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

Abstract

Neurological outcomes after traumatic spinal cord injury are variable and depend on patient-, trauma-, and treatment-related factors as well as on spinal cord injury characteristics, imaging, and biomarkers. The aims of the study were to identify and classify the early predictors of neurological outcomes after traumatic spinal cord injury. The Medline, PubMed, Embase, and the Cochrane Central Database were searched using medical subject headings. The search was extended to the reference lists of identified studies. The study eligibility criteria were assessment of neurological outcomes as primary or secondary outcome, predictors collected during the acute phase after traumatic spinal cord injury, and multivariate design. The participants were adult patients with traumatic spinal cord injury followed at least 3 mos after injury. The quality of studies was assessed by two independent reviewers using the Study Quality Assessment Tools for Observational Cohort and Cross-sectional Studies. The studies' narrative synthesis relied on a classification of the predictors according to quantity, quality, and consistency of the evidence. Results were summarized in a conceptual framework. Forty-nine articles were included. The initial severity of traumatic spinal cord injury (American Spinal Injury Association Impairment Scale, motor score, and neurological level of injury) was the strongest predictor of neurological outcomes: patients with more severe injury at admission presented poor neurological outcomes. Intramedullary magnetic resonance imaging signal abnormalities were also associated with neurological outcomes, as the presence of intramedullary hemorrhage was a factor of poor prognosis. Other largely studied predictors, such as age and surgical timing, showed some inconsistency in results depending on cutoffs. Younger age and early surgery were generally associated with good outcomes. Although widely studied, other factors, such as vertebral and associated injuries, failed to show association with outcomes. Cerebrospinal fluid inflammatory biomarkers, as emerging factors, were significantly associated with outcomes. This study provides a comprehensive review of predictors of neurological outcomes after traumatic spinal cord injury. It also highlights the heterogeneity of outcomes used by studies to assess neurological recovery. The proposed conceptual framework classifies predictors and illustrates their relationships with outcomes.