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Freund P, Boller V, Emmenegger TM, Akbar M, Hupp M, Pfender N, Wheeler-Kingshott CAMG, Cohen-Adad J, Fehlings MG, Curt A, Seif M. Quantifying neurodegeneration of the cervical cord and brain in degenerative cervical myelopathy: A multicentre study using quantitative magnetic resonance imaging. Eur J Neurol 2024:e16297. [PMID: 38713645 DOI: 10.1111/ene.16297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND AND PURPOSE Simultaneous assessment of neurodegeneration in both the cervical cord and brain across multiple centres can enhance the effectiveness of clinical trials. Thus, this study aims to simultaneously assess microstructural changes in the cervical cord and brain above the stenosis in degenerative cervical myelopathy (DCM) using quantitative magnetic resonance imaging (MRI) in a multicentre study. METHODS We applied voxelwise analysis with a probabilistic brain/spinal cord template embedded in statistical parametric mappin (SPM-BSC) to process multi parametric mapping (MPM) including effective transverse relaxation rate (R2*), longitudinal relaxation rate (R1), and magnetization transfer (MT), which are indirectly sensitive to iron and myelin content. Regression analysis was conducted to establish associations between neurodegeneration and clinical impairment. Thirty-eight DCM patients (mean age ± SD = 58.45 ± 11.47 years) and 38 healthy controls (mean age ± SD = 41.18 ± 12.75 years) were recruited at University Hospital Balgrist, Switzerland and Toronto Western Hospital, Canada. RESULTS Remote atrophy was observed in the cervical cord (p = 0.002) and in the left thalamus (0.026) of the DCM group. R1 was decreased in the periaqueductal grey matter (p = 0.014), thalamus (p = 0.001), corpus callosum (p = 0.0001), and cranial corticospinal tract (p = 0.03). R2* was increased in the primary somatosensory cortices (p = 0.008). Sensory impairments were associated with increased iron-sensitive R2* in the thalamus and periaqueductal grey matter in DCM. CONCLUSIONS Simultaneous assessment of the spinal cord and brain revealed DCM-induced demyelination, iron deposition, and atrophy. The extent of remote neurodegeneration was associated with sensory impairment, highlighting the intricate and expansive nature of microstructural neurodegeneration in DCM, reaching beyond the stenosis level.
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Affiliation(s)
- Patrick Freund
- Spinal Cord Injury Centre, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Viveka Boller
- Spinal Cord Injury Centre, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Tim M Emmenegger
- Spinal Cord Injury Centre, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Muhammad Akbar
- Spine Program Division of Neurosurgery, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Markus Hupp
- Spinal Cord Injury Centre, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Nikolai Pfender
- Spinal Cord Injury Centre, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Claudia Angela Michela Gandini Wheeler-Kingshott
- NMR Research Unit, Queen Square MS Centre, University College London (UCL) Queen Square Institute of Neurology, Faculty of Brain Sciences, London, UK
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Digital Neuroscience Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Julien Cohen-Adad
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, Quebec, Canada
- Functional Neuroimaging Unit, CRIUGM, University of Montreal, Montreal, Quebec, Canada
| | - Michael G Fehlings
- Spine Program Division of Neurosurgery, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Armin Curt
- Spinal Cord Injury Centre, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Maryam Seif
- Spinal Cord Injury Centre, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
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Berger MJ, Dengler J, Westman A, Curt A, Schubert M, Abel R, Weidner N, Röhrich F, Fox IK. Nerve Transfer After Cervical Spinal Cord Injury: Who Has a "Time Sensitive" Injury Based on Electrodiagnostic Findings? Arch Phys Med Rehabil 2024; 105:682-689. [PMID: 37979641 DOI: 10.1016/j.apmr.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE To use the ulnar compound muscle action potential (CMAP) to abductor digiti minimi (ADM) to identify the proportion of individuals with cervical spinal cord injury (SCI) who have lower motor neuron (LMN) abnormalities involving the C8-T1 spinal nerve roots, within 3-6 months, and thus may influence the response to nerve transfer surgery. DESIGN Retrospective analysis of prospectively collected data. Data were analyzed from European Multicenter Study About SCI database. SETTING Multi-center, academic hospitals. PARTICIPANTS We included 79 subjects (age=41.4±17.7, range:16-75; 59 men; N=79), who were classified as cervical level injuries 2 weeks after injury and who had manual muscle strength examinations that would warrant consideration for nerve transfer (C5≥4, C8<3). INTERVENTIONS None. MAIN OUTCOME MEASURES The ulnar nerve CMAP amplitude to ADM was used as a proxy measure for C8-T1 spinal segment health. CMAP amplitude was stratified into very abnormal (<1.0 mV), sub-normal (1.0-5.9 mV), and normal (>6.0 mV). Analysis took place at 3 (n=148 limbs) and 6 months (n=145 limbs). RESULTS At 3- and 6-month post-injury, 33.1% and 28.3% of limbs had very abnormal CMAP amplitudes, respectively, while in 54.1% and 51.7%, CMAPs were sub-normal. Median change in amplitude from 3 to 6 months was 0.0 mV for very abnormal and 1.0 mV for subnormal groups. A 3-month ulnar CMAP <1 mV had a positive predictive value of 0.73 (95% CI 0.69-0.76) and 0.78 (95% CI 0.75-0.80) for C8 and T1 muscle strength of 0 vs 1 or 2. CONCLUSION A high proportion of individuals have ulnar CMAPs below the lower limit of normal 3- and 6-month post cervical SCI and may also have intercurrent LMN injury. Failure to identify individuals with LMN denervation could result in a lost opportunity to improve hand function through timely nerve transfer surgeries.
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Affiliation(s)
- Michael J Berger
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Jana Dengler
- Division of Plastic Surgery, Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Ontario; Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario
| | - Amanda Westman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | | | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Frank Röhrich
- BG Klinikum Bergmannstrost, Zentrum für Rückenmarkverletzte und Klinik für Orthopädie, Halle, Germany
| | - Ida K Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
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Emmenegger TM, Pfyffer D, Curt A, Schading-Sassenhausen S, Hupp M, Ashburner J, Friston K, Weiskopf N, Thompson A, Freund P. Longitudinal motor system changes from acute to chronic spinal cord injury. Eur J Neurol 2024; 31:e16196. [PMID: 38258488 DOI: 10.1111/ene.16196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/05/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND AND PURPOSE In acute spinal cord injury (SCI), magnetic resonance imaging (MRI) reveals tissue bridges and neurodegeneration for 2 years. This 5-year study aims to track initial lesion changes, subsequent neurodegeneration, and their impact on recovery. METHODS This prospective longitudinal study enrolled acute SCI patients and healthy controls who were assessed clinically-and by MRI-regularly from 3 days postinjury up to 60 months. We employed histologically cross-validated quantitative MRI sequences sensitive to volume, myelin, and iron changes, thereby reflecting indirectly processes of neurodegeneration and neuroinflammation. General linear models tracked lesion and remote changes in volume, myelin- and iron-sensitive magnetic resonance indices over 5 years. Associations between lesion, degeneration, and recovery (using the Spinal Cord Independence Measure [SCIM] questionnaire and the International Standards for Neurological Classification of Spinal Cord Injury total motor score) were assessed. RESULTS Patients' motor scores improved by an average of 12.86 (95% confidence interval [CI] = 6.70-19.00) points, and SCIM by 26.08 (95% CI = 17.00-35.20) points. Within 3-28 days post-SCI, lesion size decreased by more than two-thirds (3 days: 302.52 ± 185.80 mm2 , 28 days: 76.77 ± 88.62 mm2 ), revealing tissue bridges. Cervical cord and corticospinal tract volumes transiently increased in SCI patients by 5% and 3%, respectively, accompanied by cervical myelin decreases and iron increases. Over time, progressive atrophy was observed in both regions, which was linked to early lesion dynamics. Tissue bridges, reduced swelling, and myelin content decreases were predictive of long-term motor score recovery and improved SCIM score. CONCLUSIONS Studying acute changes and their impact on longer follow-up provides insights into SCI trajectory, highlighting the importance of acute intervention while indicating the potential to influence outcomes in the later stages.
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Affiliation(s)
- Tim M Emmenegger
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dario Pfyffer
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Systems Neuroscience and Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Armin Curt
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Markus Hupp
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - John Ashburner
- Wellcome Trust Centre for Neuroimaging, Queen Square Institute of Neurology, University College London, London, UK
| | - Karl Friston
- Wellcome Trust Centre for Neuroimaging, Queen Square Institute of Neurology, University College London, London, UK
| | - Nikolaus Weiskopf
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
- Felix Bloch Institute for Solid State Physics, Faculty of Physics and Earth Sciences, Leipzig University, Leipzig, Germany
| | - Alan Thompson
- Queen Square Multiple Sclerosis Centre, Institute of Neurology, University College London, London, UK
| | - Patrick Freund
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Wellcome Trust Centre for Neuroimaging, Queen Square Institute of Neurology, University College London, London, UK
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
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Allmendinger F, Scheuren PS, De Schoenmacker I, Brunner F, Rosner J, Curt A, Hubli M. Contact-Heat Evoked Potentials: Insights into Pain Processing in CRPS Type I. J Pain Res 2024; 17:989-1003. [PMID: 38505501 PMCID: PMC10949273 DOI: 10.2147/jpr.s436645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/23/2024] [Indexed: 03/21/2024] Open
Abstract
Purpose The pathophysiological mechanisms underlying the development of chronic pain in complex regional pain syndrome (CRPS) are diverse and involve both peripheral and central changes in pain processing, such as sensitization of the nociceptive system. The aim of this study was to objectively distinguish the specific changes occurring at both peripheral and central levels in nociceptive processing in individuals with chronic CRPS type I. Patients and Methods Nineteen individuals with chronic CRPS type I and 16 age- and sex-matched healthy controls (HC) were recruited. All individuals underwent a clinical examination and pain assessment in the most painful limb, the contralateral limb, and a pain-free control area to distinguish between peripheral and central mechanisms. Contact-heat evoked potentials (CHEPs) were recorded after heat stimulation of the three different areas and amplitudes and latencies were analyzed. Additionally, quantitative sensory testing (QST) was performed in all three areas. Results Compared to HC, CHEP amplitudes in CRPS were only increased after stimulation of the painful area (p=0.025), while no increases were observed for the pain-free control area (p=0.14). None of the CHEP latencies were different between the two cohorts (all p>0.23). Furthermore, individuals with CRPS showed higher pain ratings after stimulation of the painful limb compared to their contralateral limb (p=0.013). Lastly, compared to HC, mechanical (p=0.012) and thermal (p=0.046) sensitivity was higher in the painful area of the CRPS cohort. Conclusion This study provides neurophysiological evidence supporting an intact thermo-nociceptive pathway with signs of peripheral sensitization, such as hyperexcitable primary afferent nociceptors, in individuals with CRPS type I. This is further supported by the observation of mechanical and thermal gain of sensation only in the painful limb. Additionally, the increased CHEP amplitudes might be related to fear-induced alterations of nociceptive processing.
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Affiliation(s)
- Florin Allmendinger
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Paulina Simonne Scheuren
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Iara De Schoenmacker
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Davies BM, Khan DZ, Barzangi K, Ali A, Mowforth OD, Nouri A, Harrop JS, Aarabi B, Rahimi-Movaghar V, Kurpad SN, Guest JD, Tetreault L, Kwon BK, Boerger TF, Rodrigues-Pinto R, Furlan JC, Chen R, Zipser CM, Curt A, Milligan J, Kalsi-Rayn S, Sarewitz E, Sadler I, Widdop S, Fehlings MG, Kotter MR. We Choose to Call it 'Degenerative Cervical Myelopathy': Findings of AO Spine RECODE-DCM, an International and Multi-Stakeholder Partnership to Agree a Standard Unifying Term and Definition for a Disease. Global Spine J 2024; 14:503-512. [PMID: 35769029 PMCID: PMC10802519 DOI: 10.1177/21925682221111780] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Modified DELPHI Consensus Process. OBJECTIVE To agree a single unifying term and definition. Globally, cervical myelopathy caused by degenerative changes to the spine is known by over 11 different names. This inconsistency contributes to many clinical and research challenges, including a lack of awareness. METHOD AO Spine RECODE-DCM (Research objectives and Common Data Elements Degenerative Cervical Myelopathy). To determine the index term, a longlist of candidate terms and their rationale, was created using a literature review and interviews. This was shared with the community, to select their preferred terms (248 members (58%) including 149 (60%) surgeons, 45 (18%) other healthcare professionals and 54 (22%) People with DCM or their supporters) and finalized using a consensus meeting. To determine a definition, a medical definition framework was created using inductive thematic analysis of selected International Classification of Disease definitions. Separately, stakeholders submitted their suggested definition which also underwent inductive thematic analysis (317 members (76%), 190 (59%) surgeons, 62 (20%) other healthcare professionals and 72 (23%) persons living with DCM or their supporters). Using this definition framework, a working definition was created based on submitted content, and finalized using consensus meetings. RESULTS Degenerative Cervical Myelopathy was selected as the unifying term, defined in short, as a progressive spinal cord injury caused by narrowing of the cervical spinal canal. CONCLUSION A consistent term and definition can support education and research initiatives. This was selected using a structured and iterative methodology, which may serve as an exemplar for others in the future.
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Affiliation(s)
- Benjamin M. Davies
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
| | - Danyal Z Khan
- Department of Neurosurgery, Walton Centre, UK
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, UK
| | - Kara Barzangi
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
| | - Ahmad Ali
- Department of Neurosurgery, Walton Centre, UK
| | - Oliver D. Mowforth
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
| | - Aria Nouri
- Department of Neurosurgery, Geneva University Hospital, University of Geneva, Switzerland
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Iran
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Lindsay Tetreault
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Brian K. Kwon
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto - Hospital de Santo António, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Portugal
| | - Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
| | - Robert Chen
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | | | - Armin Curt
- University Spine Center, Balgrist University Hospital, Switzerland
| | | | | | | | | | | | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mark R.N. Kotter
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
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Eriks-Hoogland IE, Barth MA, Müller LL, Braun D, Curt A, Arora M, Middleton JW, Pannek J. COVID-19 and spinal cord injury: clinical presentation, clinical course, and clinical outcomes of people hospitalised. Spinal Cord Ser Cases 2024; 10:5. [PMID: 38351025 PMCID: PMC10864293 DOI: 10.1038/s41394-024-00617-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/16/2024] Open
Abstract
STUDY DESIGN Retrospective study OBJECTIVES: To describe the presenting symptoms/signs, clinical course and outcomes in hospitalised people with spinal cord injury (SCI) and symptomatic COVID-19 infections. SETTING One university hospital and two SCI centres in Switzerland. METHODS Descriptive analysis of symptoms/signs, clinical course and outcomes of people with SCI with symptomatic COVID-19 infections and need for hospitalisation. RESULTS Twenty-two people with SCI were included, 15 (68%) were male, median age 64.5 years (interquartile range, IQR, 52-73 years). Nine (41%) had tetraplegia, and eight (36%) were classified with motor-complete lesions. Frequent clinical symptoms were fever (59%), coughing (54%), fatigue (50%), and dyspnoea (27%). Most frequent complications were bacterial pulmonary superinfection (18%), and acute respiratory distress syndrome (18%). Fifteen persons (68%) needed oxygen therapy during the course of hospitalisation, and 7 (32%) people were ventilated. Median length of stay (LOS) was 23 days (IQR 15-35), varying by age for people under 60 years with a median LOS of 9 days (IQR 8-27), and for those older than 60 years with a median of 34 days (IQR 17-39), respectively. In total, 3 persons (14%) died during hospitalisation, all older with paraplegia. CONCLUSIONS Typical symptoms like fever and coughing were not present in all people. People with tetraplegia did not demonstrate worse outcomes, on the contrary, they had shorter LOS, no difference in ventilation needs, and no higher mortality compared to people with paraplegia. Older people showed longer LOS. This study recommends close supervision of the SCI population to detect early signs and symptoms of COVID-19 infection.
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Affiliation(s)
- Inge E Eriks-Hoogland
- Swiss Paraplegic Centre, Nottwil, Switzerland.
- Faculty of Health Sciences and Medicine at the University of Lucerne, Lucerne, Switzerland.
