spinal cord injury

OBJECTIVE

To examine differences in rehabilitation outcomes for older patients with a nontraumatic spinal cord injury (NT-SCI) for 5 etiologic diagnoses: degenerative spinal disease (DSD), malignant spinal tumor, benign spinal tumor, vascular ischemia, and spinal abscess.

DESIGN

Retrospective cohort study that used Medicare claims and assessment data.

SETTING

A total of 479 inpatient rehabilitation hospitals and units.

PATIENTS

A total of 1780 Medicare beneficiaries (65-74 years old) with incomplete paraplegia attributable to NT-SCI who were discharged from inpatient rehabilitation facilities from 2002 through 2005.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Length of stay, discharge Functional Independence Measure (FIM) instrument motor item and subscale scores, and discharge destination.

RESULTS

Demographic characteristics varied by etiology group. Mean +/- SD rehabilitation stays ranged from 13.3 +/- 7.7 days for DSD to 26.4 +/- 13.4 days for vascular ischemia. Adjusted data showed stays differed (P < .001) across etiology groups. Adjusted discharge mean self-care and mobility subscores revealed that patients with DSD and benign tumor were more independent (P < .001) than patients with a malignant tumor or spinal abscess. Patients with vascular ischemia were more dependent (P < .01) in mobility than the DSD and benign tumor groups. Etiologic differences (P < .01) in independence in discharge FIM modifiers for walking (FIM > or = 4), bladder (FIM > or = 6) and bowel management (FIM > or = 6) and bowel accidents/continence (FIM > or = 6), but not bladder accidents (FIM > or = 6), were present. The percent of patients discharged to a community residence ranged from 59.3% to 92.6%. Adjusted data showed that significantly larger percentages (P < .01) of patients in the DSD and malignant tumor groups than in the spinal abscess group were discharged to a community residence (versus nursing home).

CONCLUSION

There are etiologic differences in demographics, rehabilitation length of stay, functional outcomes, and discharge destination in elderly patients with NT-SCI.

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

The neurological severity of a spinal cord injury (SCI) is commonly classified according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS). The aim of this study was to assess the course of the AIS following SCI, and to discern the nature of any changes in the classification that occur. Assessments were performed in a European cohort of SCI patients within 2 weeks and at 1, 3, 6, and 12 months after the initial injury. Overall, about 70% of the patients initially diagnosed as AIS A did not convert, as did 90% of the AIS D patients. When only evaluating patients with complete datasets, 68% did not convert, while the AIS category improved in 30% of patients and deteriorated in 2%. A change in the last sacral segments (40%), motor improvement (31%), sensory improvement (19%), and a change in the neurological level of the SCI (10%) contributed to or accompanied the AIS conversion. When the AIS remained unchanged between successive assessment points, there was no change in the number of muscles graded three or more (NMG3(+)) in 73% of the transitions. An improvement in AIS was associated with a gain in NMG3(+) in 49% of the transitions, while an aggravation in AIS was accompanied by a loss in NMG3(+) in 10% of the transitions. These results, documenting a substantial amount of spontaneous AIS conversions, should be taken into consideration when designing clinical trials to assess the effects of potential new treatments for SCI.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

PURPOSE

To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 at Loewenstein Rehabilitation Hospital, Israel.

METHOD

This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA.

RESULTS

Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay.

CONCLUSIONS

Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Surgical management of pressure ulcers during inpatient neurologic rehabilitation: outcomes for patients with spinal cord disease

BACKGROUND/OBJECTIVE

To study efficacy of surgery in the management of pressure ulcers and evaluate the effect of simultaneous comprehensive rehabilitation in improving outcome.

METHOD

Prospective, follow-up study.

SETTING

Neurologic rehabilitation unit of a tertiary care center.

PARTICIPANTS

Patients with spinal cord diseases who had stage III/IV pressure ulcers underwent surgical reconstruction and inpatient rehabilitation in 2005 with a minimum follow-up duration of 1 year.

OUTCOME MEASURES

Ulcer healing rate, postoperative complications, ulcers recurrence rate, and neurologic (ASIA grade), and functional recovery (Barthel Index).

