A scale for evaluation of spinal cord injury

Management of traumatic spinal cord injury: A current concepts review of contemporary and future treatment

Spinal Cord Injury (SCI) is a condition leading to inflammation, edema, and dysfunction of the spinal cord, most commonly due to trauma, tumor, infection, or vascular disturbance. Symptoms include sensory and motor loss starting at the level of injury; the extent of damage depends on injury severity as detailed in the ASIA score. In the acute setting, maintaining mean arterial pressure (MAP) higher than 85 mmHg for up to 7 days following injury is preferred; although caution must be exercised when using vasopressors such as phenylephrine due to serious side effects such as pulmonary edema and death. Decompression surgery (DS) may theoretically relieve edema and reduce intraspinal pressure, although timing of surgery remains a matter of debate. Methylprednisolone (MP) is currently used due to its ability to reduce inflammation but more recent studies question its clinical benefits, especially with inconsistency in recommending it nationally and internationally. The choice of MP is further complicated by conflicting evidence for optimal timing to initiate treatment, and by the reported observation that higher doses are correlated with increased risk of complications. Thyrotropin-releasing hormone may be beneficial in less severe injuries. Finally, this review discusses many options currently being researched and have shown promising pre-clinical results.

Advantages and Limitations in the Evaluation of the Neurological and Functional Deficit in Patients with Spinal Cord Injuries

(1) Background: Vertebro-medullary trauma (VMT) causes osteo-articular injuries in a varied anatomical lesion associated with multiple clinical manifestations and therapeutic indications. The neurological evaluation of patients who have suffered a spinal cord injury (SCI) is costly in testing the motor and sensory function. To standardize the assessment, several scales are used that measure the neurological deficit in order to guide subsequent treatment according to complete or incomplete SCI. The aim of this study is to identify and present the relevant tools for assessing SCI. (2) Methods: Relevant SCI studies were used for a fact-finding investigation from a rational and critical perspective of this field of research. The relationship between clinical tools and those with a psychosocial component was assessed based on studies reported in the literature. (3) Results: SCI severity scales have been proposed throughout to be able to estimate the functional prognosis of victims of these traumatic events. These tools can be divided into scales for assessing the neurological deficit due to trauma, and functional scales that assess the ability to perform daily activities, self-care, etc. (4) Conclusions: The closest scale to the need for standardization and the most accurate assessment of neurological deficits secondary to SCI is ASIA/IMSOP.

Traumatic Spinal Cord Injury: An Overview of Pathophysiology, Models and Acute Injury Mechanisms

Traumatic spinal cord injury (SCI) is a life changing neurological condition with substantial socioeconomic implications for patients and their care-givers. Recent advances in medical management of SCI has significantly improved diagnosis, stabilization, survival rate and well-being of SCI patients. However, there has been small progress on treatment options for improving the neurological outcomes of SCI patients. This incremental success mainly reflects the complexity of SCI pathophysiology and the diverse biochemical and physiological changes that occur in the injured spinal cord. Therefore, in the past few decades, considerable efforts have been made by SCI researchers to elucidate the pathophysiology of SCI and unravel the underlying cellular and molecular mechanisms of tissue degeneration and repair in the injured spinal cord. To this end, a number of preclinical animal and injury models have been developed to more closely recapitulate the primary and secondary injury processes of SCI. In this review, we will provide a comprehensive overview of the recent advances in our understanding of the pathophysiology of SCI. We will also discuss the neurological outcomes of human SCI and the available experimental model systems that have been employed to identify SCI mechanisms and develop therapeutic strategies for this condition.

The impact of blood pressure management after spinal cord injury: a systematic review of the literature

OBJECTIVE

Spinal cord injury (SCI) results in significant morbidity and mortality. Improving neurological recovery by reducing secondary injury is a major principle in the management of SCI. To minimize secondary injury, blood pressure (BP) augmentation has been advocated. The objective of this study was to review the evidence behind BP management after SCI.

METHODS

This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Using the PubMed database, the authors identified studies that investigated BP management after acute SCI. Information on BP goals, duration of BP management, vasopressor selection, and neurological outcomes were analyzed.