- Swiss Paraplegic Research, Nottwil, Switzerland.
| | | | | | - Dominique Braun
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mohit Arora
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, St Leonards, NSW, Australia
- The Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, St Leonards, NSW, Australia
- The Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jürgen Pannek
- Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Willi R, Werner C, Demkó L, de Bie R, Filli L, Zörner B, Curt A, Bolliger M. Reliability of patient-specific gait profiles with inertial measurement units during the 2-min walk test in incomplete spinal cord injury. Sci Rep 2024; 14:3049. [PMID: 38321085 PMCID: PMC10847409 DOI: 10.1038/s41598-024-53301-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 01/30/2024] [Indexed: 02/08/2024] Open
Abstract
Most established clinical walking tests assess specific aspects of movement function (velocity, endurance, etc.) but are generally unable to determine specific biomechanical or neurological deficits that limit an individual's ability to walk. Recently, inertial measurement units (IMU) have been used to collect objective kinematic data for gait analysis and could be a valuable extension for clinical assessments (e.g., functional walking measures). This study assesses the reliability of an IMU-based overground gait analysis during the 2-min walk test (2mWT) in individuals with spinal cord injury (SCI). Furthermore, the study elaborates on the capability of IMUs to distinguish between different gait characteristics in individuals with SCI. Twenty-six individuals (aged 22-79) with acute or chronic SCI (AIS: C and D) completed the 2mWT with IMUs attached above each ankle on 2 test days, separated by 1 to 7 days. The IMU-based gait analysis showed good to excellent test-retest reliability (ICC: 0.77-0.99) for all gait parameters. Gait profiles remained stable between two measurements. Sensor-based gait profiling was able to reveal patient-specific gait impairments even in individuals with the same walking performance in the 2mWT. IMUs are a valuable add-on to clinical gait assessments and deliver reliable information on detailed gait pathologies in individuals with SCI.Trial registration: NCT04555759.
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Affiliation(s)
- Romina Willi
- Spinal Cord Injury Centre Balgrist, University Hospital, Zurich, Switzerland
| | - Charlotte Werner
- Spinal Cord Injury Centre Balgrist, University Hospital, Zurich, Switzerland
| | - László Demkó
- Spinal Cord Injury Centre Balgrist, University Hospital, Zurich, Switzerland
| | - Rob de Bie
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Linard Filli
- Spinal Cord Injury Centre Balgrist, University Hospital, Zurich, Switzerland
- Swiss Center for Movement Analysis (SCMA), Balgrist Campus AG, Zurich, Switzerland
| | - Björn Zörner
- Spinal Cord Injury Centre Balgrist, University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Centre Balgrist, University Hospital, Zurich, Switzerland
| | - Marc Bolliger
- Spinal Cord Injury Centre Balgrist, University Hospital, Zurich, Switzerland.
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Bourguignon L, Lukas LP, Guest JD, Geisler FH, Noonan V, Curt A, Brüningk SC, Jutzeler CR. Studying missingness in spinal cord injury data: challenges and impact of data imputation. BMC Med Res Methodol 2024; 24:5. [PMID: 38184529 PMCID: PMC10770973 DOI: 10.1186/s12874-023-02125-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 12/08/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND In the last decades, medical research fields studying rare conditions such as spinal cord injury (SCI) have made extensive efforts to collect large-scale data. However, most analysis methods rely on complete data. This is particularly troublesome when studying clinical data as they are prone to missingness. Often, researchers mitigate this problem by removing patients with missing data from the analyses. Less commonly, imputation methods to infer likely values are applied. OBJECTIVE Our objective was to study how handling missing data influences the results reported, taking the example of SCI registries. We aimed to raise awareness on the effects of missing data and provide guidelines to be applied for future research projects, in SCI research and beyond. METHODS Using the Sygen clinical trial data (n = 797), we analyzed the impact of the type of variable in which data is missing, the pattern according to which data is missing, and the imputation strategy (e.g. mean imputation, last observation carried forward, multiple imputation). RESULTS Our simulations show that mean imputation may lead to results strongly deviating from the underlying expected results. For repeated measures missing at late stages (> = 6 months after injury in this simulation study), carrying the last observation forward seems the preferable option for the imputation. This simulation study could show that a one-size-fit-all imputation strategy falls short in SCI data sets. CONCLUSIONS Data-tailored imputation strategies are required (e.g., characterisation of the missingness pattern, last observation carried forward for repeated measures evolving to a plateau over time). Therefore, systematically reporting the extent, kind and decisions made regarding missing data will be essential to improve the interpretation, transparency, and reproducibility of the research presented.
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Affiliation(s)
- Lucie Bourguignon
- Department of Health Sciences and Technology (D-HEST), ETH Zurich, Universitätstrasse 2, 8092, Zürich, Switzerland.
- Schulthess Klinik, Lengghalde 2, 8008, Zürich, Switzerland.
- SIB Swiss Institute of Bioinformatics, Lausanne, Switzerland.
| | - Louis P Lukas
- Department of Health Sciences and Technology (D-HEST), ETH Zurich, Universitätstrasse 2, 8092, Zürich, Switzerland
- Schulthess Klinik, Lengghalde 2, 8008, Zürich, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - James D Guest
- Neurological Surgery and the Miami Project to Cure Paralysis, U Miami, Miami, FL, 33136, USA
| | - Fred H Geisler
- Department of Medical Imaging, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Vanessa Noonan
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Armin Curt
- Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Lengghalde 2, 8006, Zürich, Switzerland
| | - Sarah C Brüningk
- Department of Health Sciences and Technology (D-HEST), ETH Zurich, Universitätstrasse 2, 8092, Zürich, Switzerland
- Schulthess Klinik, Lengghalde 2, 8008, Zürich, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Catherine R Jutzeler
- Department of Health Sciences and Technology (D-HEST), ETH Zurich, Universitätstrasse 2, 8092, Zürich, Switzerland
- Schulthess Klinik, Lengghalde 2, 8008, Zürich, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne, Switzerland
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9
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Lebret A, Lévy S, Pfender N, Farshad M, Altorfer FCS, Callot V, Curt A, Freund P, Seif M. Investigation of perfusion impairment in degenerative cervical myelopathy beyond the site of cord compression. Sci Rep 2023; 13:22660. [PMID: 38114733 PMCID: PMC10730822 DOI: 10.1038/s41598-023-49896-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
The aim of this study was to determine tissue-specific blood perfusion impairment of the cervical cord above the compression site in patients with degenerative cervical myelopathy (DCM) using intravoxel incoherent motion (IVIM) imaging. A quantitative MRI protocol, including structural and IVIM imaging, was conducted in healthy controls and patients. In patients, T2-weighted scans were acquired to quantify intramedullary signal changes, the maximal canal compromise, and the maximal cord compression. T2*-weighted MRI and IVIM were applied in all participants in the cervical cord (covering C1-C3 levels) to determine white matter (WM) and grey matter (GM) cross-sectional areas (as a marker of atrophy), and tissue-specific perfusion indices, respectively. IVIM imaging resulted in microvascular volume fraction ([Formula: see text]), blood velocity ([Formula: see text]), and blood flow ([Formula: see text]) indices. DCM patients additionally underwent a standard neurological clinical assessment. Regression analysis assessed associations between perfusion parameters, clinical outcome measures, and remote spinal cord atrophy. Twenty-nine DCM patients and 30 healthy controls were enrolled in the study. At the level of stenosis, 11 patients showed focal radiological evidence of cervical myelopathy. Above the stenosis level, cord atrophy was observed in the WM (- 9.3%; p = 0.005) and GM (- 6.3%; p = 0.008) in patients compared to healthy controls. Blood velocity (BV) and blood flow (BF) indices were decreased in the ventral horns of the GM (BV: - 20.1%, p = 0.0009; BF: - 28.2%, p = 0.0008), in the ventral funiculi (BV: - 18.2%, p = 0.01; BF: - 21.5%, p = 0.04) and lateral funiculi (BV: - 8.5%, p = 0.03; BF: - 16.5%, p = 0.03) of the WM, across C1-C3 levels. A decrease in microvascular volume fraction was associated with GM atrophy (R = 0.46, p = 0.02). This study demonstrates tissue-specific cervical perfusion impairment rostral to the compression site in DCM patients. IVIM indices are sensitive to remote perfusion changes in the cervical cord in DCM and may serve as neuroimaging biomarkers of hemodynamic impairment in future studies. The association between perfusion impairment and cervical cord atrophy indicates that changes in hemodynamics caused by compression may contribute to the neurodegenerative processes in DCM.
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Affiliation(s)
- Anna Lebret
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
| | - Simon Lévy
- CNRS, CRMBM, Aix-Marseille University, Marseille, France
- APHM, CEMEREM, Hôpital Universitaire Timone, Marseille, France
- MR Research Collaborations, Siemens Healthcare Pty Ltd, Melbourne, Australia
| | - Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, Zürich, Switzerland
| | | | - Virginie Callot
- CNRS, CRMBM, Aix-Marseille University, Marseille, France
- APHM, CEMEREM, Hôpital Universitaire Timone, Marseille, France
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland
- Department of Brain Repair and Rehabilitation, Wellcome Trust Center for Neuroimaging, Institute of Neurology, University College London, London, UK
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Maryam Seif
- Spinal Cord Injury Center, Balgrist University Hospital, Zürich, Switzerland.
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.
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De Schoenmacker I, Sirucek L, Scheuren PS, Lütolf R, Gorrell LM, Brunner F, Curt A, Rosner J, Schweinhardt P, Hubli M. Sensory phenotypes in complex regional pain syndrome and chronic low back pain-indication of common underlying pathomechanisms. Pain Rep 2023; 8:e1110. [PMID: 38027464 PMCID: PMC10653599 DOI: 10.1097/pr9.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction First-line pain treatment is unsatisfactory in more than 50% of chronic pain patients, likely because of the heterogeneity of mechanisms underlying pain chronification. Objectives This cross-sectional study aimed to better understand pathomechanisms across different chronic pain cohorts, regardless of their diagnoses, by identifying distinct sensory phenotypes through a cluster analysis. Methods We recruited 81 chronic pain patients and 63 age-matched and sex-matched healthy controls (HC). Two distinct chronic pain cohorts were recruited, ie, complex regional pain syndrome (N = 20) and low back pain (N = 61). Quantitative sensory testing (QST) was performed in the most painful body area to investigate somatosensory changes related to clinical pain. Furthermore, QST was conducted in a pain-free area to identify remote sensory alterations, indicating more widespread changes in somatosensory processing. Results Two clusters were identified based on the QST measures in the painful area, which did not represent the 2 distinct pain diagnoses but contained patients from both cohorts. Cluster 1 showed increased pain sensitivities in the painful and control area, indicating central sensitization as a potential pathomechanism. Cluster 2 showed a similar sensory profile as HC in both tested areas. Hence, either QST was not sensitive enough and more objective measures are needed to detect sensitization within the nociceptive neuraxis or cluster 2 may not have pain primarily because of sensitization, but other factors such as psychosocial ones are involved. Conclusion These findings support the notion of shared pathomechanisms irrespective of the pain diagnosis. Conversely, different mechanisms might contribute to the pain of patients with the same diagnosis.
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Affiliation(s)
- Iara De Schoenmacker
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
| | - Laura Sirucek
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Paulina S. Scheuren
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Robin Lütolf
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lindsay M. Gorrell
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Florian Brunner
- Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Petra Schweinhardt
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Alan Edward Center for Research on Pain, McGill University, Montreal, QC, Canada
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Dittli J, Meyer JT, Gantenbein J, Bützer T, Ranzani R, Linke A, Curt A, Gassert R, Lambercy O. Mixed methods usability evaluation of an assistive wearable robotic hand orthosis for people with spinal cord injury. J Neuroeng Rehabil 2023; 20:162. [PMID: 38041135 PMCID: PMC10693050 DOI: 10.1186/s12984-023-01284-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/18/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Robotic hand orthoses (RHO) aim to provide grasp assistance for people with sensorimotor hand impairment during daily tasks. Many of such devices have been shown to bring a functional benefit to the user. However, assessing functional benefit is not sufficient to evaluate the usability of such technologies for daily life application. A comprehensive and structured evaluation of device usability not only focusing on effectiveness but also efficiency and satisfaction is required, yet often falls short in existing literature. Mixed methods evaluations, i.e., assessing a combination of quantitative and qualitative measures, allow to obtain a more holistic picture of all relevant aspects of device usability. Considering these aspects already in early development stages allows to identify design issues and generate generalizable benchmarks for future developments. METHODS We evaluated the short-term usability of the RELab tenoexo, a RHO for hand function assistance, in 15 users with tetraplegia after a spinal cord injury through a comprehensive mixed methods approach. We collected quantitative data using the Action Research Arm Test (ARAT), the System Usability Scale (SUS), and timed tasks such as the donning process. In addition, qualitative data were collected through semi-structured interviews and user observations, and analyzed with a thematic analysis to enhance the usability evaluation. All insights were attributed and discussed in relation to specifically defined usability attributes such as comfort, ease of use, functional benefit, and safety. RESULTS The RELab tenoexo provided an immediate functional benefit to the users, resulting in a mean improvement of the ARAT score by 5.8 points and peaking at 15 points improvement for one user (clinically important difference: 5.7 points). The mean SUS rating of 60.6 represents an adequate usability, however, indicating that especially the RHO donning (average task time = 295 s) was perceived as too long and cumbersome. The participants were generally very satisfied with the ergonomics (size, dimensions, fit) of the RHO. Enhancing the ease of use, specifically in donning, increasing the provided grasping force, as well as the availability of tailoring options and customization were identified as main improvement areas to promote RHO usability. CONCLUSION The short-term usability of the RELab tenoexo was thoroughly evaluated with a mixed methods approach, which generated valuable data to improve the RHO in future iterations. In addition, learnings that might be transferable to the evaluation and design of other RHO were generated, which have the potential to increase the daily life applicability and acceptance of similar technologies.
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Affiliation(s)
- Jan Dittli
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland.
| | - Jan T Meyer
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland
| | - Jessica Gantenbein
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland
| | - Tobias Bützer
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland
| | - Raffaele Ranzani
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland
| | - Anita Linke
- Spinal Cord Injury Center, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Roger Gassert
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland
- Singapore-ETH Centre, Future Health Technologies Programme, CREATE campus, 1 Create Way, #06-01 CREATE Tower, 138602, Singapore, Singapore
| | - Olivier Lambercy
- Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zurich, Lengghalde 5, 8008, Zurich, Switzerland
- Singapore-ETH Centre, Future Health Technologies Programme, CREATE campus, 1 Create Way, #06-01 CREATE Tower, 138602, Singapore, Singapore
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12
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Pfender N, Rosner J, Zipser CM, Friedl S, Schubert M, Sutter R, Klarhoefer M, Spirig JM, Betz M, Freund P, Farshad M, Curt A, Hupp M. Increased cranio-caudal spinal cord oscillations are the cardinal pathophysiological change in degenerative cervical myelopathy. Front Neurol 2023; 14:1217526. [PMID: 38020663 PMCID: PMC10663304 DOI: 10.3389/fneur.2023.1217526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Degenerative cervical myelopathy (DCM) is the most common cause of non-traumatic incomplete spinal cord injury, but its pathophysiology is poorly understood. As spinal cord compression observed in standard MRI often fails to explain a patient's status, new diagnostic techniques to assess DCM are one of the research priorities. Minor cardiac-related cranio-caudal oscillations of the cervical spinal cord are observed by phase-contrast MRI (PC-MRI) in healthy controls (HCs), while they become pathologically increased in patients suffering from degenerative cervical myelopathy. Whether transversal oscillations (i.e., anterior-posterior and right-left) also change in DCM patients is not known. Methods We assessed spinal cord motion simultaneously in all three spatial directions (i.e., cranio-caudal, anterior-posterior, and right-left) using sagittal PC-MRI and compared physiological oscillations in 18 HCs to pathological changes in 72 DCM patients with spinal canal stenosis. The parameter of interest was the amplitude of the velocity signal (i.e., maximum positive to maximum negative peak) during the cardiac cycle. Results Most patients suffered from mild DCM (mJOA score 16 (14-18) points), and the majority (68.1%) presented with multisegmental stenosis. The spinal canal was considerably constricted in DCM patients in all segments compared to HCs. Under physiological conditions in HCs, the cervical spinal cord oscillates in the cranio-caudal and anterior-posterior directions, while right-left motion was marginal [e.g., segment C5 amplitudes: cranio-caudal: 0.40 (0.27-0.48) cm/s; anterior-posterior: 0.18 (0.16-0.29) cm/s; right-left: 0.10 (0.08-0.13) cm/s]. Compared to HCs, DCM patients presented with considerably increased cranio-caudal oscillations due to the cardinal pathophysiologic change in non-stenotic [e.g., segment C5 amplitudes: 0.79 (0.49-1.32) cm/s] and stenotic segments [.g., segment C5 amplitudes: 0.99 (0.69-1.42) cm/s]). In contrast, right-left [e.g., segment C5 amplitudes: non-stenotic segment: 0.20 (0.13-0.32) cm/s; stenotic segment: 0.11 (0.09-0.18) cm/s] and anterior-posterior oscillations [e.g., segment C5 amplitudes: non-stenotic segment: 0.26 (0.15-0.45) cm/s; stenotic segment: 0.11 (0.09-0.18) cm/s] remained on low magnitudes comparable to HCs. Conclusion Increased cranio-caudal oscillations of the cervical cord are the cardinal pathophysiologic change and can be quantified using PC-MRI in DCM patients. This study addresses spinal cord oscillations as a relevant biomarker reflecting dynamic mechanical cord stress in DCM patients, potentially contributing to a loss of function.
