American Spinal Injury Association Motor Score Research Articles

A clinical prediction model for long-term functional outcome after traumatic spinal cord injury based on acute clinical and imaging factors.

To improve clinicians' ability to predict outcome after spinal cord injury (SCI) and to help classify patients within clinical trials, we have created a novel prediction model relating acute clinical and imaging information to functional outcome at 1 year. Data were obtained from two large prospective SCI datasets. Functional independence measure (FIM) motor score at 1 year follow-up was the primary outcome, and functional independence (score ≥ 6 for each FIM motor item) was the secondary outcome. A linear regression model was created with the primary outcome modeled relative to clinical and imaging predictors obtained within 3 days of injury. A logistic model was then created using the dichotomized secondary outcome and the same predictor variables. Model validation was performed using a bootstrap resampling procedure. Of 729 patients, 376 met the inclusion criteria. The mean FIM motor score at 1 year was 62.9 (±28.6). Better functional status was predicted by less severe initial American Spinal Injury Association (ASIA) Impairment Scale grade, and by an ASIA motor score >50 at admission. In contrast, older age and magnetic resonance imaging (MRI) signal characteristics consistent with spinal cord edema or hemorrhage predicted worse functional outcome. The linear model predicting FIM motor score demonstrated an R-square of 0.52 in the original dataset, and 0.52 (95% CI 0.52,0.53) across the 200 bootstraps. Functional independence was achieved by 148 patients (39.4%). For the logistic model, the area under the curve was 0.93 in the original dataset, and 0.92 (95% CI 0.92,0.93) across the bootstraps, indicating excellent predictive discrimination. These models will have important clinical impact to guide decision making and to counsel patients and families.

Claustrophobia

Case-control study. The aim of this study was to assess the levels of psychological distress in patients with back pain who expressed claustrophobia at the time of their magnetic resonance imaging (MRI) scan, compared with sex and age-matched normal controls who did not exhibit claustrophobia. The secondary aim was to document the level of disability and intervention rates in this group. Psychosocial factors influence the outcomes of low back pain treatment with psychological distress being associated with poorer surgical outcomes in patients with low back pain. Up to 14% of patients experience claustrophobia during MRI scans requiring sedation to complete the scan. The effect of claustrophobia on back pain disability and outcomes has not been previously reported. Twenty females and 13 males all requiring MRI scan under sedation for claustrophobia (group 1) were compared with an age and sex-matched cohort that had MRI scan without sedation (group 2). Both groups were drawn from a chronic back clinic. Average age in both groups was 54 years (range, 27 to 79 y). Both groups had standard conservative therapy, together with psychometric evaluation: Zung Depression Index and Modified Somatic Perception Questionnaire. Disability was measured by Oswestry Disability Index. Primary outcome measures were intervention rates (surgery, injections, and physiotherapy sessions) and prevalence of psychological distress. Mean Zung Depression Index in group 1 was significantly higher than in group 2 (59.5 vs. 28.9, P<0.05) as was the mean Modified Somatic Perception Questionnaire score (13.3 vs. 9.2, P<0.05.) Prevalence of psychological distress was higher in group 1 (75.8% vs. 18.2%, P<0.05). Oswestry Disability Index was the same in both groups (50% vs. 48%). Group 1 had 13 interventions (13 patients=39.4%) compared with 26 in group 2 (26 patients=78.8%) (P< 0.05). Twenty-two patients (66.7%) in group 1 were discharged after their MRI scan with no intervention compared with 7 patients (21.2%) in group 2 (P<0.05). Claustrophobic patients with back pain showed higher levels of depression than nonclaustrophobic patients, with a higher rate of psychological distress. Disability, however, was not higher. The majority of claustrophobic patients did not require surgical intervention. The reasons for this are unclear and require further investigation. Claustrophobia requiring sedation for MRI scans may be a proxy for psychological distress in these patients and psychometric testing is advised during assessment to help with surgical decision making.

