AIS Grade Research Articles

56 The Impact of Inhalation Injury Grade on Bacterial Isolates from Diagnostic Bronchoscopy with Bronchoalveolar Lavage

Abstract Introduction Inhalation injury is associated with increased incidence of pneumonia. Bacteria are commonly isolated from bronchoalveolar lavage (BAL) within 12-48 hours of injury with unclear clinical significance. We aimed to determine if grade of inhalation injury is associated with different bacterial species isolated from initial BAL, and if higher inhalation injury grade is associated with increased risk of pneumonia. Methods Abbreviated injury scores (AIS) and clinical microbiology isolates from diagnostic bronchoscopy with BAL performed within 48 hours of injury among adults with inhalation injuries from 2009-2022 were extracted from medical records at an ABA-verified burn center. CDC PNU1 criteria was used to identify pneumonia >48 hours after admission. Modified Poisson regression with robust standard errors was used to assess the association of inhalation injury grade and subsequent pneumonia. Results Two hundred forty-six patients with inhalation injury who underwent diagnostic bronchoscopy for airway inspection and surveillance BAL within 48 hours of injury were included in this analysis. Fourteen (5.7%) were grade 0, 106 (43.1%) grade 1, 75 (30.5%) grade 2, 51 (20.7%) grade 3-4. The most common bacterial isolate was Streptococcus spp irrespective of AIS grade. Higher AIS grade was associated with increased incidence of pneumonia (IRR 1.3; 95% CI 1.09-1.61; p = 0.01) after adjustment for age, sex, and total body surface area of burn involvement. Conclusions Bacterial species isolated did not differ by inhalation injury grade. Higher inhalation injury grade was associated with increased risk of pneumonia. Applicability of Research to Practice Providers should be vigilant that patients with higher grade of inhalation injury are at increased risk of pneumonia. Further research is urgently needed to assess the clinical significance of organisms isolated on initial BAL and their role – if any – on the development of pneumonia.

Bulbocavernosus Reflex Has No Prognostic Features During the Acute Evaluation of Spinal Cord Injuries.

The bulbocavernosus reflex (BCR) has been used during the initial evaluation of a spinal cord injury patient as a metric to determine prognosis and whether the patient is in "spinal shock." This reflex has been less utilized over the last decade, and therefore a review was performed to assess the value of BCR in patient prognosis. The North American Clinical Trials Network (NACTN) for Spinal Cord Injury (SCI) is a consortium of tertiary medical centers that includes a prospective SCI registry. The NACTN registry data was analyzed to evaluate the prognostic implication of the BCR during the initial evaluation of a spinal cord injury patient. SCI patients were divided into those with an intact or absent BCR during their initial evaluation. Associations of participants' descriptors and neurological status on follow-up were performed, followed by associations with the presence of a BCR. A total of 769 registry patients with recorded BCRs were included in the study. The median age was 49 years (32-61 years), and the majority were male (n = 566, 77%) and white (n = 519, 73%). Among included patients, high blood pressure was the most common comorbidity (n = 230, 31%). Cervical spinal cord injury was the most common (n = 470, 76%) with fall (n = 320, 43%) being the most frequent mechanism of injury. BCR was present in 311 patients (40.4%), while 458 (59.6%) had a negative BCR within 7 days of injury or before surgery. At 6 months post-injury, 230 patients (29.9%) followed up, of which 145 had a positive BCR, while 85 had a negative BCR. The presence/absence of BCR was significantly different in patients with cervical (p = 0.0015) or thoracic SCI (p = 0.0089), or conus medullaris syndrome (p = 0.0035), and in those who were American Spinal Injury Association Impairment Scale grade A (p = 0.0313). No significant relationship was observed between BCR results and demographics, AIS grade conversion, motor score changes (p = 0.1669), and changes in pin prick (p = 0.3795) and light touch scores (p = 0.8178). In addition, cohorts were not different in surgery decision (p = 0.7762) and injury to surgery time (p = 0.0681). In our review of the NACTN spinal cord registry, the BCR did not provide prognostic utility in the acute evaluation of spinal cord injury patients. Therefore, it should not be used as a reliable marker for predicting neurological outcomes post-injury.

Are early-onset spasms predictive of poor neurological recovery after traumatic spinal cord injury?

Context Following spinal cord injury (SCI), early spasms are associated with decreased functional recovery. It has also been hypothesized that early spasticity might sign underlying maladaptive neuroplasticity, which could translate in worse neurological outcomes. Objective In this context, this paper aims to evaluate if early-onset spasms are also associated with neurological outcomes after SCI. Methods A retrospective review of 196 cases from a prospective SCI database was conducted. The presence of early spasms during the acute hospitalization was assessed by a single physiatrist. The characteristics and long-term neurological outcomes of individuals with and without early spasms were first compared. Multivariate regression analyses were then performed to determine the relationship between early spasms and neurological outcomes. Results 30.1% (N = 59) of patients presented early spasms. These patients had several distinguishing characteristics including higher odds of tetraplegia (vs. paraplegia) and more severe injuries. At the bivariate level, patients with early spasms had higher odds of improving at least 1 AIS grade between baseline and follow-up. However, this was not significant at the multivariate level. Conclusions Early spasms are not significantly associated with poorer neurological outcomes, contrasting with the unwritten consensus that early spasticity translates maladaptive neuroplasticity.

