Impact of multiple injuries on functional and neurological outcomes of patients with spinal cord injury

Association between injury severity scores and clinical outcomes in patients with traumatic spinal injury in an aging Japanese society

The Injury Severity Score (ISS) is widely used to evaluate patients with multiple injuries. This study investigated the association between ISS and clinical outcomes of patients with spinal cord injury (SCI) in an aging Japanese population. This retrospective cohort study investigated patients admitted to a Japanese university hospital. In the study, 89 patients with traumatic SCI were included. Traumatic SCI was categorized as monotrauma or polytrauma, and the ISS was used to evaluate trauma severity. Spearman's correlation coefficient was used to estimate the correlation between ISS and the American Spinal Injury Association (ASIA) motor score, Barthel Index (activities of daily living assessment), and the European Quality of Life (QOL) scale (EQ5d) as an assessment of QOL at admission or the last follow-up with the adjustment for age, sex, and body mass index. Return to home and work were analyzed using the chi-squared test after the ISS was divided into three groups (<14, 14-19, and 20). The mean ISS was significantly higher for polytrauma than monotrauma. Significant negative correlations between the ISS and ASIA motor scores at the first visit (P < .001, r = -0.37) and the last follow-up (adjusted, P = .007, r = -0.30) were observed. The Barthel Index was also negatively correlated with ISS at the first visit (P = .04, r = -0.21) and at the last follow-up period (P < .001, r = -0.35). Moreover, ISS was significantly negatively correlated with EQ5d score at the last follow-up (P = .01, r = -0.28). The chi-squared test demonstrated that patients with an ISS of < 14 returned home (P = .03), while those with an ISS of < 19 returned to work (P = .02). ISS is associated with paralysis, activities of daily living, QOL, and lifestyle in patients with SCI and is an important initial injury assessment method.

Primary motor hand area corticospinal excitability indicates overall functional recovery after spinal cord injury

Background

After spinal cord injury (SCI), the excitability of the primary motor cortex (M1) lower extremity area decreases or disappears. A recent study reported that the M1 hand area of the SCI patient encodes the activity information of both the upper and lower extremities. However, the characteristics of the M1 hand area corticospinal excitability (CSE) changes after SCI and its correlation with extremities motor function are still unknown.

Methods

A retrospective study was conducted on the data of 347 SCI patients and 80 healthy controls on motor evoked potentials (MEP, reflection of CSE), extremity motor function, and activities of daily living (ADL) ability. Correlation analysis and multiple linear regression analysis were conducted to analyze the relationship between the degree of MEP hemispheric conversion and extremity motor function/ADL ability.

Results

The CSE of the dominant hemisphere M1 hand area decreased in SCI patients. In 0-6 m, AIS A grade, or non-cervical injury SCI patients, the degree of M1 hand area MEP hemispheric conversion was positively correlated with total motor score, lower extremity motor score (LEMS), and ADL ability. Multiple linear regression analysis further confirmed the contribution of MEP hemispheric conversion degree in ADL changes as an independent factor.

Conclusion

The closer the degree of M1 hand area MEP hemispheric conversion is to that of healthy controls, the better the extremity motor function/ADL ability patients achieve. Based on the law of this phenomenon, targeted intervention to regulate the excitability of bilateral M1 hand areas might be a novel strategy for SCI overall functional recovery.

Use of Regression Tree Analysis for Predicting the Functional Outcome after Traumatic Spinal Cord Injury