Correlation of Posterior Ligamentous Complex Injury and Neurological Injury to Loss of Vertebral Body Height, Kyphosis, and Canal Compromise

Retrospective, case-control study. The purpose of this study was to determine if thoracolumbar vertebral body collapse, translation, or canal compromise (CC) is associated with injury to the posterior ligamentous complex (PLC) or neurological elements. Radiographical parameters, including loss of vertebral body height (LOVBH), vertebral body translation, local kyphosis (LK), and CC, are often used as indicators of spinal instability. The hypothesis of this study was that LOVBH greater than 50%, LK greater than 20°, translation greater than 3.5 mm, or CC greater than 50% is associated with ligamentous and neurological injury. Retrospective review of prospectively collected spinal cord injury database was performed. Inclusion criteria include consecutive patients with thoracolumbar burst fractures. Exclusion criteria include flexion-distraction injuries and pathological fractures. Computed tomographic scan measurements of the spine were performed by 2 experienced spine surgeons blinded to magnetic resonance imaging results. On magnetic resonance imaging, the supraspinous ligament, interspinous ligament, ligamentum flavum, facet joints, and disc were graded as intact, indeterminate, or disrupted. American Spinal Injury Association (ASIA) score and Frankel Scale score were recorded. Spearman correlation coefficients were calculated to evaluate relationships between vertebral body measurements, ligamentous injury, and neurological injury. Forty-six patients were included in the study. Ten patients had kyphosis greater than 20°, 1 patient had kyphosis greater than 30°, and 9 patients had LOVBH greater than 50%. There were 34 patients with vertebral body translation greater than 3.5 mm and 15 patients with CC greater than 50%. Sixteen patients had ligamentous injury. There was a significant correlation between subjacent segment translation greater than 3.5 mm and ligamentous injury (R = 0.323, P = 0.029) and ASIA motor score (R = -0.379, P = 0.009). There was no significant correlation between ligamentous injury or neurological injury and the following threshold parameters: LOVBH greater than 50%, vertebral body kyphosis greater than 20°, caudal or cephalad interspinous widening greater than 7 mm, CC greater than 50%, and sagittal transverse ratio less than 0.48. The results of this study indicate that LOVBH greater than 50% and LK greater than 20° are not predictive of PLC injury in thoracolumbar burst fractures. Translation greater than 3.5 mm was associated with PLC injury. The PLC and neural elements should be directly assessed with magnetic resonance imaging if there is clinical concern.

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.

Primary Pyogenic Infection of the Spine in Intravenous Drug Users

A prospective comparative analysis of surgically-treated nontuberculous primary pyogenic infection of the spine (PPIS). To evaluate and compare the demographics, presentation, treatment and outcomes of surgically-treated PPIS between intravenous drug users (IVDU) and non-IVDU patients. This is the first prospective cohort comparative analysis of the clinical outcomes of surgically-treated PPIS between IVDU and non-IVDU populations. This is also the largest cohort of consecutive surgically-treated PPIS in a population of IVDU. Data on all patients with PPIS presenting to a quaternary referral center during a 4-year period from 2004 were collected in a prospectively maintained customized database. During the study period there were 102 patients treated for PPIS of which 51 were IVDU. Of this IVDU group, the mean age was 43 years (range: 25-57). Twenty-three had human immunodeficiency virus, 43 had hepatitis C, and 13 had hepatitis B. All were using cocaine, 26 were also using heroin and 44 were using at least 3 recreational drugs. Thirty patients presented with axial pain of a mean duration of 51 days (range: 3-120 days). Of the IVDU patients with neurological deficit on presentation, the mean American Spinal Injury Association (ASIA) motor score was 58.6. The most common ASIA motor levels involved were C4 and C5. Mean duration of neurological symptoms was 7 days (range: 1-60 days). Twenty-six were already receiving i.v. antibiotics for known spinal infection and 33 patients had an identifiable organism on blood cultures (19 methicillin-sensitive Staphylococcus aureus, 9 methicillin-resistant S. aureus). Forty-four of the 51 IVDU patients were treated surgically. Thirty-four of the 44 surgically treated cases involved the cervical spine. Twenty-two had a posterior approach alone, 13 had anterior only while 9 required combined anterior and posterior approaches at the index surgery. Seven required early revision for hardware failure (none of whom has combined approach) and 2 developed a postoperative surgical site infection (SSI). Thirty-seven of the 51 IVDU patients were apprehended at least once using illicit drugs while in hospital. Mean duration of antibiotic treatment after surgery was 62 days. At discharge, 28 of 44 patients had neurological improvement (mean = 20 ASIA points, range: 1-55), 11 had neurological deterioration during treatment (mean = 13, range = 1-50), and 5 were unchanged. Among the IVDUs there were no in-hospital deaths. At 2 years after index admission 13 IVDU patients were dead, and none were attending for follow-up despite all efforts to locate the patients. In the non-IVDU group, the mean age of the 51 patients was 56 years (range 25-83). Thirty-four patients presented with axial pain with a mean duration of 105 days (range 2-365). Mean ASIA motor score of patients with neurological deficit on admission was 74. Most common ASIA level was T12. Mean duration of neurological symptoms was 12 days (range 1-84). Thirteen patients were receiving i.v. antibiotics for known spinal infection and 20 patients had an identifiable organism on blood culture (30% methicillin-sensitive S. aureus, 50% methicillin-resistant S. aureus). Forty-four of these 51 non-IVDU patients were treated surgically. Thirty-five of the 44 surgically-treated cases involved the thoracic or lumbar spines. Twenty-nine had a posterior approach alone, 3 had anterior alone while 12 required combined approaches. No early hardware failures were seen in the non-IVDU group while 4 developed SSI. Mean duration of antibiotic treatment after surgery was 45 days. At discharge 21 patients had neurological improvement (mean 9 ASIA points, range: 1-17). Five had neurologic deterioration with a mean motor loss of 16 points (10-23). There were 4 in-hospital deaths among the non-IVDU group. At 2 years after index admission, 19 patients were dead and the remainder were all available for follow-up. There are significant differences in demographics, presentation, treatment and outcomes of primary spinal pyogenic infection between a population of IVDU and a comparable cohort of non-IVDU. The IVDU group presents with cervical quadriplegia while it is the thoracolumbar spine that is almost exclusively involved in the non-IVDU group. Among the IVDUs, surgical management is complex with a high incidence of early hardware failure. SSI is significantly more common among non-IVDU. Significant neurological improvement can be expected in the majority of IVDU patients with a high mortality rate among the non-IVDU. IVDU are unreliable patients and in-hospital, in-halo incarceration is recommended where possible.