Derivation and Validation of a Clinical Prediction Rule for Upper Limb Functional Outcomes After Traumatic Cervical Spinal Cord Injury

Traumatic cervical spinal cord injury (SCI) can result in debilitating paralysis. Following cervical SCI, accurate early prediction of upper limb recovery can serve an important role in guiding the appropriateness and timing of reconstructive therapies. To develop a clinical prediction rule to prognosticate upper limb functional recovery after cervical SCI. This prognostic study was a retrospective review of a longitudinal cohort study including patients enrolled in the National SCI model systems (SCIMS) database in US. Eligible patients were 15 years or older with tetraplegia (neurological level of injury C1-C8, American Spinal Cord Injury Association [ASIA] impairment scale [AIS] A-D), with early (within 1 month of SCI) and late (1-year follow-up) clinical examinations from 2011 to 2016. The data analysis was conducted from September 2021 to June 2022. The primary outcome was a composite of dependency in eating, bladder management, transfers, and locomotion domains of functional independence measure at 1-year follow-up. Each domain ranges from 1 to 7 with a lower score indicating greater functional dependence. Composite dependency was defined as a score of 4 or higher in at least 3 chosen domains. Multivariable logistic regression was used to predict the outcome based on early neurological variables. Discrimination was quantified using C statistics, and model performance was internally validated with bootstrapping and 10-fold cross-validation. The performance of the prediction score was compared with AIS grading. Data were split into derivation (2011-2014) and temporal-validation (2015-2016) cohorts. Among 2373 patients with traumatic cervical SCI, 940 had complete 1-year outcome data (237 patients [25%] aged 60 years or older; 753 men [80%]). The primary outcome was present in 118 patients (13%), which included 92 men (78%), 83 (70%) patients who were younger than 60 years, and 73 (62%) patients experiencing AIS grade A SCI. The variables significantly associated with the outcome were age (age 60 years or older: OR, 2.31; 95% CI, 1.26-4.19), sex (men: OR, 0.60; 95% CI, 0.31-1.17), light-touch sensation at C5 (OR, 0.44; 95% CI, 0.44-1.01) and C8 (OR, 036; 95% CI, 0.24-0.53) dermatomes, and motor scores of the elbow flexors (C5) (OR, 0.74; 95% CI, 0.60-0.89) and wrist extensors (C6) (OR, 0.61; 95% CI, 0.49-0.75). A multivariable model including these variables had excellent discrimination in distinguishing dependent from independent patients in the temporal-validation cohort (C statistic, 0.90; 95% CI, 0.88-0.93). A clinical prediction score (range, 0 to 45 points) was developed based on these measures, with higher scores increasing the probability of dependency. The discrimination of the prediction score was significantly higher than from AIS grading (change in AUC, 0.14; 95% CI, 0.10-0.18; P < .001). The findings of this study suggest that this prediction rule may help prognosticate upper limb function following cervical SCI. This tool can be used to set patient expectations, rehabilitation goals, and aid decision-making regarding the appropriateness and timing for upper limb reconstructive surgeries.

Effect of virtual reality training on standing balance in individuals with incomplete spinal cord injury

Recovery of balance ability during standing is one of the primary and essential aims of rehabilitative programs in individuals with incomplete spinal cord injury (iSCI). A sample of ten participants (mean age: 35.7 years, range: 25-63 years) with traumatic or non-traumatic iSCI (AIS grade C or D) and were able to stand with or without the support of an assistive device for a minimum of 2 min were recruited from the rehabilitation department of the Indian Spinal Injuries Centre, New Delhi, India. The participants received Virtual Reality (VR) based balance training for one hour, three times a week for four weeks on the Nintendo Wii gaming console. Participants were assessed three times: pre-intervention, post-intervention and follow-up assessment for the total ellipse area (TEA), total sway perimeter (TSP), sway range (anterior-posterior/medio-lateral (AP/ML)) and limits of stability (LOS). At post-intervention assessment, significant increases in comparison with pre-intervention scores was found in LOS (P=0.00), TEA with eyes open (EO) (P=0.00) and eyes closed (EC) (P=0.00), TSP with EO (P=0.00) and EC (P=0.00), sway range in AP direction (SD-AP) with EO (P=0.01) and EC (P=0.02) and sway range in ML direction (SD-ML) with EO (P=0.02) and EC (P=0.01). At follow-up assessment, a significant improvement in comparison to post intervention scores was found in TEA measured both in EO (P=0.01) and EC conditions (P=0.02), TSP measured with EO (P=0.01) and SD-ML both with EO (P=0.04) and EC (P=0.01). No significant changes were found in LOS (P=0.89), TSP measured with EC (P=0.38) and SD-AP both with EO (P=0.50) and EC (P=1). However, significant improvement was seen on comparing follow-up assessment scores with pre-intervention scores for all variables, such as LOS (P=0.00), TEA in EO (P=0.00) and EC (P=0.00), TSP with EO (P=0.00) and EC (P=0.00), SD-AP with EO (P=0.01) and EC (P=0.02) and SD-ML with EO (P=0.01) and EC (P=0.00). VR-based balance training intervention was able to elicit improvements in balance ability and maintain it during follow-up despite a small training dosage suggesting that it is a promising intervention for standing balance rehabilitation among individuals with iSCI. The VR-based balance training challenges elements of balance, which physical therapists may want to consider when designing a comprehensive rehabilitation program. Clinical Trials Registry-India: CTRI/2018/12/016814.