Predicting the long-term functional outcome after traumatic spinal cord injury (TSCI) is needed to adapt medical strategies and plan an optimized rehabilitation. This study investigates the use of regression trees for the development of predictive models based on acute clinical and demographic predictors. This prospective study was performed on 172 patients hospitalized after TSCI. Functional outcome was quantified using the Spinal Cord Independence Measure (SCIM) collected within the first-year post-injury. Age, delay before surgery, and Injury Severity Score (ISS) were considered as continuous predictors whereas energy of injury, trauma mechanisms, neurological level of injury, injury severity, occurrence of early spasticity, urinary tract infection, pressure ulcer, and pneumonia were coded as categorical inputs. A simplified model was built using only American Spinal Injury Association Impairment Scale grade, neurological level, energy, and age as predictor and was compared to a more complex model considering all 11 predictors mentioned above. The models built using 4 and 11 predictors were found to explain 51.4% and 62.3% of the variance of the SCIM total score after validation, respectively. Severity of the neurological deficit at admission was found to be the most important predictor. Other important predictors were the ISS, age, neurological level, and delay before surgery. Regression trees offer promising performances for predicting the functional outcome after a TSCI. It could help to determine the number and type of predictors leading to a prediction model of the functional outcome that can be used clinically in the future.

Impact of complications at admission to rehabilitation on the functional status of patients with spinal cord lesion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Aim of the study is to evaluate the impact of complications at admission on the functional status of spinal cord lesions patients.

SETTING

Rehabilitation hospital in Italy.

METHODS

Two hundred and seven patients with complications (mostly pressure ulcers) at admission to rehabilitation were matched for neurological level of injury and AIS grade with 207 patients without complications.

MEASURES

International Standards for Neurological Classification of Spinal Cord Injury, Spinal Cord Independence Measure, Rivermead Mobility Index, and Walking Index for Spinal Cord Injury. These measures were recorded at admission to rehabilitation and at discharge. We also recorded length of acute and rehabilitation stay and discharge destination.

STATISTICS

Student's T test for paired samples, McNemar's chi-square test.

RESULTS

Patients with complications at admission suffered more often from a traumatic lesions. The functional status at admission and discharge of the patients without complications was significantly better than the functional status of patients with complications (Spinal Cord Independence Measure mean difference between the two groups 5.7 (CI 2.8-8.5) at admission, and 10 (CI 5.3-14.7) at discharge). Length of stay was significantly higher in patients with complications. Patients with complications were more often institutionalized than their counterparts (46/161 vs. 20/187, odds ratio 0.4 (CI 0.2-0.7)).

CONCLUSIONS

Complications seem to be more frequent in patients with traumatic lesions. The presence of complications has a negative effect on patients' functional status at discharge and length of stay, and it determines a higher risk of being institutionalized.

Rehabilitation of the multiple injured patient with spinal cord injury: A systematic review of the literature

INTRODUCTION

Patients with multiple injuries including spinal cord injury (SCI) have low survivability. Little is known for the effect of SCI in their rehabilitation process.

PURPOSE

To define differences in characteristics and outcomes during the rehabilitation of multiple injured patients with SCI compared to other polytrauma patients.

MATERIALS AND METHODS

Electronic libraries provided 425 relevant articles. Applying the criteria, 6 articles were eligible for inclusion in this review.

RESULTS

The extracted data show that multiple injured patients with SCI have an increased length of stay (LOS) in rehabilitation. Initial functional levels, as also one- and two-years follow-up are also decreased. Similar results were found comparing SCI patients with or without multiple injuries: SCI patients with multiple injuries have an increased LOS and decreased functional levels compared with SCI patients. Finally, there was nota relevance between the circumstances of the injuries, like acts of terror, and the expected rehabilitation outcome.

CONCLUSION

Due to the rarity of eligible articles and the lack of homogenous accessing tools, a meta-analysis was not possible. There is a lack of a universal evaluation strategy or tool, for the severity of the multiple injured patients aiming at the rehabilitation outcome prognosis. Multiple-injured patients with SCI have longer rehabilitation LOS and functional outcomes compared to other polytrauma patients. Prospective studies are needed for evaluation of the differences according to the severity and the complexity of the injuries and the rehabilitation outcome depending on different rehabilitation methods and strategies.