Depression and Quality of Life in Patients within the First 6 Months after the Spinal Cord Injury

ObjectiveTo evaluate the severity of depression, degree of life satisfaction, level of stress, and resilience among patients in the first 6 months after a spinal cord injury (SCI).Method36 patients with SCI were asked to fill out questionnaires concerning Beck Depression Inventory (BDI), World Health Organization Quality of Life Questionnaire-BREF, Stress Response Inventory, and Connor-Davidson resilience scale. All patients had experienced an SCI within the last 6 months before the commencement of this study.ResultsIn our study, the patients who experienced the SCI within the last six months had a higher rate of depression (63.9%) and a higher overall level of depression (13.8 points). The unmarried group had a significantly higher quality of life (QOL; p<0.05) when compared with the married group. In the motor complete group, severity of depression and level of stress were higher, whereas QOL was lower than the motor incomplete group (p<0.05). The mean American Spinal Injury Association (ASIA) Motor Score (AMS) was much higher in the non-depressive group (p<0.05) when compared with the depressive group.ConclusionWe found the patients within six months after SCI injury had higher rate of depression and higher overall level of depression. Also, patients with motor complete injury had affected significantly on depression, QOL and stress. We found the married patients had poorer QOL and depressive group had lower AMS score of lower extremity. Therefore, there should be emphasis of psychological care who have motor complete injury and are married during the early stage.

Correlation of MR Diffusion Tensor Imaging Parameters with ASIA Motor Scores in Hemorrhagic and Nonhemorrhagic Acute Spinal Cord Injury

This study investigated correlations between American Spinal Injury Association (ASIA) clinical injury motor scores in patients with traumatic cervical cord injury and magnetic resonance (MR) diffusion tensor imaging (DTI) parameters. Conventional imaging and DTI were performed to evaluate 25 patients (age, 39.7±13.9 years; 4 women, 21 men) with blunt spinal cord injury and 11 volunteers (age, 31.5±10.7 years; 3 women, 8 men). Cord contusions were hemorrhagic (HC) in 13 and non-hemorrhagic (NHC) in 12 patients. The spinal cord was divided into three regions to account for spatial and pathological variation in DTI parameters. Comparisons of regional and injury site mean diffusivity (MD), fractional anisotropy (FA), radial diffusivity ( λ(⊥)), and longitudinal diffusivity ( λ(‖)) were made with control subjects. ASIA motor scores were correlated with DTI using linear regression analysis. HC and NHC patients showed significant reduction (p<0.001) in MD and λ(‖) in all three regions. At the injury site, significant decreases in FA and λ(‖) were seen for both injury groups (p<0.001). λ(⊥) values were significantly increased only for patients with NHC (p<0.05). Significant reduction in FA and λ(‖) (p<0.0001) was observed at the whole cord level between the injured (NH and NHC) and control groups. Within the NHC group, strong correlations were observed between ASIA motor scores and average MD, FA, λ(⊥), and λ(‖) at the injury site. However, no correlation was observed within the HC group between any of the DTI parameters and ASIA motor scores. DTI parameters reflect the severity of spinal cord injury and correlate well with ASIA motor scores in patients with NHC.