STATISTICAL ANALYSIS

Frequency analysis and paired t test on SPSS 13.0.

RESULTS

Surgical intervention was carried out in 25 participants (19 men, 6 women), having a total of 39 ulcers (13 Stage III, 23 Stage IV, 3 unstaged). Surgeries performed were debridement (3), split skin grafting (13), and flap mobilization and closure (23). Only 4 participants (16.6%) had initial complications: wound dehiscence (2) and delayed graft healing (2). Follow-up rate was 92.0% (23/25 patients), with a duration of 12 to 21 months (mean, 15.4 +/- 7.45 months), and only 4 participants (17.3%) had ulcer recurrence. The majority of participants (13 of 25; 56.5%) improved neurologically on ASIA grade and functional evaluation on Barthel Index, suggesting statistically significant improvement (P < 0.005).

CONCLUSIONS

All outcome variables showed significant improvement at follow-up with good ulcer healing rate (87.0%), low initial complication (16.6%) and recurrence rates (17.3%), and good neurologic (56.5%) and functional (P < 0.005) recovery. Timely surgical interventions are necessary for Stage III to IV pressure ulcers, and simultaneous inpatient rehabilitation significantly improves outcome of patients with spinal cord disease.

Clinical prognostic factors for bladder function recovery of patients with spinal cord and cauda equina lesions

OBJECTIVE

To investigate the relationship between lesion severity and other clinical factors and bladder function recovery.

PATIENTS AND METHODS

The charts of 269 patients with traumatic and non traumatic spinal cord lesion (SCL) were reviewed and the following information was recorded: lesion to admission time, injury variables, length of stay and neurological status. At five months, urological outcome was assessed by voiding modalities, and urodynamics according to International Continence Society. Logistic approach with univariate and multivariate analysis.

RESULTS

Both ASIA impairment at admission and age were significantly correlated with bladder function outcome. None of the patients with ASIA A impairment at admission reached volitional voiding at five months. ASIA B patients had a 90% lower probability of achieving good bladder control and ASIA C ones a 65% lower than ASIA D patients (p < 0.05). Older patients had a significant lower probability (60%) of achieving volitional voiding than younger ones (p < 0.05). Of the 121 patients with ASIA D impairment at discharge only 78 voided spontaneously and showed a higher frequency of cervical lesions and a lower frequency of detrusor-external sphincter dyssynergia.

DISCUSSION AND CONCLUSION

Bladder recovery in patients with complete SCL is limited. ASIA B patients showed a better neurological recovery and, concurrently, better bladder function recovery than ASIA A patients, thus demonstrating the importance of sensation preservation for recovery. Younger patients show better bladder recovery than older ones, probably because of different efficiency of spinal cord plasticity. Finally, patients with good neurological recovery may not achieve volitional voiding. Patients with bladder function recovery show a higher frequency of central cord and Brown-Sequard syndromes (with better prognosis) and a lower frequency of detrusor-sphincter dyssynergia.

Comparison of functional results in non-traumatic and traumatic spinal cord injury

PURPOSE

This study was conducted primarily to be a descriptive study about non-traumatic (NT) spinal cord injury (SCI) patients, in terms of their demographic and neurological features, and to investigate the complications and efficient results of rehabilitation in this group. The second aim of the study was to conduct a comparison between non-traumatic SCI patients and traumatic SCI patients.

MATERIALS AND METHODS

The design was a retrospective study at a Physical Medicine and Rehabilitation Training and Research center. The study was carried out with 194 patients, of whom 63 had non-traumatic SCI and 131 had traumatic SCI. Main outcome measures were: Demographics, etiology, Functional Independent Measure score, and level of injury.

RESULTS

A total of 32.47% (n = 63) of the patients in the study had a non-traumatic SCI. In traumatic SCI group, the proportion of male patients were significantly more than the proportion of female patients (p = 0.002). Admission FIM score of non-traumatic SCI group was better than the traumatic SCI group (p = 0.004). The comparison of discharge FIM scores between traumatic SCI and non-traumatic SCI groups did not yield any significant results (p = 0.303). However, the comparison of FIM gain between the two groups showed a significant difference (p = 0.03). The most common complication in non-traumatic SCI group was urinary tract infection and this was observed in 25 patients (39.68%).