RESULTS

Eleven studies that met inclusion criteria were identified. Nine studies were retrospective, and 2 were single-cohort prospective investigations. Of the 9 retrospective studies, 7 reported a goal mean arterial pressure (MAP) of higher than 85 mm Hg. For the 2 prospective studies, the MAP goals were higher than 85 mm Hg and higher than 90 mm Hg. The duration of BP management varied from more than 24 hours to 7 days in 6 of the retrospective studies that reported the duration of treatment. In both prospective studies, the duration of treatment was 7 days. In the 2 prospective studies, neurological outcomes were stable to improved with BP management. The retrospective studies, however, were contradictory with regard to the correlation of BP management and outcomes. Dopamine, norepinephrine, and phenylephrine were the agents that were frequently used to augment BP. However, more complications have been associated with dopamine use than with the other vasopressors.

CONCLUSIONS

There are no high-quality data regarding optimal BP goals and duration in the management of acute SCI. Based on the highest level of evidence available from the 2 prospective studies, MAP goals of 85–90 mm Hg for a duration of 5–7 days should be considered. Norepinephrine for cervical and upper thoracic injuries and phenylephrine or norepinephrine for mid- to lower thoracic injuries should be considered.

Updates for the International Standards for Neurological Classification of Spinal Cord Injury

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most widely used classification in the field of spinal cord injury medicine. Since its first publication in 1982, multiple revisions refining the recommended examination, scaling, and classification have taken place to improve communication, consistency, and clarity. This article describes a brief historical perspective on the development and changes over the years leading to the current ISNCSCI, detailing the most recent updates of 2011 and the worksheet 2013 as well as issues facing the ISNCSCI for the future.

Minimum 6-year follow-up after ulnar nerve decompression and submuscular transposition for primary entrapment

PURPOSE

To retrospectively evaluate patients with 6-year minimum follow-up after submuscular transposition of the ulnar nerve for primary entrapment.

METHODS

From 1992 to 2005, 142 patients were treated surgically for ulnar neuropathy at the elbow by 2 senior surgeons using a technique that preserved nerve vascularity. A total of 99 cases were eligible, and 82 elbows in 76 patients, average age 48 years, were followed for at least 6 years (average, 8.3 y). Thirty-two (42%) were male, and the dominant limb was involved in 49 (64%). The average duration of symptoms before surgery was 25 months. Clinical records were reviewed, and sensory (S0-2) and motor (M0-5) testing was performed. Dellon scores were determined, and visual analog scale and modified questionnaires from Novak et al and Kleinman and Bishop were completed. Preoperatively, 48 elbows were Dellon grade III, 33 were grade II, and one was grade I.

RESULTS

There were clinically and statistically significant improvements in patient and surgeon-reported data regardless of the preoperative disease severity. Visual analog scale questionnaires, sensory scale, and motor strength all improved, with at least antigravity strength in all subjects. Dellon scores also improved, and 38 elbows had normalized to Dellon 0. Of the 33 preoperative elbows that were grade III, 15 improved to grade II, 13 to grade I, and 5 normalized. Of the 48 preoperative elbows that were grade II, 16 improved to grade I and 32 normalized. Preoperative Dellon III elbows had more residual symptoms than grade II elbows. A total of 73 elbows (89%) had a good or excellent outcome. There were no reoperations or infections.

CONCLUSIONS

Submuscular transposition is a safe and durable option for primary ulnar neuropathy at the elbow. Overall, good or excellent results were achieved in 89% of patients with a low complication rate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome

The purpose of this prospective randomised study was to evaluate which operative technique for treatment of cubital tunnel syndrome is preferable: subcutaneous anterior transposition or nerve decompression without transposition. This study included 66 patients suffering from pain and/or neurological deficits with clinically and electromyographically proven cubital tunnel syndrome. Thirty-two patients underwent nerve decompression without transposition and 34 underwent subcutaneous transposition of the nerve. Follow-up examinations evaluating pain, motor and sensory deficits as well as motor nerve conduction velocities, were performed 3 and 9 months postoperatively. There were no significant differences between the outcomes of the two groups at either postoperative follow-up examination. We recommend simple decompression of the nerve in cases without deformity of the elbow, as this is the less invasive operative procedure.

Clinical assessment after acute cervical spinal cord injury

NEUROLOGICAL EXAMINATION:

STANDARDS

There is insufficient evidence to support neurological examination standards.

GUIDELINES

There is insufficient evidence to support neurological examination guidelines.

OPTIONS

The American Spinal Injury Association international standards for neurological and functional classification of spinal cord injury are recommended as the preferred neurological examination tool for clinicians involved in the assessment and care of patients with acute spinal cord injuries. FUNCTIONAL OUTCOME ASSESSMENT:

STANDARDS

There is insufficient evidence to support functional outcome assessment standards.