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Affiliation(s)
- Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Carl M. Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Susanne Friedl
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Reto Sutter
- Radiology, Balgrist University Hospital, Zurich, Switzerland
| | | | - José M. Spirig
- University Spine Center Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- University Spine Center Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Center Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Markus Hupp
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
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13
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Maggioni S, Lünenburger L, Riener R, Curt A, Bolliger M, Melendez-Calderon A. Assessing walking ability using a robotic gait trainer: opportunities and limitations of assist-as-needed control in spinal cord injury. J Neuroeng Rehabil 2023; 20:121. [PMID: 37735690 PMCID: PMC10515081 DOI: 10.1186/s12984-023-01226-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/27/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Walking impairments are a common consequence of neurological disorders and are assessed with clinical scores that suffer from several limitations. Robot-assisted locomotor training is becoming an established clinical practice. Besides training, these devices could be used for assessing walking ability in a controlled environment. Here, we propose an adaptive assist-as-needed (AAN) control for a treadmill-based robotic exoskeleton, the Lokomat, that reduces the support of the device (body weight support and impedance of the robotic joints) based on the ability of the patient to follow a gait pattern displayed on screen. We hypothesize that the converged values of robotic support provide valid and reliable information about individuals' walking ability. METHODS Fifteen participants with spinal cord injury and twelve controls used the AAN software in the Lokomat twice within a week and were assessed using clinical scores (10MWT, TUG). We used a regression method to identify the robotic measure that could provide the most relevant information about walking ability and determined the test-retest reliability. We also checked whether this result could be extrapolated to non-ambulatory and to unimpaired subjects. RESULTS The AAN controller could be used in patients with different injury severity levels. A linear model based on one variable (robotic knee stiffness at terminal swing) could explain 74% of the variance in the 10MWT and 61% in the TUG in ambulatory patients and showed good relative reliability but poor absolute reliability. Adding the variable 'maximum hip flexor torque' to the model increased the explained variance above 85%. This did not extend to non-ambulatory nor to able-bodied individuals, where variables related to stance phase and to push-off phase seem more relevant. CONCLUSIONS The novel AAN software for the Lokomat can be used to quantify the support required by a patient while performing robotic gait training. The adaptive software might enable more challenging training conditions tuned to the ability of the individuals. While the current implementation is not ready for assessment in clinical practice, we could demonstrate that this approach is safe, and it could be integrated as assist-as-needed training, rather than as assessment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02425332.
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Affiliation(s)
| | | | - Robert Riener
- Sensory-Motor Systems (SMS) Lab, ETH Zurich, Zurich, Switzerland
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Marc Bolliger
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Alejandro Melendez-Calderon
- School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Australia.
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
- Jamieson Trauma Institute, Metro North Health, Brisbane, Australia.
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Kelly-Hedrik M, Abd-El-Barr MM, Aarabi B, Curt A, Howley SP, Harrop JS, Kirshblum S, Neal CJ, Noonan V, Park C, Ugiliweneza B, Tator C, Toups EG, Fehlings MG, Williamson T, Guest JD. Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care. J Neurotrauma 2023; 40:1834-1848. [PMID: 36576020 DOI: 10.1089/neu.2022.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.
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Affiliation(s)
| | | | - Bizhan Aarabi
- University of Maryland School of Medicine, Maryland, USA
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Susan P Howley
- Christopher & Dana Reeve Foundation, Short Hills, New Jersey, USA
| | - James S Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Kirshblum
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Christopher J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Vanessa Noonan
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Christine Park
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Charles Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G Toups
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James D Guest
- Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami, Miami, USA
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15
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Scheuren PS, Bösch S, Rosner J, Allmendinger F, Kramer JLK, Curt A, Hubli M. Priming of the autonomic nervous system after an experimental human pain model. J Neurophysiol 2023; 130:436-446. [PMID: 37405990 PMCID: PMC10625835 DOI: 10.1152/jn.00064.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023] Open
Abstract
Modulated autonomic responses to noxious stimulation have been reported in experimental and clinical pain. These effects are likely mediated by nociceptive sensitization, but may also, more simply reflect increased stimulus-associated arousal. To disentangle between sensitization- and arousal-mediated effects on autonomic responses to noxious input, we recorded sympathetic skin responses (SSRs) in response to 10 pinprick and heat stimuli before (PRE) and after (POST) an experimental heat pain model to induce secondary hyperalgesia (EXP) and a control model (CTRL) in 20 healthy females. Pinprick and heat stimuli were individually adapted for pain perception (4/10) across all assessments. Heart rate, heart rate variability, and skin conductance level (SCL) were assessed before, during, and after the experimental heat pain model. Both pinprick- and heat-induced SSRs habituated from PRE to POST in CTRL, but not EXP (P = 0.033). Background SCL (during stimuli application) was heightened in EXP compared with CTRL condition during pinprick and heat stimuli (P = 0.009). Our findings indicate that enhanced SSRs after an experimental pain model are neither fully related to subjective pain, as SSRs dissociated from perceptual responses, nor to nociceptive sensitization, as SSRs were enhanced for both modalities. Our findings can, however, be explained by priming of the autonomic nervous system during the experimental pain model, which makes the autonomic nervous system more susceptible to noxious input. Taken together, autonomic readouts have the potential to objectively assess not only nociceptive sensitization but also priming of the autonomic nervous system, which may be involved in the generation of distinct clinical pain phenotypes.NEW & NOTEWORTHY The facilitation of pain-induced sympathetic skin responses observed after experimentally induced central sensitization is unspecific to the stimulation modality and thereby unlikely solely driven by nociceptive sensitization. In addition, these enhanced pain-induced autonomic responses are also not related to higher stimulus-associated arousal, but rather a general priming of the autonomic nervous system. Hence, autonomic readouts may be able to detect generalized hyperexcitability in chronic pain, beyond the nociceptive system, which may contribute to clinical pain phenotypes.
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Affiliation(s)
- Paulina Simonne Scheuren
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Sofia Bösch
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Florin Allmendinger
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - John Lawrence Kipling Kramer
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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De Schoenmacker I, Mollo A, Scheuren PS, Sirucek L, Brunner F, Schweinhardt P, Curt A, Rosner J, Hubli M. Central sensitization in CRPS patients with widespread pain: a cross-sectional study. Pain Med 2023; 24:974-984. [PMID: 36946277 PMCID: PMC10391588 DOI: 10.1093/pm/pnad040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/08/2023] [Accepted: 03/20/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Widespread pain hypersensitivity and enhanced temporal summation of pain (TSP) are commonly reported in patients with complex regional pain syndrome (CRPS) and discussed as proxies for central sensitization. This study aimed to directly relate such signs of neuronal hyperexcitability to the pain phenotype of CRPS patients. METHODS Twenty-one CRPS patients and 20 healthy controls (HC) were recruited. The pain phenotype including spatial pain extent (assessed in % body surface) and intensity were assessed and related to widespread pain hypersensitivity, TSP, and psychological factors. Quantitative sensory testing (QST) was performed in the affected, the contralateral and a remote (control) area. RESULTS CRPS patients showed decreased pressure pain thresholds in all tested areas (affected: t(34) = 4.98, P < .001, contralateral: t(35) = 3.19, P = .005, control: t(31) = 2.65, P = .012). Additionally, patients showed increased TSP in the affected area (F(3,111) = 4.57, P = .009) compared to HC. TSP was even more enhanced in patients with a high compared to a low spatial pain extent (F(3,51) = 5.67, P = .008), suggesting pronounced spinal sensitization in patients with extended pain patterns. Furthermore, the spatial pain extent positively correlated with the Bath Body Perception Disturbance Scale (ρ = 0.491; P = .048). CONCLUSIONS Overall, we provide evidence that the pain phenotype in CRPS, that is, spatial pain extent, might be related to sensitization mechanism within the central nociceptive system. This study points towards central neuronal excitability as a potential therapeutic target in patients with more widespread CRPS.
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Affiliation(s)
- Iara De Schoenmacker
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Anna Mollo
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Paulina Simonne Scheuren
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Laura Sirucek
- Integrative Spinal Research, Department of Chiropractic Medicine, University Hospital Balgrist, University of Zurich, 8008 Zurich, Switzerland
| | - Florian Brunner
- Physical Medicine and Rheumatology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Petra Schweinhardt
- Integrative Spinal Research, Department of Chiropractic Medicine, University Hospital Balgrist, University of Zurich, 8008 Zurich, Switzerland
- Alan Edward Center for Research on Pain, McGill University, Montreal, Quebec, Canada
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
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Huynh V, Lütolf R, Rosner J, Luechinger R, Curt A, Kollias S, Michels L, Hubli M. Intrinsic brain connectivity alterations despite intact pain inhibition in subjects with neuropathic pain after spinal cord injury: a pilot study. Sci Rep 2023; 13:11943. [PMID: 37488130 PMCID: PMC10366123 DOI: 10.1038/s41598-023-37783-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/27/2023] [Indexed: 07/26/2023] Open
Abstract
Endogenous pain modulation in humans is frequently investigated with conditioned pain modulation (CPM). Deficient pain inhibition is a proposed mechanism that contributes to neuropathic pain (NP) after spinal cord injury (SCI). Recent studies have combined CPM testing and neuroimaging to reveal neural correlates of CPM efficiency in chronic pain. This study investigated differences in CPM efficiency in relation to resting-state functional connectivity (rsFC) between 12 SCI-NP subjects and 13 age- and sex-matched healthy controls (HC). Twelve and 11 SCI-NP subjects were included in psychophysical and rsFC analyses, respectively. All HC were included in the final analyses. Psychophysical readouts were analysed to determine CPM efficiency within and between cohorts. Group differences of rsFC, in relation to CPM efficiency, were explored with seed-to-voxel rsFC analyses with pain modulatory regions, e.g. ventrolateral periaqueductal gray (vlPAG) and amygdala. Overall, pain inhibition was not deficient in SCI-NP subjects and was greater in those with more intense NP. Greater pain inhibition was associated with weaker rsFC between the vlPAG and amygdala with the visual and frontal cortex, respectively, in SCI-NP subjects but with stronger rsFC in HC. Taken together, SCI-NP subjects present with intact pain inhibition, but can be differentiated from HC by an inverse relationship between CPM efficiency and intrinsic connectivity of supraspinal regions. Future studies with larger cohorts are necessary to consolidate the findings in this study.
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Affiliation(s)
- Vincent Huynh
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich & University of Zurich, Zurich, Switzerland.
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Robin Lütolf
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Roger Luechinger
- Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Spyridon Kollias
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Lars Michels
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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18
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Stalder SA, van der Lely S, Anderson CE, Birkhäuser V, Curt A, Gross O, Leitner L, Mehnert U, Schubert M, Tornic J, Kessler TM, Liechti MD. Development of a Sham Protocol to Investigate Transcutaneous Tibial Nerve Stimulation in Randomised, Sham-Controlled, Double-Blind Clinical Trials. Biomedicines 2023; 11:1931. [PMID: 37509569 PMCID: PMC10377596 DOI: 10.3390/biomedicines11071931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Transcutaneous tibial nerve stimulation (TTNS) is a promising treatment for neurogenic lower urinary tract symptoms. However, the evidence is limited due to a general lack of randomised controlled trials (RCTs) and, also, inconsistency in the sham and blinding conditions. In the context of much-needed RCTs, we aimed to develop a suitable sham-control protocol for a clinical setting to maintain blinding but avoid meaningful stimulation of the tibial nerve. Three potential electrode positions (lateral malleolus/5th metatarsal/plantar calcaneus) and two electrode sizes (diameter: 2.5 cm/3.2 cm) were tested to determine which combination provided the optimal sham configuration for a TTNS approach, based on a visible motor response. Sixteen healthy volunteers underwent sensory and motor assessments for each sham configuration. Eight out of them came back for an extra TTNS visit. Sensory thresholds were present for all sham configurations, with linear regression models revealing a significant effect regarding electrode position (highest at plantar calcaneus) but not size. In addition, motor thresholds varied with the position-lowest for the 5th metatarsal. Only using this position and 3.2 cm electrodes attained a 100% response rate. Compared to TTNS, sensory and motor thresholds were generally higher for the sham configurations; meanwhile, perceived pain was only higher at the lateral malleolus. In conclusion, using the 5th metatarsal position and 3.2 cm electrodes proved to be the most suitable sham configuration. Implemented as a four-electrode setup with standardized procedures, this appears to be a suitable RCT protocol for maintaining blinding and controlling for nonspecific TTNS effects in a clinical setting.
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Affiliation(s)
- Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Health Sciences and Technology, ETH Zürich, 8092 Zürich, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Collene E Anderson
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Swiss Paraplegic Research, 6207 Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, 6002 Lucerne, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Jure Tornic
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
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19
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Kopp MA, Meisel C, Liebscher T, Watzlawick R, Cinelli P, Schweizerhof O, Blex C, Lübstorf T, Prilipp E, Niedeggen A, Druschel C, Schaser KD, Wanner GA, Curt A, Lindemann G, Nugeva N, Fehlings MG, Vajkoczy P, Cabraja M, Dengler J, Ertel W, Ekkernkamp A, Rehahn K, Martus P, Volk HD, Unterwalder N, Kölsch U, Brommer B, Hellmann RC, Baumgartner E, Hirt J, Geurtz LC, Saidy RRO, Prüss H, Laginha I, Failli V, Grittner U, Dirnagl U, Schwab JM. The spinal cord injury-induced immune deficiency syndrome: results of the SCIentinel study. Brain 2023:awad092. [PMID: 37370200 PMCID: PMC10393404 DOI: 10.1093/brain/awad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 01/13/2023] [Accepted: 01/29/2023] [Indexed: 06/29/2023] Open
Abstract
Infections are prevalent after spinal cord injury (SCI), constitute the main cause of death and are a rehabilitation confounder associated with impaired recovery. We hypothesize that SCI causes an acquired lesion-dependent (neurogenic) immune suppression as an underlying mechanism to facilitate infections. The international prospective multicentre cohort study (SCIentinel; protocol registration DRKS00000122; n = 111 patients) was designed to distinguish neurogenic from general trauma-related effects on the immune system. Therefore, SCI patient groups differing by neurological level, i.e. high SCI [thoracic (Th)4 or higher]; low SCI (Th5 or lower) and severity (complete SCI; incomplete SCI), were compared with a reference group of vertebral fracture (VF) patients without SCI. The primary outcome was quantitative monocytic Human Leukocyte Antigen-DR expression (mHLA-DR, synonym MHC II), a validated marker for immune suppression in critically ill patients associated with infection susceptibility. mHLA-DR was assessed from Day 1 to 10 weeks after injury by applying standardized flow cytometry procedures. Secondary outcomes were leucocyte subpopulation counts, serum immunoglobulin levels and clinically defined infections. Linear mixed models with multiple imputation were applied to evaluate group differences of logarithmic-transformed parameters. Mean quantitative mHLA-DR [ln (antibodies/cell)] levels at the primary end point 84 h after injury indicated an immune suppressive state below the normative values of 9.62 in all groups, which further differed in its dimension by neurological level: high SCI [8.95 (98.3% confidence interval, CI: 8.63; 9.26), n = 41], low SCI [9.05 (98.3% CI: 8.73; 9.36), n = 29], and VF without SCI [9.25 (98.3% CI: 8.97; 9.53), n = 41, P = 0.003]. Post hoc analysis accounting for SCI severity revealed the strongest mHLA-DR decrease [8.79 (95% CI: 8.50; 9.08)] in the complete, high SCI group, further demonstrating delayed mHLA-DR recovery [9.08 (95% CI: 8.82; 9.38)] and showing a difference from the VF controls of -0.43 (95% CI: -0.66; -0.20) at 14 days. Complete, high SCI patients also revealed constantly lower serum immunoglobulin G [-0.27 (95% CI: -0.45; -0.10)] and immunoglobulin A [-0.25 (95% CI: -0.49; -0.01)] levels [ln (g/l × 1000)] up to 10 weeks after injury. Low mHLA-DR levels in the range of borderline immunoparalysis (below 9.21) were positively associated with the occurrence and earlier onset of infections, which is consistent with results from studies on stroke or major surgery. Spinal cord injured patients can acquire a secondary, neurogenic immune deficiency syndrome characterized by reduced mHLA-DR expression and relative hypogammaglobulinaemia (combined cellular and humoral immune deficiency). mHLA-DR expression provides a basis to stratify infection-risk in patients with SCI.