CONCLUSIONS

The present study showed that there are certain differences between NT and traumatic SCI patients. Therefore, not all SCI patients should be considered to be falling under a single category, and should be divided into groups on the basis of the etiology of the injury. It is important to consider this information while developing the targets and planning of the rehabilitation program.

Survival, neurological recovery and morbidity after spinal cord injuries following road accidents in Israel

DESIGN

A retrospective cohort study.

OBJECTIVE

Assess outcomes in patients with spinal cord injuries (SCI) following road accidents, and factors that affect them.

SETTING

Loewenstein Rehabilitation Hospital, Raanana, Israel.

SUBJECTS

A total of 143 patients admitted for rehabilitation between 1962 and 2004.

METHODS

Survival rates were estimated using the product limit (Kaplan-Meyer) method and their association with risk factors was analyzed with the Cox model. Neurological recovery was determined by comparing the Frankel grade at admission to rehabilitation and at discharge. The relation between recovery and various factors was tested with logistic regression.

RESULTS

The risk of SCI in road accidents is higher among car drivers and motorcycle or bicycle riders. Median survival was 43 years. Survival was negatively associated with age at injury (P<0.0002) and with diagnosis of pressure sores (P=0.0065). Recovery of at least one Frankel grade occurred in 29.1% of patients. Useful recovery (upgrade to Frankel grade D or E) occurred in 23.1% of all patients. Neurological recovery was negatively associated with the severity of neurological deficit (P<0.001) and with thoracic injuries (P=0.046). The most common complications were pressure sores and those of the urinary and respiratory systems.

CONCLUSIONS

In SCI following road accidents, survival rates were higher and recovery rates lower than in mixed types of trauma. This may be related to better compensation followed by better nursing for road accident victims in Israel, which may prevent life-shortening complications, and to more severe injuries caused by road accidents.

Correlation of outcome measures with epidemiological factors in thoracolumbar spinal trauma

BACKGROUND

The epidemiological data of a given population on spinal trauma in India is lacking. The present study was undertaken to evaluate the profile of patients with thoracolumbar fractures in a tertiary care hospital in an urban setup.

MATERIALS AND METHODS

Four hundred forty patients with thoracolumbar spinal injuries admitted from January 1990 to May 2000 to the All India Institute of Medical Sciences were included in the analysis. Both retrospective data retrieval and prospective data evaluation of patients were done from January 1998 to May 2000. Epidemiological factors like age, sex and type of injury, mode of transport, time of reporting and number of transfers before admission were recorded. Frankel's grading was used to assess neurological status. Functional assessment of all patients was done using the FIM™ instrument (Functional Independence Measure). Average followup was 33 months (24-41 months).

RESULTS

Of the 440 patients, females comprised 17.95% (n=79), while 82.04% (n=361) were males. As many as 40.9% (n=180) of them were in the third decade. Fall from height remained the most common cause (n=230, 52.3%). Two hundred sixty (59.1%) patients reported within 48 hours. Thirty-two (7.27%) patients had single transfer, and all 32 showed complete independence for mobility at final followup. 100 of 260 (38.5%) patients reporting within 48 hours developed pressure sores, while 114 of 142 (80.28%) patients reporting after 5 days developed pressure sores.

CONCLUSION

The present study highlights the magnitude of the problems of our trauma-care and transport system and the difference an effective system can make in the care of spinal injury patients. There is an urgent need for epidemiological data on a larger scale to emphasize the need for a better trauma-care system and pave way for adaptation of well-established trauma-care systems from developed countries.

Paragliding accidents with spinal cord injury: 10 years' experience at a single institution

STUDY DESIGN

A retrospective analysis of 41 patients with spinal cord injury (SCI) after paragliding accidents.

OBJECTIVE

To determine the lesioned pattern and prognostic radiologic factors for rehabilitation potential.

SUMMARY OF BACKGROUND DATA

Paragliding accidents with SCI present a new injury pattern, dealt with in the current literature from a purely orthopedic, sports medicine, or insurance point of view. Few combinations of orthopedic and neurologic data are available.