Acidic fibroblast growth factor for repair of human spinal cord injury: a clinical trial

The study aimed to verify the safety and feasibility of applying acidic fibroblast growth factor (aFGF) with fibrin glue in combination with surgical neurolysis for nonacute spinal cord injury. This open-label, prospective, uncontrolled human clinical trial recruited 60 patients with spinal cord injuries (30 cervical and 30 thoracolumbar). The mean patient age was 36.5 ± 15.33 (mean ± SD) years, and the male/female ratio was 3:1. The mean time from injury to treatment was 25.7 ± 26.58 months, and the cause of injury included motor vehicle accident (26 patients [43.3%]), fall from a height (17 patients [28.3%]), sports (4 patients [6.7%]), and other (13 patients [21.7%]). Application of aFGF with fibrin glue and duraplasty was performed via laminectomy, and an adjuvant booster of combined aFGF and fibrin glue (2 ml) was given at 3 and 6 months postsurgery via lumbar puncture. Outcome measurements included the American Spinal Injury Association (ASIA) motor scores, sensory scores, impairment scales, and neurological levels. Examination of functional independence measures, visual analog scale, MR imaging, electrophysiological and urodynamic studies, hematology and biochemistry tests, tumor markers, and serum inflammatory cytokines were all conducted. All adverse events were monitored and reported. Exclusions were based on refusal, unrelated adverse events, or failure to participate in the planned rehabilitation. Forty-nine patients (26 with cervical and 23 with thoracolumbar injuries) completed the 24-month trial. Compared with preoperative conditions, the 24-month postoperative ASIA motor scores improved significantly in the cervical group (from 27.6 ± 15.55 to 37.0 ± 19.93, p < 0.001) and thoracolumbar group (from 56.8 ± 9.21 to 60.7 ± 10.10, p < 0.001). The ASIA sensory scores also demonstrated significant improvement in light touch and pinprick in both groups: from 55.8 ± 24.89 to 59.8 ± 26.47 (p = 0.049) and 56.3 ± 23.36 to 62.3 ± 24.87 (p = 0.003), respectively, in the cervical group and from 75.7 ± 15.65 to 79.2 ± 15.81 (p < 0.001) and 78.2 ± 14.72 to 82.7 ± 16.60 (p < 0.001), respectively, in the thoracolumbar group. At 24-month follow-up, the ASIA impairment scale improved significantly in both groups (30% cervical [p = 0.011] and 30% thoracolumbar [p = 0.003]). There was also significant improvement in neurological level in the cervical (from 5.17 ± 1.60 to 6.27 ± 3.27, p = 0.022) and thoracolumbar (from 18.03 ± 4.19 to 18.67 ± 3.96, p = 0.001) groups. The average sum of motor items in functional independence measure also had significant improvement in both groups (p < 0.05). The walking/wheelchair locomotion subscale showed increased percentages of patients who were ambulatory (from 3.4% to 13.8% and from 17.9% to 35.7% in the cervical and thoracolumbar groups, respectively). There were no related adverse events. The use of aFGF for spinal cord injury was safe and feasible in the present trial. There were significant improvements in ASIA motor and sensory scale scores, ASIA impairment scales, neurological levels, and functional independence measure at 24 months after treatment. Further large-scale, randomized, and controlled investigations are warranted to evaluate the efficacy and long-term results.

