Validation of a New Tool to Detect and Characterize Spinal Cord Injury in the Acute Trauma Patient: The Montreal Acute Classification of Spinal Cord Injury

STUDY DESIGN

Retrospective validation protocol.

OBJECTIVE

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive tool for classifying spinal cord injuries (SCI), but it is not adapted for the evaluation of trauma patients. The objective is to develop and validate a streamlined tool, the Montreal Acute Classification of Spinal Cord Injury (MAC-SCI) that can be integrated in the evaluation of trauma patients to detect and characterize traumatic SCI (tSCI).

METHODS

The completion rate of the ISCNSCI during initial evaluation after tSCI was estimated at a Level-1 trauma center specialized in SCI care. Using a modified Delphi technique, we designed the MAC-SCI, a new tool to detect and characterize the severity grade and level of SCI in the polytrauma patient. A cohort consisting of 35 consecutive tSCI patients with complete ISNCSCI documentation was used to validate the MAC-SCI. The severity grade and neurological level of injury (NLI) were assessed using the MAC-SCI, and compared to those obtained with the ISNCSCI.

RESULTS

Only 33% of 148 patients admitted after a tSCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI retains 53 of the 134 elements from the ISNCSCI. There was a 100% concordance in severity grade between the MAC-SCI and ISNCSCI. The NLI were within 2 levels between the MAC-SCI and ISNCSI for 100% of patients.

CONCLUSION

The MAC-SCI is a streamlined tool that accurately detects and characterizes tSCI in the acute trauma setting. It could be implemented in trauma protocols to guide the management of SCI patients.

LEVEL OF EVIDENCE

Level III Diagnostic criteria.

Comprehensive Evaluation of Healthy Volunteers Using Multi-Modality Brain Injury Assessments: An Exploratory, Observational Study

Introduction: Even though mild traumatic brain injury is common and can result in persistent symptoms, traditional measurement tools can be insensitive in detecting functional deficits after injury. Some newer assessments do not have well-established norms, and little is known about how these measures perform over time or how cross-domain assessments correlate with one another. We conducted an exploratory study to measure the distribution, stability, and correlation of results from assessments used in mild traumatic brain injury in healthy, community-dwelling adults. Materials and Methods: In this prospective cohort study, healthy adult men and women without a history of brain injury underwent a comprehensive brain injury evaluation that included self-report questionnaires and neurological, electroencephalography, sleep, audiology/vestibular, autonomic, visual, neuroimaging, and laboratory testing. Most testing was performed at 3 intervals over 6 months. Results: The study enrolled 83 participants, and 75 were included in the primary analysis. Mean age was 38 years, 58 were male, and 53 were civilians. Participants did not endorse symptoms of post-concussive syndrome, PTSD, or depression. Abnormal neurological examination findings were rare, and 6 had generalized slowing on electroencephalography. Actigraphy and sleep diary showed good sleep maintenance efficiency, but 21 reported poor sleep quality. Heart rate variability was most stable over time in the sleep segment. Dynavision performance was normal, but 41 participants had abnormal ocular torsion. On eye tracking, circular, horizontal ramp, and reading tasks were more likely to be abnormal than other tasks. Most participants had normal hearing, videonystagmography, and rotational chair testing, but computerized dynamic posturography was abnormal in up to 21% of participants. Twenty-two participants had greater than expected white matter changes for age by MRI. Most abnormal findings were dispersed across the population, though a few participants had clusters of abnormalities. Conclusions: Despite our efforts to enroll normal, healthy volunteers, abnormalities on some measures were surprisingly common. Trial Registration: This study was registered at www.clinicaltrials.gov, trial identifier NCT01925963.

Neurological assessment scores in rabbit embolic stroke models

Background:

Neurological outcomes and behavioral assessments are widely used in animal models of stroke, but assessments in rabbit models are not fully validated. The wryneck model of neurological assessment scores (NAS) was compared to percent infarct volume (%IV) values (infarct volume is a proven clinical indicator of stroke severity) and arterial occlusion localization in three rabbit angiographic stroke models.

Hypothesis:

NAS values will correlate with percent infarct volume values.

Methods:

Anesthetized New Zealand White rabbits (N=131, 4-5 kg) received internal carotid artery emboli by angiographic catheter introduced into the femoral artery and occlusions were characterized. Rabbits were evaluated at 24 hours post embolism using the NAS test of 0 (normal) to 10 (death). Deficit criteria included neck twist, righting reflex, extension reflex in hind paw and forepaw, and posture. Brain sections stained with triphenyltetrazolium chloride (TTC) were analyzed for %IV. Volume of the infarct was measured and calculated as a percent of the total brain volume.

Results:

The aggregate correlation for NAS values vs. %IV values was R=0.61, p<0.0001, a strong positive relationship, while correlations of the NAS components ranged from R=0.28-0.46. Occlusionsof the posterior cerebral artery vs. the middle cerebral artery alone produced significantly greater deficit scores at p<0.0001.

Conclusions:

These positive results validate the NAS system in the rabbit angiographic embolic stroke model.