METHODS

Over a 10-year period, the case records of 41 patients with SCI caused by paragliding accidents were analyzed with regard to vertebral and other skeletal fractures, neurologic recovery (American Spine Injury Association score), and professional reintegration.

RESULTS

Vertebral fractures peaked in the thoracolumbar region, with L1 most frequently (30%) affected. The levels of vertebral lesion and neurologic deficit differed in 32% of patients. Combination with lower-limb fractures was characteristic for paragliding SCI (P < 0.001); 93% of patients with initial bony occlusion of the spinal canal of <70% left the clinic ambulatory.

CONCLUSION

Paragliding accidents with SCI show a characteristic injury pattern associated with a high recovery potential if the initial bony spinal canal occlusion is <70%. Half the patients will reintegrate in their former profession and place of employment.

Economic assessment of pressure sore prevention using a computerized mattress system in patients with spinal cord injury

PURPOSE

To assess the economic profitability of a new computerized mattress system in patients with spinal cord injuries (SCI) by comparison with two other alternatives, as an example of the use of a quantitative approach for decision-making in choosing between alternatives for sore prevention.

METHOD

The cost of achieving one day without signs of impending pressure sore was compared between the alternative options using cost minimization analysis. Savings in nursing costs for the three options were calculated for cost-benefit analysis.

RESULTS

A foam mattress system is significantly cheaper than the other examined alternatives, and if the nursing manpower cost is constant and the nursing staff is capable of performing sufficient repositioning, this system would achieve the desired medical outcome at a minimal cost. However, if the nursing staff cannot perform sufficient repositioning, or if the use of nursing manpower can be adjusted to the actual need, then it is the computerized mattress system that achieves the desired outcome at the minimal cost. In this case, less than 20 New Israeli Shekels (NIS) per day spent on the equipment save NIS 45 per day in labor costs.

CONCLUSIONS

The economic evaluation indicates that the computerized mattress system is advisable for patients with SCI who require assistance for repositioning, but its profitability depends on the employment terms of the nursing manpower. In addition, other possible alternative pressure management systems should be examined, and additional research may be needed to determine the optimal combination of such systems for a spinal cord rehabilitation department.

Motor recovery, functional status, and health-related quality of life in patients with complete spinal cord injuries

STUDY DESIGN

A retrospective cohort with cross- sectional follow-up.

OBJECTIVES

The primary objective was to determine motor recovery in patients with complete traumatic spinal cord injury (SCI). Secondary objectives included: 1) determining which factors predict local recovery, 2) assessing functional status using the Functional Independence Measure (FIM), and 3) assessing generic health-related quality of life using the Short Form-36 (SF-36).

SUMMARY OF BACKGROUND DATA

Motor recovery following complete SCI has been documented in the literature; however, it has been difficult to interpret: 1) spinal shock is often not addressed; 2) the definition of complete SCI has changed over the last 10 years; and 3) few studies differentiate between local neurologic recovery in the zone of partial preservation and neurologic recovery caudal to the lesion.

METHODS

All patients admitted to Vancouver Hospital with a complete SCI between 1994 and 2001 were identified and included in the study if they remained complete following the resolution of spinal shock. Minimum 2-year follow-up consisted of an ASIA motor score, an FIM, and the SF-36.

RESULTS

Of 133 patients identified, 94 were eligible and 70 completed follow-up. For the tetraplegic patients, the average ASIA motor score was 11.9 +/- 10.7 on admission and 20.1 +/- 10.8 at follow-up, a change reflecting local recovery only. For the paraplegic patients, the average ASIA motor score was 49.3 +/- 2.4 on admission and 50.6 +/- 1.7 at follow-up.

CONCLUSIONS

Motor recovery does not occur below the zone of injury for patients with complete SCI. Varying degrees of local recovery can be expected in tetraplegic individuals.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

PURPOSE

To evaluate outcome measures and the factors affecting them in patients treated between 1,962 and 2,000 at Loewenstein Rehabilitation Hospital, Israel.

METHOD

This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA.

RESULTS

Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay.