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Affiliation(s)
- Marcel A Kopp
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, QUEST-Center for Transforming Biomedical Research, 10178 Berlin, Germany
| | - Christian Meisel
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Immunology, Labor Berlin-Charité Vivantes GmbH, 13353 Berlin, Germany
| | - Thomas Liebscher
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, 12683 Berlin, Germany
| | - Ralf Watzlawick
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurosurgery, Freiburg University Medical Center, 79106 Freiburg, Germany
| | - Paolo Cinelli
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Oliver Schweizerhof
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
| | - Christian Blex
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Tom Lübstorf
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Erik Prilipp
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, 12683 Berlin, Germany
| | - Andreas Niedeggen
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, 12683 Berlin, Germany
- Brandenburg Center for Spinal Cord Injuries, Kliniken Beelitz, 14547 Beelitz-Heilstätten, Germany
| | - Claudia Druschel
- Department of Orthopaedic and Trauma Surgery, Universitätsklinikum Carl-Gustav Carus, 01307 Dresden, Germany
| | - Klaus-Dieter Schaser
- Department of Orthopaedic and Trauma Surgery, Universitätsklinikum Carl-Gustav Carus, 01307 Dresden, Germany
| | - Guido A Wanner
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
- Spine and Back Centre, Centres for Spinal Surgery, Privatklinik Bethanien, 8044 Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, University Hospital Balgrist, 8008 Zurich, Switzerland
| | - Gertraut Lindemann
- Swiss Scoliosis-Centre for Spinal and Scoliosis Surgery, 8027 Zurich, Switzerland
| | - Natalia Nugeva
- University Health Network, Toronto Western Hospital, Toronto, ON M5T 2S8, Canada
| | - Michael G Fehlings
- Department of Neurosurgery, University of Toronto, Toronto, ON M5T 2S8, Canada
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Mario Cabraja
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Spinal Surgery, Vivantes Auguste-Viktoria-Hospital, 12157 Berlin, Germany
| | - Julius Dengler
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Neurosurgery, Helios Clinic, 15526 Bad Saarow, Germany
| | - Wolfgang Ertel
- Centre for Trauma- and Reconstructive Surgery, Charité-Universitätsmedizin Berlin, 12200 Berlin, Germany
| | - Axel Ekkernkamp
- Trauma Surgery and Orthopedics Clinic, BG Hospital Unfallkrankenhaus Berlin, 12683 Berlin, Germany
| | - Kerstin Rehahn
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, 12683 Berlin, Germany
- Brandenburg Center for Spinal Cord Injuries, Kliniken Beelitz, 14547 Beelitz-Heilstätten, Germany
| | - Peter Martus
- Department of Clinical Epidemiology and Applied Biostatistics, Eberhard Karls Universität Tübingen, 72076 TübingenGermany
| | - Hans-Dieter Volk
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Nadine Unterwalder
- Department of Immunology, Labor Berlin-Charité Vivantes GmbH, 13353 Berlin, Germany
| | - Uwe Kölsch
- Department of Immunology, Labor Berlin-Charité Vivantes GmbH, 13353 Berlin, Germany
| | - Benedikt Brommer
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Boston Children's Hospital, F.M. Kirby Neurobiology Center, Center for Life Science, Harvard Medical School, Boston, MA 02115, USA
| | - Rick C Hellmann
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Elias Baumgartner
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Pulmonology, DRK Klinikum Mitte, 13359 Berlin, Germany
| | - Julian Hirt
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Laura-Christin Geurtz
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Ramin Raul Ossami Saidy
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Surgery, Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Ines Laginha
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Vieri Failli
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
| | - Ulrich Dirnagl
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Jan M Schwab
- Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Department of Neurology, Spinal Cord Injury Section, The Neurological Institute, The Ohio State University, Wexner Medical Center, Columbus, Columbus, OH 43210, USA
- Belford Center for Spinal Cord Injury, Departments of Neuroscience and Physical Medicine and Rehabilitation, The Neurological Institute, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA
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20
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Zipser-Mohammadzada F, Scheffers MF, Conway BA, Halliday DM, Zipser CM, Curt A, Schubert M. Intramuscular coherence enables robust assessment of modulated supra-spinal input in human gait: an inter-dependence study of visual task and walking speed. Exp Brain Res 2023; 241:1675-1689. [PMID: 37199775 DOI: 10.1007/s00221-023-06635-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/11/2023] [Indexed: 05/19/2023]
Abstract
Intramuscular high-frequency coherence is increased during visually guided treadmill walking as a consequence of increased supra-spinal input. The influence of walking speed on intramuscular coherence and its inter-trial reproducibility need to be established before adoption as a functional gait assessment tool in clinical settings. Here, fifteen healthy controls performed a normal and a target walking task on a treadmill at various speeds (0.3 m/s, 0.5 m/s, 0.9 m/s, and preferred) during two sessions. Intramuscular coherence was calculated between two surface EMG recordings sites of the Tibialis anterior muscle during the swing phase of walking. The results were averaged across low-frequency (5-14 Hz) and high-frequency (15-55 Hz) bands. The effect of speed, task, and time on mean coherence was assessed using three-way repeated measures ANOVA. Reliability and agreement were calculated with the intra-class correlation coefficient and Bland-Altman method, respectively. Intramuscular coherence during target walking was significantly higher than during normal walking across all walking speeds in the high-frequency band as obtained by the three-way repeated measures ANOVA. Interaction effects between task and speed were found for the low- and high-frequency bands, suggesting that task-dependent differences increase at higher walking speeds. Reliability of intramuscular coherence was moderate to excellent for most normal and target walking tasks in all frequency bands. This study confirms previous reports of increased intramuscular coherence during target walking, while providing first evidence for reproducibility and robustness of this measure as a requirement to investigate supra-spinal input.Trial registration Registry number/ClinicalTrials.gov Identifier: NCT03343132, date of registration 2017/11/17.
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Affiliation(s)
| | - Marjelle Fredie Scheffers
- Department of Neurophysiology, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Bernard A Conway
- Biomedical Engineering, University of Strathclyde, Glasgow, G4 0NW, UK
| | - David M Halliday
- School of Physics, Engineering and Technology, University of York, York, YO10 5DD, UK
- York Biomedical Research Institute, University of York, York, UK
| | - Carl Moritz Zipser
- Department of Neurophysiology, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Department of Neurophysiology, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Department of Neurophysiology, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
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21
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Schwab JM, Haider C, Kopp MA, Zrzavy T, Endmayr V, Ricken G, Kubista H, Haider T, Liebscher T, Lübstorf T, Blex C, Serdani-Neuhaus L, Curt A, Cinelli P, Scivoletto G, Fehlings MG, May C, Guntermann A, Marcus K, Meisel C, Dirnagl U, Martus P, Prüss H, Popovich PG, Lassmann H, Höftberger R. Lesional Antibody Synthesis and Complement Deposition Associate With De Novo Antineuronal Antibody Synthesis After Spinal Cord Injury. Neurol Neuroimmunol Neuroinflamm 2023; 10:e200099. [PMID: 37019668 PMCID: PMC10075523 DOI: 10.1212/nxi.0000000000200099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/06/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Spinal cord injury (SCI) disrupts the fine-balanced interaction between the CNS and immune system and can cause maladaptive aberrant immune responses. The study examines emerging autoantibody synthesis after SCI with binding to conformational spinal cord epitopes and surface peptides located on the intact neuronal membrane. METHODS This is a prospective longitudinal cohort study conducted in acute care and inpatient rehabilitation centers in conjunction with a neuropathologic case-control study in archival tissue samples ranging from acute injury (baseline) to several months thereafter (follow-up). In the cohort study, serum autoantibody binding was examined in a blinded manner using tissue-based assays (TBAs) and dorsal root ganglia (DRG) neuronal cultures. Groups with traumatic motor complete SCI vs motor incomplete SCI vs isolated vertebral fracture without SCI (controls) were compared. In the neuropathologic study, B cell infiltration and antibody synthesis at the spinal lesion site were examined by comparing SCI with neuropathologically unaltered cord tissue. In addition, the CSF in an individual patient was explored. RESULTS Emerging autoantibody binding in both TBA and DRG assessments was restricted to an SCI patient subpopulation only (16%, 9/55 sera) while being absent in vertebral fracture controls (0%, 0/19 sera). Autoantibody binding to the spinal cord characteristically detected the substantia gelatinosa, a less-myelinated region of high synaptic density involved in sensory-motor integration and pain processing. Autoantibody binding was most frequent after motor complete SCI (grade American Spinal Injury Association impairment scale A/B, 22%, 8/37 sera) and was associated with neuropathic pain medication. In conjunction, the neuropathologic study demonstrated lesional spinal infiltration of B cells (CD20, CD79a) in 27% (6/22) of patients with SCI, the presence of plasma cells (CD138) in 9% (2/22). IgG and IgM antibody syntheses colocalized to areas of activated complement (C9neo) deposition. Longitudinal CSF analysis of an additional single patient demonstrated de novo (IgM) intrathecal antibody synthesis emerging with late reopening of the blood-spinal cord barrier. DISCUSSION This study provides immunologic, neurobiological, and neuropathologic proof-of-principle for an antibody-mediated autoimmunity response emerging approximately 3 weeks after SCI in a patient subpopulation with a high demand of neuropathic pain medication. Emerging autoimmunity directed against specific spinal cord and neuronal epitopes suggests the existence of paratraumatic CNS autoimmune syndromes.
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Affiliation(s)
- Jan M Schwab
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria.
| | - Carmen Haider
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Marcel A Kopp
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Tobias Zrzavy
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Verena Endmayr
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Gerda Ricken
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Helmut Kubista
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Thomas Haider
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Thomas Liebscher
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Tom Lübstorf
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Christian Blex
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Leonarda Serdani-Neuhaus
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Armin Curt
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Paolo Cinelli
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Giorgio Scivoletto
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Michael G Fehlings
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Caroline May
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Annika Guntermann
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Katrin Marcus
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Christian Meisel
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Ulrich Dirnagl
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Peter Martus
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Harald Prüss
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Phillip G Popovich
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Hans Lassmann
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria
| | - Romana Höftberger
- From the The Belford Center for Spinal Cord Injury (J.M.S., P.G.P.), The Ohio State University, Wexner Medical Center, Columbus; Departments of Neurology (J.M.S.), Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus; Department of Neurology and Experimental Neurology (J.M.S., M.A.K., T. Liebscher, T. Lübstorf, C.B., L.S.-N., U.D., H.P.), Spinal Cord Injury Research (Neuroparaplegiology), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Division of Neuropathology and Neurochemistry (C.H., V.E., G.R., R.H.), Department of Neurology, Medical University of Vienna, Austria; Department of Neurology (T.Z.), Medical University of Vienna, Austria; Department of Neurophysiology and Neuropharmacology (Center for Physiology and Pharmacology) (H.K.), Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery (T.H.), Medical University of Vienna, Austria; Treatment Centre for Spinal Cord Injuries (Thomas Liebscher), BG Hospital Unfallkrankenhaus Berlin, Germany; Spinal Cord Injury Center (A.C.), Balgrist University Hospital, Zurich, Switzerland; Division of Trauma Surgery (P.C.), University Hospital Zürich, Switzerland; IRCCS Fondazione S. Lucia (G.S.), Spinal Cord Unit, Rome, Italy; Division of Neurosurgery and Spine Program (M.G.F.), University of Toronto, ON, Canada; Ruhr-University Bochum (C. May, A.G., K.M.), Center for Protein Diagnostics (PRODI), Medical Proteome Center, Universitätsstraße 150, Bochum, Germany; Institute of Medical Immunology (C. Meisel), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; Department of Immunology (C. Meisel), Labor Berlin-Charité Vivantes GmbH, Germany; Berlin Institute of Health (U.D.), QUEST-Center for Transforming Biomedical Research, Germany; Department of Clinical Epidemiology and Applied Biostatistics (P.M.), Eberhard Karls Universität Tübingen, Germany; Department of Neurosciences (P.G.P.), The Ohio State University, Columbus; and Center for Brain Research (H.L.), Medical University of Vienna, Austria; Comprehensive Center for Clinical Neurosciences and Mental Health (C.H., T.Z., V.E., G.R., R.H.), Medical University of Vienna, Austria.
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22
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Werner C, Gönel M, Lerch I, Curt A, Demkó L. Data-driven characterization of walking after a spinal cord injury using inertial sensors. J Neuroeng Rehabil 2023; 20:55. [PMID: 37120519 PMCID: PMC10149024 DOI: 10.1186/s12984-023-01178-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 04/19/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND An incomplete spinal cord injury (SCI) refers to remaining sensorimotor function below the injury with the possibility for the patient to regain walking abilities. However, these patients often suffer from diverse gait deficits, which are not objectively assessed in the current clinical routine. Wearable inertial sensors are a promising tool to capture gait patterns objectively and started to gain ground for other neurological disorders such as stroke, multiple sclerosis, and Parkinson's disease. In this work, we present a data-driven approach to assess walking for SCI patients based on sensor-derived outcome measures. We aimed to (i) characterize their walking pattern in more depth by identifying groups with similar walking characteristics and (ii) use sensor-derived gait parameters as predictors for future walking capacity. METHODS The dataset analyzed consisted of 66 SCI patients and 20 healthy controls performing a standardized gait test, namely the 6-min walking test (6MWT), while wearing a sparse sensor setup of one sensor attached to each ankle. A data-driven approach has been followed using statistical methods and machine learning models to identify relevant and non-redundant gait parameters. RESULTS Clustering resulted in 4 groups of patients that were compared to each other and to the healthy controls. The clusters did differ in terms of their average walking speed but also in terms of more qualitative gait parameters such as variability or parameters indicating compensatory movements. Further, using longitudinal data from a subset of patients that performed the 6MWT several times during their rehabilitation, a prediction model has been trained to estimate whether the patient's walking speed will improve significantly in the future. Including sensor-derived gait parameters as inputs for the prediction model resulted in an accuracy of 80%, which is a considerable improvement of 10% compared to using only the days since injury, the present 6MWT distance, and the days until the next 6MWT as predictors. CONCLUSIONS In summary, the work presented proves that sensor-derived gait parameters provide additional information on walking characteristics and thus are beneficial to complement clinical walking assessments of SCI patients. This work is a step towards a more deficit-oriented therapy and paves the way for better rehabilitation outcome predictions.
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Affiliation(s)
- Charlotte Werner
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.
- Rehabilitation Engineering Laboratory, ETH Zurich, Zurich, Switzerland.
| | - Meltem Gönel
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Irina Lerch
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - László Demkó
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
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23
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Kheram N, Boraschi A, Pfender N, Spiegelberg A, Kurtcuoglu V, Curt A, Schubert M, Zipser CM. Queckenstedt's test repurposed for the quantitative assessment of the cerebrospinal fluid pulsatility curve. Acta Neurochir (Wien) 2023; 165:1533-1543. [PMID: 37079108 DOI: 10.1007/s00701-023-05583-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 03/16/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE Before the era of spinal imaging, presence of a spinal canal block was tested through gross changes in cerebrospinal fluid pressure (CSFP) provoked by manual compression of the jugular veins (referred to as Queckenstedt's test; QT). Beyond these provoked gross changes, cardiac-driven CSFP peak-to-valley amplitudes (CSFPp) can be recorded during CSFP registration. This is the first study to assess whether the QT can be repurposed to derive descriptors of the CSF pulsatility curve, focusing on feasibility and repeatability. METHOD Lumbar puncture was performed in lateral recumbent position in fourteen elderly patients (59.7±9.3 years, 6F) (NCT02170155) without stenosis of the spinal canal. CSFP was recorded during resting state and QT. A surrogate for the relative pulse pressure coefficient was computed from repeated QTs (i.e., RPPC-Q). RESULTS Resting state mean CSFP was 12.3 mmHg (IQR 3.2) and CSFPp was 1.0 mmHg (0.5). Mean CSFP rise during QT was 12.5 mmHg (7.3). CSFPp showed an average 3-fold increase at peak QT compared to the resting state. Median RPPC-Q was 0.18 (0.04). There was no systematic error in the computed metrics between the first and second QT. CONCLUSION This technical note describes a method to reliably derive, beyond gross CSFP increments, metrics related to cardiac-driven amplitudes during QT (i.e., RPPC-Q). A study comparing these metrics as obtained by established procedures (i.e., infusion testing) and by QT is warranted.
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Affiliation(s)
- Najmeh Kheram
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Andrea Boraschi
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Nikolai Pfender
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
| | - Andreas Spiegelberg
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Vartan Kurtcuoglu
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
| | - Carl Moritz Zipser
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland.
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24
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Cathomen A, Maier D, Kriz J, Abel R, Röhrich F, Baumberger M, Scivoletto G, Weidner N, Rupp R, Jutzeler CR, Steeves JD, Curt A, Bolliger M. Walking Outcome After Traumatic Paraplegic Spinal Cord Injury: The Function of Which Myotomes Makes a Difference? Neurorehabil Neural Repair 2023:15459683231166937. [PMID: 37039327 DOI: 10.1177/15459683231166937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
BACKGROUND Accurate prediction of walking function after a traumatic spinal cord injury (SCI) is crucial for an appropriate tailoring and application of therapeutical interventions. Long-term outcome of ambulation is strongly related to residual muscle function acutely after injury and its recovery potential. The identification of the underlying determinants of ambulation, however, remains a challenging task in SCI, a neurological disorder presented with heterogeneous clinical manifestations and recovery trajectories. OBJECTIVES Stratification of walking function and determination of its most relevant underlying muscle functions based on stratified homogeneous patient subgroups. METHODS Data from individuals with paraplegic SCI were used to develop a prediction-based stratification model, applying unbiased recursive partitioning conditional inference tree (URP-CTREE). The primary outcome was the 6-minute walk test at 6 months after injury. Standardized neurological assessments ≤15 days after injury were chosen as predictors. Resulting subgroups were incorporated into a subsequent node-specific analysis to attribute the role of individual lower extremity myotomes for the prognosis of walking function. RESULTS Using URP-CTREE, the study group of 361 SCI patients was divided into 8 homogeneous subgroups. The node specific analysis uncovered that proximal myotomes L2 and L3 were driving factors for the differentiation between walkers and non-walkers. Distal myotomes L4-S1 were revealed to be responsible for the prognostic distinction of indoor and outdoor walkers (with and without aids). CONCLUSION Stratification of a heterogeneous population with paraplegic SCI into more homogeneous subgroups, combined with the identification of underlying muscle functions prospectively determining the walking outcome, enable potential benefit for application in clinical trials and practice.
