Early Predictors of Neurological Outcomes After Traumatic Spinal Cord Injury: A Systematic Review and Proposal of a Conceptual Framework

Bedside electromyography for clinical assessment of sacral motor and reflex activity adapted for patients hospitalized with acute neurological conditions: a pilot study

STUDY DESIGN

Pilot cohort study.

OBJECTIVE

To develop and implement a sacral electromyographic (sEMG) technique at bedside to ascertain sparing of sacral motor activity and reflexes in patients hospitalized for acute neurological conditions.

SETTING

Hôpital du Sacré-Coeur de Montréal a Canadian Level-1 university trauma center specialized in SCI care.

METHODS

Nine patients underwent digital rectal examination (DRE) and sEMG, assessing voluntary anal contraction and sacral spinal reflexes (bulbocavernosus reflex and the anal wink). Our sEMG technique utilized surface recording electrodes and tactile elicitation of reflexes. EMG signal was acquired at bedside through the Noraxon MR3 system.

RESULTS

It was quick, well accepted and did no harm. We found that contrary to the DRE, sEMG detected subclinical sacral motor activity and reflexes in 20% of cases for voluntary anal contraction and 40% of cases for the anal wink.

CONCLUSION

We believe our sEMG technique is a powerful tool able to enhance management of patients suffering from acute neurological impairments and requiring sacral function assessment.

Classifying clinical phenotypes of functional recovery for acute traumatic spinal cord injury. An observational cohort study

PURPOSE

Identify patient subgroups with different functional outcomes after SCI and study the association between functional status and initial ISNCSCI components.

METHODS

Using CART, we performed an observational cohort study on data from 675 patients enrolled in the Rick-Hansen Registry(RHSCIR) between 2014 and 2019. The outcome was the Spinal Cord Independence Measure (SCIM) and predictors included AIS, NLI, UEMS, LEMS, pinprick(PPSS), and light touch(LTSS) scores. A temporal validation was performed on data from 62 patients treated between 2020 and 2021 in one of the RHSCIR participating centers.

RESULTS

The final CART resulted in four subgroups with increasing totSCIM according to PPSS, LEMS, and UEMS: 1)PPSS < 27(totSCIM = 28.4 ± 16.3); 2)PPSS ≥ 27, LEMS < 1.5, UEMS < 45(totSCIM = 39.5 ± 19.0); 3)PPSS ≥ 27, LEMS < 1.5, UEMS ≥ 45(totSCIM = 57.4 ± 13.8); 4)PPSS ≥ 27, LEMS ≥ 1.5(totSCIM = 66.3 ± 21.7). The validation model performed similarly to the original model. The adjusted R-squared and F-test were respectively 0.556 and 62.2(P-value <0.001) in the development cohort and, 0.520 and 31.9(P-value <0.001) in the validation cohort.

CONCLUSION

Acknowledging the presence of four characteristic subgroups of patients with distinct phenotypes of functional recovery based on PPSS, LEMS, and UEMS could be used by clinicians early after tSCI to plan rehabilitation and establish realistic goals. An improved sensory function could be key for potentiating motor gains, as a PPSS ≥ 27 was a predictor of a good function.

Lower Extremity Somatosensory Evoked Potentials Predict Functional Outcomes in Complete Traumatic Cervical Spinal Cord Injury

BACKGROUND

Traumatic cervical spinal cord injury (tCSCI) is often a debilitating injury, making early prognosis important for medical and surgical planning. Currently, the best early predictors of prognosis are physical examination, imaging studies, and patient demographics. Despite these factors, patient outcomes continue to vary significantly. The purpose of this study was to evaluate the prognostic value of somatosensory evoked potentials (SSEPs) with functional outcomes in tCSCI patients.

METHODS

A retrospective study was conducted on prospectively collected data from 2 academic institutions. Patients 18 years and older who had tCSCI and underwent posterior cervical decompression and stabilization with intraoperative neuromonitoring were reviewed. The outcomes of interest were the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and ASIA motor score at follow-up. Outcomes measures were assessed via student t-tests, chi-squared tests, and multivariable regression analysis.