Efficacy of a machine learning-based approach in predicting neurological prognosis of cervical spinal cord injury patients following urgent surgery within 24 h after injury

We aimed to develop a machine learning (ML) model for predicting the neurological outcomes of cervical spinal cord injury (CSCI). We retrospectively analyzed 135 patients with CSCI who underwent surgery within 24 h after injury. Patients were assessed with the American Spinal Injury Association Impairment Scale (AIS; grades A to E) 6 months after injury. A total of 34 features extracted from demographic variables, surgical factors, laboratory variables, neurological status, and radiological findings were analyzed. The ML model was created using Light GBM, XGBoost, and CatBoost. We evaluated Shapley Additive Explanations (SHAP) values to determine the variables that contributed most to the prediction models. We constructed multiclass prediction models for the five AIS grades and binary classification models to predict more than one-grade improvement in AIS 6 months after injury. Of the ML models used, CatBoost showed the highest accuracy (0.800) for the prediction of AIS grade and the highest AUC (0.90) for predicting improvement in AIS. AIS grade at admission, intramedullary hemorrhage, longitudinal extent of intramedullary T2 hyperintensity, and HbA1c were identified as important features for these prediction models. The ML models successfully predicted neurological outcomes 6 months after injury following urgent surgery in patients with CSCI.

Temporal development of unfavourable urodynamic parameters during the first year after spinal cord injury.

To describe the temporal development of and risk factors for the occurrence of unfavourable urodynamic parameters during the first year after spinal cord injury (SCI). This population-based longitudinal study used data from 97 adult patients with a single-event traumatic or ischaemic SCI who underwent video-urodynamic investigation (UDI) at a university SCI centre. The first occurrences of unfavourable urodynamic parameters (detrusor overactivity combined with detrusor sphincter dyssynergia [DO-DSD], maximum storage detrusor pressure ≥40 cmH2 O, bladder compliance <20 mL/cmH2 O, vesico-ureteric reflux [VUR] and any unfavourable parameter [composite outcome]) were evaluated using time-to-event analysis. The majority of the population (87/97 [90%]) had at least one unfavourable urodynamic parameter. Most unfavourable urodynamic parameters were initially identified during the 1- or 3-month UDI, including 92% of the DO-DSD (78/85), 82% of the maximum storage pressure ≥40 cmH2 O (31/38), and 100% of the VUR (seven of seven) observations. No low bladder compliance was observed. The risk of DO-DSD was elevated in patients with thoracic SCI compared to those with lumbar SCI (adjusted hazard ratio [aHR] 2.38, 95% confidence interval [CI] 1.16-4.89). Risk of maximum storage detrusor pressure ≥40 cmH2 O was higher in males than females (aHR 8.33, 95% CI 2.51-27.66), in patients with a cervical SCI compared to those with lumbar SCI (aHR 14.89, 95% CI 3.28-67.55), and in patients with AIS Grade B or C compared to AIS Grade D SCI (aHR 6.17, 95% CI 1.78-21.39). No risk factors were identified for the composite outcome of any unfavourable urodynamic parameter. The first UDI should take place within 3 months after SCI as to facilitate early diagnosis of unfavourable urodynamic parameters and timely treatment. Neuro-urological guidelines and individualised management strategies for patients with SCI may be strengthened by considering sex and SCI characteristics in the scheduling of UDIs.

Neurogenic Lower Urinary Tract Dysfunction in the First Year After Spinal Cord Injury: A Descriptive Study of Urodynamic Findings.