Update on critical care for acute spinal cord injury in the setting of polytrauma

Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

Outcomes Following Ischemic Myelopathies and Traumatic Spinal Injury

Background: As the general population ages, the rising prevalence of vascular lesions of the spinal cord will become significant. Purpose: The aim of this study was to compare the neurological and functional outcomes of patients with ischemic spinal cord injury (ISCI) and traumatic spinal cord injury (TSCI). Methods: We conducted a retrospective study in a spinal cord unit of 2 rehabilitation hospitals. We studied 168 patients with a TSCI and 72 with an ISCI. At admission and discharge, patients were evaluated by American Spinal Injury Association Impairment Scale (AIS) standards and Spinal Cord Independence Measure (SCIM). Length of stay, occurrence of complications, and discharge dispositions were also recorded. Linear and logistic regression models were used to analyze the effects of the etiology of the lesion, AIS level at admission, and level of the lesion. Results: Patients with an ISCI were older and experienced fewer cervical lesions and fewer complete lesions than patients with TSCI. By linear and logistic regression, etiology was a predictor (together with lesion features) of functional (SCIM improvement and SCIM at discharge) outcome, with traumatic patients having better outcome than ischemic ones. Age, AIS level, and lesion level were the chief predictors of length of stay, occurrence of complications, and discharge dispositions. Conclusions: A diagnosis of ischemia and trauma could be a determinant of functional recovery in SCI patients.

Prediction Model for the Presence of Complications at Admission to Rehabilitation After Traumatic Spinal Cord Injury

Background: Complications frequently occur in patients with spinal cord injury (SCI) during acute care or rehabilitation and have an impact on rehabilitation outcomes. Purpose: The aim of this study was to determine the occurrence and risk factors for complications in recently injured SCI patients. Methods: Two hundred fifty patients with traumatic injuries with and without complications were counted for the following dichotomous parameters: gender (male/female), associated lesions (presence/absence), surgery (yes/no), American Spinal Injury Association Impairment Scale (AIS) grade (A/other categories), lesion level (lumbar/other levels), and lesion-to-admission time (less than/longer than 1 month). The odds ratio (OR) and 95% confidence interval were computed for all the parameters that influenced the presence of complications at admission. These factors have been included in a binary logistic regression analysis (forward stepwise). Results: Complications at admission were observed in 104 patients (41.6%), especially for males, lesion-to-admission time longer than 1 month, presence of associated lesions, AIS grade A, and motor completeness, whereas lumbar lesions were associated with a reduced presence of complications at admission. In the regression analysis, 4 factors entered into the model: motor completeness, lesion-to-admission time, associated lesions, and gender. The final model explained 74% of the variance of data. Conclusions: Despite advances in the acute management of patients with SCI, the study unveiled a high percentage of patients with complications at admission to rehabilitation. The risk factors identified in the study allow determination of the population of subjects who are at higher risk of developing complications and need special management.

MiR-17 targets PTEN and facilitates glial scar formation after spinal cord injuries via the PI3K/Akt/mTOR pathway

OBJECTIVES

We attempted to discover the regulatory role of miR-17 and PTEN in glial scar formation accompanied with spinal cord injuries.

METHODS

We established a spinal cord injury (SCI) model in mice which were transfected with different groups of adenoviruses: miR-17 mimics, miR-17 inhibitors and PTEN cDNAs. The improvement of hind limb functions was assessed using the 21-point Basso-Beattie-Bresnahan (BBB) locomotion scale. Immunohistochemistry was used to detect the expression levels of glial fibrillary acidic protein (GFAP), Vimentin and neurofilaments. The expression of miR-17 was quantified using Real time-PCR (RT-PCR). Western blot was conducted to detect the expressions of PTEN, PI3K, Akt, mTOR and S6. Finally, dual luciferase reporter gene assay was conducted to confirm the target relationship between miR-17 and PTEN.