RESULTS

A total of 79 patients were included. In complete injuries, detectable lower extremity SSEPs were associated with higher ASIA motor scores at follow-up (P = 0.002), greater increases in ASIA motor scores at follow-up (P = 0.009), and a greater likelihood of clinically important improvement in ASIA motor score (P = 0.024). Incomplete, AIS grade C injuries has higher rates of grade conversion (P = 0.019) and clinically important improvement in ASIA motor score (P = 0.010), compared to AIS grade A or B injuries.

CONCLUSIONS

The detection of lower extremity SSEP signals during initial surgical treatment of tCSCI is associated with greater improvement in ASIA motor scores postoperatively. The association is most applicable to patients with complete injury.

Can the Initial Parameters of Functional Scales Predict Recovery in Patients with Complete Spinal Cord Injury? A Retrospective Cohort Study

Regaining greater independence in performing daily activities constitutes a priority for people with tetraplegia following spinal cord injury (SCI). The highest expectations are connected with the improvement of hand function. Therefore, it is so important for the clinician to identify reliable and commonly applicable prognostic factors for functional improvement. The aim of this study was to conduct an analysis to assess the impact of initial functional factors on the clinical improvement in patients during early neurological rehabilitation (ENR). This study assessed 38 patients with complete SCI aged 17-78 who underwent ENR in 2012-2022. The analysis included the motor score from the AIS (MS), the Barthel Index (BI) and the SCIM scale values at the beginning of the ENR program and after its completion. During ENR, patients achieved a statistically significant improvement in MS, BI and SCIM. The initial MS and the level of neurological injury constituted the predictors of functional improvement during ENR. Significant statistical relationships were observed primarily in the correlations between the initial MS and BI, and the increase in the analyzed functional scales of SCI patients. Higher initial MS may increase the chances of a greater and faster functional improvement during ENR.

Research priorities to enhance life for people with spinal cord injury: a Swedish priority setting partnership

STUDY DESIGN

Mixed-method consensus development project.

OBJECTIVE

To identify the top ten research priorities for spinal cord injury (SCI).

SETTING

Nationwide in Sweden in 2021-22.

METHODS

The PSP process proposed by the James Lind Alliance was used. It comprises two main phases: question identification and priority selection. People living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI were included.

RESULTS

In the first phase, 242 respondents provided 431 inputs addressing potentially unanswered questions. Of these, 128 were beyond the scope of this study. The remaining 303 were merged to formulate 57 questions. The literature review found one question answered, so 56 questions proceeded to the prioritisation. In the second phase, the interim prioritisation survey, 276 respondents ranked the 56 questions. The top 24 questions then proceeded to the final prioritisation workshop, at which 23 participants agreed on the top ten priorities.

CONCLUSIONS

This paper reveals issues that people living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI find difficult to get answered. The top-priority questions for people living with SCI in Sweden concern specialist SCI care and rehabilitation, followed by a number of questions addressing physical health. Other topics, from the 56 key questions include Mental health, Ageing with SCI, Community support and personal care assistance, and Body functions. This result can guide researchers to design appropriate studies relevant to people with SCI.

SPONSORSHIP

The project was funded by the Gothenburg Competence Centre for Spinal Cord Injury and the Swedish Association for Survivors of Accident and Injury (RTP).

Meglumine cyclic adenylate improves cardiovascular hemodynamics and motor-function in a rat model of acute T4 thoracic spinal cord injury

STUDY DESIGN

Animal experimental study.

OBJECTIVES

Spinal cord injury (SCI) at or above the T6 level causes cardiovascular dysfunction. Maintaining cAMP levels with cAMP analogs can facilitate neurological recovery. In the present study, the effects of meglumine cyclic adenylate (MCA), a cAMP analog and approved cardiovascular drug, on cardiovascular and neurological recovery in acute T4-SCI in rats were investigated.