CONCLUSIONS

Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study

OBJECTIVE

To examine what effect the injury-to-rehabilitation interval has on the outcome of spinal cord injury (SCI) rehabilitation.

DESIGN

Retrospective study.

SETTING

Spinal unit of a large rehabilitation hospital.

PARTICIPANTS

Consecutive admissions were divided into groups according to age, sex, and American Spinal Injury Association impairment grade and neurologic level of injury. The patients were matched for these variables and divided into groups according to the interval from injury to admission into acute rehabilitation. This approach resulted in 150 patients with SCI grouped into 50 comparison subgroupings. Interventions Three comparison groups-short (<30 d), medium (31-60 d), and long (>60 d) time to admission (TTA)-were evaluated for rehabilitation outcomes.

MAIN OUTCOME MEASURES

Barthel Index, Rivermead Mobility Index, Walking Index for Spinal Cord Injury, and motor scores at admission and discharge were examined. The changes and efficiencies were evaluated.

RESULTS

The 3 groups were comparable for all medical and demographic characteristics as well as neurologic recovery. The 3 subgroups differed significantly in activity of daily living outcomes, with the short TTA group exhibiting higher Barthel Index raw discharge scores, score increases, and score efficiencies.

CONCLUSIONS

Early rehabilitation seems to be a relevant prognostic factor of functional outcome. Rehabilitation intervention in patients with SCI should begin as soon as possible, in a specialized setting, because delay may adversely affect functional recovery.

Spinal injuries centres (SICs) for acute traumatic spinal cord injury

BACKGROUND

The majority of complications in traumatic spinal cord injury (SCI) can occur in the first 24 hours and it has been suggested that spinal injury centres (SICs) may influence the pre-transfer care of people with SCI. The specialist SIC concept has been adopted in a number of high-income countries. However, even in such countries, a potentially significant number of people with SCI do not have the opportunity to access this system and are managed in a non-specialist environment.

OBJECTIVES

To answer the question: does immediate referral to an SIC result in a better outcome than delayed referral?

SEARCH STRATEGY

The following databases were searched: AMED, CCTR, CINAHL, DARE, EMBASE, HEED, HMIC, MEDLINE, NRR, NHS EED, and PsycLIT. Searches were updated in May 2003 and included the Cochrane Injuries Group Specialist Register. The reference lists of retrieved articles were checked.

SELECTION CRITERIA

Randomised controlled trials and controlled trials that compared immediate referral to an SIC with delayed referral in patients with a traumatic SCI.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies. One reviewer was to have assessed the quality of the studies and extracted data.

MAIN RESULTS

No randomised controlled trials or controlled trials were identified that compared immediate referral to an SIC with delayed referral in patients with a traumatic SCI. All of the studies identified were retrospective observational studies and of poor quality.

REVIEWERS' CONCLUSIONS

The current evidence does not enable conclusions to be drawn about the benefits or disadvantages of immediate referral versus late referral to SICs. Well-designed, prospective experimental studies with appropriately matched controls are needed.

Recovery of neurologic function following nontraumatic spinal cord lesions in Israel

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess neurologic recovery and the manner in which it is affected by various factors following nontraumatic spinal cord lesions (NTSCLs).

SUMMARY OF BACKGROUND DATA

NTSCLs comprise a considerable portion of spinal cord lesions. However, information about neurologic recovery in these lesions is scarce.

METHOD

The study sample included 1,085 patients with NTSCL treated between 1962 and 2000 at the premier referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from hospital charts. The degree of neurologic recovery was determined by comparing each patient's Frankel grades of neurologic deficit at first admission to rehabilitation and at discharge from the same hospitalization. The study population was also compared with previously studied 250 patients with traumatic spinal cord lesions (TSCLs).

RESULTS

Complete or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred during rehabilitation in 51% of patients who were Grade A, B, or C on admission, and in 57% of those who were Grade C. Neurologic recovery in NTSCL during rehabilitation was significantly affected by initial Frankel grade and by NTSCL etiology. Age had a borderline effect. Gender, lesion level, and the decade of rehabilitation did not affect recovery. Recovery rate was usually higher in NTSCLs than in TSCLs.