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Affiliation(s)
- Adrian Cathomen
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- ETH Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
| | | | - Jiri Kriz
- Spinal Cord Unit, University Hospital Motol, Prague, Czech Republic
| | | | - Frank Röhrich
- Berufsgenossenschaftliche Kliniken Bergmannstrost, Zentrum für Rückenmarkverletzte und Klinik für Orthopädie, Halle, Germany
| | | | - Giorgio Scivoletto
- Spinal Unit and Spinal Rehabilitation (SpiRe) Lab, IRCCS Fondazione S. Lucia, Rome, Italy
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Catherine R Jutzeler
- Biomedical Data Science Lab, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
- Schulthess Clinic, Zurich, Switzerland
| | - John D Steeves
- ICORD, University of British Columbia and Vancouver Coastal Health, Blusson Spinal Cord Centre, Vancouver, BC, Canada
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
| | - Marc Bolliger
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
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25
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Schading S, Seif M, Leutritz T, Hupp M, Curt A, Weiskopf N, Freund P. Reliability of spinal cord measures based on synthetic T 1-weighted MRI derived from multiparametric mapping (MPM). Neuroimage 2023; 271:120046. [PMID: 36948280 DOI: 10.1016/j.neuroimage.2023.120046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/14/2023] [Accepted: 03/18/2023] [Indexed: 03/24/2023] Open
Abstract
Short MRI acquisition time, high signal-to-noise ratio, and high reliability are crucial for image quality when scanning healthy volunteers and patients. Cross-sectional cervical cord area (CSA) has been suggested as a marker of neurodegeneration and potential outcome measure in clinical trials and is conventionally measured on T1-weigthed 3D Magnetization Prepared Rapid Acquisition Gradient-Echo (MPRAGE) images. This study aims to reduce the acquisition time for the comprehensive assessment of the spinal cord, which is typically based on MPRAGE for morphometry and multi-parameter mapping (MPM) for microstructure. The MPRAGE is replaced by a synthetic T1-w MRI (synT1-w) estimated from the MPM, in order to measure CSA. SynT1-w images were reconstructed using the MPRAGE signal equation based on quantitative maps of proton density (PD), longitudinal (R1) and effective transverse (R2*) relaxation rates. The reliability of CSA measurements from synT1-w images was determined within a multi-center test-retest study format and validated against acquired MPRAGE scans by assessing the agreement between both methods. The response to pathological changes was tested by longitudinally measuring spinal cord atrophy following spinal cord injury (SCI) for synT1-w and MPRAGE using linear mixed effect models. CSA measurements based on the synT1-w MRI showed high intra-site (Coefficient of variation [CoV]: 1.43% to 2.71%) and inter-site repeatability (CoV: 2.90% to 5.76%), and only a minor deviation of -1.65 mm2 compared to MPRAGE. Crucially, by assessing atrophy rates and by comparing SCI patients with healthy controls longitudinally, differences between synT1-w and MPRAGE were negligible. These results demonstrate that reliable estimates of CSA can be obtained from synT1-w images, thereby reducing scan time significantly.
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Affiliation(s)
- Simon Schading
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Maryam Seif
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Tobias Leutritz
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Markus Hupp
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Nikolaus Weiskopf
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Felix Bloch Institute for Solid State Physics, Faculty of Physics and Earth Sciences, Leipzig University, Leipzig, Germany
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Wellcome Trust Centre for Neuroimaging, UCL Queen Square Institute of Neurology, University College London, London, UK.
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26
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Kheram N, Boraschi A, Pfender N, Friedl S, Rasenack M, Fritz B, Kurtcuoglu V, Schubert M, Curt A, Zipser CM. Cerebrospinal Fluid Pressure Dynamics as a Bedside Test in Traumatic Spinal Cord Injury to Assess Surgical Spinal Cord Decompression: Safety, Feasibility, and Proof-of-Concept. Neurorehabil Neural Repair 2023; 37:171-182. [PMID: 36919616 PMCID: PMC10152574 DOI: 10.1177/15459683231159662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Sufficient and timely spinal cord decompression is a critical surgical objective for neurological recovery in spinal cord injury (SCI). Residual cord compression may be associated with disturbed cerebrospinal fluid pressure (CSFP) dynamics. OBJECTIVES This study aims to assess whether intrathecal CSFP dynamics in SCI following surgical decompression are feasible and safe, and to explore the diagnostic utility. METHODS Prospective cohort study. Bedside lumbar CSFP dynamics and cervical MRI were obtained following surgical decompression in N = 9 with mostly cervical acute-subacute SCI and N = 2 patients with non-traumatic SCI. CSFP measurements included mean CSFP, cardiac-driven CSFP peak-to-valley amplitudes (CSFPp), Valsalva maneuver, and Queckenstedt's test (firm pressure on jugular veins, QT). From QT, proxies for cerebrospinal fluid pulsatility curve were calculated (ie, relative pulse pressure coefficient; RPPC-Q). CSFP metrics were compared to spine-healthy patients. computer tomography (CT)-myelography was done in 3/8 simultaneous to CSFP measurements. RESULTS Mean age was 45 ± 9 years (range 17-67; 3F), SCI was complete (AIS A, N = 5) or incomplete (AIS B-D, N = 6). No adverse events related to CSFP assessments. CSFP rise during QT was induced in all patients [range 9.6-26.6 mmHg]. However, CSFPp was reduced in 3/11 (0.1-0.3 mmHg), and in 3/11 RPPC-Q was abnormal (0.01-0.05). Valsalva response was reduced in 8/11 (2.6-23.4 mmHg). CSFP dynamics corresponded to CT-myelography. CONCLUSIONS Comprehensive bedside lumbar CSFP dynamics in SCI following decompression are safe, feasible, and can reveal distinct patterns of residual spinal cord compression. Longitudinal studies are required to define critical thresholds of impaired CSFP dynamics that may impact neurological recovery and requiring surgical revisions.
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Affiliation(s)
- Najmeh Kheram
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.,Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Andrea Boraschi
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Susanne Friedl
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Maria Rasenack
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Benjamin Fritz
- Department of Radiology, Balgrist University Hospital, Zurich, Switzerland
| | | | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
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27
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Schading S, David G, Max Emmenegger T, Achim C, Thompson A, Weiskopf N, Curt A, Freund P. Dynamics of progressive degeneration of major spinal pathways following spinal cord injury: A longitudinal study. Neuroimage Clin 2023; 37:103339. [PMID: 36758456 PMCID: PMC9939725 DOI: 10.1016/j.nicl.2023.103339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/23/2022] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Following spinal cord injury (SCI), disease processes spread gradually along the spinal cord forming a spatial gradient with most pronounced changes located at the lesion site. However, the dynamics of this gradient in SCI patients is not established. OBJECTIVE This study tracks the spatiotemporal dynamics of remote anterograde and retrograde spinal tract degeneration in the upper cervical cord following SCI over two years utilizing quantitative MRI. METHODS Twenty-three acute SCI patients (11 paraplegics, 12 tetraplegics) and 21 healthy controls were scanned with a T1-weighted sequence for volumetry and a FLASH sequence for myelin-sensitive magnetization transfer saturation (MTsat) of the upper cervical cord. We estimated myelin content from MTsat maps within the corticospinal tracts (CST) and dorsal columns (DC) and measured spinal cord atrophy by means of left-right width (LRW) and anterior-posterior width (APW) on the T1-weighted images across cervical levels C1-C3. MTsat in the CST and LRW were considered proxies for retrograde degeneration, while MTsat in the DC and APW provided evidence for anterograde degeneration, respectively. Using regression models, we compared the temporal and spatial trajectories of these MRI readouts between tetraplegics, paraplegics, and controls over a 2-year period and assessed their associations with clinical improvement. RESULTS Linear rates and absolute differences in myelin-sensitive MTsat indicated retrograde and anterograde neurodegeneration in the CST and DC, respectively. Changes in MTsat within the CST and in LRW progressively developed over time forming a gradient towards lower cervical levels by 2 years after injury, especially in tetraplegics (change per cervical level in MTsat: -0.247 p.u./level, p = 0.034; in LRW: -0.323 mm/level, p = 0.024). MTsat within the DC was already decreased at cervical levels C1-C3 at baseline (1.5 months after injury) in both tetra- and paraplegics, while linear decreases in APW over time were similar across C1-C3, preserving the spatial gradient. The relative improvement in light touch score was associated with MTsat within the DC at baseline (rs = 0.575, p = 0.014). CONCLUSION Rostral and remote to the injury, the CST and DC show ongoing structural changes, indicative of myelin reductions and atrophy within 2 years after SCI. While anterograde degeneration in the DC was already detectable uniformly at C1-C3 early following SCI, retrograde degeneration in the CST developed over time revealing specific spatial and temporal neurodegenerative gradients. Disentangling and quantifying such dynamic pathological processes may provide biomarkers for regenerative and remyelinating therapies along entire spinal pathways.
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Affiliation(s)
- Simon Schading
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Gergely David
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tim Max Emmenegger
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Cristian Achim
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Alan Thompson
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Nikolaus Weiskopf
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Felix Bloch Institute for Solid State Physics, Faculty of Physics and Earth Sciences, Leipzig University, Leipzig, Germany
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Wellcome Trust Centre for Neuroimaging, UCL Queen Square Institute of Neurology, University College London, London, UK.
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Wolf K, Pfender N, Hupp M, Reisert M, Krafft A, Sutter R, Hohenhaus M, Urbach H, Farshad M, Curt A. Spinal cord motion assessed by phase-contrast MRI - An inter-center pooled data analysis. Neuroimage Clin 2023; 37:103334. [PMID: 36724733 PMCID: PMC9918779 DOI: 10.1016/j.nicl.2023.103334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Phase-contrast MRI of CSF and spinal cord dynamics has evolved among diseases caused by altered CSF volume (spontaneous intracranial hypotension, normal pressure hydrocephalus) and by altered CSF space (degenerative cervical myelopathy (DCM), Chiari malformation). While CSF seems to be an obvious target for possible diagnostic use, craniocaudal spinal cord motion analysis offers the benefit of fast and reliable assessments. It is driven by volume shifts between the intracranial and the intraspinal compartments (Monro-Kellie hypothesis). Despite promising initial reports, comparison of spinal cord motion data across different centers is challenged by reports of varying value, raising questions about the validity of the findings. OBJECTIVE To systematically investigate inter-center differences between phase-contrast MRI data. METHODS Age- and gender matched, retrospective, pooled-data analysis across two centers: cardiac-gated, sagittal phase-contrast MRI of the cervical spinal cord (segments C2/C3 to C7/T1) including healthy participants and DCM patients; comparison and analysis of different MRI sequences and processing techniques (manual versus fully automated). RESULTS A genuine craniocaudal spinal cord motion pattern and an increased focal spinal cord motion among DCM patients were depicted by both MRI sequences (p < 0.01). Higher time-resolution resolved steeper and larger peaks, causing inter-center differences (p < 0.01). Comparison of different processing methods showed a high level of rating reliability (ICC > 0.86 at segments C2/C3 to C6/C7). DISCUSSION Craniocaudal spinal cord motion is a genuine finding. Differences between values were attributed to time-resolution of the MRI sequences. Automated processing confers the benefit of unbiased and consistent analysis, while data did not reveal any superiority.
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Affiliation(s)
- Katharina Wolf
- Department of Neurology and Neurophysiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| | - Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Markus Hupp
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marco Reisert
- Department of Radiology, Medical Physics, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Axel Krafft
- Department of Radiology, Medical Physics, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Reto Sutter
- Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marc Hohenhaus
- Department of Neurosurgery, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Mazda Farshad
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Scheuren PS, De Schoenmacker I, Rosner J, Brunner F, Curt A, Hubli M. Pain-autonomic measures reveal nociceptive sensitization in complex regional pain syndrome. Eur J Pain 2023; 27:72-85. [PMID: 36130736 PMCID: PMC10092513 DOI: 10.1002/ejp.2040] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/01/2022] [Accepted: 09/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Allodynia and hyperalgesia are common signs in individuals with complex regional pain syndrome (CRPS), mainly attributed to sensitization of the nociceptive system. Appropriate diagnostic tools for the objective assessment of such hypersensitivities are still lacking, which are essential for the development of mechanism-based treatment strategies. OBJECTIVES This study investigated the use of pain-autonomic readouts to objectively detect sensitization processes in CRPS. METHODS Twenty individuals with chronic CRPS were recruited for the study alongside 16 age- and sex-matched healthy controls (HC). All individuals underwent quantitative sensory testing and neurophysiological assessments. Sympathetic skin responses (SSRs) were recorded in response to 15 pinprick and 15 noxious heat stimuli of the affected (CRPS hand/foot) and a control area (contralateral shoulder/hand). RESULTS Individuals with CRPS showed increased mechanical pain sensitivity and increased SSR amplitudes compared with HC in response to pinprick and heat stimulation of the affected (p < 0.001), but not in the control area (p > 0.05). Habituation of pinprick-induced SSRs was reduced in CRPS compared to HC in both the affected (p = 0.018) and slightly in the control area (p = 0.048). Habituation of heat-induced SSR was reduced in CRPS in the affected (p = 0.008), but not the control area (p = 0.053). CONCLUSIONS This is the first study demonstrating clinical evidence that pain-related autonomic responses may represent objective tools to quantify sensitization processes along the nociceptive neuraxis in CRPS (e.g. widespread hyperexcitability). Pain-autonomic readouts could help scrutinize mechanisms underlying the development and maintenance of chronic pain in CRPS and provide valuable metrics to detect mechanism-based treatment responses in clinical trials. SIGNIFICANCE This study provides clinical evidence that autonomic measures to noxious stimuli can objectively detect sensitization processes along the nociceptive neuraxis in complex regional pain syndrome (CRPS) (e.g. widespread hyperexcitability). Pain-autonomic readouts may represent valuable tools to explore pathophysiological mechanisms in a variety of pain patients and offer novel avenues to help guide mechanism-based therapeutic strategies.
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Affiliation(s)
- Paulina S Scheuren
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Iara De Schoenmacker
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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30
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Kalsi-Ryan S, Balbinot G, Wang JZ, Abel R, Bolliger M, Curt A, Fehlings MG, Jin D, Verrier M, Velstra IM. Minimal Clinically Important Difference of Graded Redefined Assessment of Strength, Sensibility, and Prehension Version 1 in Acute Cervical Traumatic Spinal Cord Injury. J Neurotrauma 2022; 39:1645-1653. [PMID: 35652348 DOI: 10.1089/neu.2021.0500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The Graded Redefined Assessment of Strength, Sensibility, and Prehension Version 1 (GRASSP v1) is a validated measure of upper extremity impairment shown to be sensitive and responsive for traumatic cervical spinal cord injury (SCI) in both North American (NA) and European (EU) cohorts. The minimal clinically important difference (MCID) is the quantitative change in an assessment scale that patients perceive as being beneficial. Our aim was to establish the MCID of all subtests of the GRASSP v1 for cervical SCI. We prospectively analyzed 127 patients from NA and EU for up to six months after motor complete and incomplete cervical SCI using the GRASSP v1, Spinal Cord Independence Measure, and International Standards of Neurological Classification of Spinal Cord Injury. We used a patient global rating of change and the anchor-based method to calculate MCID of GRASSP v1 at six months post-injury. The MCID was established for the whole group, dividing the sample by "better" and "much better." Improvement in GRASSP v1 Strength and Prehension Performance scores of 13 and 3 are the MCID for the better category, and 19 and 7 are the MCID for the much better category, respectively. The MCID was also established for the motor complete and incomplete groups. Improvement in GRASSP v1 Strength and Prehension Performance scores of 12 and 6 are the MCID for the motor complete group, and 17 and 12 are the MCID for the motor incomplete group, respectively. The GRASSP v1 Strength subscore is the most sensitive for detecting meaningful clinical change in patients and is most closely related to measures of independence. Thus, use of GRASSP v1 Strength and Prehension Performance as measures of change is substantiated by this study.
