Admission American Spinal Injury Association Research Articles

Safety and comparative efficacy of initiating low-molecular-weight heparin within 24 hours of injury or surgery for venous thromboembolism prophylaxis in patients with spinal cord injury: a prospective TRACK-SCI registry study.

Venous thromboembolism (VTE) following traumatic spinal cord injury (SCI) is a significant clinical concern. This study sought to determine the incidence of VTE and hemorrhagic complications among patients with SCI who received low-molecular-weight heparin (LMWH) within 24 hours of injury or surgery and identify variables that predict VTE using the prospective Transforming Research and Clinical Knowledge in SCI (TRACK-SCI) database. The TRACK-SCI database was queried for individuals with traumatic SCI from 2015 to 2022. Primary outcomes of interest included rates of VTE (including deep vein thrombosis [DVT] and pulmonary embolism [PE]) and in-hospital hemorrhagic complications that occurred after LWMH administration. Secondary outcomes included intensive care unit and hospital length of stay, discharge location type, and in-hospital mortality. The study cohort consisted of 162 patients with SCI. Fifteen of the 162 patients withdrew from the study, leading to loss of data for certain variables for these patients. One hundred thirty patients (87.8%) underwent decompression and/or fusion surgery for SCI. DVT occurred in 11 (7.4%) of 148 patients, PE in 9 (6.1%) of 148, and any VTE in 18 (12.2%) of 148 patients. The analysis showed that admission lower-extremity motor score (p = 0.0408), injury at the thoracic level (p = 0.0086), admission American Spinal Injury Association grade (p = 0.0070), and younger age (p = 0.0372) were significantly associated with VTE. There were 3 instances of postoperative spine surgery-related bleeding (2.4%) in the 127 patients who had spine surgery with bleeding complication data available, with one requiring return to surgery (0.8%). Thirteen (8.8%) of 147 patients had a bleeding complication not related to spine surgery. There were 2 gastrointestinal bleeds associated with nasogastric tube placement, 3 cases of postoperative non-spine-related surgery bleeding, and 8 cases of other bleeding complications (5.4%) not related to any surgery. Initiation of LMWH within 24 hours was associated with a low rate of spine surgery-related bleeding. Bleeding complications unrelated to SCI surgery still occur with LMWH administration. Because neurosurgical intervention is typically the limiting factor in initializing chemical DVT prophylaxis, many of these bleeding complications would have likely occurred regardless of the protocol.

Intraoperative Sensory Signals Predict Prognosis for Patients with Traumatic Cervical Spinal Cord Injury

In patients with traumatic cervical spinal cord injury (tCSCI), the potential role of intraoperative neuromonitoring as a prognostic tool has been insufficiently studied. This study aimed to determine if detectable signals during intraoperative neuromonitoring portend a greater likelihood of recovery for patients with tCSCI. Patients who underwent decompression and surgical fixation following tCSCI were retrospectively reviewed through previously prospectively collected data from the Surgical Timing in Acute Spinal Cord Injury Study. Improvement in American Spinal Injury Association (ASIA) motor score and ASIA Impairment Scale grade conversion rates at final follow-up were compared between patients with detectable intraoperative neuromonitoring somatosensory evoked potential (SSEP) signals and those without detectable signals. Forty-nine patients had intraoperative neuromonitoring. Patients with incomplete tCSCI had detectable lower extremity SSEPs more often than patients with complete tCSCI (56.3% vs. 23.5%, P= 0.028). There was no difference in detectable upper extremity SSEPs between complete and incomplete tCSCI (65.6% vs. 58.8%, P= 0.638). Of the 17 patients with complete tCSCI, patients with detectable lower extremity SSEPs had ASIA motor scores similar to the nondetectable cohort on admission (21.5 vs. 16.2, P= 0.609) but higher ASIA motor scores at final follow-up (57.5 vs. 27.1, P= 0.041). Of the 32 patients with incomplete spinal cord injury, there was no difference in grade conversion or motor scores between detectable and nondetectable SSEP cohorts. The presence of upper extremity SSEP signals in patients who present with complete tCSCI portends greater improvement in ASIA motor scores and likelihood of American Spinal Injury Association Impairment Scale grade conversion at final follow-up.