We aimed to provide a real-world description of neurogenic lower urinary tract dysfunction within the first year after spinal cord injury with a focus on unfavorable urodynamic parameters that are associated with urological morbidity. Urodynamic investigations from 97 patients with traumatic or ischemic acute spinal cord injury and managed according to the European Association of Urology Guidelines on Neuro-Urology were analyzed at a single university spinal cord injury center at 1 month, 3 months, 6 months, and 12 months after injury. Unfavorable urodynamic parameters were defined as detrusor overactivity in combination with detrusor sphincter dyssynergia, maximum storage detrusor pressure of 40 cm H2O or higher, bladder compliance less than 20 mL/cm H2O, and vesicoureteral reflux of any grade. One or more unfavorable urodynamic parameter was observed in 87 out of 97 patients (90%) within the first year after spinal cord injury. Eighty-eight percent of the patients showed detrusor overactivity with detrusor sphincter dyssynergia, 39% a maximum storage detrusor pressure of 40 cm H2O or higher, and 7% vesicoureteral reflux. No patient developed a low-compliance bladder. Using a standardized urodynamic follow-up schedule, we found unfavorable urodynamic parameters in a majority of the population within the first year after spinal cord injury. As early treatment based on urodynamic findings might reduce the risk of deterioration of upper and lower urinary tract function, thereby improving long-term outcomes, there is need for further research regarding recommendations for a urodynamic follow-up schedule during the first year after spinal cord injury.

A Novel Method to Classify Cervical Incomplete Spinal Cord Injury Based on Potential for Recovery: A Group-Based Trajectory Analysis.

The outcomes of cervical incomplete spinal cord injury (SCI) are heterogeneous. This study sought to dissociate subgroups of cervical incomplete SCI patients with distinct longitudinal temporal profiles of recovery in upper limb motor function. Patients with cervical incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] B-D; C1-C8) were identified from four prospective, multi-center SCI datasets. A group-based trajectory model was fit to longitudinal upper extremity motor scores out to 1 year. Multi-variable multinomial logistic regression was performed to identify features that characterize each trajectory group. A classification system for predicting trajectory group at baseline was developed by recursive partitioning. In total, 801 patients were eligible. Four distinct trajectory groups were identified: 1) "Poor outcome": Severe injury, very minimal recovery; 2) "Moderate recovery": Moderate-to-severe injury, moderate recovery; most recovery occurs by 6 months, with mild, gradual recovery continuing thereafter; 3) "Good recovery": Moderate injury, good recovery; most recovery occurs by 3 months, with mild, gradual recovery continuing thereafter; and 4) "Excellent outcome": Mild injury, recovery to normal/near-normal by 3 months. On adjusted analyses, older age was associated with lower likelihood of "excellent outcome" (p = 0.020). AIS C and D injuries were associated with "moderate recovery," "good recovery," and "excellent outcome" (p < 0.001). Mid-cervical injuries occurred more frequently in "moderate recovery," "good recovery," and "excellent outcome" (p < 0.001) groups. Early surgical decompression (< 24 h) was associated with increased propensity for "good recovery" (p = 0.039) and "excellent outcome" (p = 0.048). A classification model based on recursive partitioning could predict trajectory group using age, AIS grade, and neurological level with an area under the curve of 0.81. Patients with cervical incomplete SCI demonstrate distinct temporal profiles of recovery in upper limb motor function. The trajectory a patient is likely to follow may be predicted at baseline with fair accuracy.

P115. Intraoperative sensory signals predict prognosis for patients with traumatic cervical spinal cord injury

<h3>BACKGROUND CONTEXT</h3> Traumatic cervical spinal cord injury (tCSCI) is a devasting life-altering event. Prognosis is largely determined by the formal neurological assessment known as International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), which is graded using the American Spinal Injury Association Impairment Scale grade (AIS grade). AIS grade A is designated as a loss of sacral motor and sensory functions and is associated with the worst prognosis. Many studies have shown that AIS grades are a predictor for neurologic recovery and functional status postinjury. However, the timing of the ISNCSCI exam and AIS grade can greatly influence the reliability of the prognosis. Intraoperative neuromonitoring is routinely used during spine surgery to detect injuries to the spinal cord or nerve roots by measuring signal transmission. However, in patients with SCI, the role of intraoperative neuromonitoring as a potential prognostic tool has not been studied. <h3>PURPOSE</h3> The purpose of this study was to assess if detected signals during intraoperative neuromonitoring portends a greater likelihood of recovery for patients with tCSCI. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study at a high-volume, academic level I trauma center. <h3>PATIENT SAMPLE</h3> A total of 49 patients undergoing decompression and surgical fixation of following tCSCI. <h3>OUTCOME MEASURES</h3> Improvement in ASIA motor score and AIS grade conversion rate. <h3>METHODS</h3> Patients undergoing decompression and surgical fixation following tCSCI were retrospectively reviewed at a single high-volume, academic level I trauma center. Improvement in ASIA motor score and AIS grade conversion rates at final followup were compared between patients with detectable intraoperative neuromonitoring upper extremity somatosensory evoked potential (SSEP) signals and those without detectable signals. Motor evoked potentials (MEP) were not routinely performed. <h3>RESULTS</h3> A total of 49 patients with tCSCI underwent decompression and surgical fixation with intraoperative neuromonitoring. Seventeen patients with complete SCI and 32 patients with AIS grades B or C on admission were included in the study with a mean followup of 14.3 months. Patients with incomplete SCI had detectable lower extremity SSEPs more often compared to patients with complete SCI (56.3% vs 23.5%, p = 0.028). However, there was no difference in detectable upper extremity SSEPs between complete and incomplete SCI (65.6% vs 58.8%, p=0.638). Of the 17 patients with complete SCI, patients with detectable upper extremity SSEPs cohort had a higher rate of AIS grade conversion compared to the nondetectable cohort (80.0% vs 28.6%, p = 0.034). Furthermore, the detectable upper extremity SSEPs cohort had greater ASIA motor scores on admission (25.9 vs 5.4, p=0.002), at final follow-up (54.0 vs 8.9, and with overall improvement (26.1 vs 3.4, p=0.021) compared to the non-detectable cohort. Patients with detectable lower extremity SSEPs had similar ASIA motor scores on admission (21.5 vs 16.2, 0.609) but higher ASIA motor scores at final followup (57.5 vs 27.1, p=0.041) compared to the nondetectable cohort. Of the 32 patients with incomplete SCI, there was no difference in AIS grade conversion or ASIA motor scores between the detectable and non-detectable SSEP cohorts. <h3>CONCLUSIONS</h3> The presence of upper extremity SSEP signals in patients who present with complete tCSCI portended a better prognosis with greater likelihood of conversion to an incomplete AIS grade and greater motor score at final followup. These results demonstrate an objective and measurable marker of prognosis that can be used for clinical decision making and patient counseling regarding neurologic recovery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