GUIDELINES

The Functional Independence Measure is recommended as the functional outcome assessment tool for clinicians involved in the assessment and care of patients with acute spinal cord injuries.

OPTIONS

The modified Barthel index is recommended as a functional outcome assessment tool for clinicians involved in the assessment and care of patients with acute spinal cord injuries.

Effectiveness of spinal cord Injury Rehabilitation

As in other areas of rehabilitation, relatively small numbers and diversity –both of condition and of patients' goals – hinder the assimilation of robust evidence for the effectiveness of rehabilitation. Patients with spinal cord injury (SCI) tend to be gathered together in a small number of regional services, each with their own philosophy and each with different attitudes to outcome measurement, and thus collection of the existing trials for meta-analysis is problematic.

The marked improvement in outcome from SCI that has occurred with the development of specialist rehabilitation programmes argues strongly for the effectiveness of rehabilitation, and we have progressed beyond the point where randomized controlled trials that deny a group such intervention could be considered ethical. Current research is aimed at teasing apart the aspects of different care models that are most effective, or the evidence for the usefulness of interventions for control of symptoms such as spasticity and pain. This evidence is reviewed and discussed.

Validation of the American Spinal Injury Association (ASIA) motor score and the National Acute Spinal Cord Injury Study (NASCIS) motor score

STUDY DESIGN

In this study the motor scores of 62 consecutive acute spinal cord-injured patients were retrospectively reviewed.

OBJECTIVE

The reliability of the American Spinal Injury Association and National Acute Spinal Cord Injury Study motor scores, compared with the conventional motor scores, was retrospectively assessed.

SUMMARY OF BACKGROUND DATA

The reliability of the American Spinal Injury Association and National Acute Spinal Cord Injury Study scores has not as yet been confirmed.

METHODS

Sixty-two consecutive adult patients admitted within 7 days of acute spinal cord injury between April, 1983, and September, 1992, were evaluated. The motor deficit percentage and the motor recovery percentage of each of the American Spinal Injury Association and the National Acute Spinal Cord Injury Study motor scores were compared with those of the conventional motor score. From the initial and final motor score, the motor deficit percentage and motor recovery percentage were calculated. There were 38 patients with cervical and thoracic lesions, 12 patients with dorso-lumbar lesions, and 12 patients with lower lumbar lesions. The average follow-up period was 41 months.

RESULTS

Both the American Spinal Injury Association motor score and the National Acute Spinal Cord Injury Study motor score were representative of the conventional motor score for the evaluation of the motor deficit percentage and the motor recovery percentage in all levels (P < 0.0001). The differences in all correlation coefficients between the American Spinal Injury Association motor score and the National Acute Spinal Cord Injury Study motor score were not statistically significant in all levels and in every group.

CONCLUSIONS

The American Spinal Injury Association and National Acute Spinal Cord Injury Study motor scores can both be used for the neurological quantification of motor deficit and motor recovery.

The long term outcome in 149 patients with spinal cord injury

A longitudinal follow-up study of 149 spinal cord injured patients is presented. Ninety two patients have been visited and interviewed at home 7-10 years after injury (28% died during the follow-up). Disability was assessed using the Functional Independence Measure (FIM), and was correlated with the neurological level, impairment and spasticity. The handicap was assessed using the Reintegration to Normal Living Index (RNLI). Multivariate analysis showed a correlation with age, neurological impairment, sexual impairment, living conditions and social life. There was a high correlation with depression and the Functional Independence Measure. The early neurological examination correlated with their long term disability but not with their handicap.

Measurement, nature, and implications of skeletal muscle strength in patients with neurological disorders

Muscle strength is frequently impaired in patients with neurological disorders. Numerous instrumented and non-instrumented options exist for measuring the strength of such patients. Such measurements are useful for clarifying patient status and documenting changes over time. Moreover the measurements are often informative of present or future function among a variety of diagnostic groups. Measurements of muscle strength are an essential component of the neurological evaluation and provide information of substantial importance to clinical care.

Future ambulation prognosis as predicted by somatosensory evoked potentials in motor complete and incomplete quadriplegia

OBJECTIVE

The purpose of this prospective study was to determine the efficacy of tibial somatosensory evoked potentials (SEPs) in predicting ambulation in tetraplegic individuals.

DESIGN

This was a prospective study of a cohort of cervical spinal cord-injured patients who had SEPs recorded within 72 hours to 2 weeks post-SCI and whose ambulation outcome was followed up to 2 years post-SCI.