SETTING

Hospital in Kunming, China.

METHODS

Eighty rats were randomly allocated to five groups, and groups A-D received SCI: (A) a group administered MCA at 2 mg/kg/d iv qd, (B) a group administered dopamine at 2.5 to 5 μg/kg/min iv to maintain mean arterial pressure above 85 mm Hg, (C) a group administered atropine at 1 mg/kg iv bid, (D) a group receiving an equal volume of saline iv qd for 3 weeks after SCI and (E) a group undergoing laminectomy only. The cardiovascular and behavioral parameters of the rats were examined, and spinal cord tissues were processed for hematoxylin and eosin staining, Nissl staining, electron microscopy, and analysis of cAMP levels.

RESULTS

Compared with dopamine or atropine, MCA significantly reversed the decrease in cAMP levels in both myocardial cells and the injured spinal cord; improved hypotension, bradycardia and behavioral parameters at 6 weeks; and improved spinal cord blood flow and histological structure at 7 days post-SCI. The regression analysis suggested spinal cord motor-function improved as decreased heart rate and mean arterial pressure were stopped post-SCI.

CONCLUSIONS

MCA may be an effective treatment for acute SCI by sustaining cAMP-dependent reparative processes and improving post-SCI cardiovascular dysfunction.

SPONSORSHIP

N/A.

Do all patients with functional motor-incomplete (AIS-D) traumatic spinal cord injury need specialized inpatient functional rehabilitation? A prospective observational cohort study proposing clinical criteria for home-based rehabilitation after acute care

CONTEXT/OBJECTIVE

Functional motor-incomplete AIS-D traumatic spinal cord injury (tSCI) represents an important growing population in neuro-traumatology. There is thus an important need for establishing strategies to optimize SCI rehabilitation resources. This study aims at proposing eligibility criteria to select individuals who could be discharged home (home-based rehabilitation) after acute care following an AIS-D tSCI and investigate its impact on the long-term functional status and quality of life (QOL), as compared to transfer to inpatient functional rehabilitation (IFR) resources.

DESIGN

An observational prospective cohort study.

SETTING

A single Level-1 specialized trauma center.

PARTICIPANTS

213 individuals sustaining an AIS-D tSCI.

INTERVENTIONS

Home-based rehabilitation based on clinical specific criteria to be assessed by the acute care team.

OUTCOME MEASURES

Functional status and QOL as assessed by the Spinal Cord Independence Measure version 3 and WHOQOL-BREF questionnaire one year following the injury, respectively.

RESULTS

A total 37.9% of individuals fulfilled proposed criteria for home-based rehabilitation after acute care. As expected, this group was significantly younger, experienced lesser comorbidities and acute complications, and showed higher motor and sensory function compared to the IFR group. Home-rehabilitation was associated with a higher long-term functional status, physical and psychological QOL, when accounting for relevant confounding factors after an acute AIS-D tSCI. There was no readmission due to failure of home-based rehabilitation.

CONCLUSION

Home-based rehabilitation in selected individuals sustaining an acute AIS-D tSCI is a safe and interesting strategy to optimize the long-term outcome in terms of functional recovery, physical and psychological QOL, as well as to optimize inpatient rehabilitation resources. The proposed eligibility criteria can be used by the acute care team to select the optimal discharge orientation in this important subpopulation.

Impact of Mechanism of Injury on Long-term Neurological Outcomes of Cervical Sensorimotor Complete Acute Traumatic Spinal Cord Injury

OBJECTIVE

Mechanism of injury is a largely understudied descriptor of acute traumatic spinal cord injury (tSCI). This study sought to compare the impact of high-energy and low-energy mechanisms of injury in neurological outcomes of cervical sensorimotor complete tSCI.