22. Early vs (

<h3>BACKGROUND CONTEXT</h3> The optimal clinical management of central cord syndrome (CCS) remains unclear; yet this is becoming an increasingly relevant public health problem in the face of the global aging population. <h3>PURPOSE</h3> To provide a head-to-head comparison of the neurological and functional outcomes of early (<24 hrs) vs late (24 hrs) surgical decompression for CCS. <h3>STUDY DESIGN/SETTING</h3> Propensity, score-matched analysis cohort study. <h3>PATIENT SAMPLE</h3> Participants were included if they had a documented baseline American Spinal Injury Association (ASIA) / International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) neurological examination performed within 14 days of injury. Participants were eligible if they underwent surgical decompression for CCS, as defined by apoint difference of five or more between baseline ASIA lower extremity motor score (LEMS) and upper extremity motor score (UEMS), in favor of the lower limbs (LEMS - UEMS 5). <h3>OUTCOME MEASURES</h3> The primary endpoint was motor recovery (upper extremity motor score (UEMS); lower extremity motor score (LEMS); AMS) at one year. Secondary endpoints were Functional Independence Measure (FIM) motor score and complete independence in each FIM motor domain at one year. <h3>METHODS</h3> This study identified CCS patients from three international, multicentre studies examining the timing of surgical decompression in spinal cord injury. Patients who underwent surgery for CCS (LEMS-UEMS5) were identified from three spinal cord injury (SCI) datasets (NACTN; STASCIS; NASCIS III). Propensity scores were calculated as the probability of undergoing early (< 24 hrs) compared to late (24 hrs) surgery using the logit method and adjusting for data source, age, injury mechanism, and baseline ASIA motor score (AMS), AIS grade, and neurological level. Propensity score matching was performed in a one-to-one ratio by an "optimal matching" technique. Effect sizes for outcomes were summarized by mean differences (MDs) or odds ratios (ORs) and associated 95% confidence intervals. <h3>RESULTS</h3> The final study cohort consisted of 186 patients with CCS. Baseline characteristics were balanced between matched early (N=93) and late (N=93) surgery groups. Early surgical decompression resulted in significantly improved recovery in upper limb (MD 2.3, P=0.047), but not lower limb (MD 1.1, P=0.256), motor function, as compared with late surgery. More patients in the early surgery group appeared to achieve complete independence in various functional activities, particularly those involving upper limb function; however, these associations did not reach statistical significance, and there was no difference in one-year FIM motor score (MD 4.4, P=0.182). On subgroup analysis, outcomes were comparable with early or late decompressive surgery in AIS grade D patients. However, in patients with AIS grade C injury, early surgery resulted in significantly greater recovery in overall motor score (MD 9.5, P=0.038), owing to gains in both upper and lower limb motor function. <h3>CONCLUSIONS</h3> This study found early (<24 hrs) compared to late (24 hrs) surgical decompression to result in improved recovery in upper limb motor function at one year in patients with central cord syndrome. The benefit of early surgery was especially realized in patients with AIS grade C injury. Treatment paradigms for central cord syndrome should be redefined to encompass early surgical decompression as a neuroprotective therapy. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Proposal of a Management Algorithm to Predict the Need for Expansion Duraplasty in American Spinal Injury Association Impairment Scale Grades A-C Traumatic Cervical Spinal Cord Injury Patients.