Elderly traumatic central cord syndrome in the USA: a review of management and outcomes.

As the incidence of elderly spinal cord injury rises, improved understanding of risk profiles and outcomes is needed. This review summarizes clinical characteristics, management, and outcomes specific to the elderly (≥65-years) with acute traumatic central cord syndrome in the USA. Literature review of the PubMed, Embase, and CINAHL databases (01/2007-03/2020) regarding elderly subjects with acute traumatic central cord syndrome. Nine studies met inclusion criteria. Acute traumatic central cord syndrome was more common among married (50%), Caucasian (22-71%) males (63-86%) with an annual income <40,999 USA dollars (30%). Mechanisms consisted predominantly of traumatic falls (32-55%) and motor vehicle collisions (15-34%), with admission American Spinal Injury Association Impairment Scale grades D (25-79%) and C (21-51%). Mortality was 2-3%. American Spinal Injury Association Impairment Scale motor score, maximum canal compromise, and extent of parenchymal damage were predictors of one-year recovery. Greater comorbidities (heart failure, weight loss, coagulopathy, diabetes), lower income (<51,000 USA dollars), and age ≥80 were predictors of mortality. A substantial cohort underwent surgery (40-45%). Elderly patients were less likely to receive surgical intervention, and surgery timing had variable effects on recovery. Elderly patients with acute traumatic central cord syndrome are uniquely at risk due to cumulative comorbidities, protracted recovery times, and unclear effects of surgical timing on outcomes. Prospective research should focus on validating age-specific risk factors, formalizing surgical indications, and delineating the impact of time to surgery on acute and long-term outcomes for this condition.

Efficacy of Early (≤ 24 Hours), Late (25–72 Hours), and Delayed (&gt;72 Hours) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades C and D Acute Traumatic Central Cord Syndrome Caused by Spinal Stenosis

The therapeutic significance of timing of decompression in acute traumatic central cord syndrome (ATCCS) caused by spinal stenosis remains unsettled. We retrospectively examined a homogenous cohort of patients with ATCCS and magnetic resonance imaging (MRI) evidence of post-treatment spinal cord decompression to determine whether timing of decompression played a significant role in American Spinal Injury Association (ASIA) motor score (AMS) 6 months following trauma. We used the t test, analysis of variance, Pearson correlation coefficient, and multiple regression for statistical analysis. During a 19-year period, 101 patients with ATCCS, admission ASIA Impairment Scale (AIS) grades C and D, and an admission AMS of ≤95 were surgically decompressed. Twenty-four of 101 patients had an AIS grade C injury. Eighty-two patients were males, the mean age of patients was 57.9 years, and 69 patients had had a fall. AMS at admission was 68.3 (standard deviation [SD] 23.4); upper extremities (UE) 28.6 (SD 14.7), and lower extremities (LE) 41.0 (SD 12.7). AMS at the latest follow-up was 93.1 (SD 12.8), UE 45.4 (SD 7.6), and LE 47.9 (SD 6.6). Mean number of stenotic segments was 2.8, mean canal compromise was 38.6% (SD 8.7%), and mean intramedullary lesion length (IMLL) was 23 mm (SD 11). Thirty-six of 101 patients had decompression within 24 h, 38 patients had decompression between 25 and 72 h, and 27 patients had decompression >72 h after injury. Demographics, etiology, AMS, AIS grade, morphometry, lesion length, surgical technique, steroid protocol, and follow-up AMS were not statistically different between groups treated at different times. We analyzed the effect size of timing of decompression categorically and in a continuous fashion. There was no significant effect of the timing of decompression on follow-up AMS. Only AMS at admission determined AMS at follow-up (coefficient = 0.31; 95% confidence interval [CI]:0.21; p = 0.001). We conclude that timing of decompression in ATCCS caused by spinal stenosis has little bearing on ultimate AMS at follow-up.