SETTING

Regional Spinal Cord Injury (SCI) Center.

PATIENTS

All male and female subjects admitted to the center from 1988 to 1991 between the ages of 15 and 60 years who demonstrated C4 through T1 complete and incomplete acute SCIs were asked to participate in this study.

MEASUREMENTS

The tibial nerve cortical SEPs were graded as either present or absent. The waveforms were also graded as less than 0.5 microV or > or = 0.5 microV. Quadriceps strength plus touch and pin sensation were tested within 72 hours to 2 weeks post-SCI. Ambulation was rated as absent, exercise, household, or community. The ambulatory and clinical status were assessed monthly for 3 months, and then at 6, 12, 18, and 24 months post-SCI. Statistical analysis using the two-tailed Fisher's exact test was performed relating the initial clinical and SEP data to ambulation outcome up to 24 months post-SCI.

RESULTS

All 13 subjects with a right and/or left quadriceps manual muscle test (MMT) greater than 0/5 became ambulatory. Of the 9 subjects with an initial bilateral quadriceps MMT = 0/5, only 1 recovered enough lower limb function to ambulate (p = .0001). One of the 7 subjects with absent touch sensation in the lower limbs became ambulatory, whereas 14 of the 15 subjects with touch sensation present became ambulatory (p = .002). All 7 subjects with absent pin sensation in the lower limbs were nonambulatory, and 14 of 15 subjects with pin sensation present became ambulatory (p < .0001). Of the 9 subjects with bilaterally absent cortical SEP waveforms, 2 became ambulatory. Twelve of the 13 subjects with a cortical SEP wave present became ambulatory (p = .0015). Of the 10 subjects with a cortical SEP wave amplitude less than 0.5 microV, only two became ambulatory, whereas all 12 subjects with an amplitude > or = 0.5 microV became ambulatory (p = .00014). In no subject did the SEP predict future ambulation where the clinical examination did not also predict recovery of ambulation.

CONCLUSION

Both the early postinjury clinical evaluation and the SEP predicted ambulation outcome to a significant degree, but the SEP offered no additional prognostic accuracy over that provided by the clinical examination.

Stabilization of subaxial cervical spinal injuries

With subaxial cervical spine fractures, it has not been established which injuries can be adequately stabilized by external orthoses and which will require surgical stabilization. After review of 64 consecutive patients with C3-C7 spinal injuries, fracture characteristics on admission roentgenograms were identified that accurately predict the success or failure of nonoperative management. These include evidence of severe ligamentous injury (SLI) and severe vertebral body injury (SVBI). The presence of SLI, SVBI, or both SLI and SVBI correlated strongly with nonoperative stabilization failure (p < 0.001, p = 0.002, and p = 0.004, respectively). Injuries without SLI or SVBI were all successfully stabilized by cervical orthoses. Additionally, characterizing injuries by evidence of SLI and SVBI directs the approach for surgical stabilization.

Assessment of rehabilitation in patients with spinal cord injuries: methodological considerations

It is becoming a necessity to predict the outcome of spinal cord injured patients, because their prognosis has greatly improved in recent years. The assessment of rehabilitation should be done with methodology to avoid selection bias and confounding factors, and to choose criteria for measuring outcome. Some simple rules are proposed in order to correctly use major statistical models.

Spinal cord injury: prognosis for ambulation based on quadriceps recovery

The purpose of this study was to determine if early recovery of quadricep muscle strength post spinal cord injury (SCI) is a useful predictor of future ambulation. Seventeen C4-T10 motor incomplete (Frankel C) spinal cord injured patients admitted to our center between March 1988 and April 1990 were examined within 72 hours to one week post injury. All patients had initial quadricep strengths < or = 2/5 in both legs. Strength in the strongest quadricep was followed prospectively at intervals from admission to one year post injury. Recovery time to a > 3/5 quadricep was established for each patient. Patients were categorized into 2 groups: FA (n = 11) were those patients who achieved functional ambulation and NA (n = 6) were those subjects who were nonambulators. Functional ambulators were defined as those patients who were able to walk in the household and/or the community while non ambulators were those who either did not ambulate or did so only for exercise. All patients (n = 9) who achieved a > 3/5 quadricep by 2 months post SCI became functional ambulators whereas in the group of 8 patients who did not achieve a > 3/5 by 2 months, only 2 became functional ambulators. This result was found to be significant using a point-by-serial correlation with p < 0.05. In conclusion, motor incomplete spinal cord injured patients who recovered to a > 3/5 quadricep strength by 2 months post injury had an excellent prognosis for subsequent ambulation by 6 months post injury.