Expansion duraplasty to reopen effaced subarachnoid space and improve spinal cord perfusion, autoregulation, and spinal pressure reactivity index (sPRX) has been advocated in patients with traumatic cervical spinal cord injury (tCSCI). We designed this study to identify candidates for expansion duraplasty, based on the absence of cerebrospinal fluid (CSF) interface around the spinal cord on magnetic resonance imaging (MRI), in the setting of otherwise adequate bony decompression. Over a 61-month period, 104 consecutive American Spinal Injury Association Impairment Scale (AIS) grades A-C patients with tCSCI had post-operative MRI to assess the adequacy of surgical decompression. Their mean age was 53.4 years, and 89% were male. Sixty-one patients had falls, 31 motor vehicle collisions, 11 sport injuries, and one an assault. The AIS grade was A in 56, B in 18, and C in 30 patients. Fifty-four patients had fracture dislocations; there was no evidence of skeletal injury in 50 patients. Mean intramedullary lesion length (IMLL) was 46.9 (standard deviation = 19.4) mm. Median time from injury to decompression was 17 h (interquartile range 15.2 h). After surgery, 94 patients had adequate decompression as judged by the presence of CSF anterior and posterior to the spinal cord, whereas 10 patients had effacement of the subarachnoid space at the injury epicenter. In two patients whose decompression was not definitive and post-operative MRI indicated inadequate decompression, expansion duraplasty was performed. Candidates for expansion duraplasty (i.e., those with inadequate decompression) were significantly younger (p < 0.0001), were AIS grade A (p < 0.0016), had either sport injuries (six patients) or motor vehicle collisions (three patients) (p < 0.0001), had fracture dislocation (p = 0.00016), and had longer IMLL (p = 0.0097). In regression models, patients with sport injuries and inadequate decompression were suitable candidates for expansion duraplasty (p = 0.03). Further, 9.6% of patients failed bony decompression alone and either did (2) or would have (8) benefited from expansion duraplasty.

Influence of severity and level of injury on the occurrence of complications during the subacute and chronic stage of traumatic spinal cord injury: a systematic review.

Secondary health conditions (SHCs) are long-term complications that frequently occur due to traumatic spinal cord injury (tSCI) and can negatively affect quality of life in this patient population. This study provides an overview of the associations between the severity and level of injury and the occurrence of SHCs in tSCI. A systematic search was conducted in PubMed and Embase that retrieved 44 studies on the influence of severity and/or level of injury on the occurrence of SHCs in the subacute and chronic phase of tSCI (from 3 months after trauma). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. In the majority of studies, patients with motor-complete tSCI (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade A or B) had a significantly increased occurrence of SHCs in comparison to patients with motor-incomplete tSCI (AIS grade C or D), such as respiratory and urogenital complications, musculoskeletal disorders, pressure ulcers, and autonomic dysreflexia. In contrast, an increased prevalence of pain was seen in patients with motor-incomplete injuries. In addition, higher rates of pulmonary infections, spasticity, and autonomic dysreflexia were observed in patients with tetraplegia. Patients with paraplegia more commonly suffered from hypertension, venous thromboembolism, and pain. This review suggests that patients with a motor-complete tSCI have an increased risk of developing SHCs during the subacute and chronic stage of tSCI in comparison with patients with motor-incomplete tSCI. Future studies should examine whether systematic monitoring during rehabilitation and the subacute and chronic phase in patients with motor-complete tSCI could lead to early detection and potential prevention of SHCs in this population.

Impact of Surgical Timing on Motor Level Lowering in Motor Complete Traumatic Spinal Cord Injury Patients.

Patients with complete traumatic spinal cord injury (tSCI) have a low potential to recover ambulation. Motor level recovery, adjacent to the level of injury, could influence functional independency. This study addresses whether surgical timing influences motor level recovery in patients with motor complete (American Spinal Injury Association [ASIA] Impairment Scale A [AIS A]) and motor incomplete (AIS B) tSCI. A retrospective cohort study was performed in the Netherlands in patients with AIS A/B tSCI (C2-L2), who consecutively underwent surgery between January 2010 and April 2020. Neurological examination was performed directly at presentation to the emergency room and at discharge from the rehabilitation facility. Motor level lowering, AIS grade, and upper and lower extremity motor score recovery were calculated for patients who underwent early (< 24 h) and late (24 h+) surgery. A total of 96 patients met the inclusion criteria. In the multi-variate analysis, late surgical decompression (24 h+) was negatively associated with ≥1 motor level lowering and ≥2 AIS grade improvement [odds ratio (OR) 0.11 [95% confidence interval (CI): 0.01, 0.67], p = 0.046, and OR 0.06 [95% CI: 0.00, 047], p = 0.030. respectively). The presence of sacral sparing (AIS B) at initial examination, and cervical level of the tSCI were associated with ≥1 motor level lowering. In addition, AO Spine C-type injuries were negatively associated with any type of neurological recovery, except motor level lowering. Although sensorimotor complete injuries as well as thoracolumbar injuries negatively influence neurological recovery, early surgical decompression (< 24 h) appears independently associated with enhanced neurological recovery in patients with traumatic spinal cord injury despite level and severity of injury.