Mean arterial pressure maintenance following spinal cord injury: Does meeting the target matter?

Neurosurgical guidelines recommend maintaining mean arterial pressure (MAP) between 85 and 90 mm Hg following acute spinal cord injury (SCI). In our hospital, SCI patients receive orders for MAP targeting for 72 hours following admission, but it is unclear how often the patient's MAP meets the target and whether or not this affects outcome. We hypothesized that the proportion of MAP measurements ≥85 mm Hg would be associated with neurologic recovery. Spinal cord injury patients with blunt mechanism of injury admitted between 2014 and 2019 were identified from the registry of a level 1 trauma center. Proportion of MAP values ≥85 mm Hg was calculated for each patient. Neurologic improvement, as measured by positive change in American Spinal Injury Association (ASIA) impairment scale by ≥1 level from admission to discharge was evaluated with respect to proportion of elevated MAP values. A total of 136 SCI patients were evaluated. Average proportion of elevated MAP values was 75%. Admission ASIA grades were as follows: A, 30 (22.1%); B, 20 (14.7%); C, 28 (20.6%); and D, 58 (42.6%). One hundred six patients (77.9%) required vasopressors to elevate MAP (ASIA A, 86.7%; B, 95.0%; C, 92.9%; D, 60.3%). Forty patients (29.4%) were observed to have improvement in ASIA grade by discharge (admission ASIA A, 15%; B, 33%; C, 40%; D, 13%). The proportion of elevated MAP values was higher for patients with neurologic improvement (0.81 ± 0.15 vs. 0.72 ± 0.25, p = 0.014). Multivariate modeling demonstrated a significant association between proportion of elevated MAP values and neurologic improvement (p = 0.028). An interaction revealed this association to be moderated by vasopressor dose (p = 0.032). The proportion of MAP measurements ≥85 mm Hg was determined to be an independent predictor of neurologic improvement. Increased vigilance regarding MAP maintenance above 85 mm Hg is warranted to optimize neurologic recovery following SCI. Therapeutic/care management, level IV.

Efficacy of Ultra-Early (< 12 h), Early (12-24 h), and Late (>24-138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury.

In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12–24 h), and 15 underwent decompressive surgery late (> 24–138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862–0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.

Clinical Implementation of Novel Spinal Cord Perfusion Pressure Protocol in Acute Traumatic Spinal Cord Injury at U.S. Level I Trauma Center: TRACK-SCI Study

We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center. Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A-C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day7. Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A-C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care. In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.

Magnetic Resonance Imaging Evidence of Therapeutic Efficacy of Timing of Decompression in American Spinal Injury Association Impairment Scale Grades A to C Cervical Spinal Cord Injury Patients

Abstract INTRODUCTION In traumatic cervical spinal cord injury (SCI), the therapeutic effect of surgery and its timing as neuroprotective measures remain uncertain. Additionally, the relationship between timing of decompression, extent of decompression, imaging biomarkers evidence of injury severity, and outcome are incompletely understood. METHODS We investigated the effect of timing of decompression and long-term neurological outcome in patients with postoperatively confirmed decompression using computed tomography (CT) and magnetic resonance imaging (MRI) studies. A total of 6 mo after cervical SCI, American Spinal Injury Association Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients whose postoperative CT and MRI confirmed spinal cord decompression. A total of 32 patients underwent decompressive surgery less than 12 hr from injury, 25 within 12 to 24 hr, and 15 more than 24 hr after trauma. RESULTS Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission American Spinal Injury Association (ASIA) motor score, and surgical technique were not statistically different in-between groups. Motor complete patients (P = .009) and those with fracture dislocations (P = .01) tended to be operated earlier. One or more grade improvement was 55.6% in AIS grade A, 60.9% in AIS grade B, and 86.4% in AIS grade C patients. Admission AIS motor score (P = .0004) and preoperative IMLL (P = 0001) were the strongest predictors of neurological outcome. AIS grade improvement was 65.6% in patients undergoing decompressive surgery within 12 hr after trauma, 60% in patients undergoing surgery within 12 to 24 hr, and 80% when decompression was performed more than 24 hr after injury (P = .424). Multiple regression analysis of all significant and marginally significant variables revealed that the only significant variable predictive of AIS grade conversion to a better grade was IMLL (odds ratio 133.51, CI 11.68-1525.71, P &lt; .0001). CONCLUSION In patients with postoperative CT and MRI confirmation of decompression following traumatic cervical SCI, preoperative IMLL and not the timing of surgery appears to determine long-term neurological outcome.