Evidence of subclinical brain influence in clinically complete spinal cord injury: discomplete SCI

Previous studies of the neurocontrol of movement in spinal cord injury (SCI) subjects revealed that even those without volitional movement may retain some degree of preservation of distal brain influence. We previously defined a discomplete lesion as one which is clinically complete but which is accompanied by neurophysiological evidence of residual brain influence on spinal cord function below the lesion. In order to document the nature and extent of such neurocontrol, we recorded surface EMGs from multiple muscle groups to study patterns of motor unit activity in response to tendon vibration, activation of muscles below the lesion by reinforcement maneuvers above the lesion and by voluntary suppression of plantar withdrawal reflexes. We analyzed data from this brain motor control assessment (BMCA) procedure in order to describe the frequency of occurrence and characteristics of residual control in discomplete SCI subjects, comparing with findings in (clinically and neurophysiologically) complete and in (clinically and neurophysiologically) incomplete SCI subjects. From a group of 139 SCI subjects seen for management of spasticity, 88 had clinically complete lesions. Of these, 74 (84%) were discomplete as defined by responses to the above maneuvers. The selection of management and intervention strategies, whether physiological, pharmacological, behavioral or surgical, should give consideration to the high likelihood that clinically complete subjects may be neurophysiologically incomplete.

A model for estimating level and net severity of spinal cord injuries

Objective and detailed neurological assessments are essential in studies of the treatment and the epidemiology of acute spinal cord injuries. In practice, investigators use the expanded score, found by taking the total of the individual determinations, but this summary obscures important detail as to the level and the overall severity of injury. To address this issue, we present a method for estimating level and net severity of injury that makes use of isotonic regression and the Spearman-Kärber estimator. We describe the method for both sensory and motor assessments of neurologic function. In the special case where one gives an identical weight to the response at each level, these estimators algebraically partition the expanded score into separate contributions due to level and net severity. We provide a numerical example using data from the first National Acute Spinal Cord Injury Study, and we present a summary of the distribution of these parameters for this population.

Prognostic significance of magnetic resonance imaging in the acute phase of cervical spine injury

Fifty-seven patients with acute cervical spine injuries and associated major neurological deficit were examined within 2 weeks of injury by magnetic resonance (MR) imaging. All patients had abnormal scans, indicating intramedullary lesions. This study was undertaken to determine if the early MR imaging pattern had a prognostic relationship to the eventual neurological outcome. Three different MR imaging patterns were observed in these patients: 21 patients had patterns characteristic of intramedullary hematoma (Group 1); 17 had intramedullary edema over more than one spinal segment, but no hemorrhage (Group 2); and 19 had restricted zones of intramedullary edema involving one spinal segment or less (Group 3). The neurological state was determined using standard motor index scores at admission and at follow-up examination. Characteristically, the patients in Group 1 had admission motor scores significantly lower than the other two groups. At follow-up examination, the median percent motor recovery was 9% for Group 1, 41% for Group 2, and 72% for Group 3. These studies suggest that the MR imaging pattern observed in the acutely injured human spinal cord has a prognostic significance in the final outcome of the motor system. It is only when an accurate prognosis can be given at the outset that useful treatment data might be collected for homogeneous injury groups, and accurately based long-term planning made for the best patient care.

MR-imaging of chronic spinal cord injury. Association with neurologic function

Twenty-two para- and tetraplegic patients with chronic spinal cord injuries were examined with magnetic resonance imaging (MRI). The clinical course in the entire rehabilitation period was recorded and an attempt was made to associate the functional status of the patients with the morphologic findings on MRI. Small and large spinal cord cysts and syringomyelia, cord atrophy, and spinal stenosis were found. Additionally, in a number of patients regions of increased signal intensity within the cord, interpreted as myelomalacia, and obliteration of the intradural extramedullary space, interpreted as arachnopathy, were noted. The large number (13/22) of cystic lesions in our patients was unexpected. It was in contrast to the rate reported in autopsy studies of paraplegics which note only few cysts. Whereas a direct association of morphologic findings with neurologic symptoms and the clinical course was difficult, it was found that patients with large cysts and spinal cord atrophy generally showed no tendency to improve in spite of the measures taken during the rehabilitation period. It is difficult to decide whether the initial trauma with cord hemorrhage is limiting the chance of neurological improvement or if a sequence of events leading from hemorrhage to gliosis and cystic necrosis is the determining factor.