METHODS

Patients with tSCI were identified in 4 prospective, multicenter clinical trials and registries. American Spinal Injury Association Impairment Scale (AIS) grade was assessed ≤ 72 hours postinjury and followed up between 12 to 52 weeks. Patients were included if they had a cervical and sensorimotor complete (AIS-A) injury at baseline. Study outcomes were change in AIS grade and lower extremity motor, upper extremity motor, and total motor scores. Propensity score matching between high-energy mechanisms of injury (HEMI; e.g. , motor vehicle collisions) and low-energy mechanisms of injury (LEMI; e.g. , falls) groups was performed. Adjusted groups were compared with paired t-tests and McNemar test.

RESULTS

Of 667 patients eligible for inclusion, 523 experienced HEMI (78.4%). HEMI patients were younger, had lower body mass index, more associated fractures or dislocations, and lower baseline lower extremity motor scores. After propensity score matching of these baseline variables, 118 pairs were matched. HEMI patients had a significantly worse motor recovery from baseline to follow-up based on their diminished change in upper extremity motor scores and total motor scores.

CONCLUSION

Cervical sensorimotor complete tSCIs from HEMI were associated with significantly lower motor recovery compared to LEMI patients. Our findings suggest that mechanism of injury should be considered in modelling prognosis and in understanding the heterogeneity of outcomes after acute tSCI.

Accuracy of self-reported severity and level of spinal cord injury

Study design

Observational.

Objectives

To assess accuracy of self-reported level of injury (LOI) and severity in individuals with chronic spinal cord injury (SCI) as compared with clinical examination.

Setting

An SCI Model System Hospital.

Methods

A 20-item survey evaluated demographics, physical abilities, and self-reported injury level and severity. A decision tree algorithm used responses to categorize participants into injury severity groups. Following the survey, participants underwent clinical examination to determine current injury level and severity. Participants were later asked three questions regarding S1 sparing. Chart abstraction was utilized to obtain initial injury level and severity. Injury level and severity from self-report, decision tree, clinical exam, and chart abstraction were compared.

Results

Twenty-eight individuals participated. Ninety-three percent correctly self-reported anatomical region of injury (ROI). Self-report of specific LOI matched current clinical LOI for 25% of participants, but matched initial LOI for 61%. Self-report of ASIA Impairment Scale (AIS) matched clinical AIS for 36%, but matched initial AIS for 46%. The injury severity decision tree was 75% accurate without, but 79% accurate with additional S1 questions. Self-report of deep anal pressure (DAP) was correct for 86% of participants, while self-report of voluntary anal contraction (VAC) was correct for 82%.

Conclusion

Individuals with SCI are more accurate reporting ROI than specific LOI. Self-reported injury level and severity align more closely with initial clinical examination results than current exam results. Using aggregate data from multiple questions can categorize injury severity more reliably than self-report. Using this type of decision tree may improve injury severity classification in large survey studies.

Factors for Predicting Instant Neurological Recovery of Patients with Motor Complete Traumatic Spinal Cord Injury

The objective of this study was to analyze the factors affecting the instant recovery of neurological function in patients with motor complete traumatic spinal cord injury (TSCI) treated in hospital. Methods: A retrospective analysis of 1053 patients with TSCI classified according to the American Spinal Cord Injury Association (ASIA) as grades A and B at 59 tertiary hospitals from 1 January 2018 to 31 December 2018 was performed. All patients were classified into motor complete injury (ASIA A or B) and motor incomplete injury (ASIA C or D) groups, according to the ASIA upon discharge. The injury level, fracture segment, fracture type, ASIA score at admission and discharge, treatment protocol, and complications were recorded. Univariate and multivariate analyses were performed to evaluate the relationship between various factors and the recovery of neurological function. Results: The results of multiple logistic regression analysis revealed that the ASIA score on admission (p < 0.001, odds ratio (OR) = 5.722, 95% confidence interval (CI): 4.147−7.895), fracture or dislocation (p = 0.001, OR = 0.523, 95% CI: 0.357−0.767), treatment protocol (p < 0.001; OR = 2.664, 95% CI: 1.689−4.203), and inpatient rehabilitation (p < 0.001, OR = 2.089, 95% CI: 1.501−2.909) were independently associated with the recovery of neurological function. Conclusion: The recovery of neurological function is dependent on the ASIA score on admission, fracture or dislocation, treatment protocol, and inpatient rehabilitation.