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Affiliation(s)
- Sukhvinder Kalsi-Ryan
- Toronto Rehabilitation Institute-UHN, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Department of Physical Therapy, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, Toronto, Ontario, Canada
| | | | - Justin Zhang Wang
- University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Toronto, Ontario, Canada
| | - Rainer Abel
- Spinal Cord Injury Centre, Hohe Warte, Bayreuth, Germany.,European Multicenter Study about Human Spinal Cord Injury, Zurich, Switzerland
| | - Marc Bolliger
- Spinal Cord Injury Centre, University Hospital Balgrist, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Centre, University Hospital Balgrist, Zurich, Switzerland
| | - Michael G Fehlings
- University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Toronto, Ontario, Canada.,Krembil Neuroscience Centre, Toronto, Ontario, Canada
| | - Daniel Jin
- Toronto Rehabilitation Institute-UHN, Toronto, Ontario, Canada.,University of Waterloo, Waterloo, Ontario, Canada
| | - Mary Verrier
- Toronto Rehabilitation Institute-UHN, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Department of Physical Therapy, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, Toronto, Ontario, Canada
| | - Inge-Marie Velstra
- European Multicenter Study about Human Spinal Cord Injury, Zurich, Switzerland.,Swiss Paraplegic Centre, Knotwil, Switzerland
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Seif M, Leutritz T, Schading S, Emmengger T, Curt A, Weiskopf N, Freund P. Reliability of multi-parameter mapping (MPM) in the cervical cord: A multi-center multi-vendor quantitative MRI study. Neuroimage 2022; 264:119751. [PMID: 36384206 DOI: 10.1016/j.neuroimage.2022.119751] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 11/14/2022] Open
Abstract
MRI based multicenter studies which target neurological pathologies affecting the spinal cord and brain - including spinal cord injury (SCI) - require standardized acquisition protocols and image processing methods. We have optimized and applied a multi-parameter mapping (MPM) protocol that simultaneously covers the brain and the cervical cord within a traveling heads study across six clinical centers (Leutritz et al., 2020). The MPM protocol includes quantitative maps (magnetization transfer saturation (MT), proton density (PD), longitudinal (R1), and effective transverse (R2*) relaxation rates) sensitive to myelination, water content, iron concentration, and morphometric measures, such as cross-sectional cord area. Previously, we assessed the repeatability and reproducibility of the brain MPM data acquired in the five healthy participants who underwent two scan-rescans (Leutritz et al., 2020). This study focuses on the cervical cord MPM data derived from the same acquisitions to determine its repeatability and reproducibility in the cervical cord. MPM matrices of the cervical cord were generated and processed using the hMRI and the spinal cord toolbox. To determine reliability of the cervical MPM data, the intra-site (i.e., scan-rescan) coefficient of variation (CoV), inter-site CoV, and bias within region of interests (C1, C2 and C3 levels) were determined. The range of the mean intra- and inter-site CoV of MT, R1 and PD was between 2.5% and 12%, and between 1.1% and 4.0% for the morphometric measures. In conclusion, the cervical MPM data showed a high repeatability and reproducibility for key imaging biomarkers and hence can be employed as a standardized tool in multi-center studies, including clinical trials.
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Affiliation(s)
- Maryam Seif
- Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Forchstrasse 340, Zurich 8008, Switzerland; Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.
| | - Tobias Leutritz
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Simon Schading
- Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Forchstrasse 340, Zurich 8008, Switzerland
| | - Tim Emmengger
- Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Forchstrasse 340, Zurich 8008, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Forchstrasse 340, Zurich 8008, Switzerland
| | - Nikolaus Weiskopf
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Faculty of Physics and Earth Sciences, Felix Bloch Institute for Solid State Physics, Leipzig University, Leipzig, Germany
| | - Patrick Freund
- Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Forchstrasse 340, Zurich 8008, Switzerland; Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Wellcome Centre for Human Neuroimaging, Institute of Neurology, University College London, London, UK
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Lütolf R, Rosner J, Curt A, Hubli M. Indicators of central sensitization in chronic neuropathic pain after spinal cord injury. Eur J Pain 2022; 26:2162-2175. [PMID: 36008094 PMCID: PMC9826442 DOI: 10.1002/ejp.2028] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 08/01/2022] [Accepted: 08/20/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Central sensitization is considered a key mechanism underlying neuropathic pain (NP) after spinal cord injury (SCI). METHODS Two novel proxies for central sensitization were investigated in thoracic SCI subjects with (SCI-NP) and without NP (SCI-nonNP) compared to healthy controls (HC). Specifically, temporal summation of pain (TSP) was investigated by examining pain ratings during a 2-min tonic heat application to the volar forearm. Additionally, palmar heat-induced sympathetic skin responses (SSR) were recorded in order to reveal changes in pain-autonomic interaction above the lesion level. Pain extent was assessed as the percentage of the body area and the number of body regions being affected by NP. RESULTS Enhanced TSP was observed in SCI-NP (+66%) compared to SCI-nonNP (-75%, p = 0.009) and HC (-59%, p = 0.021). In contrast, no group differences were found (p = 0.685) for SSR habituation. However, pain extent in SCI-NP was positively correlated with deficient SSR habituation (body area: r = 0.561, p = 0.024; body regions: r = 0.564, p = 0.023). CONCLUSIONS These results support the value of TSP and heat-induced SSRs as proxies for central sensitization in widespread neuropathic pain syndromes after SCI. Measures of pain-autonomic interaction emerged as a promising tool for the objective investigation of sensitized neuronal states in chronic pain conditions. SIGNIFICANCE We present two surrogate readouts for central sensitization in neuropathic pain following SCI. On the one hand, temporal summation of tonic heat pain is enhanced in subjects with neuropathic pain. On the other hand, pain-autonomic interaction reveals potential advanced measures in chronic pain, as subjects with a high extent of neuropathic pain showed diminished habituation of pain-induced sympathetic measures. A possible implication for clinical practice is constituted by an improved assessment of neuronal hyperexcitability potentially enabling mechanism-based treatment.
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Affiliation(s)
- Robin Lütolf
- Spinal Cord Injury CenterBalgrist University Hospital, University of ZurichZurichSwitzerland
| | - Jan Rosner
- Spinal Cord Injury CenterBalgrist University Hospital, University of ZurichZurichSwitzerland,Department of NeurologyUniversity Hospital Bern, Inselspital, University of BernBernSwitzerland
| | - Armin Curt
- Spinal Cord Injury CenterBalgrist University Hospital, University of ZurichZurichSwitzerland
| | - Michèle Hubli
- Spinal Cord Injury CenterBalgrist University Hospital, University of ZurichZurichSwitzerland
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Lütolf R, De Schoenmacker I, Rosner J, Sirucek L, Schweinhardt P, Curt A, Hubli M. Anti- and Pro-Nociceptive mechanisms in neuropathic pain after human spinal cord injury. Eur J Pain 2022; 26:2176-2187. [PMID: 36000307 PMCID: PMC9826499 DOI: 10.1002/ejp.2029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/01/2022] [Accepted: 08/20/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Deficient endogenous pain modulation and increased nociceptive excitability are key features of central sensitization and can be assessed in humans by conditioned pain modulation (CPM, anti-nociceptive) and temporal summation of pain (TSP, pro-nociceptive), respectively. This study aimed to investigate these measures as proxies for central sensitization in subjects with chronic neuropathic pain (NP) after spinal cord injury (SCI). METHODS In paraplegic subjects with NP (SCI-NP; n = 17) and healthy controls (HC; n = 17), parallel and sequential sham-controlled CPM paradigms were performed using pressure pain threshold at the hand, that is, above lesion level, as test stimulus. The conditioning stimulus was a noxious cold (verum) or lukewarm water bath (sham) applied contralaterally. Regarding pro-nociceptive mechanisms, a TSP protocol with individually-adjusted pressure pain stimuli at the thenar eminence was used. CPM and TSP magnitudes were related to intensity and spatial extent of spontaneous NP. RESULTS Neither the parallel nor sequential sham-controlled CPM paradigm showed any significant inhibition of above-level pressure pain thresholds for SCI-NP or HC. Accordingly, no group difference in CPM capacity was found, however, subjects with more intense spontaneous NP showed lower inhibitory CPM capacity. TSP was observed for both groups but was not enhanced in SCI-NP. CONCLUSIONS Our results do not support altered above-level anti- or pro-nociceptive mechanisms in SCI-NP compared with HC; however, they also highlight the relevance of spontaneous NP intensity with regards to the capacity of endogenous pain modulation in SCI subjects. SIGNIFICANCE Central sensitization encompasses deficient endogenous pain modulation and increased nociceptive excitability. These two mechanisms can be assessed in humans by conditioned pain modulation and temporal summation of pain, respectively. Our data demonstrates a lack of descending pain inhibition only in subjects with severe neuropathic pain which may hint towards central sensitization at spinal and/or supra-spinal levels. Disentangling the mechanisms of endogenous pain modulation and neuronal hyperexcitability might improve mechanism-based treatment of neuropathic pain in subjects with spinal cord injury.
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Affiliation(s)
- Robin Lütolf
- Spinal Cord Injury Center, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Iara De Schoenmacker
- Spinal Cord Injury Center, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University HospitalUniversity of ZurichZurichSwitzerland,Department of NeurologyUniversity Hospital Bern, Inselspital, University of BernBernSwitzerland
| | - Laura Sirucek
- Integrative Spinal Research, Department of Chiropractic MedicineBalgrist University Hospital, University of ZurichZurichSwitzerland
| | - Petra Schweinhardt
- Integrative Spinal Research, Department of Chiropractic MedicineBalgrist University Hospital, University of ZurichZurichSwitzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University HospitalUniversity of ZurichZurichSwitzerland
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Pavese C, Scivoletto G, Puci MV, Abel R, Curt A, Maier D, Rupp R, Schubert M, Weidner N, Montomoli C, Kessler TM. Prediction of bowel management independence after ischemic spinal cord injury. Eur J Phys Rehabil Med 2022; 58:709-714. [PMID: 35666490 PMCID: PMC10019474 DOI: 10.23736/s1973-9087.22.07366-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ischemic spinal cord injury (SCI) belongs to the heterogeneous group of non-traumatic SCI, while the course of sensorimotor and functional recovery is comparable to traumatic SCI. Recently, we derived from data of patients with traumatic SCI a valid model to predict an independent and reliable bowel management one year after SCI. AIM To evaluate the performance of this model to predict an independent and reliable bowel management one year following ischemic SCI. DESIGN Prognostic study - observational study. SETTING European Multicenter Study about Spinal Cord Injury (EMSCI) ClinicalTrials.gov: NCT01571531. POPULATION One hundred and forty-two patients with ischemic SCI of various level and severity of injury. METHODS The prediction model relied on a single predictor collected within 40 days from injury, the International Standards for Neurological Classification of Spinal Cord Injury total motor score. Bowel outcome one year after SCI derived from the dichotomization of the Spinal Cord Independence Measure (SCIM) item 7 scores. We defined a positive outcome as independent bowel management with regular movements and appropriate timing with no or rare accidents (score of 10 in SCIM version II and score of 8 or 10 in version III). RESULTS The model showed a fair discrimination with an area under the receiver operating characteristic (ROC) curve of 0.780 (95% confidence interval=0.702-0.860). In addition, the model displayed an acceptable accuracy and calibration. CONCLUSIONS The study extends the validity of our rule to patients with ischemic SCI, thus providing the first model to predict an independent and reliable bowel management in this population. CLINICAL REHABILITATION IMPACT The model may be employed in clinical practice to counsel patients, to define the rehabilitation aims and to estimate the need of assistance after discharge, as well as in the research field for the optimization of patients' allocation in the design of future clinical trials.
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Affiliation(s)
- Chiara Pavese
- Department of Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation and Spinal Unit, Pavia Institute, Pavia, Italy
| | - Giorgio Scivoletto
- Spinal Cord Unit and Spinal Rehabilitation (SpiRe) Lab, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Mariangela V Puci
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Rainer Abel
- Spinal Cord Injury Center, Hohe Warte, Bayreuth, Germany
| | - Armin Curt
- Department of Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schubert
- Department of Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Cristina Montomoli
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland -
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Zipser CM, Fehlings MG, Margetis K, Curt A, Betz M, Sadler I, Tetreault L, Davies BM. Proposing a Framework to Understand the Role of Imaging in Degenerative Cervical Myelopathy: Enhancement of MRI Protocols Needed for Accurate Diagnosis and Evaluation. Spine (Phila Pa 1976) 2022; 47:1259-1262. [PMID: 35857708 PMCID: PMC9365266 DOI: 10.1097/brs.0000000000004389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Carl M. Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Michael G. Fehlings
- Division of Neurosurgery and Spinal Program, University of Toronto and Krembil Brain Institute, University Health Network, Toronto, ON, Canada
| | | | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Iwan Sadler
- Myelopathy Support, Myelopathy.org, Cambridge, UK
| | - Lindsay Tetreault
- Department of Neurology, NYU Langone Health, Graduate Medical Education, New York, NY
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Cathomen A, Meier F, Lerch I, Killeen T, Zörner B, Curt A, Bolliger M. Corticospinal control of a challenging ankle task in incomplete spinal cord injury. J Neurotrauma 2022; 40:952-964. [PMID: 36029211 DOI: 10.1089/neu.2022.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
After incomplete spinal cord injury (iSCI), the control of lower extremity movements may be affected by impairments in descending corticospinal tract function. Previous iSCI studies demonstrated relatively well-preserved movement control during simple alternating dorsi- and plantarflexions albeit with severely reduced motor strength and range of motion. However, this task required comparably limited fine motor control, impeding the sensitivity to assess the modulatory capacity of corticospinal control. Therefore, we introduced a more challenging ankle motor task requiring complex and dynamic feedback-based movement adjustments to modulate corticospinal drive. Nineteen individuals with iSCI and 22 control subjects performed two different ankle movement tasks: i) a regular, auditory-guided ankle movement task at a constant frequency as baseline assessment, and ii) an irregular, visually-guided ankle movement task following a predefined trajectory as a more challenging motor task. Both tasks were performed separately and in a randomised order. Electromyography (EMG) and kinematic data were recorded. EMG frequency characteristics were investigated using wavelet transformations. Control participants exhibited a shift of relative EMG intensity from higher (>100Hz) to lower frequencies (20-60Hz) comparing the regular with the irregular movement task. There is evidence that EMG activity within these lower frequencies comprise information on corticospinal drive. The EMG frequency shift was less pronounced for the less impaired leg and absent for the more impaired leg of individuals with iSCI. The precision error during the irregular task was significantly higher for individuals with iSCI (more impaired leg: 12.34±11.14%; less impaired leg: 6.93±2.74%) compared to control participants (4.10±0.84%). These results, along with the walking performance, correlated well with the delta frequency shift between the regular and irregular movement task in the 38Hz band (corticospinal drive frequency) in the iSCI group, suggesting that task performance is related to the capacity to modulate corticospinal control. The irregular movement task holds promise as a tool for revealing further insights into corticospinal control of single-joint movements. It may serve as a surrogate marker for the assessment of modulatory capacity and the integrity of corticospinal control in individuals with iSCI early after injury and throughout rehabilitation.
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Affiliation(s)
- Adrian Cathomen
- Balgrist University Hospital, Spinal Cord Injury Center, Zurich, Zurich, Switzerland;
| | - Franziska Meier
- Balgrist University Hospital, Spinal Cord Injury Center, Zurich, Zurich, Switzerland;
| | - Irina Lerch
- Balgrist University Hospital, Spinal Cord Injury Center, Zurich, Zurich, Switzerland;
| | - Tim Killeen
- Balgrist University Hospital, Spinal Cord Injury Center, Zurich, Zurich, Switzerland;
| | - Björn Zörner
- Balgrist University Hospital, Spinal Cord Injury Center, Zurich, Zurich, Switzerland;
| | - Armin Curt
- Balgrist University Hospital, Spinal Cord Injury Center, Zurich, Zurich, Switzerland;
| | - Marc Bolliger
- Balgrist University Hospital, Spinal Cord Injury Center, Zurich, Zurich, Switzerland;
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Kheram N, Pfender N, Boraschi A, Farshad M, Kurtcuoglu V, Curt A, Schubert M, Zipser CM. Cerebrospinal fluid pressure dynamics reveal signs of effective spinal canal narrowing in ambiguous spine conditions. Front Neurol 2022; 13:951018. [PMID: 36016547 PMCID: PMC9397118 DOI: 10.3389/fneur.2022.951018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/15/2022] [Indexed: 12/03/2022] Open
Abstract
Spinal canal narrowing with consecutive spinal cord compression is considered a key mechanism in degenerative cervical myelopathy (DCM). DCM is a common spine condition associated with progressive neurological disability, and timely decompressive surgery is recommended. However, the clinical and radiological diagnostic workup is often ambiguous, challenging confident proactive treatment recommendations. Cerebrospinal fluid pressure dynamics (CSFP) are altered by spinal canal narrowing. Therefore, we aim to explore the potential value of bedside CSFP assessments for qualitative and quantitative assessment of spinal canal narrowing in DCM. In this prospective case series, seven patients with DCM underwent bedside lumbar puncture with measurement of CSFP dynamics and routine CSF analysis (NCT02170155). The patients were enrolled when standard diagnostic algorithms did not permit a clear treatment decision. Measurements include baseline CSFP, cardiac-driven CSFP peak-to-trough amplitude (CSFPp), and the Queckenstedt's test (firm pressure on jugular veins) in neutral and reclined head position. From the Queckenstedt's test, proxies for craniospinal elastance (i.e., relative pulse pressure coefficient; RPPC-Q) were calculated analogously to infusion testing. CSFP metrics were deemed suspicious of canal narrowing when numbers were lower than the minimum value from a previously tested elderly spine-healthy cohort (N = 14). Mean age was 56 ± 13 years (range, 38–75; 2F); symptom severity was mostly mild to moderate (mean mJOA, 13.5 ± 2.6; range, 9–17). All the patients showed some extent of cervical stenosis in the MRI of unclear significance (5/7 following decompressive cervical spine surgery with an adjacent level or residual stenosis). Baseline CSFP was normal except for one patient (range, 4.7–17.4 mmHg). Normal values were found for CSFPp (0.4–1.3 mmHg) and the Queckenstedt's test in normal head positioning (9.-25.3 mmHg). During reclination, the Queckenstedt's test significantly decreased in one, and CSFPp in another case (>50% compared to normal position). RPPC-Q (0.07–0.19) aligned with lower values from spine-healthy (0.10–0.44). Routine CSF examinations showed mild total protein elevation (mean, 522 ± 108 mg/ml) without further evidence for the disturbed blood brain barrier. Intrathecal CSFP measurements allow discerning disturbed from normal CSFP dynamics in this population. Prospective longitudinal studies should further evaluate the diagnostic utility of CSFP assessments in DCM.