Initial factors predicting functional performance in patients with traumatic tetraplegia

The authors present a prospective analysis of the functional outcome in 99 patients with traumatic tetraplegia consecutively admitted to the Pellegrin Hospital (University Hospital, Bordeaux, France). There was a 29% death rate. Eighteen months after injury, 33% of the patients were dependent (not able to perform activities of daily living without the presence of a helping individual), 38% were independent. Two predictors of independence (age and initial Yale Scale Score) were found by a statistical analysis of the course of the disorder.

Initial factors predicting survival in patients with a spinal cord injury

A study is presented of a prospective analysis of survival rates in 157 patients with spinal cord injury consecutively admitted to the Pellegrin Hospital (University Hospital, Bordeaux, France). There was a 20% death rate, occurring in the first three months after injury. Three independent predictors of survival in patients with spinal cord injuries (age, initial conscious level and respiratory assistance) were found by analysis of the course of the disorder.

Early prognostic factors for walking in spinal cord injuries

The authors present a prospective analysis with 1 year follow-up of about 157 consecutive spinal cord injured patients admitted to the Bordeaux CHU, over a 3 year period (1982-1985). They present a method of analysing the walking status recovery in patients with spinal cord injuries from the early factors recorded on initial clinical examination. Twenty eight per cent of all patients are 'functional walkers', 1 year after injury. Three early factors were selected: age; the level of injury; and the initial Yale Scale Score. Only the age and the initial Yale Scale Score are independent predictive factors, according to the Cox model. The authors present a model of walking status recovery, 1 year after the injury, predicted from age and the initial Yale Scale Score.

The use of hyperbaric oxygen to modify the effects of recent contusion injury to the spinal cord

Studies on the experimental spinal contusion injury in animals confirm that posttraumatic ischemia contributes to central cystic necrosis or fibrosis occurring at the level of the spinal cord lesion. Hyperbaric oxygen (HBO) modifies the degree and extent of the pathology in the spinal cord of the experimental animals. HBO has been used for 45 patients with recent spinal cord injuries. The extent of recovery in 27 patients with upper motor neuron lesions treated with adequate HBO is reported. Fifteen of the 27 patients had useful functional recovery.

The demonstration and significance of neural compression after spinal injury

Standard metrizamide myeLography and CT myelography can accurately and safely define neural compression after a spinal injury. A lateral C1-C2 spinal puncture and a radiolucent fracture board reduce movement of the spine, and by injecting metrizamide in an isotonic concentration and by limiting the amount of contrast above a block, the risk of seizure is minimized. This capability for directly determining neural compression has important implications for the treatment of spinal fractures, and the significance of persisting posttraumatic neural compression is discussed. We believe neural compression should be the primary indication for surgical decompression after spinal injury and that evaluation for it should now be a standard part of the examination of patients with spinal fractures with potential for neurological recovery.

Early decompression and neurological outcome in acute cervical spinal cord injuries

To evaluate the effect on neurological outcome of spinal core compression persisting after a closed injury, the authors reviewed 44 of 62 consecutively managed cases of cervical spinal cord and spine injuries at C3-7, inclusive. Decompression within 48 hours of injury confirmed by myelography or open reduction. Neurological status, graded numerically on a spinal trauma scale at admission and at follow-up review (an average of 1 year +/- 2 months after admission), and precent recovery of neurological deficit were compared to canal narrowing (22 severe, greater than or equal to 30%, versus 22 moderate, 11% to 29%; or mild, less than or equal to 10%) and to delay before treatment (30 within 8 hours of injury versus 14 treated 9 to 48 hours after injury). Severe narrowing was equated with compression. Status at admission and at follow-up review was positively correlated. Patients with admission scores of less than 2 recovered a mean of 15% of their deficit, while those with scores more than 2 recovered a mean of 77%. Admission status correlated significantly with spinal canal narrowing but not with vertebral body displacement. Time of treatment had no significant effect upon admission status and percent recovery. No significant difference in the percent of recovery was noted, whether decompression was early (up to 8 hours) or late (9 to 48 hours) after injury. Surgery did not significantly alter the percent of recovery. The findings indicate that the initial injury to the cervical spinal cord and spine remains the primary determinant of neurological outcome. Severe canal narrowing with cord compression thereafter appears to have comparatively little effect. The conclusion that decompression is without effect is not possible without comparison with a group of patients whose spinal canals remained narrowed at follow-up review.