Impact of Admission Imaging Findings on Neurological Outcomes in Acute Cervical Traumatic Spinal Cord Injury.

Variable and unpredictable spontaneous recovery can occur after acute cervical traumatic spinal cord injury (tSCI). Despite the critical clinical and interventional trial planning implications of this tSCI feature, baseline measures to predict neurologic recovery accurately are not well defined. In this study, we used data derived from 99 consecutive patients (78 male, 21 female) with acute cervical tSCIs to assess the sensitivity and specificity of various clinical and radiological factors in predicting recovery at one year after injury. Categorical magnetic resonance imaging parameters included maximum canal compromise (MCC), maximum spinal cord compression (MSCC), longitudinal length of intramedullary lesion (IML), Brain and Spinal Injury Center (BASIC) score, and a novel derived Combined Axial and Sagittal Score (CASS). Logistic regression analysis of the area under the receiver operating characteristic curve (AUC) was applied to assess the differential predictive value of individual imaging markers. Admission American Spinal Injury Association Impairment Scale (AIS) grade, presence of a spinal fracture, and central cord syndrome were predictive of AIS conversion at one year. Both BASIC and IML were stronger predictors of AIS conversion compared with MCC and MSCC (p = 0.0002 and p = 0.04). The BASIC score demonstrated the highest overall predictive value for AIS conversion at one year (AUC 0.94). We conclude that admission intrinsic cord signal findings are robust predictive surrogate markers of neurologic recovery after cervical tSCI. Direct comparison of imaging parameters in this cohort of patients indicates that the BASIC score is the single best acute predictor of the likelihood of AIS conversion.

Failure of Mean Arterial Pressure Goals to Improve Outcomes Following Penetrating Spinal Cord Injury.

Increased spinal cord perfusion and blood pressure goals have been recommended for spinal cord injury (SCI). Penetrating SCI is associated with poor prognosis, but there is a paucity of literature examining the role of vasopressor administration for the maintenance of mean arterial pressure (MAP) goals in this patient population. To elucidate this topic and to determine the efficacy of vasopressor administration in penetrating SCI by examining a case series of consecutive penetrating SCIs. We reviewed consecutive patients with complete penetrating SCI who met inclusion and exclusion criteria, including the administration of vasopressors to maintain MAP goals. We identified 14 patients with complete penetrating SCIs with an admission American Spinal Injury Association grade of A from 2005 to 2011. The neurological recovery, complications, interventions, and vasopressor administration strategies were reviewed and compared with those of a cohort with complete blunt SCI. In our patient population, only 1 patient with penetrating SCI (7.1%) experienced neurological recovery, as determined by improvement in the American Spinal Injury Association grade, despite the administration of vasopressors for supraphysiological MAP goals for an average of 101.07 ± 34.96 hours. Furthermore, 71.43% of patients with penetrating SCI treated with vasopressors experienced associated cardiogenic complications. Given the decreased likelihood of neurological improvement in penetrating injuries, it may be important to re-examine intervention strategies in this population. Specifically, the use of vasopressors, in particular dopamine, with their associated complications is more likely to cause complications than to result in neurological improvement. Our experience shows that patients with acute penetrating SCI are unlikely to recover, despite aggressive cardiopulmonary management. ASIA, American Spinal Injury AssociationMAP, mean arterial pressureSCI, spinal cord injury.