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Affiliation(s)
- Najmeh Kheram
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Andrea Boraschi
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | | | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Carl M. Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
- *Correspondence: Carl M. Zipser
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Zipser-Mohammadzada F, Conway BA, Halliday DM, Zipser CM, Easthope CA, Curt A, Schubert M. Intramuscular coherence during challenging walking in incomplete spinal cord injury: Reduced high-frequency coherence reflects impaired supra-spinal control. Front Hum Neurosci 2022; 16:927704. [PMID: 35992941 PMCID: PMC9387543 DOI: 10.3389/fnhum.2022.927704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
Individuals regaining reliable day-to-day walking function after incomplete spinal cord injury (iSCI) report persisting unsteadiness when confronted with walking challenges. However, quantifiable measures of walking capacity lack the sensitivity to reveal underlying impairments of supra-spinal locomotor control. This study investigates the relationship between intramuscular coherence and corticospinal dynamic balance control during a visually guided Target walking treadmill task. In thirteen individuals with iSCI and 24 controls, intramuscular coherence and cumulant densities were estimated from pairs of Tibialis anterior surface EMG recordings during normal treadmill walking and a Target walking task. The approximate center of mass was calculated from pelvis markers. Spearman rank correlations were performed to evaluate the relationship between intramuscular coherence, clinical parameters, and center of mass parameters. In controls, we found that the Target walking task results in increased high-frequency (21–44 Hz) intramuscular coherence, which negatively related to changes in the center of mass movement, whereas this modulation was largely reduced in individuals with iSCI. The impaired modulation of high-frequency intramuscular coherence during the Target walking task correlated with neurophysiological and functional readouts, such as motor-evoked potential amplitude and outdoor mobility score, as well as center of mass trajectory length. The Target walking effect, the difference between Target and Normal walking intramuscular coherence, was significantly higher in controls than in individuals with iSCI [F(1.0,35.0) = 13.042, p < 0.001]. Intramuscular coherence obtained during challenging walking in individuals with iSCI may provide information on corticospinal gait control. The relationships between biomechanics, clinical scores, and neurophysiology suggest that intramuscular coherence assessed during challenging tasks may be meaningful for understanding impaired supra-spinal control in individuals with iSCI.
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Affiliation(s)
- Freschta Zipser-Mohammadzada
- Spinal Cord Injury Center, Department of Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- *Correspondence: Freschta Zipser-Mohammadzada,
| | - Bernard A. Conway
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - David M. Halliday
- Department of Electronic Engineering, University of York, York, United Kingdom
- York Biomedical Research Institute, University of York, York, United Kingdom
| | - Carl Moritz Zipser
- Spinal Cord Injury Center, Department of Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
| | - Chris A. Easthope
- Spinal Cord Injury Center, Department of Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- Cereneo Foundation, Center for Interdisciplinary Research, Vitznau, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Department of Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Department of Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
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Dengler J, Steeves JD, Curt A, Mehra M, Novak CB, Fox IK. Spontaneous Motor Recovery after Cervical Spinal Cord Injury: Issues for Nerve Transfer Surgery Decision Making. Spinal Cord 2022; 60:922-927. [PMID: 35896613 DOI: 10.1038/s41393-022-00834-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To quantify spontaneous upper extremity motor recovery between 6 and 12 months after spinal cord injury (SCI) to help guide timing of nerve transfer surgery to improve upper limb function in cervical SCI. SETTING Nineteen European SCI rehabilitation centers. METHODS Data was extracted from the European Multicenter Study of SCI database for individuals with mid-level cervical SCI (N = 268). Muscle function grades at 6 and 12 months post-SCI were categorized for analysis. RESULTS From 6 to 12 months after SCI, spontaneous surgically-relevant recovery was limited. Of all limbs (N = 263) with grade 0-2 elbow extension at 6 months, 4% regained grade 4-5 and 11% regained grade 3 muscle function at 12 months. Of all limbs (N = 380) with grade 0-2 finger flexion at 6 months, 3% regained grade 4-5 and 5% regained grade 3 muscle function at 12 months. CONCLUSION This information supports early (6 month) post-injury surgical consultation and evaluation. With this information, individuals with SCI can more fully engage in preference-based decision-making about surgical intervention versus continued rehabilitation and spontaneous recovery to gain elbow extension and/or hand opening and closing.
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Affiliation(s)
- Jana Dengler
- Division of Plastic and Reconstructive Surgery, Tory Trauma Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,University of Toronto, Division of Plastic & Reconstructive Surgery, Toronto, Ontario, Canada
| | - John D Steeves
- ICORD, University of British Columbia, Vancouver British Columbia, Vancouver, Canada
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Munish Mehra
- Tigermed-BDM Inc, Gaithersburg Maryland, Maryland, USA
| | - Christine B Novak
- University of Toronto, Division of Plastic & Reconstructive Surgery, Toronto, Ontario, Canada
| | | | | | - Ida K Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis Missouri, USA. .,VA St. Louis Healthcare System, St Louis Missouri, USA.
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Bourguignon L, Tong B, Geisler F, Schubert M, Röhrich F, Saur M, Weidner N, Rupp R, Kalke YBB, Abel R, Maier D, Grassner L, Chhabra HS, Liebscher T, Cragg JJ, Kramer J, Curt A, Jutzeler CR. International surveillance study in acute spinal cord injury confirms viability of multinational clinical trials. BMC Med 2022; 20:225. [PMID: 35705947 PMCID: PMC9202190 DOI: 10.1186/s12916-022-02395-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/04/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The epidemiological international landscape of traumatic spinal cord injury (SCI) has evolved over the last decades along with given inherent differences in acute care and rehabilitation across countries and jurisdictions. However, to what extent these differences may influence neurological and functional recovery as well as the integrity of international trials is unclear. The latter also relates to historical clinical data that are exploited to inform clinical trial design and as potential comparative data. METHODS Epidemiological and clinical data of individuals with traumatic and ischemic SCI enrolled in the European Multi-Center Study about Spinal Cord Injury (EMSCI) were analyzed. Mixed-effect models were employed to account for the longitudinal nature of the data, efficiently handle missing data, and adjust for covariates. The primary outcomes comprised demographics/injury characteristics and standard scores to quantify neurological (i.e., motor and sensory scores examined according to the International Standards for the Neurological Classification of Spinal Cord Injury) and functional recovery (walking function). We externally validated our findings leveraging data from a completed North American landmark clinical trial. RESULTS A total of 4601 patients with acute SCI were included. Over the course of 20 years, the ratio of male to female patients remained stable at 3:1, while the distribution of age at injury significantly shifted from unimodal (2001/02) to bimodal distribution (2019). The proportional distribution of injury severities and levels remained stable with the largest percentages of motor complete injuries. Both, the rate and pattern of neurological and functional recovery, remained unchanged throughout the surveillance period despite the increasing age at injury. The findings related to recovery profiles were confirmed by an external validation cohort (n=791). Lastly, we built an open-access and online surveillance platform ("Neurosurveillance") to interactively exploit the study results and beyond. CONCLUSIONS Despite some epidemiological changes and considerable advances in clinical management and rehabilitation, the neurological and functional recovery following SCI has remained stable over the last two decades. Our study, including a newly created open-access and online surveillance tool, constitutes an unparalleled resource to inform clinical practice and implementation of forthcoming clinical trials targeting neural repair and plasticity in acute spinal cord injury.
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Affiliation(s)
- Lucie Bourguignon
- Department of Health Sciences and Technology (D-HEST), ETH Zurich, Zürich, Switzerland.,SIB Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Bobo Tong
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
| | - Fred Geisler
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Martin Schubert
- Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Lengghalde 2, 8006, Zürich, Switzerland
| | - Frank Röhrich
- Berufsgenossenschaftliche Klinik Bergmanstrost of Halle, Halle, Germany
| | - Marion Saur
- Orthopädische Klinik, Hessisch Lichtenau, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Rainer Abel
- Spinal Cord Injury Center, Bayreuth, Germany
| | - Doris Maier
- Spinal Cord Injury Center, Trauma Center Murnau, Murnau, Germany
| | - Lukas Grassner
- Spinal Cord Injury Center, Trauma Center Murnau, Murnau, Germany.,Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Harvinder S Chhabra
- Spine Service, Indian Spinal Injuries Centre, Sector C, Vasant Kunj, New Delhi, India
| | - Thomas Liebscher
- Treatment Centre for Spinal Cord Injuries, Trauma Hospital Berlin, Berlin, Germany
| | - Jacquelyn J Cragg
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada.,Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | | | - John Kramer
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada.,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada.,Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Armin Curt
- Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Lengghalde 2, 8006, Zürich, Switzerland
| | - Catherine R Jutzeler
- Department of Health Sciences and Technology (D-HEST), ETH Zurich, Zürich, Switzerland. .,SIB Swiss Institute of Bioinformatics, Lausanne, Switzerland. .,Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Lengghalde 2, 8006, Zürich, Switzerland.
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Davies BM, Yanez Touzet A, Mowforth OD, Lee KS, Khan D, Furlan JC, Fehlings MG, Harrop JS, Zipser CM, Rodrigues-Pinto R, Milligan J, Sarewitz E, Curt A, Rahimi-Movaghar V, Aarabi B, Boerger TF, Tetreault L, Chen R, Guest JD, Kalsi-Ryan S, Sadler I, Widdop S, McNair AGK, Kwon BK, Kotter MRN. Development of a core measurement set for research in degenerative cervical myelopathy: a study protocol (AO Spine RECODE-DCM CMS). BMJ Open 2022; 12:e060436. [PMID: 35680260 PMCID: PMC9185555 DOI: 10.1136/bmjopen-2021-060436] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Progress in degenerative cervical myelopathy (DCM) is hindered by inconsistent measurement and reporting. This impedes data aggregation and outcome comparison across studies. This limitation can be reversed by developing a core measurement set (CMS) for DCM research. Previously, the AO Spine Research Objectives and Common Data Elements for DCM (AO Spine RECODE-DCM) defined 'what' should be measured in DCM: the next step of this initiative is to determine 'how' to measure these features. This protocol outlines the steps necessary for the development of a CMS for DCM research and audit. METHODS AND ANALYSIS The CMS will be developed in accordance with the guidance developed by the Core Outcome Measures in Effectiveness Trials and the Consensus-based Standards for the selection of health Measurement Instruments. The process involves five phases. In phase 1, the steering committee agreed on the constructs to be measured by sourcing consensus definitions from patients, professionals and the literature. In phases 2 and 3, systematic reviews were conducted to identify tools for each construct and aggregate their evidence. Constructs with and without tools were identified, and scoping reviews were conducted for constructs without tools. Evidence on measurement properties, as well as on timing of assessments, are currently being aggregated. These will be presented in phase 4: a consensus meeting where a multi-disciplinary panel of experts will select the instruments that will form the CMS. Following selection, guidance on the implementation of the CMS will be developed and disseminated (phase 5). A preliminary CMS review scheduled at 4 years from release. ETHICS AND DISSEMINATION Ethical approval was obtained from the University of Cambridge (HBREC2019.14). Dissemination strategies will include peer-reviewed scientific publications; conference presentations; podcasts; the identification of AO Spine RECODE-DCM ambassadors; and engagement with relevant journals, funders and the DCM community.
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Affiliation(s)
- Benjamin M Davies
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Alvaro Yanez Touzet
- School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Oliver D Mowforth
- Department of Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Danyal Khan
- Academic Neurosurgery Unit, University College London, London, UK
| | - Julio C Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spinal Program, Toronto Western Hospital, Toronto, Ontario, Canada
| | - James S Harrop
- Thomas Jefferson University, Jefferson Health System, St Louis, Missouri, USA
| | | | - Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto EPE, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - James Milligan
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Armin Curt
- University Hospital Balgrist, Zürich, Switzerland
| | - Vafa Rahimi-Movaghar
- Academic Department of Neurological Surgery, Sina Trauma and Surgery Research Center, Tehran, Iran
| | - Bizhan Aarabi
- Division of Neurosurgery, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Timothy F Boerger
- Neurosurgery, Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | - Lindsay Tetreault
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University College Cork, Cork, Ireland
| | - Robert Chen
- Neurology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - James D Guest
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | | | | | - Angus G K McNair
- Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, Avon, UK
- GI Surgery, North Bristol NHS Trust, Bristol, UK
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Blusson Spinal Cord Center, Vancouver, British Columbia, Canada
| | - Mark R N Kotter
- Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, Ann McLaren Laboratory of Regenerative Medicine, Cambridge, UK
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De Schoenmacker I, Leu C, Curt A, Hubli M. Pain‐autonomic interaction is a reliable measure of pain habituation in healthy subjects. Eur J Pain 2022; 26:1679-1690. [PMID: 35671124 PMCID: PMC9544564 DOI: 10.1002/ejp.1990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/16/2022] [Accepted: 06/04/2022] [Indexed: 11/24/2022]
Abstract
Background Habituation is a response decrement resulting from repeated stimuli. Reduced habituation to noxious stimuli is considered to be a proxy for central sensitization in subjects with chronic pain. Despite numerous investigations of pain habituation in relation to central sensitization, there is no consensus on the most sensitive and reliable readout, as well as analysis approach. Therefore, this study compared the usability and reliability of different readouts and habituation analysis approaches to measure pain habituation in response to repetitive heat simulation. Methods Three blocks of 20 contact heat stimuli were applied on the volar forearm of 20 healthy subjects on two separate visits. Habituation was assessed by three different readouts: pain ratings, contact heat evoked potentials (CHEPs) and heat‐induced sympathetic skin responses (SSRs). In addition, two different habituation analysis approaches were used: between the three stimulation blocks (between‐block) and within the first stimulation block (within‐block). Results Significant between‐block habituation for SSRs (p < 0.001), but not for pain ratings (p = 1.000) and CHEPs (p = 0.078) was found. There was significant within‐block habituation for pain ratings (p = 0.012) and SSRs (p < 0.001), but not for CHEPs (p = 0.246). Only the between‐block habituation of heat‐induced SSR was reliable between the two visits (first to second block: intraclass correlation coefficient [ICC] = 0.58, p = 0.030; first to third block: ICC = 0.64, p = 0.015). Conclusion Heat‐induced SSR as a measure of pain‐autonomic interaction revealed the strongest pain habituation and showed the highest test–retest reliability.
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Affiliation(s)
- Iara De Schoenmacker
- Spinal Cord Injury CenterBalgrist University Hospital, University of ZurichZurichSwitzerland
| | - Chiara Leu
- Spinal Cord Injury CenterBalgrist University Hospital, University of ZurichZurichSwitzerland
- Institute of NeuroscienceUniversité Catholique de LouvainBrusselsBelgium
| | - Armin Curt
- Spinal Cord Injury CenterBalgrist University Hospital, University of ZurichZurichSwitzerland
| | - Michèle Hubli
- Spinal Cord Injury CenterBalgrist University Hospital, University of ZurichZurichSwitzerland
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Scheel-Sailer A, Selb M, Gmünder HP, Baumberger M, Curt A, Hund-Georgiadis M, Jordan X, Stucki G. Towards the implementation of clinical quality management at the national level: description of current types of rehabilitation services for spinal cord injury/disorder in Switzerland using an interdisciplinary consensus process. Eur J Phys Rehabil Med 2022; 58:190-198. [PMID: 34002976 PMCID: PMC9980538 DOI: 10.23736/s1973-9087.21.06923-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Aligned with WHO's Global Disability Action Plan 2014-2021, the Section and Board of the European Union of Medical Specialists (UEMS-PRM) set up a plan to strengthen rehabilitation and support International Classification for Functioning, Disability and Health-based clinical quality management. Accordingly, the UEMS-PRM developed the European Framework of Rehabilitation Service Types ("European Framework"). The specifications of these service types may differ across countries and for specific application areas. AIM The objective of this paper is to report on the development of a framework of rehabilitation service types for spinal cord injury/disorder (SCI/D) in Switzerland ("SCI/D Framework"). DESIGN Quality improvement in healthcare. SETTING The setting of this study was in Switzerland. POPULATION Representatives of medical societies. METHODS A multistage consensus process was conducted and involved representatives of national medical and rehabilitation societies recruited based on a situational analysis of existing national quality management documents. The process comprised the development of an initial framework based on the European Framework, a survey, a face-to-face consensus meeting, and a confirmatory feedback round on the version of the SCI/D Framework resulting from the meeting. RESULTS Representatives of 12 national medical societies, one political body in rehabilitation, one national interprofessional rehabilitation society, the Swiss representative of two international rehabilitation societies and heads of four SCI/D specialized centers participated in the multistage consensus process. After the modifications based on the results of the survey, the consensus meeting and confirmatory feedback round were made, the resulting SCI/D Framework version encompassed 19 rehabilitation service types, structured in nine different clusters, of which six were subdivided into general, other specific or SCI/D-specific rehabilitation service types. CONCLUSIONS Developing the SCI/D Framework for Switzerland was a further step toward refining existing quality criteria and national quality standards for rehabilitation and toward scaling up SCI/D rehabilitation in Switzerland. CLINICAL REHABILITATION IMPACT The SCI/D Framework can support national efforts to address any gaps in health care provision and guide an optimal response to meet the rehabilitation needs of persons with SCI/D in Switzerland. Furthermore, the development of the SCI/D Framework illustrates an outline that can be used to develop a similar framework for other health conditions and for other countries to follow in adapting the European Framework for their own country context.