Established and Emerging Therapies in Acute Spinal Cord Injury

Acute spinal cord injury (SCI) is devastating for patients and their caretakers and has an annual incidence of 20–50 per million people. Following initial assessment with appropriate physical examination and imaging, patients who are deemed surgical candidates should undergo decompression with stabilization. Earlier intervention can improve neurological recovery in the post-operative period while allowing earlier mobilization. Optimized medical management is paramount to improve outcomes. Emerging strategies for managing SCI in the acute period stem from an evolving understanding of the pathophysiology of the injury. General areas of focus include ischemia prevention, reduction of secondary injury due to inflammation, modulation of the cytotoxic and immune response, and promotion of cellular regeneration. In this article, we review established, emerging, and novel experimental therapies. Continued translational research on these methods will improve the feasibility of bench-to-bedside innovations in treating patients with acute SCI.

Indicators of Health-Related Quality of Life in Cats With Degenerative Joint Disease: Systematic Review and Proposal of a Conceptual Framework

Objectives: The assessment of health-related quality of life (HRQoL) is becoming increasingly important in companion animals. This study describes a systematic review and development of a proposed conceptual framework to assess HRQoL in cats with osteoarthritis (OA). Methods: The conceptual framework was developed according to published guidelines. A comprehensive search of the CAB Direct, Scopus, PubMed, and Web of Science databases was carried out for publications in English from inception to November 12, 2019. Search words used were "cat", "feline", "chronic pain", "pain", and "quality of life". Publications were selected if they were full-text and peer-reviewed, based on primary data, and identified or measured behavioral symptoms of chronic musculoskeletal pain in cats. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A data extraction form was developed from categories identified in the literature review and piloted on a small number of studies to ascertain the appropriateness for relevant data extraction. Categories were then finalized, and key domains were identified. The domains were then synthesized to develop a conceptual framework. Results: A total of 454 studies were identified, of which 14 met the eligibility criteria and were included in the meta-synthesis. All 14 were assessed to be of good quality. Seven domains related to HRQoL in cats with OA were thematically identified from the data: mobility, physical appearance, energy and vitality, mood, pain expression, sociability, and physical and mental wellbeing. The three main HRQoL domains were pain expression, mobility, and physical and mental wellbeing, which impacted all the others. Pain and mobility impacted all six other domains, with increased pain and decreased mobility negatively impacting physical appearance, energy and vitality, mood, sociability, and physical and mental wellbeing. Conclusions and Relevance: This is the first study to develop an evidence-based conceptual framework for the assessment of HRQoL in cats with OA. The proposed conceptual framework suggests that effective management of chronic pain in cats may improve their overall HRQoL.

Peripheral white blood cell responses as emerging biomarkers for patient stratification and prognosis in acute spinal cord injury

PURPOSE OF REVIEW

To date, prognostication of patients after acute traumatic spinal cord injury (SCI) mostly relies on the neurological assessment of residual function attributed to lesion characteristics. With emerging treatment candidates awaiting to be tested in early clinical trials, there is a need for wholistic high-yield prognostic biomarkers that integrate both neurogenic and nonneurogenic SCI pathophysiology as well as premorbid patient characteristics.

RECENT FINDINGS

It is becoming clearer that effective prognostication after acute SCI would benefit from integrating an assessment of pathophysiological changes on a systemic level, and with that, extend from a lesion-centric approach. Immunological markers mirror tissue injury as well as host immune function and are easily accessible through routine blood sampling. New studies have highlighted the value of circulating white blood cells, neutrophils and lymphocytes in particular, as prognostic systemic indicators of SCI severity and outcomes.

SUMMARY

We survey recent advances in methods and approaches that may allow for a more refined diagnosis and better prognostication after acute SCI, discuss how these may help deepen our understanding of SCI pathophysiology, and be of use in clinical trials.