RESULTS

The model group exhibited significantly increased expression levels of GFAP, Vimentin, miR-17, PTEN, PI3K, Akt and mTOR. The above trend was enhanced by the transfection of miR-17 mimics (P<0.05). By contrast, the transfection of miR-17 inhibitors significantly down-regulated the expression of GFAP, Vimentin, PTEN, PI3K, Akt, mTOR and p-S6 whereas the expression of GFAP, Vimentin, PI3K, Akt, mTOR and p-S6 in the cells transfected with PTEN cDNAs significantly decreased (P<0.05). Also, the transfection of miR-17 inhibitors and PTEN cDNAs alleviated the astrogliosis in SCI lesions, contributed to the regeneration of nerve filament and improved the functional recovery of the hind limb of mice. Finally, the targeting relationship between miR-17 and PTEN was verified by the dual luciferase reporter gene assay.

CONCLUSION

MiR-17 is able to target PTEN and stimulate the PI3K/Akt/mTOR pathway. The formation of glial scar resulted from spinal cord injuries can be reduced either by inhibiting miR-17 or by overexpressing PTEN.

Observational study of the effectiveness of spinal cord injury rehabilitation using the Spinal Cord Injury-Ability Realization Measurement Index

STUDY DESIGN

Retrospective observational study.

OBJECTIVES

The objective of this study was to determine the rehabilitation potential and the extent to which it is realized in a cohort of spinal cord injury patients using the Spinal Cord Injury-Ability Realization Measurement Index (SCI-ARMI) and to study the clinical factors that influence this realization.

SETTING

Two spinal units in Italy.

METHODS

Consecutive patients were assessed at the end of an in-patient rehabilitation program using the Spinal Cord Independence Measure and the International Standards for Neurological Classification of Spinal Cord Injury. On the basis of these data and of the age and gender of the patients, we calculated the SCI-ARMI score. Regression analyses were performed to study the relationship between clinical factors and the extent to which rehabilitation potential is realized.

RESULTS

We examined the data for 306 patients. Most patients were discharged without having reached their rehabilitation potential, with an SCI-ARMI score <80%. SCI-ARMI scores at discharge were positively influenced by etiology and the lesion level and correlated negatively with lesion severity and the presence of complications during rehabilitation.

CONCLUSION

The SCI-ARMI is an effective tool that can be used to measure the achievement of rehabilitation potential in SCI patients and to identify groups of patients who are at risk of not meeting their rehabilitative potential.

Several time indicators and Barthel index relationships at different spinal cord injury levels

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To compare different injury levels in spinal cord injury (SCI) patients with respect to operation intervention time (OIT), rehabilitation intervention time (RIT), average length of hospital stay (ALOS) and Barthel Index (BI) on admission and discharge.

SETTING

China.

METHODS

We retrospectively analyzed data from 95 SCI cases who received treatment in our rehabilitation center from 2010-2013.

RESULTS

SCI resulted from high falls (55.79%), traffic accidents (28.42%), diseases (8.42%) and low falls (7.37%). We found no correlations between OIT, RIT, ALOS and discharge BI for all spinal segments (P>0.05). The OIT of thoracic SCI and lumbar SCI correlated negatively with RIT (P<0.01). The OIT of lumbar SCI correlated negatively with ALOS (P<0.05).

CONCLUSION

BI had no correlation with OIT, RIT or ALOS for all spinal segments; the OIT of thoracic and lumbar SCI correlated negatively with RIT; and the OIT of lumbar SCI correlated negatively with ALOS.

Association between the number of injuries sustained and 12-month disability outcomes: evidence from the injury-VIBES study

Objective

To determine associations between the number of injuries sustained and three measures of disability 12-months post-injury for hospitalised patients.

Methods

Data from 27,840 adult (18+ years) participants, hospitalised for injury, were extracted for analysis from the Validating and Improving injury Burden Estimates (Injury-VIBES) Study. Modified Poisson and linear regression analyses were used to estimate relative risks and mean differences, respectively, for a range of outcomes (Glasgow Outcome Scale-Extended, GOS-E; EQ-5D and 12-item Short Form health survey physical and mental component summary scores, PCS-12 and MCS-12) according to the number of injuries sustained, adjusted for age, sex and contributing study.