Anterior Approach Versus Posterior Approach With Subtotal Corpectomy, Decompression, and Reconstruction of Spine in the Treatment of Thoracolumbar Burst Fractures

A randomized, controlled follow-up study. The objective of this study was to compare the results of anterior approach versus posterior approach with subtotal corpectomy, decompression, and reconstruction of spine in the treatment of thoracolumbar burst fractures. Burst fractures are frequently associated with instability or neurological deficit. Anterior subtotal corpectomy, decompression, and reconstruction with instrumentation are an established method for a highly unstable burst fracture. In the past few years, subtotal corpectomy, decompression, and reconstruction of spine could be completed by posterior approach. Posterior segmental pedicle screw instrumentation, with its more rigid fixation and less technically demanding, could offer potential advantages. A total of 64 patients with thoracolumbar burst fractures were divided into 2 groups randomly. Group A was treated by anterior approach and group B was treated by posterior approach with subtotal corpectomy, decompression, and reconstruction of spine. During the minimum 24 months (range, 24 to 72 mo) follow-up period, all patients were prospectively evaluated for clinical and radiologic outcomes. The intraoperative blood loss, operative time, complications of operation, pulmonary function, Frankel scale, and the American Spinal Injury Association (ASIA) motor score were used for clinical evaluation, whereas the heights of anterior edge of vertebral body and the Cobb angle were examined for radiologic outcome. RESULTS: All patients in this study achieved solid fusion, with significant neurological improvement. The intraoperative blood loss (P<0.05) and complications of operation were less, the operative time was shorter (P<0.05), and the pulmonary function after operation was better in the group B (P<0.05). The Frankel scale, the ASIA motor score, and the radiologic results were not significantly different (P<0.05) at all time points between the 2 groups A and B. But the 2 groups improved in their neurological function by approximately 1.3 Frankel grade and 15.6 ASIA motor scores at final follow-up. Anterior approach and posterior approach with subtotal corpectomy, decompression, and reconstruction of spine are sufficient for surgical treatment of thoracolumbar burst fractures. Less intraoperative blood loss and complications, shorter operative time, and better pulmonary function after operation are the significant advantages of posterior surgery.

Long-term outcomes of adults with pediatric-onset spinal cord injuries as a function of neurological impairment

Objective: To identify outcomes of participation, life satisfaction, and medical complications as a function of impairment in adults with pediatric-onset spinal cord injury (SCI).Methods: Study participants were adults who sustained SCI at age 18 years or younger and were interviewed at age 24 years or older (M = 26.9, SD = 3.5). The telephone interview included a questionnaire and several standardized measures: FIM® instrument (FIM®), Craig Handicap Assessment and Reporting Technique (CHART), SF-12® Health Survey, and Satisfaction with Life Scale. Using the International Standards for Neurological Classification of Spinal Cord Injury and the American Spinal Injury Association (ASIA) Impairment Scale (AIS), subjects were grouped into four impairment categories: C1–C4 ABC, C5–C8 ABC, T1–L4 ABC, and AIS D.Results: Of the 410 participants, 62% were male, 54% had tetraplegia, 70% had AIS A lesions, and average age at injury was 14 years (SD = 4.3). Of the 407 subjects who had complete neurological information, 59 had C1–C4 ABC, 140 had C5–C8 ABC, 168 had T1–L4 ABC, and 40 had AIS D lesions. The outcomes were delineated for education, employment, independent living and driving, marriage, participation, medical complications, health-related quality of life, and global life satisfaction, in addition to the ASIA motor score and FIM® motor scores, for each of the four impairment groups.Conclusions: This information should help focus interventions that facilitate positive outcomes in relationship to the severity of impairment. In addition, these data can provide a level of expectation about long-term outcomes for newly injured children and their parents.

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 47: Correlations Between Recovery of Ambulatory Capacity and Lower-Limb Somatosensory Evoked Potentials in Incomplete Spinal Cord Injury

Objective: To study relationships between posterior tibial (PT) nerve somatosensory evoked potentials (SEP) and recovery of ambulatory capacity in patients with incomplete spinal cord injury (SCI) participating in Lokomat training. Design: Correlation study of functional clinical outcome with quantitative electrophysiological measures of sensory processing. Setting: Queen Elizabeth National Spinal Injuries Unit, Scotland. Participants: 13 acute and 5 chronic incomplete SCI patients. Intervention: 30 hours Lokomat Training over a 6-week period.