Risk Factors for Poor Prognosis of Spinal Cord Injury without Radiographic Abnormality Associated with Cervical Ossification of the Posterior Longitudinal Ligament.

Purpose To investigate the factors associated with the prognosis of spinal cord injury without radiographic abnormality (SCIWORA) accompanied by cervical ossification of the posterior longitudinal ligament (C-OPLL). Methods We retrospectively investigated 287 patients with SCIWORA associated with C-OPLL, who were admitted within 30 days after trauma to our facility between August 2014 and August 2018. All patients were divided into the good or poor prognosis group. Patient demographics were analyzed. Besides, occupying ratio on CT and spinal cord high signal changes in MRI T2WI were measured and recorded. Multivariate linear regression was applied to analyze the correlation of prognosis with spinal cord high signal changes in MRI T2WI, cause of injury, and occupying ratio. Results Occupying ratio of ossification mass was 43.5 ± 10.7% in the poor prognosis group and 27.3 ± 7.7% in the good prognosis group. The occurrence rate of high signal changes in MRI T2WI was 84.2% in the poor prognosis group and 41.3% in the good prognosis group. Poor prognosis was correlated with high occupying ratio and spinal cord high signal changes in MRI T2WI. In the patient with SCIWORA associated with C-OPLL, ROC curve of occupying ratio showed 30% as a predictor for the poor prognosis. Among the 92 patients with occupying ratio ≤ 30%, poor prognosis was observed in 5 cases (5.4%), whereas in the 72 cases with occupying ratio > 30%, poor prognosis was seen in 33 cases (45.8%). Postoperative AIS grade at final follow-up in occupying ratio > 30% group was significantly worse. Conclusions Patients suffering from SCIWORA with C-OPLL have poor prognosis when they have higher occupying ratio of ossification mass and spinal cord high signal changes in MRI T2WI. The cut-off value of occupying ratio for predicting the poor prognosis was 30% in patients with SCIWORA associated with C-OPLL.

Early Decompression and Short Transport Time After Traumatic Spinal Cord Injury are Associated with Higher American Spinal Injury Association Impairment Scale Conversion.

Retrospective cohort study. This retrospective cohort study aims to determine the association of early decompressive surgery and the impact of transport time on the neurological outcomes of traumatic spinal cord injury (tSCI) patients. tSCI is a catastrophic event that may result in permanent disability or loss of function. To date, there remains significant controversy over the optimal time for surgical decompression in tSCI patients. The aim of this study is to evaluate the neurological outcomes of tSCI patients undergoing early versus late surgical decompression and the impact of transport time on neurological outcomes. Data from 84 patients with tSCI requiring surgical decompression was collected. Regression analysis was used to establish time to decompression classification cutoffs. Patients were classified into the following subgroups: 0 to 12 or >12 hours as a factor of the total or admitting hospital time to decompression. The change in American Spinal Injury Association Impairment (AIS) Grade from admission to discharge was determined. Additionally, the effect of transport time on conversion of AIS grade was assessed as patients were grouped into transport times of <6 or >6 hours. Among the time to decompression subgroups there were no significant differences (P > 0.05) in confounding factors such as age, injury severity, and AIS grade. Patients who received decompression within 0 to 12 hours were associated with significantly (P < 0.0001) higher average improvements in ASIA grade (0.76). Patient transport times <6 hours were associated with significantly (P = 0.004) higher conversion of AIS grade to less impaired states. The present study suggests an association of decompression within 12 hours and short transport times (<6 hours) with significant improvements in neurological outcomes.Level of Evidence: 4.

Role of MRI in the evaluation of spinal trauma

Aim: Role of MRI in the Evaluation of Spina Trauma. Material and methods: The present prospective observational study was on 50 patients with clinical suspicion of spinal trauma referred to Department of Radio diagnosis, from OPD/IPD of C.S.S.Hospital, Subharti Medical College, Meerut. After obtaining clinical history relevant clinical examination was done. MRI examinations were done on GE – Signa HDe contour GE 1.5 Tesla Feiloversikt, whole body MR scanner with sense surface coil and then evaluation of M R Imaging was done by using different pulse sequences. The findings were viewed in the light of complete clinical and radiographic data. Results: 78%, subjects were male, hence there was male preponderance with age group of 31-40 years with compression fracture in 72% & retropulsion of vertebral body. Spinal cord oedema was found among78% with maximum no of cases, having cord oedema >3 cm. AIS grade A, B, C, D and E was found among 20%, 20%,16%, 22% and 22% of cases respectively. Sensory & Motor loss in 24% & 74% of cases. Sensory loss was corresponded with level of spinal cord oedema & level of vertebrae fracture. Discussion: MRI plays a crucial role in evaluating and detecting spinal trauma. Subtle bone marrow, soft-tissue, and spinal cord abnormalities, which may not be apparent on other imaging modalities, can be readily detected on MRI. Early detection often leads to prompt and accurate diagnosis, expeditious management, and avoidance of unnecessary procedures. The depiction of parenchymal SCI on MRI not only correlates well with the degree of neurologic deficit, but it also bears significant implications in regard to prognosis and potential for neurologic recovery. Conclusion: With this study we concluded that MRI findings in spinal trauma correlate with the clinical findings according to ASIA impairment scale and can be helpful to clinician in predicting the outcome.