Surgical treatment of cervical spine trauma: Our experience and results.

Objective and Background:The objective of this study is to evaluate how the neurological outcome in patients operated for cervical spinal cord injury (SCI) is influenced by surgical timing, admission American Spinal Injury Association (ASIA) grading system, and age.Materials and Methods:From January 2004 to December 2011, we operated 110 patients with cervical SCI. Fifty-seven of them (44 males and 13 females) with preoperative neurological deficit, were included in this study with a complete follow-up. Age, sex, associated comorbidities (evaluated with Charlson comorbidity index [CCI]), mechanism of trauma, preoperative and follow-up ASIA score, time elapsed from injury to surgical treatment, preoperative cervical computed tomography scan or magnetic resonance imaging, type of fractures, and surgical procedure were evaluated for each patient. The patient population was divided into two groups related to the timing of surgery: Ultra-early surgery group (within 12 h from the trauma, 27 patients) and early surgery (within 12–72 h from the trauma, 30 patients).Statistical Analysis Used:The univariate analysis of data was carried out by the Chi-square test for discrete variables, the t-test for the continuous ones. Logistic regression was used for the multivariate analysis.Results:Neurological outcome was statistically better in ultra-early surgery group (<12 h) than in patient underwent surgery within 12–72 h (82.14% vs. 31%, multivariate analysis P = 0.005). The neurological improvement was also correlated with the age and the ASIA grade at admission in the univariate analysis (P = 0.006 and P = 0.017 respectively) and in the multivariate 1 (P = 0.037 and P = 0.006 respectively) while the CCI was correlated with the improvement only in the univariate analysis (P = 0.007).Conclusion:Nowadays, in patients with cervical SCI early surgery could be associated with improved outcome, most in case of young people with mild neurological impairment.

Characteristics and rehabilitation for patients with spinal cord stab injury.

[Purpose] The objective of the study was to compare the incidence, diagnosis, treatment, and prognosis of patients with spinal cord stab injury to those with the more common spinal cord contusion injury. [Subjects] Of patients hospitalized in China Rehabilitation Research Center from 1994 to 2014, 40 of those having a spinal cord stab injury and 50 with spinal cord contusion were selected. [Methods] The data of all patients were analyzed retrospectively. The cases were evaluated by collecting admission and discharge ASIA (American Spinal Injury Association) and ADL (activity of daily living) scores. [Results] After a comprehensive rehabilitation program, ASIA and ADL scores of patients having both spinal cord stab injury and spinal cord contusion significantly increase. However, the increases were noted to be higher in patients having a spinal cord stab injury than those having spinal cord contusion. [Conclusion] Comprehensive rehabilitation is effective both for patients having spinal cord stab injury and those with spinal cord contusion injury. However, the prognosis of patients having spinal cord stab injury is better than that of patients with spinal cord contusion.

Development and validation of a risk prediction model for tracheostomy in acute traumatic cervical spinal cord injury patients