The effects of gait training with a gait orthosis on the neurogenic bladder after spinal cord injury

Objective To explore the effects of gait training with an alternative gait orthosis (AGO) on the neurogenic bladders of patients with spinal cord injury (SCI). Method Twelve patients with complete SCI at the thoracic and lumbar level were trained for 8 weeks on motor and bladder function. After that, specific gait training with an AGO was given for another 8 weeks. American Spinal Injury Association ( ASIA ) sensation and motor function assessments were done before and after the gait training with the AGO, and bladder capacity, residual urine and urine flow rates were also assessed. Results Compared with pre-treatment there was no significant difference in average ASIA senzsation and motor scores after training, but the maximum rate of urine flow, average urine volume and single urination had significantly increased and residual urine volume had significantly decreased. Conclusions Therapeutic gait training with an AGO can improve bladder function after SCI. Key words: Neurogenic bladder; Spinal cord injury; Gait training; Orthoses

Risk Factors for Organ Dysfunction and Failure in Patients with Acute Traumatic Cervical Spinal Cord Injury

Traumatic injuries to the cervical spine cause significant disability. Much of the morbidity and mortality that occurs in patients afflicted with cervical spinal cord injury (SCI) occurs early after injury due to primary neurologic dysfunction, systemic inflammation, concomitant injuries, treatments to prevent and ameliorate secondary insults, and prolonged immobilization. This study was undertaken to determine the incidence of organ dysfunction and failure using validated measures: the Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA). We also sought to determine if certain patient or injury characteristics were associated with the development of organ dysfunction and failure. All patients who sustained isolated blunt cervical SCIs admitted to the R Adams Cowley Shock Trauma Center over a 15-month period were identified. American Spinal Injury Association (ASIA) motor scores, ASIA impairment scale (AIS) scores, and level of injury were recorded. Admission, first daily, worst daily, and aggregate MOD and SOFA scores were assigned for each of six organ systems. A P < 0.05 was considered significant for all statistical tests. Of 1,028 patients admitted with blunt spine injuries between January, 2007 and March, 2008, 40 patients were identified with an isolated cervical SCI that required an ICU length of stay (LOS) >24 h. Organ failure of at least one organ system occurred in 75% of patients as calculated by MOD score and 85% of patients calculated using SOFA criteria. Multiple organ failure was found in 55% by MOD and 62.5% by SOFA scores. The most frequent system to fail was the cardiovascular system by aggregate MODS (84%), while the respiratory system was the most frequently failed system by aggregate SOFA criteria (70%). There was a strong inverse correlation between ASIA motor score and aggregate MODS and SOFA scores (r = -0.56, P = 0.0002 and r = -0.51, P = 0.0009). AIS was also found to be inversely correlated with the development of organ failure (r = -0.47, P = 0.002 and r = -0.45, P = 0.004) while anatomic level of injury was found to correlate poorly with the incidence of organ failure (r = -0.11, P = 0.5 and r = -0.10, P = 0.5). Only ASIA motor score was significantly associated with sum aggregate organ dysfunction scores when controlling for age and injury severity score (parameter estimate = -0.082, P = 0.0005 for MODS and parameter estimate = -0.057, P = 0.006 for SOFA). This study is the first to describe the incidence of organ dysfunction and failure in patients with isolated acute traumatic cervical SCI using validated organ system dysfunction scores. Respiratory, cardiovascular, neurologic, renal, hepatic, and hematologic dysfunction occurred commonly both on admission and over the ICU stay. Respiratory, cardiovascular, and neurologic failure were frequently found, while renal, hepatic, and hematologic failures were uncommon. Multiple organ failure occurred in the majority of patients. ASIA motor score and AIS were found to strongly correlate with the development of organ dysfunction and failure. Level of injury should be used with caution when describing the risk of complications and the need for medical interventions.

Relevance of the diagnosis traumatic cervical Brown-Séquard-plus syndrome: an analysis based on the neurological and functional recovery in a prospective cohort of 148 patients

Prospective multi-center cohort study. To compare the neurological and functional recovery between tetraplegic Brown-Séquard-plus syndrome (BSPS) and incomplete tetraplegia (non-BSPS). European Multicenter Study of Human Spinal Cord Injury (EM-SCI). BSPS was defined as a traumatic incomplete spinal cord injury (SCI) with ipsilateral weakness and contralateral loss of pinprick sensation at neurologic levels C2-T1. Acute (0-15 days) and chronic phase (6 or 12 months) were assessed for the American Spinal Injury Association (ASIA) sensory scores, upper extremity motor scores and lower extremity motor scores. Furthermore, chronic phase scores of all Spinal Cord Independence Measure (SCIM) II items were analyzed. Differences in neurological and functional outcome between BSPS patients and non-BSPS patients were calculated using Student's t-tests and Wilcoxon signed rank tests. Out of 148 tetraplegic patients, 30 were diagnosed with BSPS. Patients with an ASIA impairment scale (AIS) B were significantly (P<0.001) more identified in non-BSPS patients (25%) compared with BSPS patients (3%), respectively. After 12 months, the median scores for sphincter management of the bladder for both BSPS and non-BSPS patients were 15. Both 25 and 75% quartile median scores were 15 for BSPS patients and 12 and 15 for non-BSPS patients (P<0.02). Except for the difference in bladder function, no significant differences were identified in other SCIM II subitems and ASIA motor or sensory scores between BSPS and non-BSPS patients when stratified for injury severity by excluding AIS B patients. Compared with incomplete tetraplegic patients, patients with cervical BSPS have a similar neurological and functional recovery when matched for the AIS.