CONCLUSIONS

The prognosis for neurologic recovery is affected mainly by SCL severity and etiology, and is usually better in NTSCLs than in TSCLs.

Survival after nontraumatic spinal cord lesions in Israel11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To assess survival in patients with nontraumatic spinal cord lesions (SCL).

DESIGN

Retrospective cohort study.

SETTING

Spinal department at a rehabilitation hospital in Israel.

PARTICIPANTS

Patients with nontraumatic SCL (N=1085) admitted between 1962 and 2000.

INTERVENTIONS

Demographic, clinical, and mortality data were collected from hospital charts and from the Population Registry of the Israel Ministry of Internal Affairs.

MAIN OUTCOME MEASURES

Survival rates and mortality risk factors. Measures were estimated by using the product limit (Kaplan-Meier) method and the Cox model.

RESULTS

Maximal survival time was 57 years. Median accumulated survival time was 24 years. Survival was significantly affected by lesion etiology, age, gender, severity of lesion, and recent decade of lesion onset; survival tended to be shorter in patients with higher level SCL. We found no significant difference between the effects of risk factors on mortality in nontraumatic SCL and traumatic SCL, other than the effect of age at lesion onset, which was a greater risk factor in the latter group.

CONCLUSIONS

The survival rate of patients with nontraumatic SCL has improved significantly in Israel in the last decade. The survival rates of a mixed nontraumatic SCL population are similar to those of traumatic SCL but may differ in specific etiologic age groups.

Outcomes in patients admitted for rehabilitation with spinal neurological lesions following intervertebral disc herniation

BACKGROUND

Little information is available about the survival, neurological recovery, and length of stay in hospital for rehabilitation (LOS) of patients with spinal neurological deficit following disc herniation (DH).

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To report on outcomes and factors affecting these.

SETTING

The Spinal Research Laboratory, Loewenstein Rehabilitation Hospital, Israel.

SUBJECTS

A total of 158 patients with DH spinal neurological lesions (DHSNL).

METHOD

Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method; relative mortality risk by the Cox proportional hazard model. Neurological recovery was evaluated by calculating the change in Frankel grades, and factors that affect it were assessed by logistic regression. LOS associations were analyzed with ANOVA.

RESULTS

The median age at lesion onset was 48 years, and the median survival 29 years. Age and gender had a significant effect on survival, but not so lesion severity, level, or decade of onset. Of the 69 patients who had Frankel grades A, B, or C on admission, 72% achieved useful recovery to grades D or E. The severity and level of the spinal neurological lesion (SNL) had a significant effect on recovery. The mean LOS was 87 days; it was significantly affected by lesion severity and level and by the decade of admission to rehabilitation, and decreased with time.

CONCLUSIONS

Patients with DHSNL who were admitted for rehabilitation have favorable survival and recovery rates compared with previously studied patients with other types of SNL. Their LOS is probably a function of medical requirements, but is decreasing with time.

Neurologic recovery of spinal cord injury patients in Italy

OBJECTIVE

To evaluate neurologic recovery of spinal cord lesion patients and its relationship to some lesion and patient features.

DESIGN

Retrospective review of the charts.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

A total of 284 consecutive, newly injured patients were included with evaluation of lesion to admission time, etiology, lesion level, associated injury, medical complications and surgical intervention, length of stay, and American Spinal Injury Association (ASIA) impairment grade and motor scores.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

ASIA impairment grade and motor scores.

RESULTS

Neurologic recovery was present in 27% of the patients. Most patients who improved and reached a functional status (ASIA class D) had an ASIA class C impairment at admission (71/129), versus ASIA class A (2/84) and ASIA class B (5/19). The lesion-to-admission interval was significantly longer in patients who did not improve (73+/-51.2d vs 47.2+/-38.4d, P=.006).

CONCLUSIONS

ASIA impairment designations have prognostic value. Recovery from complete lesions was limited. Patients with ASIA class B impairment at admission had a better prognosis than those with ASIA class A. Patients with ASIA class C at admission had the best neurologic improvement. Finally, ASIA class D patients had lower ASIA grade improvement. Neurologic recovery was negatively associated with patients' age and delayed rehabilitation, but not by other lesion features.