Tracheostomy may become indispensable for patients with acute traumatic cervical spinal cord injuries. However, the early prediction of a tracheostomy is often difficult. Previous prediction models using the pulmonary function test (PFT) have limitations because some severely injured patients could not provide acceptable PFT results. We aim to develop an alternative model for predicting tracheostomy using accessible data obtained from the bedside. Clinical, neurological and radiological data from 345 consecutive patients with acute tetraplegia were retrospectively reviewed. We applied multiple logistic regression analysis (MLRA) and classification and regression tree (CART) analysis to develop the prediction model for tracheostomy. By train-test cross-validation, we used the sensitivity, specificity, area under the receiver operating characteristics curve (AUC) and correction rate to evaluate the performance of these models. According to the American Spinal Injury Association (ASIA) standards, an admission ASIA motor score (AAMS) ≤ 22, ASIA grade A and presence of respiratory complications were identified as independent predictors of tracheostomy by both models. The model derived by CART suggested that the highest signal change (HSC) in the spinal cord on magnetic resonance imaging (MRI) also affected a patient's requirement for a tracheostomy, while MLRA demonstrated that tracheostomy was also influenced by the presence of an ASIA grade B injury. The CART model had a sensitivity of 73.7%, specificity of 89.7%, AUC of 0.909 and overall correction rate of 87.3%. The sensitivity, specificity, AUC and correction rate of the MLRA model were 81.8, 86.4, 0.889 and 85.7%, respectively. We suggest using the CART model in clinical applications. Patients with AAMS ≤ 1 exhibit an increased likelihood of requiring a tracheostomy. For patients with an AAMS in the range of 2-22, surgeons should consider giving these patients a tracheostomy once respiratory complications occur. Surgeons should be cautious to give a tracheostomy to patients with an AAMS ≥ 23, if the patient experiences an incomplete spinal cord injury and the HSC in the spinal cord is at C3 level or lower based on MRI. For other patients, close observation is necessary; generally, patients with complete SCI might require a tracheostomy more frequently.

Admission ASIA motor score predicting the need for tracheostomy after cervical spinal cord injury

Respiratory compromise and the need for tracheostomy are common after cervical spinal cord injury (cSCI). The purpose of the study was to evaluate if admission American Spinal Injury Association (ASIA) motor score is associated with the need for tracheostomy following cSCI. The trauma registry identified patients with isolated cSCI during a 3-year period. Patients with an Abbreviated Injury Scale score greater than 3 in other body regions were excluded. Medical records were reviewed for demographics, admission ASIA motor score, ASIA Impairment Scale (AIS), anatomic level of injury, need for a tracheostomy, and length of stay (LOS). Logistic regression models were constructed to examine the effect of admission ASIA motor scores on the outcome of tracheostomy. Cox proportional hazards models were fit to determine risk factors for time to tracheostomy. A total of 128 patients were identified. Seventy-four patients had a tracheostomy performed on mean (SD) hospital Day 9 (4). Median admission ASIA motor score was 22.0 (interquartile range [IQR], 8-54). Median anatomic level of injury was 5 (IQR, 4-6). Patients requiring tracheostomy had significantly lower median admission ASIA motor score (9 [IQR, 3-17] vs. 57 [IQR, 30-77], p < 0.001) and were more likely to be an AIS A. There was no difference in median anatomic level of injury (5 [IQR, 4-5.8] vs. 5 [IQR, 4-6], p = nonsignificant). ASIA motor scores less than 10 had an unadjusted odds ratio for requiring tracheostomy of 56 (95 confidence interval, 7-426). Following adjustment for independent risk factors, the odds ratio for ASIA motor score less than 10 remained statistically significant at 22 (confidence interval, 3-180). Among patients with incomplete cSCI, ASIA motor scores increased significantly from AIS B to AIS D, while Injury Severity Score (ISS), LOS and intensive care unit LOS declined significantly. Of those patients without a tracheostomy, 100% had an ASIA motor score greater than 10, 98% had an ASIA motor score greater than 20, and 86% had an ASIA motor score greater than 25. Among patients with an ASIA motor score less than 10, 100% had a tracheostomy; among patients with an ASIA motor score less than 20, 96% had a tracheostomy. Among patients with a tracheostomy, 91% were an AIS B or C, while 85% of patients classified as AIS D did not have a tracheostomy. Tracheostomy after cSCI is common. Lower admission ASIA motor score and "complete" cSCI are significantly associated with the need for tracheostomy. Anatomic level of injury was not associated with tracheostomy after cSCI. Classification of incomplete patients by AIS indicates that ASIA motor score may be used as a surrogate for grade of injury. When looking only at patients with an "incomplete" cSCI, those with an admission ASIA score of less than 10 should have an early tracheostomy. Those with an AIS D scale should not be considered for early tracheostomy. Therapeutic/care management, level II.