Influence of long-term wheelchair rugby training on the functional abilities in persons with tetraplegia over a two-year post-spinal cord injury

The aim of this study was to assess the influence of long-term wheelchair rugby training on the functional abilities of persons with tetraplegia over a 2-year period post-spinal cord injury. A prospective non-randomized controlled trial. Forty people with incomplete tetraplegia were examined. Participants were divided into 2 groups: a wheelchair rugby training group (n = 20) and a control group (n = 20). The Wheelchair Skills Test was used to assess functional changes in patients. In order to assess the strength of the 10 key muscles in the upper limb, the American Spinal Injury Association (ASIA) motor score was used. All participants were assessed at the beginning of the study (at the start of wheelchair rugby training) and reassessed after 2 years. Between pre- and post-measurements patients from the wheelchair rugby group attended wheelchair rugby training once a week. The baseline values of the Wheelchair Skills Test in the wheelchair rugby group was 71.3, and this increased significantly by 24%. In the control group, the mean Wheelchair Skills Test value was 63.2, and this improved by 4%. A significant correlation between Wheelchair Skills Test score and ASIA motor score was found in both groups. Participation in regular wheelchair rugby training may preserve and augment functional abilities in individuals with incomplete tetraplegia.

Does High Dose Methylprednisolone Sodium Succinate Really Improve Neurological Status in Patient With Acute Cervical Cord Injury?

Consecutive cohort study. To reconsider effects of the Second National Acute Spinal Cord Injury Study. High dose methylprednisolone sodium succinate (MPSS) for the patients with acute spinal cord injury has been considered standard treatment in the several countries. However, many authors have criticized the effect of MPSS because of lack of evidence about neurologic improvement and the high incidence of complications. During 2-year, all patients with cervical cord injury were treated with MPSS within 8 hours of their injuries based on the Second National Acute Spinal Cord Injury Study protocol (MPSS group). During the next 2-year, all patients were treated without MPSS (non-MPSS group). There were 38 patients in the MPSS group and 41 in the non-MPSS. Early spinal decompression and stabilization was performed as soon after injury in both the groups. According to The American Spinal Injury Association (ASIA) motor score, there was an average improvement by 3 months postinjury of 12.4 points in the MPSS group and 13.8 points in the non-MPSS group. In patients with complete motor loss, average ASIA motor score improved 9.0 points in the MPSS group and 12.6 points in the non-MPSS group. For patients with incomplete motor loss, average ASIA motor score improvement was 14.1 and 15.5 points in the MPSS and non-MPSS groups, respectively.In the MPSS group, 19 patients developed pneumonia, 13 developed urinary tract infections, and 5 developed wound infections. Incidence of pneumonia was significantly increased with the use of MPSS medication. We found no evidence supporting the opinion that high-dose MPSS administration facilitates neurologic improvement in patients with spinal cord injury. We believe MPSS should be used under limited circumstances because of the high incidence of pulmonary complication.

Spinal Epidural Abscess: A 5-Year Case-Controlled Review of Neurologic Outcomes After Rehabilitation

Koo DW, Townson AF, Dvorak MF, Fisher CG. Spinal epidural abscess: a 5-year case-controlled review of neurologic outcomes after rehabilitation. Objective To describe the neurologic outcomes of 29 spinal epidural abscess (SEA) patients after rehabilitation compared with a case-controlled traumatic spinal cord injury (TSCI) cohort. Design Five-year retrospective chart review. Setting University-affiliated surgical spine unit and inpatient rehabilitation program. Participants Patients (n=29; 19 men, 10 women) requiring inpatient rehabilitation after SEA and TSCI case controls (n=29) matched by level of injury, American Spinal Injury Association (ASIA) Impairment Scale (AIS), ASIA motor score (AMS), sex, and age. Main Outcome Measure The primary outcome was a change in AMS from acute admission to discharge from inpatient rehabilitation. Results Despite having lower admission motor scores, there was a significant trend toward greater neurologic recovery in the SEA group ( P=.047). In contrast to what is known regarding recovery from complete TSCI, this study shows potential for dramatic recovery in SEA subjects presenting with AIS grade A deficit with a 73% conversion rate to incomplete status; out of 11 SEA subjects with initial AIS grade A, 2 improved to AIS grade B, 1 to AIS grade C, and 5 to AIS grade D. Conclusions This study shows the potential for a significant improvement in neurologic deficits related to SEA. Based on the results of our study, it is clearly inappropriate to generalize recovery patterns seen in the TSCI patient population to SEA-associated myelopathy because the latter appears to have more favorable outcomes.