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Affiliation(s)
- Anke Scheel-Sailer
- Swiss Paraplegic Center, Nottwil, Switzerland - .,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland -
| | - Melissa Selb
- Swiss Paraplegic Research, Nottwil, Switzerland.,ICF Research Branch, Nottwil, Switzerland
| | | | | | - Armin Curt
- Universitätsklinik Balgrist, Zentrum für Paraplegie, Zurich, Switzerland
| | | | | | - Gerold Stucki
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.,Swiss Paraplegic Research, Nottwil, Switzerland.,ICF Research Branch, Nottwil, Switzerland
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Mohammadzada F, Zipser CM, Easthope CA, Halliday DM, Conway BA, Curt A, Schubert M. Mind your step: Target walking task reveals gait disturbance in individuals with incomplete spinal cord injury. J Neuroeng Rehabil 2022; 19:36. [PMID: 35337335 PMCID: PMC8957135 DOI: 10.1186/s12984-022-01013-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Walking over obstacles requires precise foot placement while maintaining balance control of the center of mass (CoM) and the flexibility to adapt the gait patterns. Most individuals with incomplete spinal cord injury (iSCI) are capable of overground walking on level ground; however, gait stability and adaptation may be compromised. CoM control was investigated during a challenging target walking (TW) task in individuals with iSCI compared to healthy controls. The hypothesis was that individuals with iSCI, when challenged with TW, show a lack of gait pattern adaptability which is reflected by an impaired adaptation of CoM movement compared to healthy controls. Methods A single-center controlled diagnostic clinical trial with thirteen participants with iSCI (0.3–24 years post injury; one subacute and twelve chronic) and twelve healthy controls was conducted where foot and pelvis kinematics were acquired during two conditions: normal treadmill walking (NW) and visually guided target walking (TW) with handrail support, during which participants stepped onto projected virtual targets synchronized with the moving treadmill surface. Approximated CoM was calculated from pelvis markers and used to calculate CoM trajectory length and mean CoM Euclidean distance TW-NW (primary outcome). Nonparametric statistics, including spearman rank correlations, were performed to evaluate the relationship between clinical parameter, outdoor mobility score, performance, and CoM parameters (secondary outcome). Results Healthy controls adapted to TW by decreasing anterior–posterior and vertical CoM trajectory length (p < 0.001), whereas participants with iSCI reduced CoM trajectory length only in the vertical direction (p = 0.002). Mean CoM Euclidean distance TW-NW correlated with participants’ neurological level of injury (R = 0.76, p = 0.002) and CoM trajectory length (during TW) correlated with outdoor mobility score (R = − 0.64, p = 0.026). Conclusions This study demonstrated that reduction of CoM movement is a common strategy to cope with TW challenge in controls, but it is impaired in individuals with iSCI. In the iSCI group, the ability to cope with gait challenges worsened the more rostral the level of injury. Thus, the TW task could be used as a gait challenge paradigm in ambulatory iSCI individuals. Trial registration Registry number/ ClinicalTrials.gov Identifier: NCT03343132, date of registration 2017/11/17. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-022-01013-7.
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Affiliation(s)
- Freschta Mohammadzada
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Carl Moritz Zipser
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Chris A Easthope
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.,Cereneo Foundation, Center for Interdisciplinary Research, 6354, Vitznau, Switzerland
| | - David M Halliday
- Department of Electronic Engineering, University of York, York, YO10 5DD, UK.,York Biomedical Research Institute, University of York, York, UK
| | - Bernard A Conway
- Biomedical Engineering, University of Strathclyde, Glasgow, G4 0NW, UK
| | - Armin Curt
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Neurophysiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
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45
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Failli V, Kleitman N, Lammertse DP, Hsieh JTC, Steeves JD, Fawcett JW, Tuszynski MH, Curt A, Fehlings MG, Guest JD, Blight AR. Experimental Treatments for Spinal Cord Injury: What you Should Know. Top Spinal Cord Inj Rehabil 2022; 27:50-74. [PMID: 34108834 PMCID: PMC8152172 DOI: 10.46292/sci2702-50] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | - John D Steeves
- ICORD, University of British Columbia, Vancouver, Canada
| | - James W Fawcett
- Cambridge University Centre for Brain Repair, Cambridge, United Kingdom
| | - Mark H Tuszynski
- University of California - San Diego, Department of Neuroscience, La Jolla, California
| | - Armin Curt
- Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland
| | - Michael G Fehlings
- University of Toronto Spine Program and Toronto Western Hospital, Toronto, Ontario, Canada
| | - James D Guest
- The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, Florida
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46
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Maritz R, Fellinghauer C, Brach M, Curt A, Gmünder HP, Hopfe M, Hund-Georgiadis M, Jordan X, Scheel-Sailer A, Stucki G. A Rasch-Based Comparison of the Functional Independence Measure and Spinal Cord Independence Measure for Outcome and Quality in the Rehabilitation of Persons with Spinal Cord Injury. J Rehabil Med 2022; 54:jrm00262. [PMID: 35166364 PMCID: PMC8892304 DOI: 10.2340/jrm.v54.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
Objective The Functional Independence Measure (FIM™) and spinal cord injury (SCI)-specific Spinal Cord Independence Measure (SCIM) are commonly used tools for outcome measurement and quality reporting in rehabilitation. The objective of this study was to investigate the psychometric properties of FIM™ and SCIM and to equate the 2 scales. Methods First, content equivalence of FIM™ and SCIM was established through qualitative linking with the International Classification for Functioning, Disability and Health (ICF). Secondly, a Rasch analysis of overlapping contents determined the metric properties of the scales and provided the empirical basis for scale equating. Furthermore, a transformation table for FIM™ and SCIM was created and evaluated. Subjects Patients with SCI in Swiss inpatient rehabilitation in 2017–18. Results The ICF linking and a separate Rasch analysis of FIM™ restricted the analysis to the motor scales of FIM™ and SCIM. The Rasch analysis of these scales showed good metric properties. The co-calibration of FIM™ and SCIM motor scores was supported with good fit to the Rasch model. The operational range of SCIM is larger than for FIM™ motor scale. Discussion This study supports the advantage of using SCIM compared with FIM™ for assessing the functional independence of patients with SCI in rehabilitation.
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Affiliation(s)
- Roxanne Maritz
- Swiss Paraplegic Research, Nottwil; Center for Rehabilitation in Global Health Systems, Department of Health Sciences and Medicine, University of Lucerne, Lucerne.
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47
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Cathomen A, Sirucek L, Killeen T, Abel R, Maier D, Weidner N, Rupp R, Hothorn T, Steeves JD, Curt A, Bolliger M. Inclusive Trial Designs in Acute Spinal Cord Injuries: Prediction-Based Stratification of Clinical Walking Outcome and Projected Enrolment Frequencies. Neurorehabil Neural Repair 2022; 36:274-285. [PMID: 35164574 PMCID: PMC9003761 DOI: 10.1177/15459683221078302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background New therapeutic approaches in neurological disorders are progressing into clinical development. Past failures in translational research have underlined the critical importance of selecting appropriate inclusion criteria and primary outcomes. Narrow inclusion criteria provide sensitivity, but increase trial duration and cost to the point of infeasibility, while broader requirements amplify confounding, increasing the risk of trial failure. This dilemma is perhaps most pronounced in spinal cord injury (SCI), but applies to all neurological disorders with low frequency and/or heterogeneous clinical manifestations. Objective Stratification of homogeneous patient cohorts to enable the design of clinical trials with broad inclusion criteria. Methods Prospectively–gathered data from patients with acute cervical SCI were analysed using an unbiased recursive partitioning conditional inference tree (URP–CTREE) approach. Performance in the 6-minute walk test at 6 months after injury was classified based on standardized neurological assessments within the first 15 days of injury. Functional and neurological outcomes were tracked throughout rehabilitation up to 6 months after injury. Results URP–CTREE identified homogeneous outcome cohorts in a study group of 309 SCI patients. These cohorts were validated by an internal, yet independent, validation group of 172 patients. The study group cohorts identified demonstrated distinct recovery profiles throughout rehabilitation. The baseline characteristics of the analysed groups were compared to a reference group of 477 patients. Conclusion URP–CTREE enables inclusive trial design by revealing the distribution of outcome cohorts, discerning distinct recovery profiles and projecting potential patient enrolment by providing estimates of the relative frequencies of cohorts to improve the design of clinical trials in SCI and beyond.
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Affiliation(s)
- Adrian Cathomen
- Spinal Cord Injury Center, 31031Balgrist University Hospital, Zurich, Switzerland.,ETH Zurich, Zurich, Switzerland.,Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
| | - Laura Sirucek
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland.,Integrative Spinal Research, Department of Chiropractic Medicine, 31031Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Tim Killeen
- Spinal Cord Injury Center, 31031Balgrist University Hospital, Zurich, Switzerland
| | - Rainer Abel
- Trauma Center Bayreuth, Bayreuth, Germany.,EMSCI Study Group
| | - Doris Maier
- EMSCI Study Group.,Trauma Center Murnau, Murnau, Germany
| | - Norbert Weidner
- EMSCI Study Group.,Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Rüdiger Rupp
- EMSCI Study Group.,Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Torsten Hothorn
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - John D Steeves
- ICORD, Blusson Spinal Cord Centre, University of British Columbia and Vancouver Coastal Health, Vancouver, BC, Canada
| | - Armin Curt
- Spinal Cord Injury Center, 31031Balgrist University Hospital, Zurich, Switzerland.,Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland.,EMSCI Study Group
| | - Marc Bolliger
- Spinal Cord Injury Center, 31031Balgrist University Hospital, Zurich, Switzerland.,Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland.,EMSCI Study Group
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48
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Martin AR, Tetreault L, Nouri A, Curt A, Freund P, Rahimi-Movaghar V, Wilson JR, Fehlings MG, Kwon BK, Harrop JS, Davies BM, Kotter MRN, Guest JD, Aarabi B, Kurpad SN. Imaging and Electrophysiology for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 9]. Global Spine J 2022; 12:130S-146S. [PMID: 34797993 PMCID: PMC8859711 DOI: 10.1177/21925682211057484] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE The current review aimed to describe the role of existing techniques and emerging methods of imaging and electrophysiology for the management of degenerative cervical myelopathy (DCM), a common and often progressive condition that causes spinal cord dysfunction and significant morbidity globally. METHODS A narrative review was conducted to summarize the existing literature and highlight future directions. RESULTS Anatomical magnetic resonance imaging (MRI) is well established in the literature as the key imaging tool to identify spinal cord compression, disc herniation/bulging, and inbuckling of the ligamentum flavum, thus facilitating surgical planning, while radiographs and computed tomography (CT) provide complimentary information. Electrophysiology techniques are primarily used to rule out competing diagnoses. However, signal change and measures of cord compression on conventional MRI have limited utility to characterize the degree of tissue injury, which may be helpful for diagnosis, prognostication, and repeated assessments to identify deterioration. Early translational studies of quantitative imaging and electrophysiology techniques show potential of these methods to more accurately reflect changes in spinal cord microstructure and function. CONCLUSION Currently, clinical management of DCM relies heavily on anatomical MRI, with additional contributions from radiographs, CT, and electrophysiology. Novel quantitative assessments of microstructure, perfusion, and function have the potential to transform clinical practice, but require robust validation, automation, and standardization prior to uptake.
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Affiliation(s)
- Allan R. Martin
- Department of Neurological Surgery, University of California Davis, Davis, CA, USA
| | - Lindsay Tetreault
- Department of Neurology, New York University, Langone Health, Graduate Medical Education, New York, NY, USA
| | - Aria Nouri
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Armin Curt
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Patrick Freund
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, BC, Canada
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
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Boerger TF, Hyngstrom AS, Furlan JC, Kalsi-Ryan S, Curt A, Kwon BK, Kurpad SN, Fehlings MG, Harrop JS, Aarabi B, Rahimi-Movaghar V, Guest JD, Wilson JR, Davies BM, Kotter MRN, Koljonen PA. Developing Peri-Operative Rehabilitation in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 6]: An Unexplored Opportunity? Global Spine J 2022; 12:97S-108S. [PMID: 35174735 PMCID: PMC8859699 DOI: 10.1177/21925682211050925] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE Degenerative cervical myelopathy is one of the most frequent impairments of the spinal cord encountered internationally in adults. Currently, surgical decompression is the recommended treatment for people with DCM (PwCM) presenting with moderate to severe symptoms or neurological deficits. However, despite surgical intervention, not all patients make a complete recovery due to the irreversible tissue damage within the spinal cord. The objective of this review is to describe the state and gaps in the current literature on rehabilitation for PwCM and possible innovative rehabilitation strategies. METHODS Literature search. RESULTS In other neurological disorders such as stroke and acute traumatic spinal cord injury (SCI), timely and strategic rehabilitation has been shown to be indispensable for maximizing functional outcomes, and it is imperative that appropriate perioperative rehabilitative interventions accompany surgical approaches in order to enable the best outcomes. In this review, the current state of knowledge regarding rehabilitation for PwCM is described. Additionally, various therapies that have shown to improve outcomes in comparable neurological conditions such as stroke and SCI which may be translated to DCM will be reviewed. CONCLUSIONS We conclude that locomotor training and arm/hand therapy may benefit PwCM. Further, we conclude that body weight support, robotic assistance, and virtual/augmented reality therapies may be beneficial therapeutic analogs to locomotor and hand therapies.
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Affiliation(s)
- Timothy F. Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Julio C. Furlan
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sukhvinder Kalsi-Ryan
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Armin Curt
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Brian K. Kwon
- Department of Orthopedics, Vancouver Spine Surgery Institute, The University of British Columbia, Vancouver, BC, Canada
| | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | | | - Paul A. Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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50
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Davies BM, Mowforth O, Gharooni AA, Tetreault L, Nouri A, Dhillon RS, Bednarik J, Martin AR, Young A, Takahashi H, Boerger TF, Newcombe VFJ, Zipser CM, Freund P, Koljonen PA, Rodrigues-Pinto R, Rahimi-Movaghar V, Wilson JR, Kurpad SN, Fehlings MG, Kwon BK, Harrop JS, Guest JD, Curt A, Kotter MRN. A New Framework for Investigating the Biological Basis of Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 5]: Mechanical Stress, Vulnerability and Time. Global Spine J 2022; 12:78S-96S. [PMID: 35174728 PMCID: PMC8859710 DOI: 10.1177/21925682211057546] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Literature Review (Narrative). OBJECTIVE To propose a new framework, to support the investigation and understanding of the pathobiology of DCM, AO Spine RECODE-DCM research priority number 5. METHODS Degenerative cervical myelopathy is a common and disabling spinal cord disorder. In this perspective, we review key knowledge gaps between the clinical phenotype and our biological models. We then propose a reappraisal of the key driving forces behind DCM and an individual's susceptibility, including the proposal of a new framework. RESULTS Present pathobiological and mechanistic knowledge does not adequately explain the disease phenotype; why only a subset of patients with visualized cord compression show clinical myelopathy, and the amount of cord compression only weakly correlates with disability. We propose that DCM is better represented as a function of several interacting mechanical forces, such as shear, tension and compression, alongside an individual's vulnerability to spinal cord injury, influenced by factors such as age, genetics, their cardiovascular, gastrointestinal and nervous system status, and time. CONCLUSION Understanding the disease pathobiology is a fundamental research priority. We believe a framework of mechanical stress, vulnerability, and time may better represent the disease as a whole. Whilst this remains theoretical, we hope that at the very least it will inspire new avenues of research that better encapsulate the full spectrum of disease.
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Affiliation(s)
| | - Oliver Mowforth
- Department of Neurosurgery, University of Cambridge, Cambridge, UK
| | | | - Lindsay Tetreault
- New York University, Langone Health, Graduate Medical Education, Department of Neurology, New York, NY, USA
| | - Aria Nouri
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Genève, Switzerland
| | - Rana S. Dhillon
- Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, VIC, Australia
| | - Josef Bednarik
- Department of Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Allan R. Martin
- Department of Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Adam Young
- Department of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Hitoshi Takahashi
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Timothy F. Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Virginia FJ Newcombe
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Carl Moritz Zipser
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Patrick Freund
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Paul Aarne Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto - Hospital de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, BC, Canada
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - James D. Guest
- Department of Neurosurgery and the Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Armin Curt
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
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