Findings

More than half (54%) of patients had an injury to more than one ICD-10 body region and 62% had sustained more than one Global Burden of Disease injury type. The adjusted relative risk of a poor functional recovery (GOS-E<7) and of reporting problems on each of the items of the EQ-5D increased by 5–10% for each additional injury type, or body region, injured. Adjusted mean PCS-12 and MCS-12 scores worsened with each additional injury type, or body region, injured by 1.3–1.5 points and 0.5 points, respectively.

Conclusions

Consistent and strong relationships exist between the number of injury types and body regions injured and 12-month functional and health status outcomes. Existing composite measures of anatomical injury severity such as the NISS or ISS, which use up to three diagnoses only, may be insufficient for characterising or accounting for multiple injuries in disability studies. Future studies should consider the impact of multiple injuries to avoid under-estimation of injury burden.

A Rehabilomics framework for personalized and translational rehabilitation research and care for individuals with disabilities: Perspectives and considerations for spinal cord injury

Despite many people having similar clinical presentation, demographic factors, and clinical care, outcome can differ for those sustaining significant injury such as spinal cord injury (SCI) and traumatic brain injury (TBI). In addition to traditional demographic, social, and clinical factors, variability also may be attributable to innate (including genetic, transcriptomic proteomic, epigenetic) biological variation that individuals bring to recovery and their unique response to their care and environment. Technologies collectively called "-omics" enable simultaneous measurement of an enormous number of biomolecules that can capture many potential biological contributors to heterogeneity of injury/disease course and outcome. Due to the nature of injury and complex disease, and its associations with impairment, disability, and recovery, rehabilitation does not lend itself to a singular "protocolized" plan of therapy. Yet, by nature and by necessity, rehabilitation medicine operates as a functional model of "Personalized Care". Thus, the challenge for successful programs of translational rehabilitation care and research is to identify viable approaches to examine broad populations, with varied impairments and functional limitations, and to identify effective treatment responses that incorporate personalized protocols to optimize functional recovery. The Rehabilomics framework is a translational model that provides an "-omics" overlay to the scientific study of rehabilitation processes and multidimensional outcomes. Rehabilomics research provides novel opportunities to evaluate the neurobiology of complex injury or chronic disease and can be used to examine methods and treatments for person-centered care among populations with disabilities. Exemplars for application in SCI and other neurorehabilitation populations are discussed.

Epidemiology of spinal cord injuries and risk factors for complete injuries in Guangdong, China: a retrospective study

Background

Spinal cord injuries are highly disabling and deadly injuries. Currently, few studies focus on non-traumatic spinal cord injuries, and there is little information regarding the risk factors for complete injuries. This study aims to describe the demographics and the injury characteristics for both traumatic and non-traumatic spinal cord injuries and to explore the risk factors for complete spinal cord injuries.

Methods

A retrospective study was performed by reviewing the medical records of 3,832 patients with spinal cord injuries who were first admitted to the sampled hospitals in Guangdong, China. The demographics and injury characteristics of the patients were described and compared between the different groups using the chi-square test. Logistic regression was conducted to analyze the risk factors for complete spinal cord injuries.

Results

The proportion of patients increased from 7.0% to 14.0% from 2003 to 2011. The male-to-female ratio was 3.0∶1. The major cause of spinal cord injuries was traffic accidents (21.7%). Many of the injured were workers (36.2%), peasants (22.8%), and unemployed people (13.9%); these occupations accounted for 72.9% of the total sample. A multivariate logistic regression model revealed that the OR (95% CI) for male gender compared to female gender was 1.25 (1.07–1.89), the OR (95%CI) for having a spinal fracture was 1.56 (1.35–2.60), the OR (95%CI) for having a thoracic injury was 1.23 (1.10–2.00), and the OR (95%CI) for having complications was 2.47 (1.96–3.13).

Conclusion

The proportion of males was higher than the proportion of females. Workers, peasants and the unemployed comprised the high-risk occupational categories. Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete injury. We recommend that preventive measures should focus on high-risk populations, such as young males.