Effectiveness of surgical treatment for traumatic central cord syndrome

The authors undertook a study in patients with traumatic central cord syndrome (TCCS) who underwent surgical intervention. They retrospectively assessed the motor score improvement and functional status and identified prognostic predictors of improvement. Between March 1999 and May 2004, 49 patients with TCCS were surgically treated. Motor scores were collected at admission and follow-up using the American Spinal Injury Association (ASIA) Impairment Scale. The 36-Item Short Form Health Survey (SF-36) was administered. Other parameters including walking index, spasticity, bladder management, and neuropathic pain scores were recorded. Patients were asked to assess their level of satisfaction with their final symptoms. The average ASIA score, converted into numeric values, was increased from 54.9 at admission to 81.9 and 89.6 at 6 months and final follow-up, respectively. Significant improvement of ASIA score was achieved within the first 6 months of surgery. No significant difference was found between patients who underwent surgery within 4 days of injury or after 4 days of injury, adopting different approaches (anterior, posterior, or a combination), or with different pathological entities (acute disc herniation, fracture or dislocation, or multilevel degeneration). The ASIA score improvement had a positive correlation with the age at injury (r = 0.505, p = 0.023). The SF-36 data at 6 months and final follow-up were not as satisfactory as the improvement in ASIA scores, and almost one-third of patients expressed dissatisfaction with their final symptoms. For patients who were older than 65 years at injury, the mean follow-up Walking Index for Spinal Cord Injury (WISCI) score was statistically lower than it was in younger patients. The presence of spasticity or neuropathic pain at follow-up was not related to age, sex, ASIA motor score, or WISCI outcome. Surgical intervention can be safely applied in patients with TCCS. Significant improvement of ASIA score was achieved during the first 6-month period of follow-up. Factors including type of lesion, timing of surgery within or after 4 days of injury, and surgical approach were not significantly associated with final ASIA score. The improvement in the ASIA motor score was positively correlated with age at injury. No significant correlation was found between or among the presence of spasticity, neuropathic pain, and ASIA score at final visit. Almost one-third of patients were not satisfied with their final symptoms.

Course 510: Spinal cord injury: Severity of Sensory Impairment Determines Alterations in Cortical Moto Commands in Chronic Spinal Cord: A Case Series

Objective: The aim of this study was to characterize the relation between changes in cortical motor commands and the severity of motor and sensory impairment after spinal cord injury (SCI). Design: Prospective. Setting: Outpatient. Participants: SCI subjects and healthy volunteers. Interventions: A 64-channel electroencephalogram was used to record movement related brain potentials from 9 chronic (>2y) SCI subjects and 9 neurologically intact volunteers (controls) while they attempted toe flexion. American Spinal Injury Association (ASIA) motor and sensory score and ASIA impairment scale of each SCI subject were evaluated. Main Outcome Measures: The negative slope, a component of movement related brain potentials preceding the onset of movement was identified and the Center of Cortical Activation (CCA) at the time of peak negative slope was calculated on voltage topographic maps. Difference in location of the CCA in SCI subjects compared with controls was taken as evidence of an altered pattern of motor command generation by the brain. Results: CCAs in SCI subjects were displaced posterior as compared with their location in controls. Step-wise linear regression analysis revealed that the degree of posterior displacement had a statistically significant correlation with the ASIA sensory score (P=.013), but not with the ASIA motor score or the impairment scale. Subjects with greater sensory impairment had a more posterior location of the CCA. The location of the CCA in SCI subjects with ASIA sensory scores below the median (66) for the SCI group was significantly different from that in healthy subjects (P<.05) and SCI subjects with an ASIA sensory score greater than the median (P<.05). Conclusions: Severity of sensory impairment is the major determinant of the extent of alteration in premovement cortical motor commands after SCI.