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

Background/objectiveExamine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury.MethodsPhysical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia.ResultsPT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of “walk” or “both (walk and wheelchair)” on the discharge motor FIM for patients with AIS D injuries.ConclusionInjury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings.NoteThis is the second of nine articles in the SCIRehab series.

Early versus late surgery for traumatic spinal cord injury: the results of a prospective Canadian cohort study

A multicenter Canadian cohort study. The objective of this study is to evaluate the impact of early versus late surgical decompression on motor neurological recovery after traumatic spinal cord injury (SCI). Canadian acute care and SCI rehabilitation facilities. A prospective cohort study of patients within the Ontario Spinal Cord Injury Registry program was performed. We considered SCI patients with an admission American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade of A through D, with magnetic resonance imaging-confirmed spinal cord compression. Grouped analysis was performed comparing the cohort of patients who received early surgery (<24 h after SCI) to those receiving delayed surgery (<24 h after SCI). The primary outcome was the change in ASIA motor score (AMS) occurring between hospital admission and rehabilitation discharge. A total of 35 (41.7%) patients underwent early surgery and 49 (58.3%) underwent late surgery. At admission, there was a greater proportion of patients within the early surgery group with more severe AIS grade A injuries. Of the 55 patients with neurological exam available at rehabilitation discharge, a greater proportion had at least a two-grade AIS improvement in the early-surgery group (P=0.01). The mean improvement in AMS at rehabilitation discharge was 20 points amongst early-surgery patients and 15 points amongst late-surgery patients (P=0.46). In the analysis investigating AMS improvement, adjusted for preoperative status and neurological level, there was a positive effect estimate for early surgical therapy that was statistically significant (P=0.01). The results here add weight to the growing body of literature, which supports the principle of early intervention in the setting of spinal trauma and SCI.

Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis

the objective of this study was to elucidate the relationship between admission demographic data, validated injury severity measures on imaging studies, and clinical indicators on the American Spinal Injury Association (ASIA) motor score, Functional Independence Measure (FIM), manual dexterity, and dysesthetic pain at least 12 months after surgery for acute traumatic central cord syndrome (ATCCS) due to spinal stenosis. over a 100-month period (January 2000 to April 2008), of 211 patients treated for ATCCS, 59 cases were due to spinal stenosis, and these patients underwent surgical decompression. Five of these patients died, 2 were lost to follow-up, 10 were not eligible for the study, and the remaining 42 were followed for at least 12 months. in the cohort of 42 patients, mean age was 58.3 years, 83% of the patients were men, and 52.4% of the accidents were due to falls. Mean admission ASIA motor score was 63.8 (upper extremities score, 25.8 and lower extremities score, 39.8), the spinal cord was most frequently compressed at skeletal segments C3-4 and C4-5 (71%), mean midsagittal diameter at the point of maximum compression was 5.6 mm, maximum canal compromise (MCC) was 50.5%, maximum spinal cord compression was 16.5%, and length of parenchymal damage on T2-weighted MR imaging was 29.4 mm. Time after injury until surgery was within 24 hours in 9 patients, 24-48 hours in 10 patients, and more than 48 hours in 23 patients. At the 1-year follow-up, the mean ASIA motor score was 94.1 (upper extremities score, 45.7 and lower extremities score, 47.6), FIM was 111.1, manual dexterity was 64.4% of baseline, and pain level was 3.5. Stepwise regression analysis of 10 independent variables indicated significant relationships between ASIA motor score at follow-up and admission ASIA motor score (p = 0.003), MCC (p = 0.02), and midsagittal diameter (p = 0.02); FIM and admission ASIA motor score (p = 0.03), MCC (p = 0.02), and age (p = 0.02); manual dexterity and admission ASIA motor score (p = 0.0002) and length of parenchymal damage on T2-weighted MR imaging (p = 0.002); and pain level and age (p = 0.02) and length of parenchymal lesion on T2-weighted MR imaging (p = 0.04). the main indicators of long-term ASIA motor score, FIM, manual dexterity, and dysesthetic pain were admission ASIA motor score, midsagittal diameter, MCC, length of parenchymal damage on T2-weighted MR imaging, and age, but different domains of outcome were determined by different predictors.