Effect of pelvic laparoscopic implantation of neuroprosthesis in spinal cord injured subjects: a 1-year prospective randomized controlled study

Study design1-year prospective RCT.ObjectiveExamine the effect of implantable pulse generator and low-frequency stimulation of the pelvic nerves using laparoscopic implantation of neuroprosthesis (LION) compared with neuromuscular electrical stimulation (NMES) in SCI.MethodsInclusion criteria: traumatic spinal cord injury (SCI), age 18–55 years, neurological level-of-injury Th4–L1, time-since-injury >1 year, and AIS-grades A–B. Participants were randomized to (A) LION procedure or (B) control group receiving NMES. Primary outcome measure: Walking Index for Spinal Cord Injury (WISCI-II), which is a SCI specific outcome measure assessing ability to ambulate. Secondary outcome measures: Spinal Cord Independence Measure III (SCIM III), Patient Global Impression of Change (PGIC), Penn Spasm Frequency Scale (PSFS), severity of spasticity measured by Numeric Rating Scale (NRS-11); International Spinal Cord Injury data sets-Quality of Life Basic Data Set (QoLBDS), and Brief Pain Inventory (BPI).ResultsSeventeen SCI individuals, AIS grade A, neurological level ranging from Th4–L1, were randomized to the study. One individual was excluded prior to intervention. Eight participants (7 males) with a mean age (SD) of 35.5 (12.4) years were allocated to the LION procedure, 8 participants (7 males) with age of 38.8 (15.1) years were allocated to NMES. Significantly, 5 LION group participants gained 1 point on the WISCI II scale, (p < 0.013; Fisher´s exact test). WISCI II scale score did not change in controls. No significant changes were observed in the secondary outcome measures.ConclusionThe LION procedure is a promising new treatment for individuals with SCI with significant one-year improvement in walking ability.

Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions.

Prospective, observational study. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) represent the gold standard for the assessment of patients with spinal cord injury (SCI) and their measurement properties have been evaluated in patients with traumatic lesions. Albeit the ISNCSCI are widely used also for the assessment and prognosis of patients with non-traumatic SCI, a validation of this grading system in this sample has never been performed. Therefore, the aim of this study is to evaluate the measurement properties of the ISNCSCI in a population of persons with non-traumatic SCI. Three Italian rehabilitation hospitals. The sample included 140 patients with non-traumatic SCI of different etiology, level and grade, for a total of 169 evaluations performed by two examiners. Cronbach's Alpha was used to evaluate the internal consistency of the ISNCSCI various components. The agreement between two examiners of each center in the definition of different components was used to assess the inter-rater reliability. The construct validity was evaluated through the correlation of the ISNCSCI with the Spinal Cord Independence Measure (SCIM). The ISNCSCI showed substantial internal consistency, and substantial inter-rater agreement for AIS grade, cumulative motor and sensory scores. The motor scores for upper and lower extremity showed fair to moderate correlation with SCIM self-care and motility subscores, respectively. The ISNCSCI total motor score correlated with the total SCIM score. Our study demonstrates that the ISNCSCI are a valid and reliable tool for the assessment of patients with non-traumatic SCI.

Spinal Cord Injury Induced Osteoporosis: Case Report and Current Literature

Background: Among the various etiologies of osteoporosis, spinal cord injury has a drastic progression of the disease, causing weekly bone loss. There is no definitive treatment for the prevention of osteoporosis in these individuals. This review illustrates the recent findings on the pathophysiology, treatment, and management of spinal cord injury-induced osteoporosis. Furthermore, we cover a case of a male patient who experienced severe bone loss after a spinal cord injury at the age of 21 years.&#x0D; The Case: We have a 57-year-old man with a history of AIS grade A spinal cord injury, level T11 with rod fixation from a motorcycle collision at age 21. His fracture history following the injury includes tibia, femur, and vertebral fractures. Bone mineral density imaging revealed notable T-scores ranging from -3.1 to -3.4 at the hip and femurs. Treatment plan consisted of teriparatide, dietary supplements, and physical therapy. Biomarkers from baseline to post one month of treatment revealed the following: procollagen type 1 N-terminal propeptide from 38 mcg/L to 70 mcg/L and C-terminal telopeptide from 209 pg/mL to 88 pg/mL, representing an increased bone formation and decreased bone resorption, respectively. After two years, bone mineral density T-scores improved to -2.7 on the left and the patient was capable of standing for the first time with the assistance of a standing frame.&#x0D; Conclusion: Our case exemplified the progression of the disease and treatment options. A basis for the derivation of future innovative therapies has been covered. Favorable treatments and management are described in the review.