Poster 320: Dual Spinal Cord Injury from a Single Accident: A Case Report

Setting: Tertiary care rehabilitation unit. Patient: A 58-year-old man with 2 separate spinal cord injuries (SCIs) from the same accident. Case Description: The patient admitted to the rehabilitation unit with an acute SCI and bilateral metatarsal fractures. MRI demonstrated a vertebral crush injury at T5 with spinal cord transsection and spondylotic ridging at C5 with subtle cord edema. Admission American Spinal Injury Association (ASIA) exam was consistent with a complete T5. The patient was discharged to nursing home due to inability to tolerate rehabilitation secondary to metatarsal fractures, with plans to return for further rehabilitation once fracture healing occurred. On readmission, the patient's ASIA exam demonstrated an incomplete C7 injury and a complete T5 injury. The injury at C7 was overlooked initially due to his wrist fractures. As result of this change and subsequent impairment, the patient was required to make significant adjustments for dismissal. Assessment/Results: This patient had 2 SCIs, an incomplete C7 and a complete T5. It was not diagnosed initially due to his concomitant wrist fractures. Discussion: This patient's complete thoracic level SCI and upper-limb fractures dominated his initial care planning, and led to functional expectations that may not have been achievable. Although multiple vertebral injuries are common and occur 10% of the time in SCIs, it is exceedingly rare to have 2 distant SCIs from the same accident. Limited literature is available about dual SCIs. However, the recognition of a second, incomplete, more cephalad SCI in this case had significant ramifications for the patient's level of function and rehabilitation plan. Conclusions: There are no case reports of dual SCIs from the same accident in the English literature. Hence, separate clinically evident SCIs from the same traumatic event are probably very rare. The recognition of the second SCI in this case was complicated by concurrent upper-extremity fractures. Nonetheless, identifying the second injury is critical to the establishment of an optimal rehabilitation plan and achievable outcomes.

Mortality rates in geriatric patients with spinal cord injuries

The authors undertook this study to evaluate the incidence of spinal cord injury (SCI) in geriatric patients (> or = 70 years of age) and examine the impact of patient age, extent of neurological injury, and spinal level of injury on the mortality rate associated with traumatic SCI. A prospectively maintained SCI database (3481 patients) at a single institution was retrospectively studied for the period from 1978 through 2005. Parameters analyzed included patient age, admission American Spinal Injury Association (ASIA) motor score, level of SCI, mechanism of injury, and mortality data. The data pertaining to the 412 patients 70 years of age and older were compared with those pertaining to the younger cohort using a chi-square analysis. Since 1980, the number of SCI-related hospital admissions per year have increased fivefold in geriatric patients and the percentage of geriatric patients within the SCI population has increased from 4.2 to 15.4%. In comparison with younger patients, geriatric patients were found to be less likely to have severe neurological deficits (greater percentage of ASIA Grades C and D injuries), but the mortality rates were higher in the older age group both for the period of hospitalization (27.7% compared with 3.2%, p < 0.001) and during 1-year follow-up. The mortality rates in this older population directly correlate with the severity of neurological injury (1-year mortality rate, ASIA Grade A 66%, Grade D 23%, p < 0.001). The mortality rate in elderly patients with SCI has not changed significantly over the last two decades, and the 1-year mortality rate was greater than 40% in all periods analyzed. Spinal cord injuries in older patients are becoming more prevalent. The mortality rate in this patient group is much greater than in younger patients and should be taken into account when aggressive interventions are considered and in counseling families regarding prognosis.